Rehabilitation Ergonomics

22 Rehabilitation Ergonomics Susan J. Isernhagen DSI Work Solutions, Inc. 22.1 Definition...... 22-1 22.2 Professional Guidelines... 22-1 22.3 Laws and Regulations That Effect Rehabilitation Ergonomics... 22-2 22.4 Rehabilitation Ergonomics Components..... 22-3 Functional Capacity Testing Work Rehabilitation Functional Restoration Job Modification Early Intervention 22.5 Rehabilitation Ergonomics as Part of a Medical Continuum..... 22-8 22.6 Three Models of Rehabilitation Ergonomics for Return to Work... 22-9 Overview Case Study I: Clinical Model Case Study II: Combined Clinical and Worksite Model Case Study III: Worksite Model 22.7 The Aging Worker: Special Considerations... 22-12 22.8 Rehabilitation Ergonomics in Prevention.... 22-13 22.9 Challenges for the Future... 22-13 22.1 Definition Rehabilitation Ergonomics is the practice of applying scientific and functional principles to provide a match of work and worker that prevents injury or assists in the return to work process. The practitioners are therapists and other specialists whose backgrounds include anatomy, physiology, kinesiology and pathology and ergonomics. They must analyze both the humans who perform work activities and the setting in which they work. Rehabilitation ergonomists specialize in functional evaluation, improvement of functional work performance, education of the worker and redesign of work to reduce musculoskeletal stressors. 22.2 Professional Guidelines Guidelines for occupational health, ergonomics and the care of the injured worker have been developed by practitioners who perform the specialty services. The first groups to develop guidelines were therapists whose educational background in musculoskeletal injuries and rehabilitation formed a baseline for restoring or promoting function. Those therapists, who additionally studied ergonomics, added the ability to bring their skills into the workplace. 22-1

22-2 Fundamentals and Assessment Tools for Occupational Ergonomics A. The American Physical Therapy Association developed guidelines for the practice of occupational health. The diversity of the practices parallels the diversity of the needs of those with potential or actual musculoskeletal problems related to work. Both management of the injured worker and prevention of injury are covered. 1. Occupational Health Physical Therapy Guidelines: work-related injury/illness prevention and ergonomics. 1 2. Occupational Health Physical Therapy Guidelines: physical therapist management of the acutely injured worker. 2 3. Occupation Health Physical Therapy Guidelines: work conditioning and work hardening programs. 3 4. Occupational Health Physical Therapy Guidelines: evaluating functional capacity. 4 The guidelines provide professional structure, are informational to educational programs for curricula development and are available to other professions and referral sources for delineation of the services and their goals. B. The American Occupational Therapy Association published guidelines, Occupational Therapy: Services for Ergonomics. 5 Within the guidelines, there are statements on ergonomics definition, ergonomic services provided by occupational therapists, goals of ergonomics, referral and payment mechanisms and occupational therapist background in relation to ergonomics. These serve as a guide for the occupational therapist and those who utilize the services. C. In 1994, a representative group of sixteen professionals who performed rehabilitation ergonomics defined their work and standards. 6 This provided the specialty with information on training, standards, methods, and goals. The group acknowledged that the specialty of rehabilitation ergonomics was held by more than one profession. The guidelines bridged the gap of specific professional background and, instead, emphasized the commonalities of the practitioner and the practice. It has served as a guide for definition and use. Figure 22.1 is a summary of professional and practice goals from all three groups of references. 22.3 Laws and Regulations That Effect Rehabilitation Ergonomics A. The U.S. Occupational Safety and Health Administration (OSHA), in its ergonomic regulations, sets a goal of prevention of work-related musculoskeletal disorders. Its earliest published ergonomic guide for the meatpacking industry was published in 1993. 7 Its current guidelines, available on the internet, 8 support and enhance many of the original provisions. These guidelines call for healthcare providers to be part of the team, early intervention to be provided and job modification to be utilized as a means Primary Goals of Rehabilitation Ergonomics 1. Improve the productivity of individual workers and the work group 2. Maintain the health and improve the safety of the worker in the workplace 3. Decrease lost work time due to illness or injury 4. Enhance return to work processes and minimize the likelihood of disability-induced retirement FIGURE 22.1 A Summary of professional and practice goals.

