Author(s): Alexander M Senk, MD, Haley Hicks, DO, Dean Wundrach, Katherine Weir, MS, Michael Nguyen, MD, MPH, Christopher Meserve, MD
Originally published: October 6, 2015 Last updated: December 14, 2022
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Disease/ Disorder

Definition

Occupational Safety and Health Administration (OSHA) defines occupational injury as an injury that results from a work accident or from a single instantaneous exposure in the work environment.  An occupational illness is an abnormal condition or disorder, other than one resulting from an occupational injury, caused by an exposure to environmental factors associated with employment.  A work-related disorder is a disorder that affects an individual’s ability to work. It may not necessarily be caused or aggravated by work.

Etiology

Heavy physical work, high body mass index, high psychosocial work demands, and smoking are primary risk factors for occupational injury.1 An additional risk factor for neck pain is posture, and younger age is a risk factor for low back pain (LBP).  Prolonged computer work, older age, female gender, awkward posture, and repetitive work are risk factors for wrist and hand pain.1

Musculoskeletal injuries in the workplace are often related to cumulative trauma disorders, which mainly involve the upper extremity and back. Upper extremity nerve entrapments like carpal tunnel syndrome are prevalent as well. Both activities at work and outside of work that involve abnormal or poor posture (i.e. slouched posture or hyperextension/flexion of a joint) can affect nerve entrapments. These positions can lead to increased pressure on nerves, shortened muscles leading to tightness, or weakness of muscles. Additionally, task repetitiveness with a limited variety of tasks, decreased break time, increased expectations and an aging workforce can contribute to these conditions.2

Although upper extremity and back strains or sprains are among the most common injuries, psychological causes of injury or illness at work and psychological barriers are fairly common and attributable to the nature of patients’ workplaces. For example, work-related injury cases associated with law enforcement professions less often include psychological trauma related to altercations than the more frequently musculoskeletal injuries related to reported falls or slips from ground level or a height, heavy lifting or carrying of items, or exposure to a harmful chemical or device (i.e. needle sticks).3

Epidemiology including risk factors and primary prevention

In 2020, the Bureau of Labor and Statistics recorded 2.7 million nonfatal workplace injuries and illnesses that occurred at a rate of 2.7 cases per 100 full-time equivalent workers. Nearly 43% of nonfatal occupational injuries resulted in days away from work. There was a 32.4% increase in days away from work compared to 2019. Due to the nature of the COVID-19 pandemic, the rates of respiratory illness increased by over 39.4%.4 The healthcare and social assistance industry had the highest rates of illness and injury followed by manufacturing. Musculoskeletal disorders accounted for 21% of injuries resulting in days away from work, with a median amount of 14 days. This is an increase from 2018, when the median days lost was 12. Sprains, strains and tears were the leading kind of musculoskeletal injury with over 168,570 injuries. The hand was the most commonly injured area in the upper extremity and the knee was the most common area in the lower extremity. Men accounted for 60.9% of cases and workers age 45-54 years old accounted for the most workdays missed.5 The median days away from work after injury were 12 for private industry, 13 days for local government, and 14 days for state government.6

The economic impact of days away from work is costly. According to Liberty Mutual, the largest compensation insurer in the United States, work-related musculoskeletal injuries cost employers 13.4 billion dollars annually. Nationally, such injuries lead to a loss of 45-54 billion dollars annually.7 The cumulative cost of long-term disability is costly as well despite it providing a small annual sum per recipient. The average Social Security Disability Insurance (SSDI) benefit for disabled workers is $16,310 annually.8 Without this benefit, it is estimated that half of the recipients would live below the poverty line. Even with these benefits, an estimated 20% of recipients are considered poor or nearly poor.8 There are currently 7.8 million individuals receiving SSDI and the majority of claimants have been working for 22 years.8 Over 40% of beneficiaries are over the age of 60 and suffer from severe musculoskeletal, mental health, or long-term impairment.8 This impact emphasizes the potential benefits of understanding risk factors and preventative measures impacting injury and return to work rates.

