RETURN TO WORK

CONSIDERATIONS AFTER
CHRONIC DISABLING
CONDITIONS AND INJURY

PRESENTOR: SNEHA MANDAR

 Introduction

Definition

Perspectives

CONTENTS Approaches

Models

Principles

RTW after conditions

 Work and Health
• Work forms a large part of most people’s lives bringing a range of benefits to
individuals, in addition to the financial benefits of a wage and pension.

• Work can provide people with a sense of dignity, purpose, opportunities for social
interaction, develop new skills and give something back to the community.

• Work allows full participation in our society. However, work does need to be for
financial gain: voluntary or charity work brings many of the non-financial
benefits of employment.
• Health is not always a necessary condition for work, and work is not always a risk
factor for health. There is now strong evidence that work is generally good for
health, and that the beneficial effects of work outweigh the risks of work and the
harmful effects of a life devoid of work.

• Certainly, the beneficial effects of work depend on the nature and quality of that
work and its social context and, importantly, reverse the adverse effects of
unemployment.

• It does not necessarily follow that an illness, injury, or disability results in an

inability to work. Examples are the legion of people who work despite severe
illness or disability.
• The effects of unemployment in terms of health are thus now recognized.
Unemployment causes poor health and health inequities, and this effect is still seen
after adjustment for social class, poverty, age, and preexisting morbidity.

• A person signed off work sick for 6 months has only a 50 % chance of returning to
work. By 1 year it is 25 % and by 2 years about 10 %.

• One study showed that after 6 months off-work due to ill health the majority of
people were suffering from depression, whatever the initial presenting problem.
 • 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.
Why is Work
Important? • However, five percent of all sickness absences will become
long term (i.e., 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.
 • increases physical and mental health
• enhances a worker’s sense of purpose, confidence,
self-worth, independence and fulfilment
• physical activity aids recovery - people are more
Reasons why likely to be sedentary at home
• social isolation increases during periods of absence
work is from work
important • 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
 INTRODUCTION
• Over a billion people(15% worlds population) have some form of disability.
• 10-20% of these have significant difficulties in functioning.
• Rates of disability are increasing due to population ageing and increases in chronic
health conditions.
• Work disability is associated with less economic activity, greater dependence on
social programs and decreased benefits of employment participation.
• 10% of working population reported WD (>20 million adults)
World Health Organisation
• Most common causes:
Back/neck problems(30%)
Depression/anxiety/emotional problems(20%)
Arthritis/rheumatism(20%)
 • “situations associated with injury, health, or physical conditions that
create specific limitations that have lasted (or are expected to last)
for a named period of time”
Altman 2001
• “an outcome or result of the complex relationship between an
individual’s health condition and personal factors, and of the
DISABILITY external factors that represent the circumstances in which an
individual lives”
WHO
• Clinical definitions of disability focus on
identification
qualification
quantification
• In the public arena, for example within the Americans with Disabilities Act
(ADA 1990 ), broad definitions of disability have gradually replaced
narrower, function-specific disabilities.

• ADA defines disability as:

1) a physical or mental impairment that substantially limits one or more
of the major life activities of such individuals,
2) a record of such impairment, or
3) being regarded as having such an impairment
• Injuries and illnesses sustained in the workplace are a major global source
of ill health and disability

• Worldwide, an estimated two million men and women die each year as a
result of work-related injuries or illnesses and a further 268 million
nonfatal workplace injuries result in time off work.

• Further eight percent of the global burden of disease from depression is

currently attributed to occupational risk

International labour Organisation, cited in WHO 2010

 1. Self-report of disability by an individual with disability; e.g.,
the Sickness Impact Profile
2. Report of disability by a collateral source, such as a clinician
and/or significant other
3. RTW and/or employability, including cycling between
WORK disability and RTW and repeating patterns of work absences
DISABILITY 4. Duration of disability
5. Ability to sustain employment after RTW
6. Healthcare and wage loss-based costs of disability
7. Healthcare utilization
Schultz 2008,Brede et al. 2015
• Work disability “is the result of a condition that causes a worker to miss at
least one days of work and includes time off work as well as any ongoing
work limitations. Conditions resulting in work disability may be either
traumatic or non-traumatic in etiology”
Young et al., 2005
• As time off work due to
work disability increases,
the less likely the injured
worker will ever return to
work