Rehabilitation Ergonomics 22-3 to allow workers to stay at work as they improve. Other aspects of work such as education, work redesign and selection of appropriate tools are part of the scope of the rehabilitation ergonomist, although also practiced by other professionals. B. The National Institute for Occupational Safety Health (NIOSH) discusses the roles of the healthcare provider in returning injured workers to work. In Elements of Ergonomics Programs, 9 it lists employer responsibilities that lead to involvement of rehabilitation ergonomists: 1. Provide in-house training 2. Promote early reporting and prompt evaluation by healthcare provider 3. Have healthcare provider become familiar with jobs and job tasks 4. Modify jobs or accommodate as determined by healthcare provider C. Antidiscrimination laws such as the U.S. Americans Disabilities Act, 10 as well as Canadian and European human rights legislation, mandate accommodations for disabled persons. These allow qualified disabled persons to perform the essential functions of the job. When the disability affects physical function, ergonomic enhancements of work, work tools or work methods facilitate functional performance of the specific work. D. Workers compensation laws provide wage replacement while a worker is off work with an injury. To facilitate return to work, specific work-related evaluation and rehabilitation are authorized. Onsite visits to ensure that the worker can perform the job safely and provide job modifications, are part of the rehabilitation plan that leads to return to work. At the treatment and ergonomic modification level, rehabilitation ergonomists are utilized. Following the logic of the regulations, guidelines and laws, rehabilitation ergonomists enhance the match of work and worker. This is used for primary prevention, modification of work, early return to work, prevention of disability and avoidance of discrimination in the workplace. Figure 22.2 summarizes the structure of rehabilitation ergonomics in the return to work process. It describes the attributes of the professional specialty derived from guidelines, regulations, professional definitions, and actual practice. 22.4 Rehabilitation Ergonomics Components Rehabilitation professionals have always treated workers with musculoskeletal injuries in their practice. In the 1980s, workers compensation systems began to strongly emphasize reduction in work disability. Job Requirement Functional Ability Match Recommendation 1. Floor lift 50 20 No XXX 2. Mid Level lift 50 60 Yes 3. Shoulder lift 20 30 Yes 4. Carry 50 20 No XXX 5. Push/ pull 60 30 No XXX 6. Hand grip 60 50 No XXX 8. Stair/ ladder 10 ft Not limited Yes 9. Sit 1 h 4 h Yes 10. Stand 8 h 4 h No XXX 11. Hand 6 h Not limited Yes coordination Comment: FIGURE 22.2 Example job and capacity match.

22-4 Fundamentals and Assessment Tools for Occupational Ergonomics As a result, rehabilitation professionals developed four specialties that bridge the gap between treatment and return to work. In brief, they are:. Functional capacity evaluation (FCE): FCE adds work relevance to testing by using functional activities such as lifting, pushing, pulling, carrying, gripping, climbing, walking, balancing, reaching, sitting, and standing.. Work rehabilitation: Work-related rehabilitation provides a structured regime that allows the injured worker to increase function and regain work capabilities.. Job modification: At the worksite, modifications match the work to the capacity of the worker to promote return to work and prevention of reinjury.. Early intervention: Immediate intervention when a work injury or illness threatens work ability, reduces the lost time for the worker and increases healing and functional work capability. 22.4.1 Functional Capacity Testing Functional capacity evaluations (FCE) were developed to evaluate the physical work-related abilities of an injured worker. 11 13 The impetus came from workers compensation administrators who determined that physicians restrictions alone did not provide adequate specific information for an employer to bring a worker back to work. Specific work functions were listed and physicians were asked to rate the worker on each category. In turn, therapists were called upon to develop an objective means to measure work function that could be used as an adjunct for the medical release to work. Functional evaluation is an objective measure of the ability of a worker to perform actual work tasks. There are two types, FCE and work-related tests. FCEs utilize the listing of job tasks developed by the U.S. Department of Labor and Industry. 14 Tests are standardized for each physical task and the results are given in each category. By designing functional capacity tests for these work items, it was possible to match a worker s functional capacities with the requirements of the job. This allowed appropriate job or jobs to be selected and to define what modifications would be necessary to allow safe work return. Figure 22.3 is an example of the matching of a job description with functional abilities of a worker. The XXX denotes areas where specific comments would be made. As functional capacity technology grew, so did the numbers and types of tests. To ensure confidence in an FCE, studies determined which FCEs are scientifically reliable. 15 22 This provides assurance to the referrer, end user and evacuee that the test is reproducible. Validity studies demonstrate that certain 23 25 FCEs can have impact outside of the clinical setting. Specific work-related tests differ from standardized FCEs. They are based on job descriptions. Reliability and reproducibility are more difficult, as each job description requires a different test. 26 1. Rehabilitation ergonomist: rehabilitation professional educated in ergonomics and workplace issues 2. Functional evaluation that identifies the safe capacities of a worker combined with a functional job description to provide the match of the worker and work, defining what matches and what needs modification 3. Job modifications used immediately at the worksite, to keep the worker at work safely or allow an early return to work 4. Enhancement of the work abilities as the workers healing or progress toward return to work 5. Relationship with the team of medical manager, case manager, human resource professional, safety manager, and worksite supervisors FIGURE 22.3 Structure of rehabilitation ergonomics in return to work.