There are many workplace and social risk factors that impact the rate of occupational injury and return to work time. The National Institute for Occupational Safety and Health (NIOSH) reports demonstrate that two specific work groups have higher rates of back injuries: 1 – operators, fabricators, and laborers & 2— precision, production, and repair workers.9 In a preliminary research study, social determinants of health were found to be a key non-physical factor informing return to work.10The implications of the social determinants of health were further explored in a review, looking at the return to work rates of Black men. The researchers found that age, education, type of insurance, and life-long exposure to racism were significant factors in return to work. This study also emphasized how insurance level and exposure to racism are significantly related to poor mental health outcomes.11 It is important to mention that migrant workers, who are often underrepresented in return-to-work studies, have higher rates of workplace injury and poorer health outcomes. Cultural barriers and the inaccessibility of healthcare systems serve as risk factors for occupational injury and contribute to health disparities.12

Due to system complexities and individual differences, there is not one standardized preventative plan that will be efficacious for all people. Still, there are many studies evaluating the efficacy of specific interventions as preventative measures to musculoskeletal workplace injury. For instance, one study found that nurses whose workplace implemented mechanical lifting devices and lifting teams were significantly less likely to have a musculoskeletal injury.13 When looking at ergonomic interventions in office workers, there was no evidence that devices, such as arm supports, prevented work-related musculoskeletal injuries.14 There is moderate evidence that lumbar supports are not effective in the primary prevention or treatment of LBP.15 However, there is some evidence that the use of lumbar supports combined with patient education may help reduce the prevalence of recurrent LBP in industrial workers.16

The impact of employee education as a preventative measure is also frequently researched. The implementation of workplace improvements regarding ergonomic education was found to be effective in reducing the rate of lower back pain in nurses. This was accompanied by notable improvements in workers’ quality of life, disability, and LBP.17 Another report showed that a physical therapist led educational program for postal workers did improve subjects’ knowledge of safe behaviors but did not reduce the rate of low back injury, cost per injury, time off from work, or rate of related or repeated musculoskeletal injuries.18 Some reviews have concluded that yearly educational programs with follow-up are critical for successful injury prevention strategies.19,20 However, a review of multiple randomized controlled clinical trials suggests educational interventions focused on biomechanics are not effective in preventing LBP.21 Ultimately, in terms of preventative measures, there are mixed results regarding the benefits of certain workplace improvements and education.

Patho-anatomy/physiology

Repetitive use is a common cause of workplace injuries.  For example, nearly 65% of new occupational injuries could be attributed to repeated trauma.  The likely pathophysiology of repetitive use disorders, particularly for upper extremity injuries such as carpal tunnel syndrome, include inflammation followed by repair, fibrotic scarring, and nerve injury if applicable to the anatomic area.22 Inflammation is hypothesized to play a role in pain and loss of function with repeated overstretch, compression, friction, and even ischemia.  This may cause prolonged activation of interleukin-6 and prostaglandin E2. There has also been evidence of ischemic injuries with overuse injuries that are not associated with inflammation.  However, evidence remains limited due to small sample sizes and heavy dependence on animal models.

LBP has various etiologies, even in the setting of workplace injury. This includes cumulative low back loads which have been shown to be a significant risk factor for the occurrence of LBP later in life.23

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time):

Among patients with repetitive use injuries, pain is the most commonly reported complaint. These injuries are usually caused by three main domains: muscle, tendon, and nerve injury. In carpal tunnel syndrome, these injuries occur in tandem.  Repetitive motions may lead to tenosynovitis causing narrowing of the carpal tunnel and subsequently compression of the median nerve.  This may lead to neuritis or nerve injury resulting in pain, dysesthesias, muscle weakness, and atrophy.  According to the Canadian Centre for Occupational Health and Safety, repetitive use injuries may progress through the following stages:24

Early:  Symptoms of aching, discomfort, and fatigue will occur with overuse.  Symptoms often resolve after discontinuation of activity.  There is no work performance reduction.

Intermediate:  Symptoms of aching, discomfort, and fatigue occur with overuse and persist after discontinuation of activity.  There is work performance reduction.