• These factors have brought a greater responsibility for return to work

programs to help injure worker return to work as soon as is safely possible, no
matter if the injury was work-related or not
Clayton, 2005
 • Schultz et al. observed that while occupational or work
disability has been operationally defined as “time off of work,
reduced productivity, or working with functional limitations as a
result (outcome), of either traumatic or nontraumatic clinical
conditions, the term ‘return to work’ is utilized as both a process
and outcome measure”
RETURN
TO WORK • Krause and colleagues further proposed that RTW :
 process, such as graduated return to work
 working status, considered a final, measurable outcome
related to disability and including return to pre-injury
employer and/or job and the use of accommodations
 a variety of vocational outcome definitions, including
length of work inability
 Conceptualization of RTW
• RTW has been operationalized as both an outcome and a process measure.

• RTW has also been understood as a “process” of returning an injured worker back into
the workforce (e.g., job accommodation) or a final, measurable, common disability
outcome.

• RTW outcomes are multifaceted and may involve returning to the pre-injury job, pre-
injury employer, new employer, and work with or without accommodation.
 Historical Perspectives

1. Biomedical approach
2. Social construction approach
3. Biopsychosocial approach
 Biomedical approach

disability is produced by
a medical condition that Disability is viewed as
Factors such as context
is an identified, a personal problem that
and environment are
observable deviation requires medical
from biomedical norms not considered.
treatment
of function or structure
Under the biomedical
model,
psychopharmacologic
treatment is primarily
used to treat mental
disorders
 Social construction approach

disability is viewed as complex

combination of activities,
relationships, individual Disability depends on a societal
attributes, and conditions response in a given context.
arising mainly from the social
environment of the individual.
 Biopsychosocial approach

Evolvement of this alternative

informed by both social and the paradigm furthered the
biomedical approach. conceptualization of disability as
multifactorial.
• These three major paradigms have collectively given rise to five major
groupings within the disability field, informing RTW models:

1. Biomedical and forensic

2. Psychosocial
3. Ecological/case management and economic
4. Ergonomic
5. Biopsychosocial
 Comparison of
underlying
constructs and
research tradition
in conceptual
RTW models
 • its prominence and usage are gradually losing emphasis,
primarily because this model is no longer viewed as a
complete or accurate method of evaluation due to the
recognition of many other factors that impact disability
(e.g., psychosocial factor, sociétal influences).
1. Biomedical
and Forensic • the forensic model reduced the importance of
scientifically based information on impairment,
Models focusing instead on detecting individuals who
exaggerate symptoms and present malingering
behaviors.

• Within the context of occupational disability, biomedical

and forensic models have evolved.
• involves two individuals
the client (e.g., the injured or disabled worker)
the treating physician
• The decision to RTW is primarily based on the physician’s evaluation,
treatment, and recommendations involving the injury
• The forensic model mimics the biopsychosocial approach and integrates
cognitions and motivations while attempting to explain the interactions
between the injured worker and the disability system
• The biomedical model relies heavily on objective findings, whereas the
forensic model attempts to identify the motivations that may influence the
RTW decision
 • Evolving from the traditional psychiatric
perspective of disability with a focus on
psychopathology.

2. Psychosocial • considers a broader psychosocial adaptation

perspective.
Models
• RTW is viewed as a behavior, and occupational
disability is viewed as a wide-ranging set of
conditions created by a client’s social
environment and other societal institutions
versus an individual attribute.
 • The stakeholder’s perspective forms the primary focus
of these models
• is founded on a whole host of disciplines including
anthropology, health psychology,
industrial/organizational psychology, nursing,
3. Ecological/Case occupational health and therapy, sociology, and social
Management and work
• is tightly founded on the field of economics and is
Economic Models focused on the role of systems involving interactions
between microsystems , mesosystems , and
macrosystems
• emphasizes that the most important stakeholders are
the workplace, health-care system, and the
compensation system
 • focuses on understanding the interactions among
humans and other system elements through
application of theoretical principles and methods to
optimize human well-being.
• While the field of ergonomics covers three distinct