Rehabilitation Ergonomics 22-5 However, validity and real-world usefulness can be enhanced by insuring that the job description is accurate and designing the test to match the functional job description. 27 Occupations, which lend themselves to work-specific tests have unique physical demands. Examples are nurse and nurse assistants when transfers are required, specific repetitive assembly processes, lineman who climbs power poles, etc. Choosing a standardized FCE versus a work-related functional test depends on the questions that are being asked. If there is no specific job description available for the worker, or if the worker could be considered for several jobs, then a standardized FCE is most effective. It can be compared to several job descriptions in order to prioritize which jobs match the worker more closely. If only one job is being considered, however, a specific functional test for that job can be developed from the functional job description. This provides greater opportunities for work-specific tests, but the evaluators must be careful to determine that the job description is valid and that the functional tests replicate the job demands. While functional testing is a specialty for therapists, the resultant findings and recommendations are stronger when the therapist is also a rehabilitation ergonomist. The knowledge of the worksite, the jobs and the job modification opportunities provide information for a stronger resolution of the return to work objective. 22.4.2 Work Rehabilitation For those workers whose physical limitations prevent return to work at their previous job or at full duty, rehabilitation is indicated. In addition to traditional therapeutic exercise, work rehabilitation includes actual or simulated work task and work behavior management. 28 In the 1980s Matheson defined and described work hardening. 29,30 Its use of work simulation ensured that work behaviors would be addressed and that return to actual work would be the goal. The behavioral aspects of returning a chronically injured or disabled person to work were emphasized. The medical and physical models were joined with psycho-social and vocational models. A rehabilitation model is utilized and differs from a treatment model. The essence of rehabilitation is brought into the work simulation setting:. An atmosphere is created in which the clients are responsible for their own progress. The therapist is a guide and assists, but the worker does the work to accomplish the goals.. The focus is on function, not perfection. For those with injury or illnesses that are beyond the acute phase, improving the residual function is the focus of the program. While increase in motion and strength along with decrease of discomfort are important, they only build a foundation for which function can be obtained.. The goals are related to ability to function outside the clinic. In work rehabilitation, the return to work is always the target. The program is designed for sequential improvement until full duty or the highest level of safe work is gained. The Commission on Accreditation of Rehabilitation Facilities (CARF), 31 developed the first work hardening standards. It defined work hardening as a multi-disciplinary program including physical, psychological and vocational components. In response to CARF, the American Physical Therapy Association determined that there were two types of work rehabilitation programs. Work hardening was defined in similar terms as CARF. A more direct program was additionally defined and described. Work conditioning emphasizes physical and functional strengthening for return to work. It is often performed by a single discipline rather than being multidisciplinary. The psychological and vocational aspects are not part of the program, although they may be contracted separately. Both types of work rehabilitation require full participation from the worker in a setting that emphasizes safe work behaviors, use work-related tasks for rehabilitation and have return to work as the goal.

22-6 Fundamentals and Assessment Tools for Occupational Ergonomics 22.4.3 Functional Restoration Mayer et al. 32 designed a multi-disciplinary program to return chronically injured workers to the workplace. It used a strong medical model with the core physician s involvement. In addition, objective measurements were emphasized, including those from isokinetic exercise technology. Its highly structured program gained recognition for its ability to be replicated. In the initial functional restoration and work rehabilitation programs, the population served was primarily those chronically off work with injuries or illnesses. 22.4.4 Job Modification Both FCE and work rehabilitation focus on the functional ability of the worker. If a worker has demonstrated capacities to do the essential functions of his/her job, then the rehabilitation ergonomist provides assurance, answers questions and facilitates communication with the supervisor and coworkers. If there is not a match, however, modifications of job tasks are necessary to protect the worker and yet allow essential functions to be performed productively. Clarity on the permanency of restrictions is necessary for the worker, the medical team and the employer. Both the worker and supervisor must understand if there is to be progression and how this progression will be handled. This is described in Figure 22.4. Many modifications are time-limited, as the worker s function should improve with physical work and continuation of the healing process. If a condition is permanent (e.g., spinal fusion, neurological damage), the modification may also be permanent. Figure 22.5 demonstrates how specific essential functions can be modified in the return to work process. In some cases, merely revising the work method can be a modification. There is low or no cost to this solution. In some cases, the work task can be changed through equipment, in order to accomplish the function with less effort or stress. In the third case, the employer can decide to modify the essential function by lowering the requirement, or eliminate the function. The decision requires adequate information and dialog on the choices, the ability of the employer and supervisor to modify a job and the funds that can be allocated. Each situation must be evaluated individually for the best option, as there are often more than one potential way in which modifications can be designed. 22.4.5 Early Intervention As evaluation of the success of work programs was studied, it became clear that the earlier the referral to the program, the better the result. While some of the late referral issues revolved around severity of the injury or illness, most of it was a result of slow or inadequate case management. Thus, innovative Job Modification Categories Permanence A. Temporary Time limitation specific (e.g., 4 weeks) Utilized when functional performance is expected to improve through healing, therapy or actual work performance Can be gradually upgraded as function improves B. Permanent Utilized when a worker s condition is permanent Utilized for a worker with a disability Utilized when the ergonomic job modification is desired as a permanently improved work design FIGURE 22.4 The description of both the worker and supervisor how to handle the progression.

