Assessment of Fitness for Return to Work

Original Editor - Jess Bell Top Contributors - Jess Bell, Kim Jackson, Lucinda hampton, Robin Tacchetti, Tarina van der Stockt, Vidya Acharya, Olajumoke Ogunleye and Aminat Abolade

Current Musculoskeletal Trends

Positional stress spine

Musculoskeletal injuries are one of the primary causes of disability in Western countries, resulting in absence from work or functional limitations at work, as well as a general reduction in ability to undertake normal activities. Prevalence rates of musculoskeletal pain is around 30% per year (ranging from 14-47%), with an incidence rate of 8.3% per year.  It tends to affect an individual at least once in his or her lifetime.

At present, there is a trend towards increasing disability from musculoskeletal conditions. However, while disability increases, prevalence rates for these conditions are static. There are also ever increasing treatment options and reduction in workloads because of greater regulation.

It is thought that this increase in disability may, therefore, be due to factors such as:

• Obesity
• Ageing populations
• Sedentary behaviour

Impact of Musculoskeletal Conditions on Work

The impact of a musculoskeletal condition on a worker is variable and affected by a number of factors. The type of work can have an impact - a Norweigan study from 2018 found an association between occupational physical activity and the risk of disability pension for all causes and musculoskeletal conditions.

• Patients who have chronic musculoskeletal conditions are more likely to be absent from work (i.e. 40% can work full time) than people with other medical conditions such as diabetes, heart and lung conditions (i.e. 50% can work full time).
• It is thought that this difference in working rates for individuals with musculoskeletal conditions may be related to the fact that people are more likely to connect their health condition to work than individuals with other health conditions.

However, each individual’s unique response to his / her pain will influence his / her prognosis. Depression, anxiety and psychosocial factors (including how well an individual deals with pain, fear of movement (kinesiophobia), pain catastrophization, low self-efficacy and passive pain coping mechanisms) are important areas to consider when assessing these patients’ fitness to return to work. If an individual fears that work will worsen his / her condition, it may have an impact on his / her ability to return to work.

De Vries and colleagues report that, in general, patients who have chronic nonspecific musculoskeletal pain and who remain at work report poor to moderate work ability and performance. However, they found that a subgroup of workers is able to remain at work and achieve high performance and ability. These individuals tend to have high levels of pain self-efficacy. Black and colleagues also note the existence of positive associations between high self-efficacy and return to work outcomes for patients with upper body musculoskeletal and psychological injuries. Thus, it appears that personal and work-related factors affect work ability and performance rather than pain alone.

Why is Work Important?

Work is considered an essential part of life and an inability to work due to disability or other health issues can result in significant losses for both the worker and the economy generally. Remaining active, including while at work, is an important part of recovery as inactivity will delay recovery. Thus, returning to work should be a key focus for these patients. However, five percent of all sickness absences will become long term (ie they will last more than four weeks). These long term absences account for almost half of the total working days lost each year. The more off-time an individual has, the greater the risk that she/ he will not return to work. For instance, if an individual is absent from work for six months, there is an 80% chance that s/he will be out of work for five years.

There are various reasons why work is important:

• It increases physical and mental health
• It enhances a worker’s sense of purpose, confidence, self-worth, independence and fulfilment
• Physical activity aids recovery - people are more likely to be sedentary at home
• Social isolation increases during periods of absence from work
• Individuals are more likely to return to their hobbies and sports when they return to work, which increases satisfaction
• Relationships at home can become strained with role reversals during long term absence from work

Role of the Occupational Health Physiotherapist

Occupational health physiotherapists help to manage musculoskeletal injuries in the workplace. They perform impartial and objective assessments in order to ensure the best outcome for both the worker and the employer. A key part of their roles is to provide guidance about when an individual is ready to return to work after an injury or other absence.

The primary goal of occupational health physiotherapists is to help an individual to return to his / her existing job. If this is not possible, the focus is on returning to the same job, but with some adjustments. Alternatively, they may return to a different job with the same employer. If none of these scenarios is appropriate, the goal would be to find work with a different employer.