4. Ergonomic disciplines — physical, cognitive, and organizational

— within the context of disability, this section will
Models focus on the physical and cognitive aspects.
• focuses on both interactions between individual and
system elements and in injury prevention.
• From this viewpoint, whether or not an individual is
able to RTW is an outcome based on adaptations
made in the workplace (e.g., job tasks, working
hours).
 • Integrates key aspects from both the biomedical and
the psychosocial model.
• focuses on the conceptual interaction among
biological, physical, behavioral/ psychological, and
social factors.
• a more complete comprehensive biopsychosocial
5. Biopsychosocial model includes medical, psychosocial,
Models environmental, and ergonomic factors.
• was developed using empirically driven risk factors
and the cumulative clinical experience with clients
with chronic musculoskeletal pain.
• considers the interactions between the injured worker
(or person with disability), the employer, case
managers, medical providers, and social environment
 Schultz et al. identified key features of recent RTW
models
Psychosocial model evolution:
Current The traditional, psychiatric model has been replaced
Perspectives by the broader psychosocial model, emphasis on
adaptation, individual cognitions on disability within
a social context, and cognitively mediated
motivational factors.
 Stage-based models of RTW:
These models have shown greater articulation of the
RTW process including temporal elements and
disablement patterns such as psychosocial factors
Current interacting with time and medical recovery.
Perspectives
Ecological/case management model changes:
This model has expanded to include reciprocal
interactions between stakeholders such as the employer,
insurance systems, healthcare, society, and the worker.
 Reduced role of biomedical and forensic models:
The traditional forensic model has been narrowed in its
application to forensic applications within the court system.
This change shows greater compatibility with the
ecological/case management model.
Current
Perspectives Greater reliance and support for the biopsychosocial model:
Evidence-based support in RTW literature and healthcare
and greater awareness and work toward operationalization
of the interactions between individuals and systems and the
depth of the multidimensional system.
 • Musculoskeletal disorders (MSDs) and the resulting work
absences are a major health problem in industrialized
countries and are the main cause of disability.
ISQ 2002
Concept of • Historically, since the 1980s, several interventions have
Margin of noted a decentralization of the actions aimed at the RTW
from the clinical environment to the actual work
Maneuver in environment.
RTW
• As long ago as 1998, in a review of the literature on the
topic, Krause et al. ( 1998 ) concluded that this program type,
which includes the real-life workplace environment, was
effective and produced decreases in days of absence from
work.
• In summary, the therapeutic RTW is a program that combines reactivation with a
progressive resumption of work tasks in the actual workplace under the supervision of
a clinician.
• The program involves a continuous evaluation of the interaction between the worker
and the environment.
• It also accounts the changing clinical reality of persons who reactivated and the
variability of the work situation.
• This innovative therapeutic RTW process enabled around 70 % of those admitted to
the program to RTW after an average absence of 10 months and to remain on the job 1
year.
• This type of program is usually offered by an interdisciplinary team of professionals
that may include, among others, an ergonomist, occupational therapist, kinesiologist,
general practitioner, physiotherapist, and psychologist.
• presents the example of a
worker who joined the
therapeutic RTW program

• She was a 42-year-old cook in

a daycare center who had been
off work for 11 months due to
capsulitis of the right shoulder
 • The margin of maneuver concept is central to the
concept of work as put forward by francophone
ergonomics

Definition of
• MM is the “possibility or freedom an individual has
Margin of to develop different ways of working in order to
Maneuver meet production targets, without having adverse
effects on his or her health”
Vézina
• MM is a regulation space for the individual involved
in a work activity
• For example, a bagger in a grocery store has a certain MM when provided enough
bags to do the job. A corporate policy to stop providing bags to customers reduces
the bagger’s MM. The bagger, who had developed a way of arranging the bags on
the counter to avoid the onset of musculoskeletal disorders, suddenly needs to re-
invent this work task; it has become even more difficult because the bags, now
supplied by the customers, come in various shapes and sizes. The bagger’s
regulation process is therefore compromised because of a reduction in MM.

• If sufficient, the MM allows the worker to maintain a balance between the

challenges of preserving health and attaining task related objectives, i.e., allow for
adequate productivity while minimizing health risks.
 Types and
• Specifically, four types exist based on the
Dimensions of four pivot points in the RTW program:
Margin of initial
Manoeuvre in a Work potential
Rehabilitation therapeutic
Context final
1. Initial MM (MMi)
The margin of manoeuvre held by the worker at the job prior to the
current sick leave (pre-injury)
determined during the initial interview with the worker.

