Disability Prevention and Management Guidelines …What went right? The chiropractor recommended a...

WORK-READY

Work-Ready

Case

Studies

Return-to-Work Approaches

For People with Soft-Tissue Injuries

Work-Ready Workshop: Case Studies 1

Contents

Helen M: Reassurance, Not X-rays .............................................................. 2

Allan P: Chiropractic Care and Acute Low-Back Pain ................................ 6

Ron G: Too Much, Too Early ..................................................................... 10

Denis H: Supervisors and Modified Work ................................................ 14

Shirley L: Job Demands and Work Environment ..................................... 18

Maria R: The Family Doctor: Advocate or Obstacle? ............................... 22

Randy T: An Adversarial Organizational Climate ..................................... 26

Jennifer J: Worker Issues in Return-to-Work ........................................... 30

Jerry J: Restructuring and Job Accommodation ...................................... 34

2 © January 2000 Institute for Work & Health and National Institute of Disability Management and Research for The Editors

Work-Ready Case Study

Helen M:Reassurance, Not X-rays

Helen had been experiencing pain in her low back and right leg, off and on for months.Finally, the 48-year-old hospital cleaner went to her family doctor. It was just becomingtoo hard to do her job, which included heavy floor-mopping.

Her doctor did a quick examination. There were “no signs of fracture or nerve dam-age,” he told her and ordered back X-rays (which she brought back to his office thesame day). He pointed out to her signs of “degeneration” and “wear and tear” onher X-rays. He prescribed a week off work, with the first few days in bed, plus someanti-inflammatory medication. “Come back in a few weeks if you’re not better,”he told Helen.

Helen left the office quite worried about the changes she’d been shown on her X-rays,wondering if her heavy job had contributed to them, and whether she’d be able tocontinue at work with such permanent-looking effects on her spine. The doctor hadsaid nothing about any of this.

When she dropped by work, she found she had very few days of sick leave left. A co-worker advised her to go on workers’ compensation. She did. But, after a week of lyingaround at home, she was still in pain, and very upset about her back. She was afraidto return to work lest the pain and “damage” get worse.

By the time she got another appointment with the doctor two weeks later (he had beenaway), she was quite depressed about having been home alone and off work for threeweeks. She still had pain and wondered why the doctor was “surprised” that her em-ployer had sent him workers’ compensation forms to fill in. Her doctor did his best toreassure her this time that the “damage in her back” was not going to cripple her.But now it didn’t matter. Helen heard about someone whose “spinal arthritis” had leftthem “in a wheelchair for life,” and as a result, it was very difficult to convince herto go back to work “without a specialist’s opinion.” The first available appointmentfor a specialist was in two months.

Two months later, when she did manage to see a specialist, Helen was very depressed.By this time, Helen had been off work for three months and had developed features ofchronic pain syndrome. In the end, her specialist felt that the underlying original injurywas only uncomplicated back strain, and that the original X-rays were largely irrele-vant to the case, showing as they did, only the usual aging-related changes for someoneof her years.

Work-Ready Workshop: Case Studies – 3

What went right?

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What went wrong?

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What might have improved the outcome?

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Helen M:Reassurance, Not X-rays

Helen M: Reassurance, Not X-rays


What went right?

Helen sought professional help for her painand applied for workers' compensation benefits.The physician appropriately ruled out signs andsymptoms of uncommon but potentially devas-tating conditions (red flags) with a few quickquestions and a brief physical exam. Anti-inflam-matory medications are indeed a good option toprovide short-term pain relief.

What went wrong?

This is a common story. The doctor focused onfinding a physical diagnosis for the patient’s painand missed an important opportunity to preventdisability by not reassuring the patient about herlong-term outlook and encouraging her to returnto work. More important, the physician made noeffort to inquire about, or write a note to her em-ployer recommending, modified or light workfor this manual worker. The workplace made noattempt to contact either Helen or her physician.Helen did not ask questions or voice her con-cerns with her doctor, choosing instead to listento what her friends and co-workers had to sayabout her back pain.

Three weeks is far too long a follow-up intervalfor a new case of low-back pain in a normallyactive person, especially when absence from workis prescribed as a part of a treatment regimen.

However, perhaps the most serious error com-mitted by the physician was to overstate anddwell on the X-rays, which, it is now well estab-lished, correlate very poorly with low-back painin people of Helen’s age. Indeed, this patienthad no clear indication of a need for an X-ray.

Key Research Evidence

• X-rays and other imaging tests correlatepoorly with back pain.

• Even a few days of bed rest provide nobenefit to people with uncomplicatedback pain.

Finally, even a few days of bed rest has now beenshown to provide absolutely no benefit to pa-tients with uncomplicated “mechanical low-backpain (strain).” A recent Finnish study showed thatas little as two days of prescribed bed rest extendsthe period of lost time from work, without anyfaster or more complete resolution of symptoms.

In short, this is a case of inadequate managementat the first contact with the health-care system,leading to potentially avoidable disability.

What might have improved theoutcome?

In this case, the initial visit needed to includeenough time to educate the patient about heressentially good prognosis and encourage herto carry on with her usual home activities. Thephysician could have created a more permissiveenvironment, which might have encouragedHelen to voice her concerns.

A strong recommendation for immediate assign-ment for modified work, (involving no mopping,lifting, or bending) should have been made inwriting to her employer, with follow-up by thephysician in one week to see whether furtherlight duties were still necessary. Designatinga contact person at work would have helpedHelen and her physician avoid disability.

A study published inthe New EnglandJournal of Medicine in1994 showed thatMRI scans of the backare “abnormal” inmany people withoutback pain.␣ Among 98healthy people with-out back pain, 64%had disc abnormali-ties, and 27% had discprotrusions.␣ The samecan be said of less so-phisticated tests suchas regular X-raysand CAT scans.

An MRI scan image found at<http://www.backguide.com>


How do your experience and views match the findings of the Work-Ready researchers?

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How could this case study be improved?

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Tips from the Field

• Prevention of disability should be a goalfrom the first visit.

• Building a permissive environment forthe patient to voice her concerns isessential for effective reassurance.

References

Frank,␣ J.W., et al. “Disability Resulting fromOccupational Low Back Pain, Part II: WhatDo We Know about Secondary Prevention?A Review of the Scientific Evidence onPrevention after Disability Begins.” Spine21 (1996): 2918-29.

Frank,␣ J.W., et al. “Preventing Disability fromWork-Related Low-Back Pain.␣ New EvidenceGives New Hope – If␣ We Can Just Get Allthe Players Onside.” Canadian MedicalAssociation Journal 158 (1998): 1625-31.

Institute for Work & Health, University ofCalgary,␣ and New Media Interactive. 1999.The BackGuide™ web site<http://www.backguide.com>.

Jensen,␣ M.C., et al.␣ “Magnetic Resonance Ima-ging of the Lumbar Spine in People WithoutBack Pain.”␣ New England Journal of Medi-cine 331(2): 69-73.

Malmivaara,␣ A., et al. “The Treatment of AcuteLow Back Pain – Bed Rest, Exercises, orOrdinary Activity?” New England Journalof Medicine 332(6) (1995): 351-5.