Key information that occupational physiotherapists provide to the employer and employee include:

• Advice about what jobs the worker can or cannot do
• Advice about what adjustments might be needed in terms of the demands of the job, so that the worker can manage his or her role

A fitness to work assessment will assess a worker’s ability. If the worker’s ability matches the demands of the job, then she/ he will likely have a successful job placement. However, in situations where the worker’s ability and job demands are incompatible, occupational health interventions will be necessary. These include:

• Ergonomic technology
• Altering job demands (eg reduced lifting requirements)

Return to Work Assessment

A return to work assessment will include:

• Subjective assessment
• Objective assessment
• Patient reported disability
• Psychological assessment
• Functional testing

Subjective Assessment

When conducting a subjective assessment, it is important to explore the history of the condition, including previous treatment and medical intervention. This will provide information about the stage of healing and the patient’s stage in the recovery process. While it provides key information about the patient’s history, it will not necessarily provide an indication of what is possible for the patient in the future.

Objective Assessment

The objective assessment is important as it aids with diagnosis and guides physiotherapy management. However, these tests are not always very specific and may not always correlate to functional losses. This means that they are not necessarily predictive of whether or not a patient will be able to return to work. Nor will they demonstrate how a patient will perform at work. For example, a patient who has significant shoulder pain, with restricted movement and weakness, may be able to perform his or her job normally if it is computer based. It has also been found that clinical examination tends to show greater limitations than functional testing (assessed by the Isernhagen Work Systems Functional Capacity Evaluation). Thus, while an objective assessment is useful, it cannot provide sufficient information in isolation to determine a patient’s readiness to return to work.

Self-Reported Disability

Self-reported disability measures highlight a patient’s perceived ability to engage in various activities. There are a number of different self-report disability questionnaires for different body parts, including the Roland Morris for back pain, the DASH or quickDASH for the upper limb and the KOOS for the knee. There are also a number of assessments that are specific to injuries, including the Carpal Tunnel Assessment.

Each questionnaire indicates the impact of the injury or condition on the individual’s lifestyle. However, a key disadvantage of these scales is that they are influenced by the individual patient’s perception of pain. It has been found that a patient is more likely to report higher levels of limitations when compared to limitations shown by the objective examination or functional testing.

Psychological Assessment

An individual’s response to their pain will influence their prognosis. As mentioned above, mental health and psychosocial factors are important areas to consider when assessing fitness to return to work.

There are a range of psychological tools that can be used when assessing a patient’s return to work status. However, Sleijser-Koehorst and colleagues found that when assessing musculoskeletal pain, the following areas should be explored:

• Fear of movement using the Fear Avoidance Belief Questionnaire and Tampa Scale of Kinesiophobia
• Ability to cope using the Coping Strategies Questionnaire or Chronic Pain Coping Index
• Self-efficacy and catastrophizing using the Pain Catastrophisation Scale

Functional Testing

Functional testing is often referred to as a performance measure. It is usually task based and an individual is assessed doing a range of tasks, including strength based activities, postural tolerance, balance, lifting mobility and hand dexterity. It has been suggested that these functional measures are most appropriate for tracking age-related differences in functional capacity. Return to work assessments should include tests exploring a range of different physical activities.

Biopsychosocial Model

Recent research has explored which of the above tools are best able to assess the ability to return to work. However, the evidence suggests that no single test or measure can predict fitness to return to work. For instance, self-report, clinical examination and functional testing all show significant differences when attempting to predict limitations and it is important that health professionals are aware of these limitations when utilising these measures.

However, when performance (i.e. functional testing) and non-performance (i.e. self-reported disability, social assessment) measures are taken together, they can provide information about an individual’s ability to return to work.