2. Potential MM (MMp)
MM evaluated during the first weeks of the RTW program by the
rehabilitation team
factors include results of the initial evaluation by a worker from each of
the team’s disciplines, the worker’s capacities as observed in a clinical
setting, and the job demands as described by the worker.
3. Therapeutic MM (MMt)
MM maintained throughout the therapeutic RTW program. .
To maintain a sufficient MMt, the clinicians attempt to modulate the exposure to
work based on the worker’s condition (e.g., capacity, fears, pain) and the
characteristics of the work situations.
Accordingly, as part of weekly RTW planning, the components of the MMt are
systematically reviewed by the clinicians. A new MMt is established and
communicated to the worker and the manager.
During the end-of- week analysis of the MMt, three results may arise: the MMt can
be deemed insufficient, barely sufficient, or sufficient.

4. The Final MM (MMf)

found at the end of the program.
If it is sufficient, it will favor a sustainable RTW.
 Integration and Application of ICF in Return to Work

• Work participation or employment is a major area of people’s lives.

However, when a worker becomes affected with a health condition, illness,
or disease, work disability may result and prevent the individual from
working.
• Work disability may be associated with personal suffering, limitations in
functioning, loss of income, high medical costs, and strained relationships
of the individual with others.
• Work disability poses a great burden and challenge to both developing and
developed nations
Why Integrate • The ICF was intended by the WHO to be a
ICF and Work universal language when describing functioning
and can be applied in the work context.

• The breadth of the ICF model is evident in its

comprehensive set of functioning domains, which
addresses the multifactorial nature and
complexity of vocational rehabilitation and RTW.

• The ICF model can be used to select relevant

domains for VR and measures of successful RTW.
 1. What is the job in question?
2. What is this patient’s medical problem? What are the
symptoms? Is this permanent or temporary during
recovery from injury/surgery? Is this problem
improvable with time, or medical treatment, or exercise?
How to 3. Does this patient have severe pathophysiology that
appears to meet the Social Security Administration’s
Evaluate criteria for total disability?

Work Ability 4. Is there significant risk of substantial harm with work

activity (not merely an increase in subjective
symptoms)?
5. Is this patient actually able to physically do the task in
question (not considering symptoms, but ability)?.
6. If the patient has the ability to do the work task, at
acceptable risk, and wants to do the job, certify that he
or she is medically able.
 The Five Steps From Injury to
Resolution
1. Establishing a
relationship between 2. Diagnosis and 3. Time off work and
injury and the treatment return to work
workplace

4. Impairment and 5. Settlement and

disability resolution
 1. workplace has a strong commitment to health and safety
2. work accommodation
3. support the returning worker without disadvantaging co-
workers and supervisors
Principles for 4. supervisors are trained in work disability prevention and
successful included in RTW planning
5. employer makes early and considerate contact with
RTW injured/ill workers
6. RTW coordination
7. employers and healthcare providers communicate with
each other about the workplace demands.

Institute of Work and Health in 2007

 Factors associated with return to work

• RTW is a complex and involves the interplay of many factors

• A study done by cancelliere et al. 2016 identified factors which are common across
condition and might form the basis for generic RTW strategies that can be tested
and broadly applied across setting and condition
Common prognostic factors associated with positive RTW
outcomes

• Personal, body structure and function, as well as activity related

factors included higher education and socioeconomic status, higher self-
efficacy/optimistic perceptions and expectations, lower severity of the
injury/illness, and being employed preinjury.

• Environmental factors associated with positive RTW outcomes

included stakeholder participation in the RTW process, work
modification/accommodation, and RTW coordination.
• Many interventions, especially those involving a workplace component, were
associated with positive RTW outcomes, including multidisciplinary, occupational
care/ training, education, psychological, and outpatient interventions/ comprehensive
treatment

multidisciplinary intervention included, physical, educational, psychological and

social as well as physical, psychological and vocational interventions
educational interventions included back schools, fear-avoidance training, and work
advice
psychological interventions included cognitive behavioural therapy and problem
solving therapy
 Common prognostic factors associated with negative
RTW outcomes
older age
female
higher pain/disability
depression
previous sick leave and unemployment
 activity limitations/participation restriction (ADLs)
higher physical work demands
 Modifiable Prognostic Factors
Expectations of
Pain and
recover and Depression
disability levels
RTW

Access to
Workplace
multidisciplinary
factors
resourses
Multiple factors potentially affecting RTW
Feuerstein 1991
 Subjective assessment

Return to Objective assessment

Work
Patient reported disability
Assessment
Psychological assessment

Functional testing
Subjective Assessment

• to explore the history of the condition, including previous treatment

and medical intervention

• will provide information about the stage of healing and the patient’s
stage in the recovery process
Objective Assessment

• important as it aids with diagnosis and guides physiotherapy management.