Late:  Symptoms of aching, discomfort, fatigue, and weakness persist with rest.  Inability to sleep and perform light work duties.

In general, treatment of these injuries is focused on restriction of aggravating movement, application of physical modalities such as cold and heat, therapy, exercise, and medications such as anti-inflammatories, and surgery in advanced cases. A graded approach to returning to work and performance of the offending activities should be undertaken with the guidance of a physician, physical therapist, occupational therapist, and other appropriate disciplines.

Specific secondary or associated conditions and complications

In terms of LBP, one of the most common injuries, the specific cause is not always identified. Approximately 90% of all LBP patients have at times been diagnosed with nonspecific LBP.25 Common biomechanical abnormalities leading to LBP include muscular/ligamentous strain, obesity, herniated discs, stenosis of the central canal or foramen, facet arthritis, spondylolisthesis, degenerative disc disease, or osteoporosis leading to fracture.

The pain caused by the previously listed disorders along with pre-existing conditions, such as depression, can be exacerbated by work injury. Claimants with premorbid depression have an increased likelihood of developing chronic pain.26 These associated conditions can lead to further impairment and/or disability.27-29 Prolonged unemployment increases both physical and mental morbidity and mortality.30

Essentials of Assessment

History

A detailed history of the mechanism and timing of the injury is critical in determining if the injury is work-related.  If the chief complaints, history and physical findings do not correlate, this is suggestive of symptom magnification and raises suspicion of a non-work-related or nonphysiological etiology.  History should be compared to previous records for consistency. In addition to a full medical, occupational, and exposure history, a history of previous claims and outcomes should be obtained.  This will identify risk factors for protracted recovery noted in subsequent sections.

Physical examination

A structured process of inspection, palpation, range of motion (active and passive), manual muscle testing, sensation, coordination, gait, balance, reflexes, and special testing is a good paradigm for a complete yet focused exam. Objective findings for neurological injury are reflex asymmetry and muscle atrophy. Range of motion, manual muscle testing, and sensation may be self-limited.  Observation of functional difficulties (i.e. gait, don/doff clothes, arising from chair) should match the physical examination.

Waddell signs suggest non-physiologic etiology of pain but do not necessarily imply malingering.  Distraction techniques can be used in patients with self-limited evaluations.

Depending on the mechanism of injury, the physical exam should start with a general musculoskeletal exam broadening to a neurological exam.  To help direct treatment and optimize recovery, one should perform specific exam maneuvers to elucidate the most likely cause of injury or pain including underlying biomechanical faults.  It is imperative to ask clarifying questions throughout your exam as provocative tests, such as FADIR (flexion adduction & internal rotation), may elicit discomfort in the inguinal region or over the greater trochanter. The former is suggestive of intra-articular pathology while the latter may suggest greater trochanteric pain syndrome.  If the location of the produced pain is not verified, the examination has lost its diagnostic value.

Clinical functional assessment: mobility, self-care cognition/behavior/affective state

Patient activity at home will help to establish the lowest level of work restrictions if a patient is not working.  Avoiding responsibilities at home beyond expectations may indicate other secondary gain issues or catastrophizing tendencies. The Fear Avoidance Behavior Questionnaire, Neck Disability Index and Oswestry Disability Index can help identify patients at risk. When evaluating a patient with a work-related injury, it is important to keep in mind and distinguish between aggravation (lasting or permanent worsening of a pre-existing injury or condition) and exacerbation (temporary worsening of a pre-existing injury or condition) of an injury. In terms of identifying the injury as a cause for disability, the patient and physician should be aware that an employer may apportion or assign the current injury to a previous work injury if one occurred in the past. This would happen under a certain set of circumstances where the employer identifies the disability caused by a current injury as due in part to a previous injury.

Laboratory studies

Laboratory studies may be needed to rule out medical causes of complaints particularly in patients lacking non-physiological risk factors that fail to improve as expected.  If history and physical support other possible etiologies of pain, such as inflammatory arthritides or autoimmune disorders, further work-up may be warranted.