Gouttebarge and colleagues discuss a three step process that an occupational rehabilitation workers should go through:

1. Step one - establishing the medical condition and its related functional limitations
2. Step two - assigning activities related to a functional condition
3. Step three - selecting functional tests from the full Functional Capacity Evaluation to measure activity limitations

This multimodal approach is known as the biopsychosocial model. It includes a:

• Biological assessment (subjective and clinical assessment of the condition)
• Psychological assessment (a patient’s fear, beliefs and attitudes about his / her condition and what she/ he can do
• Social assessment (self-reported disability)

The information gained from the biopsychosocial assessment should then be considered alongside functional testing so that the occupational physiotherapist has a reliable method to predict fitness to return to work.

Using Functional Tests

A key benefit of functional tests is that the therapist is able to follow a standardised protocol with standardised scoring. This means that results are consistent, valid and easily reproduced. Moreover, they provide data about the patient which can be compared to the general population (through normative data) or to the job demands. Thus, utilising these tools is beneficial when assessing fitness to return to work.

When choosing a functional test, it is important to select a test that is:

• Scientifically robust (i.e. reliable and valid)
• Clinically useful (i.e. in terms of time required, costs, equipment required)
• Relevant to the employee
• Reflective of job demands

It is also important to remember to choose a number of tests that focus on a range of physical actions. In order to select the correct tests, it is essential that you:

• Understand the medical condition, including its impact on the individual - this information will be clear based on the biopsychosocial assessment
• Identify the activities that are restricted - a job analysis should be performed to determine the tasks required for a job and the results of the functional tests should be compared to the job tasks

Examples of Functional Tests

Sit to stand test

An individual is asked to move from sitting to standing 10 times (there are variations on this, such as 5 sit to stands (shown below) or asking a patient to perform as many sit to stands as possible in 30 seconds). This test is a quick, simple and reproducible measure to quantify lower limb strength. Evidence shows that lower muscle strength is a good predictor of later disability. There is a significant relationship between time and age across genders. Thus, results can be compared to normative data, but it is important to consider if the data is representative of the population being tested (eg ethnicity, gender). Francis et al note that reference ranges for lean tissue mass or skeletal muscle are best generated from the thigh region as the thigh appears to be most responsive to age-related changes or intervention, so this is a useful measure. The maximal force generating capacity of the thigh is best represented through the knee extensors because they:

• Are the most substantial part of the thigh
• Are a more stable measure
• Play an important role in many activities of daily living
• Experience a greater decline when compared to knee flexors

Maximum grip strength

This is a measure of general fitness and strength based on an average of three maximum grip tests. Again results should be compared to normative data. The individual should not practice in advance, as this may result in fatigue. Grip strength is more than just a measure of hand strength - it is also associated with various ageing outcomes, and is connected with sarcopenia and frailty phenotypes as well as all-cause death, cardiovascular death and cardiovascular disease. Grip strength is known to peak in early adult life. This is followed by a maintenance period and then strength declines with increasing age, starting as early as 40+ years in both men and women.

Maximum lifting test

Performance-based lifting tests (such as a lifting test from floor to waist level in patients with chronic back pain) appear to be predictive of work participation. This may be because lifting involves a large number of physical actions including gripping, holding, bending, lifting and lowering - there is conflicting evidence on its association with pain intensity, fear of movement, fear or (re)injury, depression, gender and age. It is an important predictor of work ability in patients who have musculoskeletal complaints.

One lifting test is the  Progressive Isoinertial Lifting Evaluation (PILE) (shown below) - which involves an individual standing in front of a box and then lifting it 4 times within 20 seconds up to a 75cm table.

Key Points Before Commencing Functional Testing

Before undertaking any test, it is important to gain consent, check the patient's understanding of the test, and to ensure his / her safety through appropriate screening and monitoring, including:

• Biological - pain and level of exertion can be monitored using the BORG scale
• Physiological - measure BP at the beginning, and HR and RR throughout
• Biomechanical - observe muscle fatigue or weakness, poor movement pattern
• Psychosocial