Rehabilitation Ergonomics 22-7 Essential Functions (EF) and Job Modifications Examples Item Keep EF Change Method of EF Lifting Repetitive hand work Sit Rotate lift with nonlift tasks to provide a break, yet perform complete job Rotate unlike tasks to provide musculoskeletal relief, yet perform full job Use ergonomic chair Use vacuhoist for all lifts over 10# Use hand tools, assistive devices to reduce stressors Change work station to sit stand but maintain all other EF Eliminate EF Do all nonlifting components of the job Limit EF to a portion of worktime and add EF from a second job to complete shift Change position of work to standing FIGURE 22.5 Modification of specific essential functions in the return to work process. programs were designed to bring an injured worker very early for evaluation and treatment of their 33 35 musculoskeletal injuries. In many cases, the early intervention, in conjunction with modified work, keeps the injured person in the workplace without lost days. For those who do have lost time, treatment is underway at once and an early return to work is more likely. In either case, the workers retain their self-image for work and avoid the patient mindset. The coworkers see that the worker is retained and supervisors continue to see the worker as productive. The intervention is directed at healing, protecting the injured part while healing is taking place, using the uninjured portions of the worker s body in work tasks and focusing on function rather than pain. In order to develop early intervention, measures must be in place before an injury is reported. Industry management must approve the constructs of the program and facilitate education and responsibility of the injury team. These include the claims manager, human resource coordinator, safety officer and any other onsite medical personnel. In addition, all employees must understand that early reporting is desired. It will be met with positive response, not negative. At times it takes many reminders, as workers often fear that a report of a problem will result in negative action toward them. This is especially true when reward systems for no OSHA recordables is in place. Also, if the culture is to disdain a worker with an injury, or the light duty that might be a result, employees will be reluctant to report until the problem is severe. Once the early intervention process is in place, education for workers and supervisors is necessary for early symptoms of musculoskeletal disorders to be recognized. Workers must be aware of the early stages of carpal tunnel syndrome, tendonitis, strains, and others, in order for the system to work. When injury, illness or early symptoms are reported, the onsite rehabilitation ergonomist works with the employer and the medical team. Intervention includes evaluation of the condition, assessment of current functional capacity to determine if the worker can continue to work, institution of functional treatment and modification of the job when early return to work can be accomplished. Early intervention is best done onsite or in a clinic that is close to the worksite. Outcome measurement identifies the effectiveness of early intervention compared to previous traditional treatment. Analysis can also identify jobs or job tasks in the workplace where problems occur most frequently. The safety department, with the rehabilitation ergonomist as part of the team, can then institute prevention measures. These may be ergonomic redesign, new tools, education, improved job training, stretching, ergonomic postures and problem solving. Early intervention is a bridge between injury prevention and injury management.