Helen M: Reassurance, Not X-rays



Allan P:Chiropractic Care and Acute Low-Back Pain

Allan P., a healthy 29-year-old postal carrier, developed sudden low-back pain andstiffness while lifting his mail bag on his daily delivery route. Immediately after theinjury he went to the local chiropractic clinic, where he was examined and X-rayed.The chiropractor explained that Allan had sprained his low back and that “aside from afew misaligned vertebrae,” his X-rays looked normal. After manipulating Allan’s lowerback, the chiropractor suggested that he take the rest of the day off, showed him stretch-ing exercises, and advised him to put ice on his back. More important, he recommendedthat Allan return to work the next day. The chiropractor also told Allan that his painand stiffness would disappear within the following three weeks and that he would needabout eight to 10 treatments to be back to normal.

Allan was skeptical about the chiropractor’s opinion and concerned about the “mis-aligned vertebrae.” Eighteen months earlier, he had experienced a similar episodeof back pain for which he was off work for four weeks. He believed that his back wasweak, and became very anxious about being disabled again. The chiropractor told Al-lan that to prevent further injuries, it would be best for him to wear a “back belt” for the rest of his working life.

Two weeks later, Allan’s condition had improved. Although it had been difficult for thefirst few days, he had remained at work and felt that the daily manipulations had helpedhis pain and stiffness. Following the chiropractor’s advice, he had bought a back beltthat he wore while delivering the mail. The chiropractor discharged him from ongoingtreatment, but cautioned him that if he did not return to the clinic for monthly manipu-lations, his condition would likely deteriorate. He explained that these “maintenancetreatments” were necessary to ensure that his lower back joints maintain their flexibil-ity, adding that flexible joints and muscle are unlikely to get re-injured.


What went right?

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What went wrong?

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Allan P:Chiropractic Care and Acute Low-Back Pain

Allan P: Chiropractic Care and Acute Low-Back Pain


What went right?

The chiropractor recommended a short regimenof manipulation, which is an effective treatmentfor acute low-back pain. Furthermore, he encou-raged the patient to remain at work. Remainingat work and continuing one’s normal daily activi-ties is a key component of a successful rehabili-tation program.

U.S. Agency for Health CarePolicy and Research panelfindings and recommendations

• Manipulation can help patients withacute low-back problems withoutradiculopathy when used within thefirst month of symptoms (strengthof evidence = B).

• If manipulation has not resulted insymptomatic improvement that allowsincreased function after one month oftreatment, manipulation therapy shouldbe stopped and the patient re-evaluated(strength of evidence = D).

• Lumbar corsets and support belts havenot been proven beneficial for treatingpatients with acute low-back problems(strength of evidence = D)

A = multiple relevant and high-quality scientific studies.B = one relevant, high-quality scientific study or multi-ple adequate scientific studies. C = at least one adequate scientific study in patientswith low-back pain.D = panel interpretation of information that did notmeet inclusion criteria as research-based evidence


• A short course of manipulation andencouragement to remain at work areappropriate for uncomplicated acutelow-back pain.

• Back belts have not been proven effec-tive in preventing injuries or lesseningworkers’ pain.

• There is no evidence that periodic mani-pulations protect against recurrences.

What went wrong?

This is a scenario commonly seen in chiropracticpractice. The use of spinal X-rays, although com-mon among chiropractors, is not indicated foracute low-back pain, unless there are “red flags”suggesting specific pathology such as a fractureor malignancy. “Misaligned vertebrae” is a termcommonly used by chiropractors to indicate thatthe spinal joints need to be manipulated. These“misaligned vertebrae” cannot be detected byan X-ray, and the X-ray is not necessary for thechiropractor to reach a correct diagnosis.

Similarly, the use of a back belt is highly contro-versial. To date, there is no evidence suggestingthat wearing a back belt at work protects againstback injuries or lessens a worker’s pain. Further-more, wearing a back belt may have undesirableadverse effects such as weakening the back mus-cles, putting strain on the cardiovascular system,or contributing to abdominal hernia. Therefore,prescription of a back belt was not indicated andmay have created false hopes while promotingdependency on a device of questionable benefit.

The failure to involve the workplace or evenreport the injury meant that no measures weretaken to find the cause of the injury or to pre-vent its recurrence (e.g., job redesign or theimprovement of lifting techniques by Allan andother mail carriers). Allan was sent back to fullduties without consideration of temporary jobmodification.

Finally, there is no evidence that periodic ma-nipulation protects against future episodes ofback pain. In fact, stating that Allan’s conditionwould deteriorate without manipulation pro-motes the idea that back injuries are for life. Theproblem with the two preventive approachesproposed by the chiropractor is that they relyon passive strategies, rather than encouragingthe worker to take control of the situation.


The main approach used by the chiropractor,a short course of manipulation and encourage-ment to remain at work, was appropriate. Cer-tainly, his being available to see Allan after workmay have contributed to his recovery. However,he did not properly address Allan’s fear of recur-



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rent disability. Instead of recommending a backbelt and on-going maintenance treatments, thechiropractor should have educated Allan aboutthe very favourable prognosis and natural historyassociated with his back pain. He should haveaddressed lifting techniques, and might have sug-gested an ergonomic assessment to determineif there were more appropriate ways of perfor-ming Allan’s job. He should have reassured thepatient that although low- back pain tends torecur, it is a self-limiting condition that rarelyresults in prolonged disability and that in fact,the best treatment is to control the pain andmaintain one’s normal activity of daily living.

Tips from the Field

• Availability of trained rehabilitationprofessionals after usual business hoursfacilitates workers’ ability to continueworking while they are receiving treat-ment and their injuries heal.

• Passive treatments encourage depen-dence and a sense of helplessness thatslows down recovery.

References

Ammendolia, C. “The Use of Back Belts for Pre-vention of Occupational Low Back Injuries.”Institute for Work & Health Working Paper#61. Toronto: 1998.

Bigos, S., et al. Agency for Health Care Policyand Research. Clinical Practice GuidelineNumber 14: Acute Low Back Problemsin Adults. Rockville, Maryland: U.S. Depart-ment of Health and Human Services, 1994.


Van Poppel, M.N., et al. “Lumbar Supports andEducation for the Prevention of Low BackPain in Industry: A Randomized ControlledTrial.” Journal of the American MedicalAssociation 279(22) (June 10, 1998):1789-94.

Allan P: Chiropractic Care and Acute Low-Back Pain



Ron G:Too Much, Too Early

Ron, a 38-year-old mechanic, works for a large car dealership. Recently, he experi-enced sharp pain in his back one Monday morning at work when he bent over to liftan awkward and heavy box from the floor. He was unable to continue working becauseof the pain and reported the incident to his supervisor. The supervisor suggested thatRon go home and take it easy for the rest of the day. Ron remembered a previous epi-sode of low-back pain that had kept him off work for several months a few years ago,and became quite concerned.

Next morning Ron’s back felt stiff and he had sharp shooting pains when he tried to getout of bed. He called his supervisor to let him know that he couldn’t come to work, fileda compensation claim, and went to see his family doctor. The doctor examined Ron’sback, gave him a prescription for Tylenol #3 and suggested he take a few days off workand go back when his pain settled down.

After a week off work, there was some improvement in Ron’s back pain but he continuedto be anxious about his future and his ability to do his job. His supervisor called to seehow Ron was doing and to find out when he might return to work. He suggested thatRon go for physiotherapy. Ron called his doctor to get a referral and booked an ap-pointment for the following week in a clinic that offered special programs and servicesfor injured workers.

