Return to work after MSK injury in the workplace: timely return and risk factors for delay

Author(s): Kevin Komes, MD, Brian Toedebusch, MD, Rebecca Hogg, MD

Originally published:10/06/2015

Last updated:10/06/2015



OSHA (Occupational Safety and Health Administration) 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 work. It may not necessarily be caused or aggravated by work.


In 2013, the Bureau of labor and Statistics recorded 1.1 million musculoskeletal occupational injuries with an incidence rate of 109.4 per 10,000 working hours. Men accounted for 61% of cases and workers age 45-54 had most worked days missed. Injuries such as sprains, strains, and tears were the most common musculoskeletal disorder. There were 212,080 back injuries. The hand was the most commonly injured area in upper extremity and the knee was the most common area in the lower extremity.1

Epidemiology including risk factors and primary prevention

A systematic review lists heavy physical work, smoking, high body mass index, and high psychosocial work demands as primary risk factors for occupational injury. An additional risk factor for neck pain is posture and younger age is risk factor for low back pain. The same review indicates prolonged computer work, older age, female, awkward posture, and repetitive work as risk factors for wrist and hand pain.2

For primary prevention there is moderate evidence that lumbar supports are not effective in preventing or in the treatment of low-back pain.3 There is some evidence that the use of lumbar supports may be of value in preventing recurrent work related low back pain in high risk employees.4 Nurses with mechanical lifting devices and lifting teams in their workplace are significantly less likely to have a musculoskeletal injury.5 Exercise frequency significantly correlated with reduction in low back pain over a 10 year period.6

A recent review suggests educational interventions focused on biomechanics are not effective in preventing low back pain.7 A report showed that physical therapist lead educational program of 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 injures.8 Other reviews have concluded follow-up of education and yearly educational programs are critical to apply successful injury prevention strategies.9,10,11



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

Only 10% of compensation back patients are still receiving benefits at 3 months. Only 50% of those remaining will return to work.12

Specific secondary or associated conditions and complications

Up to 95% of claimants had comorbid personality disorders.13 Claimants with premorbid depression have increased likelihood of developing chronic pain.14

Prolonged unemployment increases both physical and mental morbidity and mortality.15



A detailed mechanism of injury should be obtained. Chief complaints and physical findings that do not correlate should raise suspicion of non-work related etiology or non-physiological risk factors affecting outcome. History should be compared to previous records for consistency. An occupational history and a history of previous claims and outcomes should be obtained as well as a full medical history. This will identify risk factors for protracted recovery noted in subsequent sections.

Physical examination

Objective findings for neurological injury are reflex asymmetry and atrophy. ROM, MMT and sensory may be self-limited. Observation of functional difficulties (gait, don/doff clothes, arising from chair) should match the physical. Waddell signs suggest nonphysiological etiology of pain but do not necessarily imply malingering. Distraction techniques can be used in patients with self-limited evaluations.

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 patient is not working. Avoiding responsibilities at home beyond expectations may indicate other secondary gain issues or catastrophizing tendencies. Fear Avoidance Behavior Questionnaire, Neck and Oswestry Disability Index can identify patients at risk.

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.


Imaging should be considered to negate or identify pathology when patient fails to progress appropriately. Caution must be taken to educate the patient that abnormal findings must correlate to symptoms as abnormal findings in asymptomatic individuals are common (16).

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 Oswestry Disability Index (ODI), Short Form 36 (SF- 36), Neck Disability Index (NDI), and the Fear Avoidance Beliefs Questionnaire (FABQ).

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.

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

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

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

Early prediction of outcomes

Early opioid use, premorbid psychiatric illness, and excessive use of medical services are all predictors of protracted recovery.

Washington State is the only state that will treat premorbid unrelated psychiatric illnesses that are “retarding recovery of an allowed industrial condition” in order to improve outcomes.


Job satisfaction is a stronger predictor than job activity for predicting filing of a future back claim (17). Multiple short duration jobs may indicate inability to get along with others. For workers with longevity recent changes at work (new supervisor, change in shift or duty requirements) may cause job dissatisfaction.

Social role and social support system

Social support from supervisors at work can improve outcome. Loss of identity, financial loss and home stress may contribute to depression.

Professional issues

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


Available or current treatment guidelines

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

At different disease stages

Rest, ice, compression and elevation (RICE) are employed after the acute injury.

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

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 of absence duration for acute back pain and small effect at one year to reduce sick leave in workers with chronic back pain.18

Maximal medical improvement occurs when a patient will no longer obtain substantial improvement in function. 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 edition of the “AMA Guides to the Evaluation of Permanent Impairment.”

Coordination of care

Team members include patient, physician, therapist, employer, and insurance carrier. Return to work slips with clear restrictions should be provided to patient and insurance carrier at the end of each visit. Clinic notes should be dictated promptly. Insurance carriers must act quickly to approve treatment/testing recommendations. Therapists should contact physicians if the patient fails to attend or claims to be in too much pain to participate. Employers should make efforts to accommodate with productive light duty work. Consistent feedback from all members in regard to diagnosis, goals and work status is paramount to successful outcome.

Patient & family education

Expectations and goals should be established at the first visit. 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 experience 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 which are limited from pain do not measure maximal functional abilities. The validity of FCE to determine safe return to work is questionable.19Nonphsyiological factors may be more important.