22-8 Fundamentals and Assessment Tools for Occupational Ergonomics 22.5 Rehabilitation Ergonomics as Part of a Medical Continuum In the 1990s, the focus on return to work outcomes became an important area of research. Pransky s comprehensive review of the literature categorized the variables that affect return to work. 35 He identified that work absences were related to a higher preinjury ergonomic risk, a dissatisfaction of the worker with return to work accommodations and a negative relationship with the worker s compensation insurer. He also identified an important, but lightly studied variable, that of reduction of reinjury. He concluded, that the reinjury rates are increased in women with jobs that have both high preinjury ergonomic risk and high postinjury ergonomic risk, dissatisfaction with work accommodation, negative employer reactions, dissatisfaction with the medical services and dissatisfaction with low back statistics. Two of these items relate to the ergonomic risk being either high or a negative perception of work capacity in returning workers. If workers had high postinjury ergonomic risk, it tended to decrease their perception of capacity. Feuerstein evaluated clinical and workplace factors associated with the return to modified duty in upper extremity disorders. 36 The model could predict or classify those not working and those on modified duty. Increased ergonomic stressors was one of the four primary predictors for those not working. Return to work should not just be limited to medical and clinical signs only. Staal performed a descriptive review of return to work interventions for low back pain. 37 Out of the seventeen studies that he evaluated, only three had ergonomic interventions and none of those had randomized controlled studies. He noted that multi-model treatment consisting of exercise, education, behavioral training and ergonomics would be the most promising. Matheson looked at the predictability of functional capacity to identify whether return to work would take place and at what level. 21 Data on return to work and, specifically, return to work at the original job/original employer, were collected. Functional capacities items were evaluated for their relationship to those outcomes. FCE lifts were linked with both return to work and the level of return to work. In the mid 1990s, Loisel et al. developed the Sherbrooke Model, 38 which postulated that ergonomic interventions should be used with clinical interventions in return to work. For subjects that had been off work 6 weeks, this model went into effect. Early and active treatment was part of the regime but, additionally, ergonomic evaluations and interventions were utilized. In 1997, his randomized clinical trial indicated that the occupational intervention, which included ergonomics on the job, was an important component of full case management. 39 The best results were in returning to work and were accomplished by combining clinical interventions with occupational interventions. A 6-yr follow-up study in 2002 40 demonstrated that the occupational interventions, combined with clinical interventions, saved days on benefits and saved costs. In 2003, the group defined a PREVICAP model, which had three dimensions. 41 It revolved around the worker, the work environment and the interaction between the work and work environment. Anema et al. looked at participatory ergonomics as a return to work intervention. 42 Those with low back pain were studied. Anema acknowledged the use of ergonomics for prevention and added a study for disability management. When ergonomic suggestions and interventions were developed for low back pain patients the results were positive. Over half of the ergonomic interventions were implemented and workers were satisfied with the solutions and reported that they had a stimulating effect. Lemstra s (2003) study evaluated one industry in Canada and demonstrated the effectiveness of occupational management. 43 This included a physical therapist onsite using ergonomic reassurance and encouragement to assist injured workers to be on the job safely. The work was based on the physical and functional information from the physical therapist and the medical information from the family physician. This blending of prevention and return to work ergonomics allowed the intervention to take place sooner, onsite and with professionals known to the workers. Upper extremity and back injury claims with the new model demonstrated decrease in days lost upto 91%. This was superior to the traditional medical model of standard care or a regime of clinical physical therapy service.

Rehabilitation Ergonomics 22-9 As rehabilitation professionals turn to rehabilitation ergonomics as a specialty, they are bolstered by the scientific ongoing studies that describe the specifics of programs that have demonstrated effectiveness. Costs and days lost are decreased. Workers appreciate the ergonomic modifications, assistance with understanding their capacities and assistance with return to work at the worksite. The work is positively received by employers as well. With reinjury rate now being measured, the second positive effect of rehabilitation ergonomics is being identified. 22.6 Three Models of Rehabilitation Ergonomics for Return to Work 22.6.1 Overview Three models of rehabilitation ergonomics provide return to work: 1. The clinical model utilizes an occupational rehabilitation specialist in the clinic and a rehabilitation ergonomist onsite for the re-entry to work phase. The clinical model is utilized in three situations. First, if a worker has an illness or injury that requires strict safety standards, the adherence to medical safety in the clinic provides security. This can include those with heart rate or blood pressure problems, as well as those in the healing stage of a severe sprain, fracture, etc. Second, if a worker is at a level of job readiness that is too low for even modified work, conditioning will need to be provided to raise the worker to a level that would sustain half or full day of work. Third, some occupations do not provide for anything but full duty. This could include trucking, construction work, heavy manufacturing or heavy patient handling. 2. The mixed clinical and work model combines the benefit of safe structured rehabilitation with worksite experience that prevents the worker from becoming alienated from the work and coworkers. 3. The onsite work model is utilized either when there is a clinic at the worksite or the employer approves using actual work for rehabilitation. 22.6.2 Case Study I: Clinical Model John Jones has had two lumbar surgeries. The first was a laminectomy at the L4-5 level and the second was a laminectomy at the L3-4 level with removal of scar tissue at the site of the first surgery. John s previous job, maintenance person for the transit service, is available. The functional job description identifies standing, walking, working in awkward positions, lifting upto 40 lb, gross and fine hand coordination and performing elevated work. The physician has referred John for initial rehabilitation for overall strengthening, improvement of aerobic capacity and spinal stability exercises as he has been off work for 6 of the past 7 months. John is deconditioned as well as in need of rehabilitation for this spine. Goals includes improved strength and endurance with overhead work, kneeling, crouching and aerobic activity. In addition, a low back stabilization program improves musculature in the lumbar area to sustain a stabilized position. This is necessary, as John needs to reach, get into various positions to do his maintenance work. As he heals and improves, work activities including lifting, carrying, pushing and pulling are added. With close clinical supervision and safety parameters, he can work toward the physical requirements in his job description with confidence. Monitoring of capacities takes place until John can perform seven out of ten essential functions of his job. Three heavier aspects of the job are limited but improving. A rehabilitation ergonomist joins the team to begin return to work planning. He confers with John and his therapist. It is necessary to understand John s functional abilities and limitations, meet with the supervisors at work and design modifications for the three items he cannot yet perform.