Ron was assessed by the physiotherapist. She explained that he had sprained a musclein his back. Appointments were booked for the next two weeks for a daily therapy pro-gram that included physical modalities, a progressively more intensive exercise pro-gram, and education about posture and injury prevention. Work simulation activitieswere also incorporated.

After a couple of weeks of therapy Ron’s back was feeling better. The therapist sugges-ted that Ron contact his supervisor to see about the possibility of returning to workpart-time.

Ron called his supervisor, who seemed quite anxious to have Ron back at work “as longas his back was 100%.” So Ron continued with his daily physiotherapy for two moreweeks before returning to work.


What went right?

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What went wrong?

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Ron G:Too Much, Too Early

Ron G: Too Much, Too Early


What went right?

Ron consulted his family doctor to rule out anyserious pathology. His physiotherapist appro-priately reassured Ron about the diagnosis. Sheprovided Ron with some strategies around injuryprevention and self care. The physiotherapy pro-gram included work simulation. Ron’s supervi-sor clearly showed concern by contacting Ronwhile he was off to see how he was coping, andwas eager to welcome Ron back to work.

What went wrong?

An intensive, daily program of physiotherapywas probably not indicated given the short dura-tion of Ron’s symptoms. It may have actually pro-longed Ron’s recovery and time off work.

Moreover, the supervisor’s insistence on “100%recovery” before workers with back pain returnto work was out of date and unnecessarily de-layed accommodation for the injured worker.Professional advice may be able to update theseviews — for example by pointing out that con-tinuing ordinary activity within the limits permit-ted by pain leads to a more rapid recovery.

The physiotherapist encouraged Ron to contacthis workplace about returning to work – but notuntil the end of his treatment program, whichmay have further delayed return to function,through focusing the patient’s attention exces-sively on the problem and even providing analternative schedule of activities to work itself.

There appeared to have been no contact fromthe workplace until Ron was off work more thana week. Also, despite Ron’s past history of timelost from work due to low-back pain, and theanxiety noted, little attention appeared to havebeen paid to these prognostic factors. Therewas no mention of prevention or modified workoptions.


Ron’s doctor could have reassured Ron about hisrecovery process rather than simply prescribingmedication. This might have alleviated Ron’sfears about his back pain becoming more chronic,and Ron might have felt more confident aboutgetting back to his usual activities and work.Over-the-counter medication could have beenrecommended rather than medication requiringa physician’s prescription, since the latter oftenhas more side effects and potential for depend-ency. Given Ron’s previous experience and theanxiety noted, an exploration of psychosocialissues was warranted. If Ron’s fear that hewould not be able to work could be alleviatedby exploring the options for modifying his job,this should have been pursued immediately.

A study comparing workers receiving intensiveearly physiotherapy in ‘community clinics’ acrossOntario found that there was no advantage fromthe program compared with usual care.␣ This graphis based on data from Sinclair, S.J., et al.␣ Spine 24(1997): 2919-31.


• Intensive physiotherapy disconnectedfrom the workplace in the acute stage oflow-back pain is not indicated, and mayeven contribute to prolonging recovery.

• Physiotherapy at, or linked to, the work-place in the sub-acute stage of the injurymight facilitate recovery.



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The physiotherapist could have provided Ronwith back education and pain management strat-egies and booked a re-check appointment in-stead of starting intensive physiotherapy so soonafter injury. The therapist could have contactedthe workplace or encouraged Ron to contact hissupervisor as soon as possible to plan his return-to-work. The supervisor, while well-intentioned,should update his views about insisting on“100% recovery.” We now know that the backneeds some activity to fully heal.

Closer communication between the health-careproviders and Ron’s supervisor could have facili-tated an earlier return-to-work if modified workwas available at the dealership.

Tips from the Field

• Supervisors’ insistence that the workerneeds to be 100% recovered beforeattempting to return to work might beprolonging the disability.

• Communication between health-careproviders, employers and the injuredworker to encourage and facilitate anearly and safe return-to-work is essential.

Ron G: Too Much, Too Early

References

Institute for Work & Health,␣ University ofCalgary,␣ and New Media Interactive. 1999.The BackGuide™ web site<http://www.backguide.com>.

Loisel, P., et al. “A Population-Based, Random-ized Clinical Trial on Back Pain Manage-ment. Spine 22 (1997): 2911-18.

Sinclair,␣ S.J., et al. “The Effectiveness of an EarlyActive Intervention Program for Workerswith Soft-Tissue Injuries:␣ The Early Claim-ant Cohort Study.” Spine␣ 22 (1997):␣2919-31.

Yassi, A., et al.␣ “Early Intervention for Back-Injured Nurses at a Large Canadian TertiaryCare Hospital:␣ An Evaluation of the Effec-tiveness and Cost Benefits of a Two-YearPilot Project.” Occupational Medicine 45(1995): 209-14.



Denis H:Supervisors and Modified Work

Denis is a 42-year-old machine operator in an electronics assembly plant. He had rightshoulder pain for several months and the pain was gradually getting worse.␣ His doctordiagnosed a rotator cuff tendonitis (inflammation of a tendon) of the right shoulder andprescribed the following functional limitations for work:

• Avoid repetitive, forceful movements with the right arm.

• Avoid movements of the right arm above the level of the shoulder.

• Do not lift more than 25 pounds with the right arm.

These limitations meant that Denis could not do his regular job. He went to see theplant nurse, who immediately put him on the modified work program that the HumanResources Department had recently established. She contacted Jacques, Denis’s super-visor, to inform him of Denis’s need for modified work.

But the supervisor said he had no appropriate job for Denis and could not accommo-date him. He would take him back only when he was able to do his full regular job.Jacques told the nurse he already had another worker on modified duties. There wasno way he could maintain production quotas and accommodate another “lame duck”in his department.

As the supervisor, Jacques must ensure that his department produces 1,000 finishedproduct units each week. His efficiency is measured in number of person-hours allo-cated for production of each 1,000 units and is calculated weekly. Bonuses are paid tosupervisors and the workers under their supervision when production quotas are met orexceeded. While other jobs in Denis’s department would not require shoulder exertion,Denis has never done them, and would require training and at least two weeks practicebefore he could carry out the full workload.

In this plant, costs associated with work absences (workers' compensation and sick ben-efits) are charged to the Human Resources budget and not the individual departments.


What went right?

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What went wrong?

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Denis H:Supervisors and Modified Work

Denis H: Supervisors and Modified Work


What went right?

The human resources department has set up amodified work program and has the support ofthe nurse. The worker contacted his physician,was diagnosed, and was given specific workrestrictions that could be communicated to theworkplace. The worker was able to contact theworkplace nurse as soon as the problem began,and she in turn contacted the supervisor directlyto set up a modified work plan.

What went wrong?

The supervisor faced conflicting expectations.He was caught between production demandsand demands for accommodation of injuredworkers.

The supervisor was evaluated on and rewardedfor achieving production quotas; there were noincentives and several disincentives for partici-pating in modified work plans. His department’sproductivity (measured as number of productsproduced per person-hours of labour) would ap-pear lower if he agreed to having workers whodid less than the regular amount or worked on aworkstation for which they had no experience.