A recent study showed conservative treatment is superior to lumbar fusion for degenerative disc disease, herniation or radiculopathy in workers’ compensation.20

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

Identification for risk factors for protracted recovery is essential to predicting prognosis and time to case closure. Avoiding time loss at work, integrating cognitive behavioral techniques and focusing on functional goals in therapy may minimize disability time and reduce claim costs.


Cutting edge concepts and practice

Research confirms that musculoskeletal disorders are multifactorial in nature with physical, psychological and social components. In an attempt to address the psychologic 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. Score of stress, anxiety and depression were tallied in each group, and those who underwent CBT showed statistically significant decreases in each as compared to the control group.21


Controversies and gaps in the evidence-based knowledge

Inclusion of compensation patients skews outcome research.23 Few studies use only work comp cohorts.20 These studies consistently show poorer 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.


1. US Department of Labor. Bureau of Labor Statistics USDL-14-2246.

2. Da Costa, BR., Vieira, ER. Risk Factors for Work-Related Musculoskeletal Disorders: A systematic Review of Recent Longitudinal Studies. American Journal of Industrial Medicine 53:285-323 (2010)

3. van Duijvenbode IC, Jellema P, van Poppel MN, van Tulder MW. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev. 2008 Apr 16;(2)

4. Oleske DM, Lavender SA, Andersson GB, Kwasny MM. Are back supports plus education more effective than education alone in promoting recovery from low back pain?: Results from a randomized clinical trial. Spine 2007 Sep 1;32(19):2050-7

5. Trinkoff A, Brady B, Nielsen K. Workplace prevention and musculoskeletal injuries in nurses. J Nursing Administration. 33 (3):153-158 2003 12629302

6. Aleksiev, AR, Ten-year follow-up of strengthening versus flexibility exercises with or without abdominal bracing in recurrent low back pain. Spine 2014 Jun 1;39(13):997-1003.

7. Daltroy LH, Iversen MD, Larson MG, Lew R, Wright E, Ryan J, Zwerling C, Fossel AH, Liang MH. A controlled trial of an educational program to prevent low back injuries. N Engl J Med. 1997 Jul 31;337(5):322-8.

8. Demoulin C, Marty M, Genevay S, Vanderthommen M, Mahieu G, Henrotin Y. Effectiveness of preventive back educational interventions for low back pain: a critical review of randomized controlled clinical trials. European Spine J. 2012 Dec;21(12):2520-30.

9. Gatty CM, Turner M, Buitendorp DJ, Batman H. The effectiveness of back pain and injury prevention programs in the workplace. Work. 2003;20(3):257-66.

10. Bhimani R. Prevention of work-related musculoskeletal injuries in rehabilitation nursing. Rehabilitation Nursing. 2014 Nov 25.

11. Li EJ, Li-Tsang CW, Lam CS, Hui KY, Chan CC. The effect of a “training on work readiness” program for workers with musculoskeletal injuries: a randomized control trial (RCT) study. J Occupational Rehabilitation. 2006 Dec;16(4):529-41..

12. Cheadle A, Franklin G, Wolfhagen C, Savarino J, Liu PY, Salley C, Weaver, M. Factors influencing the duration of work-related disability: a population-based study of Washington State workers’ compensation. American Journal of Public Health 1994: 84: 190-196

13. Dersh J. Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders. Spine. 2006 May 1;31(10):1156-62

14. Barth RJ. Chronic Pain: Fundamental Scientific Considerations, Specifically for Legal Claims. AMA Guides Newsletter, Jan/Feb 2013. American Medical Association

15. Waddell G & Burton AK. Is Work Good for Your Health and Well-Being? The Stationary Office (UK government). 2006.

16. Boden SD , Davis DO, Dina TS, Patronas NJ, SW Wiesel. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72:403-408.

17. Bigos SJ, Battié MC, Spengler DM, Fisher LD, Fordyce WE, Hansson TH, Nachemson AL, Wortley MD. A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine (Phila Pa 1976). 1991 Jan;16(1):1-6

18. Schaafsma FG, et al. Physical conditioning as part of return to work to reduce sickness absence for workers with back pain. Cochrane Database Systemic Review 2013 Aug 30;8.

19. Gross DP1, Battié MC Functional capacity evaluation in patients with chronic low back pain: part 2: sustained recovery. Spine (Phila Pa 1976). 2004 Apr 15;29(8):920-4.

20. Nguyen T, Randolph D, Talmage J, et al.: Long-term outcomes of lumbar fusion among workers’ compensation subjects. Spine. 36 :320-331 2011 20736894

21. Della-Posta C; Drummond PD. Cognitive behavioural therapy increases re-employment of job seeking worker’s compensation clients. Journal of Occupational Rehabilitation. 16(2):223-30, 2006 Jun

22. Harris I, Mulford J, Solomon M, van Gelder J, Young J, Association between compensation status and outcome after surgery: A meta-analysis. 2005; 293(13):1644-1652.

Author Disclosure

Kevin Komes, MD
Nothing to Disclose

Brian Toedebusch, MD
Nothing to Disclose

Rebecca Hogg, MD
Nothing to Disclose

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