22-10 Fundamentals and Assessment Tools for Occupational Ergonomics Once John returns to work, he is monitored on a regular basis to insure safety and provided with reassurance and assistance by his supervisor and coworkers. Sequential upgrading of activity takes place until full duty is reached. A satisfactory final evaluation by the therapist and physician formally releases John to full duty. Two carry-over changes will impact John: 1. John is interested in maintaining his new fitness level. He expressed concern that he had never recovered his preoperative work state until he participated in the work rehabilitation. His employer pays for a local health club membership. John s program will be transferred to this facility for maintenance and improvement in fitness and function. 2. The employer and medical providers became aware that workers who have been out for prolonged periods, with any medical condition, would benefit from functional testing prior to returning to heavy work. If there is a deficiency, a suitable rehabilitation program will be provided and the rehabilitation ergonomist will be able to serve such workers at the worksite. The employer has identified a high reinjury rate for returning employees and has targeted this for reduction with these policies and programs. This combines the best of clinical rehabilitation with the use of a rehabilitation ergonomist in return to work. 22.6.3 Case Study II: Combined Clinical and Worksite Model Shirley Walters works in the housekeeping department of a hospital. She strained both shoulders and low back and has a history of myofascial neck and upper extremity pain. Shirley previously worked at her job productively and had her myofascial symptoms under control before she suffered the shoulder and back strain moving heavy equipment. She is afraid that her strains and exacerbated myofacial pain will prevent her from returning to work. Shirley s rehabilitation program begins with a partial functional evaluation, recognizing that she is in the healing phase. The initial evaluation shows that Shirley has the motions and capability of doing 60% of her current job requirements but her endurance continues to be low and myofacial symptoms increase after approximately 4 h of work-like activities. She will be working 8-h shifts at full time. In order to return her to work and to alleviate her fears, she is put on a schedule of both clinical and return to work. Her employer and her case manager are willing to begin with 4 h of activity, increasing to 6 h, and ultimately progress to full-time work. The rehabilitation ergonomist, a physical therapist, works with Shirley on functional activities and strengthening related directly to her job description essential functions. In the first week, Shirley works in the clinic performing 4 h of simulated housekeeping activity, building her endurance and her confidence. At the end of the 4 h, symptoms are high, but she learns stretches and positioning to decrease them. They have generally subsided by the next day. On the second week, she upgrades to 6 h of clinical activity. The third week begins the return to work process with 3 h of work simulation at the clinic and 3 h at work, doing the essential functions for which she has been tested out safely. The fourth week, she is completing 6 h of modified work, all at the worksite. The rehabilitation ergonomist oversees her for half an hour per day, but she is at normal work pace and under her normal supervision processes for the shift. The rehabilitation and training have decreased symptoms in the back and neck. The myofascial symptoms continue at the level before she suffered the strain but are able to be controlled by her. On the fifth week, she returns to full duty, which includes all essential functions of her job. The gradual process of becoming stronger, learning new techniques of work and knowing that her supervisor is supportive have given Shirley confidence.