Moreover, if co-workers had to change theirwork activities to accommodate Denis, theremay have been considerable resentment of himand a subsequent drop in morale. This may haveoccurred if bonus pay was lost because of thelowered productivity of the department as awhole, or if other workers had to increase theirworkload significantly in order to maintain over-all production quotas of the department.

The modified work program in this workplaceassumes that re-assignment is the only solutionwhen the current job does not fit the functionallimitations of the injured worker. No attemptwas made to assess Denis’s job to see whetherthe force or frequency of repetitive movementsof the right arm or the elevation of the right armabove shoulder level could be reduced or elimi-nated. The Human Resources department set upthe modified work program but apparently didnot get the staff to “buy into” the program.

On his part, Denis could have spoken about hisshoulder pain much earlier to enable his supervi-sor to re-examine the situation before it becamea lost-time claim.


• Departments are less likely to co-operatewith health and safety initiatives that ap-pear to conflict with their productiondemands and rewards.

• Ergonomic assessments conducted toidentify physical job demands and haz-ards will facilitate management of work-ers with musculoskeletal disorders.


If Denis’s regular job could have been modifiedto reduce demands on his shoulder, he mighthave been able to continue doing his job andnot need re-assignment. If physical hazards werereduced or eliminated, Denis would also be atlower risk of re-aggravating his shoulder.

Reducing or eliminating these hazards may pre-vent the development of similar disorders inother workers, and thus reduce overall healthand safety costs in the long run. A plant-wideergonomic assessment might be appropriate.

Supervisors need to be included, and their pointof view taken into account, in planning and im-plementing modified work programs. Healthand safety issues, such as accommodation ofmodified work duties, should be clearly builtinto their job description. The necessary trainingshould be provided, and clear measures of per-formance established upon which they can beevaluated.

These measures should not conflict with per-formance measures of production, i.e., produc-tivity must be measured in ways that take intoaccount the savings associated with accommo-dating modified duties of workers with muscu-loskeletal problems.

Supervisors should have clear incentives to in-corporate health and safety initiatives into theirday-to-day responsibilities. Senior managementmust make it readily apparent that the companyvalues such functions and that if supervisorscarry them out well, they will be rewarded.Some companies include health and safety andworkers' compensation costs and savings into



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Denis H: Supervisors and Modified Work

Tips from the Field

• Including supervisors in planning andimplementing modified work pro-grams is essential to their success.

• The best return-to-work programs willbe ineffective if staff do not “buy into”the program.


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Halland Haldersen, E.M., et al. “Training WorkSupervisors for Reintegration of Employeestreated for Musculoskeletal Pain.” Journalof Occupational Rehabilitation 7(1)(1993): 33-43.

Mitchell, K., et al.␣ Supervisor Disability Man-agement Training: The Forgotten “Returnto Work” Option. National RehabilitationPlanners, Inc. 1995.

Simard, M., and A. Marchand. “The Behaviourof First-Line Supervisors in Accident Preven-tion and Effectiveness in OccupationalSafety.”␣ Safety Science 17 (1994): 169-185.

Stock, S., et al.␣ Obstacles and Factors Facilitat-ing Return to Work of Workers with Mus-culoskeletal Disorders: Summary of theReport on the Quebec Qualitative Study inthe Electric and Electronic Sector of␣ Work-ready Phase 1. Montreal:␣ Montreal Depart-ment of Public Health, December 1999.

Stock, S., et al.␣ Travailleuses et travailleurs at-teints de lésions musculo-squelettiques : lesstratégies de prise en charge en milieu detravail dans le secteur électrique/électro-nique de l’île de Montréal. Work-ReadyPhase 1 :␣ Volet qualitatif québécois.Montreal:␣ Montreal Department of PublicHealth,␣ June 1999.

the budgets and overall evaluation of each pro-duction department, rather than attributing themto a separate department such as Human Re-sources. Other companies have found it helpfulto set up rehabilitation job banks, consisting oftasks that could be completed by workers withcertain types of injuries while they recover fully.

An essential part of any new return-to-work pro-gram is to obtain collaboration and buy-in fromemployees, supervisors, and senior managers.

References

Gates, L.B. “The Role of the Supervisor in Suc-cessful Return to Work with a DisablingCondition: Issues for Disability Policy andPractice.” Journal of Occupational Reha-bilitation 3(4) (1993): 179-90.



Shirley L:Job Demands and Work Environment

Shirley L. is 58 years old and was employed as a unit assistant in the medical intensivecare unit of a large inner-city teaching hospital. Six months ago, Shirley strained herlower back while trying to lift a bed (which caught in a floor crack) as she was pushingit onto an elevator. Shirley was in great pain after the incident and visited her physicianlater that day. He examined her, determined that she had a soft-tissue injury, gave hermedication for pain, and suggested that she take “some time” off work.

Shirley filed for workers’ compensation benefits. Her claim was accepted, and benefitswere paid until she left the country for a vacation three weeks later. Upon return fromvacation, a medical review determined that she was still unfit to return to work andbenefits resumed.

She began physiotherapy eight weeks after the injury. At this time Shirley’s physicianstated that he thought her job was too physically demanding. The hospital’s HumanResource Department and Occupational Health Unit responded by reviewing Shirley’sinjury history and sick-time records. They found that over the past five years she hadexperienced three time-loss injuries due to lifting and transferring patients, resultingin a total of 117 days lost from work.

The two administrative units agreed that the job appeared to be beyond Shirley’s physi-cal capabilities, and began to review the job demands for a unit assistant. The reviewshowed that Shirley was required to work 12-hour shifts, days and nights. One of hertasks was to turn patients in bed. During a typical night shift, patients were turned anaverage of 30 times; during a typical day shift 10 to 15 times. Shirley’s unit had thehighest demand level. Due to the workload on the unit, other staff members were oftenunavailable to help with turning patients. Although lifting equipment was available tothe unit, it was difficult to use because of the cramped environment. The hospital hadplans for remodelling the unit, but funding for the project was not available.

To help Shirley increase physical strength and work tolerance, the hospital and thecompensation board agreed to provide a supernumerary graduated return-to-workplacement on a pediatric medical unit for six weeks while the Human Resources De-partment searched for a suitable permanent placement. The board paid Shirley’s wagesfor the six weeks that she worked as an extra to the unit. By the end of the placement,Shirley was able to work an eight-hour shift on the pediatric unit. At this point the wor-kers’ compensation board deemed her fit for work and stopped her benefit payments.Shirley applied for long-term disability benefits; however, this was also refused.


What went right?

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What went wrong?

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Shirley L:Job Demands and Work Environment

Shirley L: Job Demands and Work Environment


What went right?

Shirley did not delay seeking help, pain reliefwas given promptly and the initial workers' com-pensation claim was accepted. There was col-laboration between the Occupational HealthUnit, the Human Resources Department, theworker’s original unit, the placement unit, andthe workers’ compensation board. Income sup-port was maintained during the time that physi-cal limitations were defined and the process ofjob accommodation was initiated. A job-taskanalysis for unit assistants was completed, andextra work placements for gradual return-to-work were available. The worker was kept atwork by placing her in a job that was withinher physical capacity.

What went wrong?