Imaging

Imaging should be considered to negate or identify pathology when a patient fails to progress appropriately.  Imaging is most frequently recommended to confirm the diagnosis when the pre-test probability (index of clinical suspicion) is high. Furthermore, caution must be taken to educate the patient that abnormal findings must correlate to symptoms to be reasonably considered for causation and treatment as abnormal findings in asymptomatic individuals are common.23

Supplemental assessment tools

Self-report in the form of standardized questionnaires is utilized to assess functional limitations. Validated measures focusing on health-related quality of life include the Fear Avoidance Beliefs Questionnaire (FABQ), Neck Disability Index (NDI), Oswestry Disability Index (ODI), and Short Form 36 (SF- 36).

FABQ is a 16-question investigation of how a patient’s fear avoidance beliefs about physical activity contributes to pain, with higher scores indicating more severe fear avoidance behaviors.

The NDI is a modification of the ODI and uses self-reporting measures for neck pain.

The ODI is the gold standard of low back functional outcome tools. ODI scores are converted into a percentile, with higher percentiles equating greater disability.

SF-36 considers physical, emotional, and social functioning, plus general health perceptions on a 0-100 scale with greater scores equating lesser disability.

Early prediction of outcomes

There are multiple factors that can help predict if there will be persistent disability. Many of the principles of chronic pain and its management end up applying to return to work after musculoskeletal disorders/injuries. For example, the most common site of fracture among work related injuries is in the hand.31 The time from injury to full work duty has been cited at about 56 days for hand injuries.32 While injury severity is key to prognosticating one’s function, studies have shown other determinants of return to work after hand injuries such as post-traumatic stress disorder are associated with the injury and ongoing pain.33 Similarly, almost 30% of people sustaining acute LBP go on to have chronic pain.  Chronic intractable pain is often associated with comorbidities such as depression, behavioral disorders, substance abuse, prolonged disability, and secondary gain concerns. Prolonged pain diminishes the likelihood of returning to work, and those who are out for more than 6 months due to LBP return to work at a rate of 50%.  The rate diminishes to 25% at 1 year and under 5% after 2 years.34

Environmental

The work environment can play a role in an individual’s decision to return and stay at work. Job satisfaction is a stronger predictor than job activity for predicting the filing of a future back claim.35 Organizational policies and practices that support individuals with musculoskeletal injuries (i.e. work accommodations and pain self-efficacy) increase the rate of return to work and work role functioning.36 Patients with chronic pain noted their work environment impacted their decision to remain at work, especially if they felt unsupported or if the legitimacy of their injury was questioned by coworkers.37

Social role and social support system

Social support is associated with healthcare outcomes. Patients who have weaker perceived social support had lower rates of returning to work and higher rates of comorbidities including depression and anxiety. These patients were also more likely to identify as young, black, and male. This inverse relationship of certain identities and rates of returning to work may shine some light on the role that social determinants have on one’s health and ability to return to work.38

Within the workplace, social support from supervisors can improve return to work outcomes. The lower the level of supervisor support the more likely a worker was to be reinjured or have their return interrupted.39

Governmental support can also be beneficial in helping people return to work. The majority of participants in a Washington State return to work program, which involved vocational services, reported that the services helped them return to work and stay at work. There was also a significant increase in these rates when aligning services with an individual’s occupational goals. Washington State will also treat premorbid unrelated psychiatric illnesses that might delay recovery of an allowed industrial condition.40

Professional issues

There is a balance between being a patient advocate and fulfilling insurance carrier desires for case closure. Restrictions and off-work status should be medically based. The patient may need to be removed from work if the employer fails to follow restrictions.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Official Disability Guidelines (ODG) provide evidence-based recovery durations for specific diagnoses.  Different durations are provided if the diagnosis is not workers’ compensation.

At different disease stages

Traditionally, protection, rest, ice, compression, and elevation (PRICE) have been employed after an acute injury.  However, others have more recently suggested a transition to PEACE & LOVE (protection, elevation, avoidance of anti-inflammatories, compression, education, load, optimism, vascularization, exercise).41

Residual impairments in strength and range of motion in the post-acute or post-surgical phase are addressed with physical or occupational therapy.