Rehabilitation Ergonomics 22-11 At discharge, she does have considerations that were not in place previously. They are contained in a new agreement with her supervisor and employer: 1. When faced with pushing/lifting that is beyond her specified job requirements, she will seek help. This will prevent the sprain/strain she suffered previously. 2. If myofascial symptoms are high, she will be allowed short breaks for her stretching. She and her supervisor will work out what is acceptable. This will prevent her suffering in silence and being absent because of another physical problem. 3. The equipment she has to move has been ergonomically redesigned with larger and more movable wheels. Force required for pushing and pulling has been reduced from 100# previously to 30# with the new wheels. If other equipment or material creates high stresses, she is to report them for analysing an ergonomic modification. To this point, the employer now has a relationship with the rehabilitation ergonomist for more work to reduce stressors in the entire facility. 4. Interest in stretches, ergonomic education and fitness increased after there was interaction with the rehabilitation ergonomist. Preventive programs were discussed and are being put into place for all employees. 22.6.4 Case Study III: Worksite Model Makai Brown assembles furniture from parts shipped from a supplier. His employer sells the assembled models, which are fitted with customized additions. Makai has begun to have right thumb and finger numbness at night and discomfort in the lateral epicondyle area of his right arm during activity. His physician has diagnosed early carpal tunnel syndrome and lateral epicondylitis on the right. The company s occupational health department contracts for a rehabilitation ergonomist to work at the company 2 days a week. The role is to work with the team in prevention ergonomics, to provide ergonomic education to the workers and to work with those with early musculoskeletal symptoms, illness or injury. The physician prescribes an anti-inflammatory medicine. The rehabilitation ergonomist institutes therapeutic measures such as night splints, an epicondylitis band to support the elbow extensor muscles and a stretching and flexibility exercise program for the neck and upper extremities. In addition, modified functional testing is performed and matched with his job description. His current job requires moderate to heavy repetitive upper extremity activity and use of an impact wrench. All gripping activities increase his symptoms. He is able to do nonrepetitive work with his hands and arms and he has no limitation in walking, standing or sitting. It is desirable from his and the employer s point of view that he remains at work. He is temporarily given the job tasks of quality inspection, inventory and tool maintenance. He is treated onsite with physical therapy for his epicondylitis. His functional statistics such as grip and pinch are taken for a baseline, his carpal tunnel symptoms are documented and monitored, and he is given a home exercise and positioning program. He maintains his restrictions on gripping and repetitive work for home and recreational activities. He also takes the ergonomic training course, which educates him on stressors and modifications that he can do himself. He works for 2 weeks at the modified job. At 2 weeks, his sensory symptoms in fingers and hands have been reduced, the lateral elbow pain is gone, but the grip strength is only 75% of what his left hand shows. He states it feels weaker than before his problems. He continues all treatments, as he gradually resumes some of his normal activities. Four hours a day he resumes light furniture assembly. He is given a pneumatic impact wrench to replace the mechanically driven one. The new one is half the weight and much easier to grip than the former tool. The other 4 h continues to be the lighter duty tasks. He is aware of early symptoms and is to stop, stretch and resume activity slowly if there is a problem. At 4 weeks, both carpal tunnel and epicondylitis symptoms have subsided. His active treatment stops, but self-exercise continues as needed. He resumes full duty with self-monitoring of symptoms and regular re-evaluation by the rehabilitation ergonomist. Makai and the supervisor can call the ergonomist with questions or problems and the ergonomist will consult to make adjustments as necessary.

22-12 Fundamentals and Assessment Tools for Occupational Ergonomics His resumption of full duty is accompanied by removal of restrictions on home activity. The following ergonomic home and work guidelines remain: 1. He is to continue to use the pneumatic impact wrench at work to reduce work stressors permanently. He will make similar accommodations at home. He now realizes tool use and heavy repetitive gripping must be monitored in his recreation and home activities. New sensibilities are present in his home carpentry, sports and chores. They particularly revolve around ergonomic positions, proper tools, reduction of stressors and implementation of stretching as appropriate. 2. If he has symptoms again, he is to report these at work as soon as possible. The health department at work has determined that causation (work-related or not work-related) will not stop the process of working with him to avoid a reinjury. The rehabilitation ergonomist also can be brought in any time that there is an issue. 3. He participates in safety meetings to work on early intervention and ergonomic guidelines for all employees. Note: This case was resolved with no lost time and 4 weeks of modified duty. This result was superior to former cases of workers with similar problems. In addition to the good metrics (decreased lost time and medical costs) both the worker and supervisor rated their satisfaction as high. 22.7 The Aging Worker: Special Considerations The aging process affects the neuromusculoskeletal system and is translated into functional changes. The loss of functional work ability is noted in middle-aged and older workers. For those with chronic injuries and illnesses, aging changes add to the decrement in functional abilities. 44 For employers and workers, the age-related decrease in functional ability can translate into decreased productivity, increased injuries and increased disability. Perceived disability for older workers is also heightened, so that when an older worker is hurt, there may be the perception that they will not be able to return to the workforce without reinjury. To study the effect of education, training and ergonomics on workers, five studies were performed and reported by Finnish researchers. 45 A physiotherapist participated in the training for material handling and in planning of workplace health promotion. Results of the five studies demonstrated that both the health and work ability of aging workers can be promoted with ergonomic measures at the workplace. Team spirit, a result of the participative approach, was also enhanced. Education and training had a positive effect, especially on aging workers. These studies show that there will be a functional decline in workers, but that ergonomics, education, training and participation can be used to increase work ability. They point to an opportunity to decrease the rate of injury and disability in the aging population. Exercise is a deterrent to changes in musculoskeletal ability, and when added to the suggested regime, could slow the process of declining function. There is a need for ongoing research to specifically address the multiple interventions that can be successfully utilized in reducing work injuries, lowered productivity and diminished perceptions of work ability in the aging worker. Regarding use of exercise, the rehabilitation ergonomist must balance the presence of slow-onset repetitive injuries in physical work (known in industry as wear out ), and the exercises used to maintain fitness. Program design must take into consideration the potential interaction of concurrent overuse syndrome while promoting restorative fitness regimes. With the recognition that increasing numbers of workers are reaching middle and older age, and that older workers are valuable due to experience and loyalty, employers are seeking methods to maintain health and productivity of older employees. Rehabilitation ergonomics for both return to work and for prevention of injury can make a significant contribution.