Shirley’s physician was vague about the lengthof time she should be off work and no date wasset to review her problem. Shirley was not giveninformation on exercises she could start on herown, and her physiotherapy was delayed be-cause of her holidays. The work environmentcould not be modified and unit staffing couldnot be increased because the hospital lacked

funds. Floor cracks and a cramped working envi-ronment were safety hazards that were not ad-dressed. Compensation payments were stoppedhalfway through the process of finding a perma-nent alternative work placement.


• Assessment of job demands and workenvironment is essential when dealingwith repeated injuries.

• Offering modified or alternate workappropriate to physical capabilitieshelps recovery.


Shirley could have started some light exercisessoon after her injury, commencing a more inten-sive physiotherapy program once she had beenabsent from work for four weeks. Clear commu-nication and reassurance from the physician thatpain will be controlled and that return-to-workwill not be harmful is important.

Figure 1: Once a worker has been off work for more than a few weeks, communication andco-ordination between a large number of people becomes necessary for successful return-to-work. Often a designated co-ordinator or case-manager might facilitate the process. Adaptedfrom Frank,␣ J.W., et al. “Disability Resulting from Occupational Low Back Pain, Part II:What Do We Know about Secondary Prevention? A Review of the Scientific Evidence onPrevention after Disability Begins.” Spine 21 (1996): 2918-29. Reproduced with permission.



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Educational and practice sessions on back pro-tection techniques could be introduced into theworkplace, along with regular safety scans of thework environment by the workers to identifyproblem areas and generate possible solutions.The hospital could adopt a policy on handlingpatients, and could allocate a budget for safetyissues, such as the redesign of problem areas,modification of beds and stretchers, and thepurchase of safety equipment.

Payment of benefits could have continued dur-ing the time that a permanent alternative workplacement was being established. The union (ifthere was one) could have been more pro-activeabout workload, understaffing, and the hazardsrelated to the cramped environment.

Tips from the Field

• Some organizations have found it helpfulto designate a case manager, whose job isto facilitate appropriate communicationand co-ordination among the parties in-volved in the return-to-work program

References

Brooker,␣ A.S., et al. “Effective Disability Man-agement and Return-to-Work Practices.”Injury and the New World of Work. Ed. T.J.Sullivan.␣ Vancouver:␣ University of BritishColumbia Press, 2000. 246-61.


Yassi, A., et al. “Early Intervention for Back-Injured Nurses at a Large Canadian TertiaryCare Hospital:␣ An Evaluation of the Effec-tiveness and Cost Benefits of a Two-YearPilot Project.” Occupational Medicine 45(1995): 209-14.

Shirley L: Job Demands and Work Environment



Maria R:The Family Doctor: Advocate or Obstacle?

Maria R. is a 33-year-old production worker in a small manufacturing plant. She is asingle mother, with three young children who are minded by a neighbour when Mariais at work. Two months ago, Maria sustained a back injury when lifting a box filledwith metal screws. Her family doctor, Dr. M., who has known her family for many years,diagnosed the problem as back strain. He asked Maria about her job, and she told himthat she had to bend and lift parts during much of the day. He suggested that she takea couple of weeks off and return to his office at the end of that time.

Dr. M. knew of the demanding family situation Maria was in, but was not aware of themodified work possibilities within her company. He felt that she needed this opportunityto rest and get back on her feet. After two weeks, Maria was still reporting significantpain and Dr. M. extended her leave, hoping that full recovery would allow her to returnto work successfully in the near future. However, there has been no change, and Mariaremains off work at the present time, six weeks after her injury.

The company where Maria works has an active modified work committee, composed ofrepresentatives of management, the health and safety committee and the occupationalhealth nurse. Marg, the occupational health nurse, has made several attempts to con-tact Dr. M., to explain the program and the work options available to Maria – optionsthat would not involve lifting, bending, or other actions that could impede her recovery.

Marg has inquired about the reasons for Maria’s continued absence, and whether shecould return to modified work. She feels that Dr. M. sees such attempts as questioninghis professional judgment. It is difficult for her to reach him by telephone. When she didget through, Dr. M. said curtly that the information she was seeking was confidential,and he was not at liberty to share it with her.

Marg is frustrated in her attempts to resolve the situation. She is aware of Maria’s do-mestic situation, and has suggested that she might want to see a counsellor in the com-pany’s Employee Assistance Program (which is fully confidential) to help talk throughher problems. Maria has not done this. Dr. M’s lack of knowledge about possibilitieswithin the employment setting, and resistance to communicating openly with the em-ployer, continue to deter Maria from returning to full earning capacity.


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Maria R:The Family Doctor: Advocate or Obstacle?

Maria R: The Family Doctor:␣ Advocate or Obstacle?


What went right?

Dr. M. has an on-going relationship with theworker, but did not ask about job demands. Thefact that Maria’s company has a well-establishedreturn-to-work program, with active involvementby both labour and management parties, pro-vides a structure to successfully manage workinjuries. The Employee Assistance Program(which is fully confidential) could provide addi-tional help for Maria in handling the stresses in-herent in her dual roles as parent and wage-earner. The occupational health nurse has maderepeated attempts to contact Maria and her doc-tor.

What went wrong?

Dr. M. appeared out of touch with current prac-tice in occupational health, or at least was notcognizant of the flexibility of the employer’sreturn-to-work program or other company ben-efits. Because Maria had on-going pain and dis-tress, he thought she would benefit from restingat home until she was pain-free. In fact, researchwith acute low-back pain patients shows thatthose who are encouraged to continue theirnormal activities as much as possible benefit interms of pain levels and physical functioning.

While the workplace has a return-to-work pro-gram, it is not clear that this was conveyed to Dr.M. The doctor did not use the opportunity of-fered by the occupational health nurse to seekinformation on modified work or usual job de-mands to recommend temporary or permanentaccommodation to Maria’s job.

Unfortunately, Maria has now passed the acutephase. More concerted efforts at return-to-workprogramming are now required in order to pre-vent the injury from becoming chronic.


• Doctors’ access to accurate andcomprehensive information on modifiedwork possibilities and other employeebenefits available to their patients mighthelp the return-to-work process.

• Innovative Continuing Medical Educationcan improve knowledge, co-operationand working relationships between localbusiness and health practitioners.

A recent high-quality study conducted among em-ployees of the City of Helsinki in Finland showedthat workers with acute back pain fared much bet-ter if continuing with regular activities rather thanbed rest was recommended. The graph is based ondata from Malmivaara,␣ A., et al. “The Treatmentof Acute Low Back Pain – Bed Rest, Exercises, orOrdinary Activity?” New England Journal of Medi-cine 332(6) (1995): 351-5.


There is a clear need for improved communica-tion between the workplace and local care pro-viders. Some communities have instituted part-nerships between the health-care communityand local business in order to reduce workers’compensation costs and improve worker health.A combination of Continuous Medical Education,plant tours, case conferencing and ContinuousQuality Improvement techniques have beenused. This has resulted in increased health-careprovider familiarity with workplace environ-ments and ergonomics, improved communica-tions and a co-ordinated approach, fewer lost-time days, more modified duty days, and signi-ficantly decreased medical and compensationcosts.

Workplaces that have established return-to-workprograms should have letters outlining the pro-gram, its mechanisms, and rationale available tosend to practitioners such as Dr. M. Alternately,such documentation may be taken by the wor-



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ker to the doctor at the first visit. Setting up ameeting at the physician’s office with the patientand occupational health nurse (at the employer’sexpense) has been reported to be an effectivestrategy in some situations. Making the doctoraware that the modified work committee hadlabour and management representatives mayhave made him more receptive to modified worksuggestions.