Sleep also plays a critical role in returning to work as sleep disturbances were associated with increased higher alcohol consumption, greater body mass index (BMI), lower physical activity, higher anxiety, and an increased likelihood of not returning to work.42 Studies have found that restorative sleep and decreased trouble falling asleep can help predict faster resolution of chronic widespread pain and improved overall musculoskeletal health.43

In more protracted cases, work conditioning or work hardening are used to improve work status and function.  Work conditioning addresses work endurance through the use of strengthening and cardiovascular conditioning.  Workers advance from daily one-hour to four-hour sessions.  Work hardening addresses task-specific job deficits and the patient attends daily sessions for several hours up to a full work day. A review shows that physical conditioning has no effect on absence duration for acute back pain and a small effect at one year to reduce sick leave in workers with chronic back pain.44 Overall, when chronic pain secondary to an initial injury is obstructing return to work, there should be consideration of a referral to a comprehensive pain center with access to pain psychology among standard medical care and therapies.

Maximal medical improvement occurs when a patient has undergone the most common healing, repair and treatment pathways (i.e. chronic medical treatments and rehabilitation). At that time, the insurance carrier may request an impairment or disability rating. Over 35 states and the federal government require the use of some editions of the “AMA Guides to the Evaluation of Permanent Impairment.”45

Disability is defined by the Social Security Act as an “inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.”46 It is the purpose of the physician to perform an Independent Medical Evaluation (IME) to systematically define this subjective term of disability. This evaluation includes: a narrative history, clinical status, results of objective exams or tests, the cause of the injury related to employment, MMI assessment, identifying diagnoses and functional impairments, severity or permanence of limitations/impairments, analysis of job tasks, and the ability to perform said tasks.

At times a work capacity evaluation (WCE) can be done by a physical or occupational therapist to provide further objective functional information. However, objective evaluations of job performance are effort dependent. In the context of return to work, disability is related to both work-related and medical problems. No matter the end result of an IME, the patient should be counseled that determination of MMI does not imply the lack of a need for ongoing or future medical appointments or treatments as clinically warranted. This clarification emphasizes the role of the physiatrist as a crucial member of the medical team whose primary aim is to preserve and possibly improve the function and quality of life of the patient through holistic and longitudinal care.

Special consideration should be given to patients with primarily psychological or mental health related barriers to returning to work. Among individuals with concurrent mental health and musculoskeletal disorders, a benefit is obtained from combined clinical and work-related interventions compared to clinical interventions alone.47 It is difficult to identify and define disability, especially in chronic pain patients. During examinations, patients with multiple physical and psychological barriers to returning to work exhibit significant pain behavior characteristics (i.e., catastrophizing), but some evidence shows that malingering is present in only about 1-10% of chronic pain patients.48 Thus, it is important to take a holistic approach when evaluating these patients.

Coordination of care

Care should be coordinated involving a multidisciplinary and patient-centered approach. Along with the patient and their family, team members could include the physician, therapist, employer, insurance carrier, as well as social workers and case managers as needed.

Coordination of care involves interdisciplinary collaboration. For example, return to work slips with clear restrictions should be provided to patients and insurance carriers at the end of each visit.  Clinic notes should be documented promptly.  Therapists should contact physicians about the state of a patient’s well-being, especially if they are in too much pain to participate.  Employers should make efforts to accommodate and support workers, which is associated with workers’ decisions to return to or remain at work in a full or modified capacity such as productive light duty work.39 Insurance carriers must act quickly to approve treatment and testing recommendations.  Social workers could connect patients with appropriate resources to minimize the impact that social determinants (food insecurity, transportation, supplemental income, etc.) might have on the patient’s health outcomes.  Case managers may assist by helping to coordinate care and provide longitudinal perspective to facilitate the care teams and patient in advancing the treatment plan in alignment with the patient’s goals. Consistent feedback from all members regarding diagnosis, goals, and work status is paramount to a successful outcome.

Patient & family education

Expectations and goals should be established at the first visit.  The patient should be informed that work restrictions are written based on the diagnosis and physical findings. It is the employer’s decision whether to accommodate.  Family members with poor outcome experiences may undermine treatment.  Activity within restrictions at home and work should be encouraged.

Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally-based

Functional Capacity Evaluations (FCE) which are limited by pain do not measure maximal functional abilities. The validity of FCE to determine safe return to work is questionable.49 Nonphysiological factors may be more important.

Conservative treatment is superior to lumbar fusion for degenerative disc disease, herniation or radiculopathy in workers’ compensation.50

Translation into Practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Research confirms that musculoskeletal disorders are multifactorial in nature, with physical, psychological, and social components. Within the clinic, it is important to make sure that each of these components are addressed through a patient-centered approach. After an acute injury, patients tend to prioritize their physical recovery over secondary factors, such as returning to work.51

If a patient’s priority shifts to returning to work, a multidisciplinary approach can be beneficial. In an attempt to address the psychological contribution which may impair return to work, cognitive behavioral therapy (CBT) has resurfaced.  A recent study of worker’s compensation clients showed that re-employment was found more rapidly in the cohort undergoing CBT than those undergoing standard job search assistance.  Scores of anxiety, depression, and stress were tallied in each group, and those who underwent CBT showed statistically significant decreases in each as compared to the control group.52 Integrating cognitive behavior techniques and focusing on functional goals in therapy may minimize disability time and reduce claim costs.

Clinicians must be aware of, and able to direct patients to, supportive resources for people following a musculoskeletal injury. This information should be presented in a way that is culturally competent, which is especially important in patients who identify as minority workers.53

Historically, risk factors for protracted disability have included noncompliance with treatment, poor participation in the therapy, refusing to return to work when able, weight loss or exercise noncompliance, inability to quit smoking, patient hostility, anger, disruptive behavior, catastrophizing, and fear avoidance behaviors.54 However, it is important to explore and address the social determinants that might contribute to impairment of care. Recognition of the structural factors and systemic barriers that impact a patient’s ability to return to work after a musculoskeletal injury is an essential clinical pearl.

Cutting Edge/ Emerging and Unique Concepts and Practice

Motivational interviewing (MI) is a tool to help explore patients’ goals and potential barriers to care. Patients reported that MI allowed them to build rapport with their providers and address their feelings of stigmatization following injury or disability. Its application could be beneficial and support a patient-centered approach to care.55 Its impact on helping employees returning to work, after a musculoskeletal injury, is currently being researched. A randomized controlled trial investigated the impact of MI on return to work outcomes; they concluded that MI was a more sustainable option 1 year post-discharge among those employed prior to injury and that MI better equipped individuals who were unemployed at the time of injury to navigate the process of work accommodations in their new role.56 Although MI is routinely used across other healthcare domains, this study provided a foundation for future research into MI interventions focused specifically on return to work outcomes.

The data on MI is still limited in its direct applicability as a treatment option. MI has undetermined efficacy in its impact on the likelihood of returning to work among patients with chronic musculoskeletal disorders.57,58 Further research is needed to determine if this practice is beneficial in helping workers return to work after a musculoskeletal injury.

Gaps in the Evidence-Based Knowledge

Few studies use only workers’ compensation cohorts.50 These studies consistently show worse outcomes when compared to similar studies excluding compensation patients.  Task-specific causation studies are limited and often used inappropriately to infer causation for unstudied tasks.

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Original Version of the Topic

Kevin Komes, MD, Brian Toedebusch, MD, Rebecca Hogg, MD. Return to work after MSK injury in the workplace: timely return and risk factors for delay. 10/06/2015

Previous Revision(s) of the Topic

Alexander M Senk, MD, Christopher Meserve, MD, Michael H Nguyen, MD, MPH. Return to work after MSK injury in the workplace: timely return and risk factors for delay. 10/26/2019

Author Disclosure

Alexander M Senk, MD
Nothing to Disclose

Haley Hicks, DO
Nothing to Disclose

Dean Wundrach
Nothing to Disclose

Katherine Weir, MS
Nothing to Disclose

Michael Nguyen, MD, MPH
Nothing to Disclose

Christopher Meserve, MD
Nothing to Disclose