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Work Simulation/Conditioning/Return to Work Programs

Information

Description of Intervention

Approximately 2.8 million non-fatal injuries occur in the workplace each year, and more than 30% of these result in absenteeism.1 Work-related injuries can stem from a variety of causes, such as workers performing repetitive tasks, exerting too much force, maintaining the same activity or posture for extended periods, and withstanding excessive pressure to a sensitive body part.2 According to the Occupational Health and Safety Administration (OSHA), a nondescript cumulative trauma disorder will lead to estimated indirect and direct expenses of >$85,000 for each injured worker. About 30% of work injuries that lead to absenteeism are musculoskeletal in origin, which often leads to decreased productivity, higher turnover rates, and long-term physical and mental repercussions.1

When workers are injured on the job and unable to complete their duties, they may earn worker’s compensation benefits and be mandated to rehabilitate their injury so they can return to the workforce. Work hardening is a highly structured treatment program usually led by a physical or occupational therapist that involves targeted interventions to help patients return to work as quickly and safely as possible.3 Work simulation training is an integral component of work hardening in which patients mimic many of the situations, functional postures, and tasks that are part of their job.3 This typically includes the use of exercise machines and simulated devices and workplaces that replicate real work experiences and environments.3,4 Work simulation allows patients to practice these work activities and procedures in a therapeutic framework, thereby addressing any job-specific deficits and guiding them towards a safe eventual return to work3

Indications for Intervention

Workplace injuries can generally be classified as either overuse-related or traumatic. Overuse injuries typically result from performing repetitive tasks (eg, typing, cutting hair, painting, sewing) or maintaining the same activity or posture for extended periods (eg, hunched over posture at a desk, assembly line work, meatpacking), while traumatic injuries occur when workers exert too much force or result from unsafe workplace conditions or accidents.

Diagnosis3-6

  1. Ask the patient to provide a detailed medical history. Be sure to have the patient carefully describe the nature of their work and the cause of their injury, any pain or other symptoms, perceived functional limits, and current work tolerance.
  2. Assess the patient’s range of motion (ROM), sensory deficits, motor coordination, and manual dexterity.
  3. For work hardening programs, perform a Functional Capacity Evaluation (FCE), which should include a minimum of the following tests: lifting floor to waist, horizontal (waist to waist) and waist to overhead, unilateral carrying, standing and sitting for longer time, walking.
  4. Consider using other tools and instruments to assess the patient’s specific work capacity and related deficits.
    • One of the most widely used is the Baltimore Therapeutic Equipment (BTE) Work Simulator, which is an assessment and treatment tool for upper extremity rehabilitation that objectively evaluates various physiological patterns of movement or job simulation tasks.
    • If the BET Work Simulator is not available, other assessment tools include the Jamar Dynamometer, the Martin Vigorimeter, the desk-mounted tensiometer, and the hydraulic transducer.
  5. Ask if the patient has any comorbidities, including smoking, diabetes, or osteopenia.

Intervention Options

After performing the initial evaluation, the treating physical or occupational therapist should design an individualized work hardening program that is focused on addressing the patient’s specific work-related deficits or impairments.7 The program should include flexibility, strengthening, and endurance exercises, as well as job-specific training, with a particular focus on work simulation training. It’s also crucial for the patient and therapist to establish clear goals before treatment begins, which will help both parties to chart progress and assess outcomes.3

The therapist will first select the most appropriate work sample for training. Depending on the patient’s goals, the work sample may address a single work trait, a collection of tasks, the common critical factors of a job, or all the key tasks of an actual job. The two main types of workstations used in work simulation training are standard (or job-specific) workstations and computer-controlled work simulators3:

  • Standard workstations: designed to allow patients to simulate a variety of important work-related skills (eg, lifting, carrying, sorting, brick wall building, tool use, electrical installation) in a simple way; these types of workstations are intended to be versatile and cover a wide range of work-related functions
  • Computer-controlled work simulators: can be used to test and train patients while performing work-related strength and endurance movements, and the results can be used to gauge the patient’s abilities and progress

The BTE Work Simulator is a computer-controlled work simulator that is particularly appropriate for patients with pain or other symptoms in the upper extremity. It features a rotatable shaft that various tools can be attached to, which reproduces the motions of the job or task. Some examples of the many functions possible with the BTE Work Simulator include driving a bus, using a chainsaw, screwdriver, or ratchet, laying a brick, shoveling dirt, and raking leaves. These tools create the "feel" of the job that the patient is used to, and performing these movements repeatedly and systematically will help them gain the confidence and skills necessary to return to their profession.3,4,6

Patients should be regularly monitored throughout the work hardening program, and the therapist should pay close attention to changes in pain levels, swelling, proprioception, and overall movement patterns. As the patient improves, the intensity, frequency, and duration of the prescribed exercises should gradually increase based on their progress. As recovery continues, resistance can be gradually introduced, and the amount of assistance provided can decrease. After a set period of time has passed, the therapist should perform another FCE to determine if the patient is ready to return to work.3,7

The medical team and therapist should be mindful to focus on core strength and endurance.   The concept of proximal stability for distal mobility should remind patients and clinicians that focus should be on the “whole person” and not the sole body part.  Core focus in addition to rehabilitation and aide in prevention and in re-injury.

Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • One potential benefit of work simulation training is that some patients are more likely to temporarily forget their pain and work restrictions in this environment compared to traditional therapeutic setting.3
  • Improving grip strength during work simulation training may lead to better performance and fewer injuries in workers employed in the textile and garment manufacturing industries.2
References
  1. Boyette J, Bell J. A scoping review of the use of exercise-based upper extremity injury prevention programs for industrial workers. Journal of hand therapy : official journal of the American Society of Hand Therapists 2021;34(2):250-262. PMID: 34030956
  2. Myers E, Triscari R. Comparison of the strength endurance parameters for the Baltimore Therapeutic Equipment (BTE) Simulator II and the Jamar Handgrip Dynamometer. Work 2017;57(1):95-103. PMID: 28506016
  3. Franchignoni F, Oliveri M, Bazzini G. Work rehabilitation programs: work hardening and work conditioning. In:Vocational Rehabilitation. Vol 1. Paris, France: Springer, Paris; 2006.
  4. Curtis RM, Engalitcheff J, Jr. A work simulator for rehabilitating the upper extremity-preliminary report. J Hand Surg Am 1981;6(5):499-501. PMID: 7276482
  5. Anderson PA, Chanoski CE, Devan DL, McMahon BL, Whelan EP. Normative study of grip and wrist flexion strength employing a BTE Work Simulator. J Hand Surg Am 1990;15(3):420-425. PMID: 2348059
  6. Beaton DE, O'Driscoll SW, Richards RR. Grip strength testing using the BTE work simulator and the Jamar dynamometer: a comparative study. Baltimore Therapeutic Equipment. J Hand Surg Am 1995;20(2):293-298.PMID: 7775773
  7. Wietlisbach C. Cooper’s Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. Third ed. St. Louis, MO: Elsevier; 2020.
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