Tips from the Field

• A brief description of modified work op-tions should be available for workers totake with them when they visit theirphysicians about injuries.

• Sometimes sending a letter or setting upa meeting with the physician (paid for bythe employer) may be a more effectiveway of reaching busy practitioners thantrying to reach them by telephone.

References

Canadian Medical Association. “The Physician’sRole in Helping Patients Return to Work Af-ter an Illness or Injury.” Canadian MedicalAssociation Journal 156 (1997): 680A-680C.


Malmivaara,␣ A., et al. “The Treatment of AcuteLow Back Pain – Bed Rest, Exercises, orOrdinary Activity?” New England Journalof Medicine 332(6) (1995): 351-5.

Pyatt, R.S., et al. “Improving OutcomesThrough an Innovative Continuing MedicalEducation Partnership.” Journal of Con-tinuing Education in the Health Profes-sions 17 (1997): 239-244.

Maria R: The Family Doctor:␣ Advocate or Obstacle?



Randy T:An Adversarial Organizational Climate

Randy T. has been employed for nine years as a welder in a large manufacturing plant.Six months ago, he began to experience shoulder pain, and filed a workers' compensa-tion claim. His family doctor diagnosed an inflamed and “degenerated” shoulder, andcompleted the required forms, indicating that Randy should avoid overhead work. Theclaim was not allowed since there was doubt whether the shoulder condition was due towork or an old sports injury. The collective agreement in the plant required that Randy“bump” a worker of less seniority in order to return to a modified job. His relativelylow seniority (Randy is only 35 years old) narrowed his options significantly, and hehas been unable to return to work. Also, the bumping requirement makes accommodat-ing injured workers unpopular in the plant.

In a climate of intense competition for the consumer dollar, management has been try-ing to reduce costs and increase efficiency. Many components of the production processhave been contracted out to external suppliers, including several jobs that allowed fora measure of worker control of the pace of work and timing of rest breaks. Union-man-agement relations are adversarial, and initiatives introduced by management are seenas suspect. In the past, absenteeism rates have been high, so management instituted asystem of close monitoring of absences across the plant site by a centralized depart-ment, with daily meetings and updating of electronic personnel files, and reporting tohead office in the United States. A nurse employed in that department maintains regularcontact with the injured worker. Union spokespeople complain that the approach is tooaggressive and that the company should not harass workers who are injured on the job.

Until a year ago, each department had a union placement co-ordinator, appointed bythe company. This person took an active role in helping injured workers and their su-pervisors develop modified work placements. Under the new system, the union’s rolein the process is less active, the process less local. Accommodation of workers likeRandy is more easily avoided by supervisors in a setting where workers on compen-sation have traditionally been seen as “cherry picking,” or using their claim to gainaccess to desirable jobs.

Randy has told his family doctor that he feels the company is pushing him to returnto work before his shoulder has healed. The doctor’s communications with Randy’semployer are terse and relatively uninformative, and include restrictions that appearrigid to the employer. All parties involved seem to have reached an impasse, with noimmediate solutions to the problem of Randy’s absence in sight.


What went right?

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Randy T:An Adversarial Organizational Climate

Randy T: An Adversarial Organizational Climate


What went right?

A company nurse kept in contact with Randyduring his absence. Regular, caring contact bya nurse, supervisor, or case manager is a featureof successful return-to-work (RTW) programs.However, given the adversarial climate in theplant, a call from Randy’s supervisor, a union rep-resentative, or a known and trusted nurse fromhis own unit might have been received morepositively.

What went wrong?

An integral feature of successful RTW programsis that both union and management are fullyinvolved in their development and on-going op-eration, and committed to their success. In theadversarial climate in the plant, this was notachieved, and the lack of bipartite problem-solv-ing has led to lack of co-operation with the pro-gram, and inconsistent responses to problems.

The fact that the collective agreement requiresbumping of another employee for job accommo-dation may work against acceptance of the re-turn-to-work program by Randy’s co-workers.Companies in which successful return-to-workprograms have been developed may use non-regular work placements as long as modifiedwork is required, so that co-workers are not dis-placed, production pace is not affected, and hos-tility towards the injured worker is avoided.

Clearly, the occupational health nurse’s role inthis firm had become too narrow and insuffi-ciently arm’s-length from management, at least inthe minds of the employees. She was thus un-able to effectively carry out a key occupationalhealth professional function: the facilitation ofRTW. Instead of acting merely as an “absencepoliceman” for the company, she should havebeen monitoring this case closely. She needed,for example, to ensure that adequate rehabilita-tion was being offered. Most of all, she shouldhave been actively negotiating appropriatelymodified work for Randy, by communicatingwith his doctor, the workplace (ideally through adisability management co-ordinator, reporting toa bipartite RTW committee), and the insurer.

A key issue in this case may have been the fail-ure of the doctor’s report to convince the work-er’s compensation board to accept the claim aswork-related, so that a private disability insurer

became involved. In some settings, this can costa union more than management, leading to lowmotivation for management to bring the workerback to work. A medical consultant’s opinion,however, might well have led to a successful ap-peal to the compensation board. In some juris-dictions, Randy’s situation may also have contra-vened laws regarding the workplace’s “duty toaccommodate” after injury or illness, or even hu-man rights legislation regarding the permanentlydisabled.


• The use of supernumerary positions toaccommodate injured workers removesthe need for “bumping,” and has beenshown to be effective in helping workersreturn to work.

• Full commitment by both union andmanagement is crucial to the successof return-to-work programs.


To have improved this dysfunctional situation,someone had to convince both management andlabour that the laissez-faire approach was bothunnecessarily costly to the organization andharmful to employee health and functioning –i.e., that change is a “win-win” solution.

The occupational nurse and/or union health andsafety co-ordinator could have begun this proc-ess by calling a case conference with all parties,ideally including at least telephone participationby Randy’s doctor and the insurer. In some pro-gressive jurisdictions, insurers are beginning tobe smart about this and pay physicians standard-ized fees for such meetings. In cases of pro-longed disability marked by total impasse, thismay be the only way to obtain participationfrom self-employed, fee-for-service private practi-tioners.

Confronting everyone with the dismal failure ofRTW in this case and presenting a new approachas described above might get the ball rolling.Eventually however, both management and un-ion must make a commitment to a policy of rou-tinely returning all injured workers to employ-



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ment without “bumping” and with retrainingwhen physical restrictions appear to perma-nently rule out the worker’s old job. This policyis often most usefully laid out in a letter of un-derstanding, associated with but not directly apart of the labour-management collective agree-ment, so that it can be flexibly worded, and doesnot get “bargained away” in subsequent years’negotiations.

In many companies, participation of the union(or other worker representative, in the case ofnon-unionized settings) in return-to-work pro-gramming is being written into the company’smission statement and/or collective agreements.This practice establishes a firm foundation forfull participation of both parties, and promotesconstructive problem-solving in the on-goingdevelopment of the program. Actively involvingunions in workplace accommodation can helpaddress resentment from co-workers.

References

Battie, M.C. “Minimizing the Impact of BackPain: Workplace Strategies.” Seminars inSpine Surgery 4(1) (1992):␣ 20-28.