Rehabilitation Ergonomics 22-13 22.8 Rehabilitation Ergonomics in Prevention While rehabilitation ergonomists first became involved with work injury in the return to work arena, there has been a cross-over into prevention of musculoskeletal injuries. This derives from cases where employers formed a positive relationship with a rehabilitation ergonomist who has learned the culture, jobs and methods of a worksite through bringing employees back to work. They work in prevention because they have been requested to do so by satisfied employers and employee groups. In addition, the ergonomic resolutions created by modifying work for a returning worker often are appropriate permanent modifications for the entire work group. The process of reducing stressors for an individual worker is similar to reducing stressors for a group of workers. Rehabilitation ergonomists determined that there is a dual role of return to work and prevention. 1 6 Government guidelines or injury prevention also acknowledge the relationship with return to work and describe roles for healthcare professionals who can work on both sides. 7 10 Research into return to work outcomes and ergonomic practice describe the role of the rehabilitation professional as working in the prevention mode in industry. 34,41,43,45 Rehabilitation ergonomists specialize in the prevention of musculoskeletal injuries by utilizing ergonomic principles of worksite redesign, tool selection/modification, 46 work method design, ergonomic education, fitness and early intervention. They perform as part of a larger prevention team, often including engineer ergonomists, safety departments, production managers and other medical professional involved in prevention. Ergonomic training and education are a foundation for the prevention practice of the rehabilitation ergonomist. By referencing other chapters in this text, one can find principles of prevention used universally. 22.9 Challenges for the Future Rehabilitation ergonomics is in its early stages. It has been developed to meet specific needs. Rehabilitation professionals were invited into the return to work process by insurance systems and employers looking for better methods to return injured workers to work. Early intervention bridged the gap between return to work and prevention of injury. Job modifications began with individual patients and advanced into wider use in musculoskeletal injury prevention because of utility. Scientific studies use rehabilitation ergonomists as part of the team, but refer to them by their profession (e.g., physical therapists, occupational therapists), rather than their specialty. The studies show positive results of team effort working in several related strategies. It is difficult to point to any member of the team (e.g., safety officer, engineer, physician, nurse, case manager) as the reason for success. Thus, the role for rehabilitation ergonomists is as part of a larger team. The future challenge for rehabilitation ergonomists is similar to that of all ergonomists and specialists in work injury management and prevention. It is to define its role and set goals in the following areas:. Create educational opportunities for rehabilitation professionals that create knowledge and practice parameters in ergonomics.. Create educational opportunities in concert with related professions for effective use of specialties, which have the same goals.. Delineate its role in the return to work process and design accompanying studies to validate efficacy, cost effectiveness, worker satisfaction and employer satisfaction.. Delineate its role in the prevention of musculoskeletal injuries, specifically combining ergonomics, education and fitness and design accompanying studies to validate efficacy, cost effectiveness, worker satisfaction and employer satisfaction.. Create models for its role in teams of professionals, both in prevention and return to work.. Design and implement research that evaluates and categorizes the most effective interventions and those which need improvement.

22-14 Fundamentals and Assessment Tools for Occupational Ergonomics FIGURE 22.6 Working onsite, a rehabilitation ergonomist analyzes how the worker s neck and upper extremities function during work activity. This forms a base for tasks described in a job function description.. Assist in creation of a model that defines work health as a continuum, using the team approach to problem solving for all workers whether currently healthy or temporarily unable to perform work. Minimize the need for separate systems for injured and noninjured workers FIGURE 22.7 In the return to work process, the rehabilitation ergonomist blends knowledge of the worker s functional capacity with the demands of the job to ensure productivity and prevent reinjury.

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