Getzie,␣ Thomas J.␣ “The Importance of Labour-Management Collaboration.” National Insti-tute of Disability Management and Research(NIDMAR).␣ Strategies for Success: Disabil-ity Management in the Workplace.␣ PortAlberni, B.C.: NIDMAR, 1997.

Manitoba Federation of Labour (MFL). WorkersWith Disabilities Project: ␣ Workplace Dis-ability Programs. Winnipeg: MFL, 1995.

Randy T: An Adversarial Organizational Climate

Tips from the Field

• An organization with highly adversariallabour relations, where workers feel thatthe company sees production as moreimportant than worker well-being, isunlikely to succeed in return-to-workprogramming.

• In such adversarial situations, it mightbe necessary to involve a neutral thirdparty to convince both managementand labour that working together inreturn-to-work programming is in theirbest interests.



Jennifer J:Worker Issues in Return-to-Work

Jennifer J. is 47 years old and has been working as a parts assembler in the provincialtelephone corporation for the past 16 years. She has alternated between soldering elec-tronic circuit boards and acting as quality control supervisor in the same area.

Jennifer recently injured her right shoulder (rotator cuff strain – possibly a minor tear)by tripping over some debris on the floor while trying to prevent a stack of circuitboards from falling. She has been off work on workers’ compensation for the past 17weeks. At the six-week point her doctor suggested that she try going back to work onthe modified work program offered in her workplace, but she insisted it was too painful.He has now recommended again that she make the attempt.

The occupational health nurse at the workplace had phoned Jennifer several times dur-ing her absence. She called again to set up a meeting to plan her return-to-work pro-gram. Present at this meeting were Jennifer’s union representative, the compensationboard adjudicator, her supervisor from the plant, the occupational health nurse, theoccupational health physician and the occupational therapist who had just completedan ergonomic evaluation of the workplace.

During the last five years prior to her injury, Jennifer had three workers' compensationclaims: for two back injuries and one shoulder/neck injury. She has taken off one or twosick days every month since returning to work after her last injury eight months ago.Over the past six months she has been late for work at least once a week. Just prior tothis injury, she was warned by her supervisor that she needed to improve her attend-ance and overall performance or she would be disciplined (placed on probation).

The modified return-to-work program was designed to place Jennifer as a “buddy” in asupernumerary position until she was able to work full hours with full duties. Generallythis was a six-to-eight week program with gradually increasing hours and job duties.

Jennifer attended regularly the first week, and missed one day the second week. Duringweek three, she called the occupational health nurse to say that she had seen anotherphysician at a walk-in medical clinic who had given her permission to be off work fortwo weeks.


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Jennifer J:Worker Issues in Return-to-Work

Jennifer J: Worker Issues in Return-to-Work


What went right?

Jennifer appears to have received appropriatemedical care from her own physician, and regu-lar benefits from the workers’ compensationboard, which started without needless delay. Theoccupational health nurse maintained regularcontact with Jennifer, and the workplace seemswilling to help her return to work.

Jennifer was offered a modified work programwhen she was ready to return to work. The teamworked well together in setting up and revisingthe return-to-work plan.

What went wrong?

The physician postponed recommending modi-fied work until six weeks after the injury, andJennifer refused to try modified work at her doc-tor’s first suggestion. This may have contributedto the problem. Most soft-tissue injuries needearlier efforts to facilitate successful return-to-work. It is unclear whether functional abilitiesand/or work restrictions were identified duringthe first attempt to set up a return-to-work plan.

The physician at the walk-in clinic did not com-municate with the occupational health team re-garding Jennifer’s return-to-work program beforegiving her permission to be off work. Jennifer’sleave was extended with little knowledge of herhistory and current efforts to help her return towork.

Although Jennifer had given consent to the re-turn-to-work program, she had not discussed anydifficulties in the return-to-work process otherthan to report pain. Nevertheless, she appearedto be resisting or sabotaging the success of thereturn-to-work plan by missing days and by “doc-tor shopping.”

It is conceivable that Jennifer is experiencingsignificant difficulties in keeping up with herjob, and that possible causes have not been ad-dressed. Is there reason to suspect an imbalancebetween abilities and job demands? Are psycho-social and/or family issues making it difficult forher to continue working?

Lastly, waiting 17 weeks post-injury to set up ameeting of the return-to-work team is perhapstoo late. To encourage a more successful out-come, the team should have been convened

when Jennifer first refused to engage in the re-turn-to-work program at six weeks, if not sooner.


Given Jennifer’s history of injuries, she couldhave been assigned a workers’ compensationboard case manager who was skilled in anticipat-ing possible delays in the return-to-work plan. Acase manager with this experience would haveknown how to address the delays with earlierrehabilitation intervention — including the psy-chosocial help she appeared to need.

Jennifer’s recurrent injuries and absences in thepast, and her initial refusal to try modified work,should have indicated to the physician that refer-ral for additional interventions such as occupa-tional or physical therapy or counselling mighthave been in order. Her doctor should have ex-plored other issues such as family relationshipsor personal/psychological issues.

Considering her deteriorating work perform-ance, her employer (supervisor or occupationalhealth nurse) could have referred Jennifer forcounselling concerning family and/or workplaceconcerns. Furthermore, a representative of theworkplace could have addressed her options andthe consequences of her apparent lack of inter-est in returning to work.

Jennifer could have asked her doctor for helpregarding her difficulties at work and/or athome, rather than keeping silent about theseissues. Jennifer was given numerous opportuni-ties during the return-to-work program to askfor help and discuss any issues that might havebeen interfering with her work performance.She chose not to take advantage of them.


• A history of repeated injuries and reluc-tance to try modified work are indicatorsof a need for further intervention.

• Psychosocial and other non-work issuesare often part of real-life return-to-worksituations and need to be addressed, forexample, by referring the individual toprofessional counselling.



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References

Himmelstein, J.S., et. al. “Work-Related Upper-Extremity Disorder and Work Disability:Clinical and Psychological Presentation.”Journal of Occupational and Environ-mental Medicine 37 (11) (1995), 1278-86.

Heerwagen, J.H., et al. “Environmental Design,Work, and Well Being.” American Associa-tion of Occupational Health Nurses Jour-nal 43 (9) (1995), 458-467.

Jennifer J: Worker Issues in Return-to-Work

Tips from the Field

• In the context of deteriorating work per-formance, one or more illness or injuryleaves may reflect an imbalance betweenabilities and job demands, or the pres-ence of workplace and/or psychosocialproblems.

• Being up-front and addressing concernsand issues early often works better thanignoring performance and psychosocialconcerns.



Jerry J:Restructuring and Job Accommodation

Jerry J. has been working as a kitchen helper (Dietary Aide II) at a large personal carehome for the past 13 years. He injured his back when, while carrying a full warmingpan, he slipped on food that had been spilled on the floor. Although he experienced im-mediate pain in his lower back, he completed his shift, working one more hour.

The next day Jerry called in to say he could not work because of pain in his back andleft leg. He filed a workers' compensation claim. Jerry went to his family physicianseveral times but despite medical treatment, the symptoms persisted.

Six weeks after the injury, the leg pain was so severe that Jerry was unable to stand formore than two hours. He was still off work and had not yet begun to receive workers'compensation benefits. Jerry discussed the situation with Laura, the occupationalhealth nurse at his workplace. When Laura phoned the compensation board on Jerry’sbehalf, the adjudicator could not identify a reason for the delay in payments. He alsoseemed unaware that the employer had a return-to-work program that could help Jerryreturn to modified duties. Jerry began to receive benefits two weeks later.

At this point, Jerry was referred to an orthopaedic specialist and sent for a CAT scan.The waiting time for his appointment with the specialist and the scan added up toseven weeks. He was eventually diagnosed with a large herniated disc and surgerywas recommended. Jerry waited another four weeks for surgery, which helped the pain.Although permanent restrictions limited lifting to 25 pounds, Jerry was reinstated inhis previous position with permanent job accommodation that would allow him to deferthe heaviest lifting to his co-workers. By this time, he had been off work for 32 weeks(eight months).

During the year prior to Jerry’s injury, there had been talk of a company reorganiza-tion, particularly in the food services area. By the time he came back to the modifiedwork program, the restructuring had begun. Within the next three months, only a skel-eton staff remained in food services. All others had been laid off. Approximately 25%of the workers were able to “bump” others within the union and maintain a job.

Although Jerry had sufficient seniority to enable him to remain a part of the skeletonstaff or “bump” someone else in another department, he did not have training thatwould qualify him for positions such as nutritional counsellor, clerk or even main-tenance worker within the personal care home. This, combined with his lifting restric-tions, prohibited him from qualifying for other jobs within the physical plant. Jerrywas out of a job!


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Jerry J:Restructuring & Job Accommodation

Jerry J: Restructuring & Job Accommodation


What went right?

Jerry acted appropriately by seeing his doctorand filing a workers' compensation claim. Theoccupational health nurse helped Jerry to getcompensation benefits. The compensationboard adjudicator assigned to Jerry, however, ap-peared to take on a rather passive role – leavingall the return-to-work suggestions to the occupa-tional health nurse.

The workplace had a well-established modifiedreturn-to-work program. A plan to reinstate Jerryin his previous position with permanent jobaccommodations was suggested.

What went wrong?

The physician gave little guidance with regardsto physical and functional activity, nor did herefer to any therapies to assist with physicalfunction. Questions could also be raised aboutthe lengthy waiting periods for the delivery ofhealth-care services (orthopaedic consultation,CAT scan, surgery); was this normal for all pa-tients and if so, why? The workers' compensationpayments were delayed, and the adjudicatordid not demonstrate an interest in facilitatingrecovery.

In response to the current health managementtrends and funding cuts, the organization restruc-tured all dietary delivery services, resulting inthe loss of all the dietary aide positions.

Nobody tried to set up a retraining programfor the dietary workers. The company and theunion failed to follow through on their duty toaccommodate injured workers.


• Even when all the parties directly re-sponsible for the return-to-work of indi-vidual workers are “onside,” workplaceor other societal changes may impedesuccessful rehabilitation.

• Consideration of restructuring plans andother major changes at the workplaceshould be part of rehabilitation plans forindividual workers.


Although the restructuring of the organizationwas not directly amenable to intervention by thehealth-care providers or compensation board ad-judicators, it should have been taken into consid-eration when planning the return-to-work pro-gram for and with Jerry. Jerry had known aboutthe possibility of the changes prior to his injury,and could have been more pro-active in takingsteps for retraining or finding alternate workwithin the workplace. The adjudicator couldhave addressed this in the return-to-work planfor Jerry, by either alerting him to the need toplan for change in his working situation or byrecommending a work hardening program toupgrade his physical abilities.

The Human Resources Department and themanagers planning the restructuring could havereached out to workers on leave due to injuriesto suggest that they consider preparing them-selves for alternative placements. The unioncould have advocated on behalf of the workersfor employer in-house training for alternate jobsfor dietary workers.

In several jurisdictions, the workers' compensa-tion board has provided additional funding tospeed up diagnostic tests and treatments, de-creasing lengthy waiting periods. Many compa-nies have found it helpful to have a designatedcase manager to problem-solve around delaysand speed up processing claims and settingappointments.



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Tips from the Field

• Delays in processing claims and obtain-ing appropriate tests and treatments of-ten prolong disability.

• A designated person whose job is to fa-cilitate and speed up the process mayhelp recovery.

References

Cooper, J.E., et al. “Work Hardening in an EarlyReturn to Work Program for Nurses withBack Injury.” Work 8 (1997), 149-156.


Jerry J: Restructuring & Job Accommodation

The Work-Ready ProjectProject Sponsorship:

This work was co-sponsored by the Health Evidence Application and Linkage Network (HEALNet), the Insti-tute for Work & Health (IWH), and the National Institute of Disability Management and Research (NIDMAR).HEALNet is a member of the Networks of Centres of Excellence Program, which is a unique partnershipamong Canadian universities, Industry Canada and the federal research granting councils. The Institute forWork & Health is an independent not-for-profit research organization that receives support from the Work-place Safety & Insurance Board (WSIB) of Ontario. NIDMAR is a labour-management initiative based in BritishColumbia whose mandate includes education and training, research and policy development. The viewsexpressed in this manual are those of␣ The Editors and not necessarily those of the sponsoring organizations.

Acknowledgments:The Editors wish to acknowledge the contribution of the HEALNet Work-Ready Research Group, comprised ofthe provincial working groups listed below, and Arlene Ward in the creation of the three-part teaching packageReturn-to-Work Approaches for People with Soft-Tissue Injuries. The Editors also wish to thank the stakehold-ers who shared their thoughts with us;␣ their wisdom and candour enriched our understanding of the issuesand, we think, the quality of the product.

Ontario Project Working GroupJohn Frank – family physician/epidemiologistClaire Bombardier – rheumatologist/epidemiologistJudy Clarke – psychometrist/anthropologistDonald Cole – occupational physician/epidemiologistPierre Côté – chiropractor/epidemiologistJaime Guzmán – rheumatologist/epidemiologistDeirdre McKenzie – physiotherapist/program evaluatorVicki Pennick – occupational health/community health nurse

Quebec Project Working GroupSusan Stock – occupational physician/epidemiologistRaymond Baril – anthropologistSuzanne Deguire – sociologistMarie-José Durand – occupational therapist/epidemiologistPatrick Loisel – orthopaedic surgeon/epidemiologistMichel Rossignol – occupational physician/epidemiologist

Manitoba Project Working GroupAnnalee Yassi – occupational physician/epidemiologistJuliette Cooper – occupational therapist/rehabilitation researchMargaret Friesen – occupational therapist/adult educator

Canadian Workshop FacilitatorArlene Ward – vocational rehabilitation specialist/adult educator

Address correspondence to:Institute for Work & Health, 250 Bloor Street East, Suite 702, Toronto, ON M4W 1E6 or National Institute of Disability Management and Research, 3699 Roger Street, Port Alberni, BC V9Y 8E3Web sites: http://iwh.on.ca http://nidmar.ca

© 2000 Institute for Work & Health and National Institute of Disability Management and Research for John Frank,Annalee Yassi, Susan Stock, Jaime Guzmán, Judy Clarke, Margaret Friesen, and Donald Cole (The Editors)

Figure 1 reproduced with permission ©1996 Lippincott Williams & Wilkins, Inc.

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