• these tests are not always very specific and may not always correlate to
functional losses.
• means that they are not necessarily predictive of whether or not a patient
will be able to return to work.
• Useful but it cannot provide sufficient information in isolation to
determine a patient’s readiness to return to work.
Patient-Reported Disability
• highlight a patient’s perceived ability to engage in various activities.
• There are a no. 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.
• Each questionnaire indicates the impact of the injury or condition on
the individual’s lifestyle.
• a key disadvantage of these scales is that they are influenced by the
individual patient’s perception of pain.
Psychological Assessment
• An individual’s response to their pain will influence their
prognosis.
• 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.
• when assessing musculoskeletal pain, the following areas should be
explored: Fear of movement using the 
Fear Avoidance Belief Questionnaire 
Functional Testing
• referred to as a performance measure.
• 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. 
• these functional measures are most appropriate for tracking age-
related differences in functional capacity.
 • help to manage musculoskeletal injuries in the workplace
• perform impartial and objective assessments in order to
ensure the best outcome for both the worker and the
employer
• provides guidance about when an individual is ready to
return to work after an injury or other absence
Role of the • help an individual to return to his / her existing job. If this
Physiotherapist is not possible, the focus is on returning to the same job,
but with some adjustments
• 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
Ergonomic technology
Altering job demands (e.g., reduced lifting
requirements)
• de Boer et al. found that physical exercise could contribute to RTW.

• In a systematic review, they showed that multidisciplinary

interventions including physical exercise were more effective for RTW
than occupational support and counseling alone. This finding is in line
with studies among chronically ill workers in general.

• The mechanisms involved in the association between physical exercise

and RTW remain unknown. Physical exercise may facilitate RTW by
reducing fatigue and improving physical functioning although
exercise-induced fatigue might inhibit RTW.
• It is possible that the intensity of physical exercise is important, workers who
underwent a rehabilitation program following cardiovascular disease reported
that physical exercise did not affect RTW because it was of low intensity and
not task-specific.

• Return to work, in turn, could facilitate or restrain physical exercise. Although

the amount of daily physical activity may increase when going back to work,
participation in physical exercise may be reduced due to time constraints.

• Whether and how physical exercise influences work performance remains

unknown.
• The journey from acute muscle pain to long-term sickness, work
absenteeism and disability has been widely investigated.

• Such studies have revealed that psychological and social factors, as

well as somatic pathology, influence chronicity and disability.

• When the duration of sickness- absence due any pain or illness exceeds
8 weeks, the prognosis worsens and the probability of RTW is reduced.
• Most participants believed that physical exercise had contributed to
RTW, e.g., by increasing their energy levels. Some said that physical
exercise enhanced work performance by improving the ability to cope
with demanding work.

• For some, returning to work facilitated continued participation in

physical exercise and physical activity, primarily due to a supportive
environment at work.
 Understanding Motivation to Return to Work
• Some injured workers successfully return to work even before their symptoms
resolve fully. Others, with similar injuries, report long-term work incapacity.
• Failure to return to work is theoretically and operationally equated with
disability.
• The longer an injured worker is disabled, the less likely a return to work will
occur .
• For example:
an injured worker with 2 months of disability has a 70 % probability to return
to work; after 6 months of disability, this probability drops to 50 %, after 12
months to 30 %, and after 2 years to 10 %.
• Financial compensation is a strong potential barrier to return to work.

• Research indicates that individuals on disability compensation benefits

have poorer treatment outcomes relative to those without compensation
for various types of medical conditions, including heterogeneous chronic
pain, chronic low back pain, closed head injury, crush injury to the foot
and whiplash injury.
 RTW after Injury/Illness
• A longer duration of unnecessary missed work after a work injury can
increase the risk of long-term work disability.
• Of the factors that influence the risk of long-term disability, individual and
medical factors may be more difficult to modify than workplace factors.
• Supervisors often serve as a point of first contact for employees with work-
related injuries or illnesses.
• A supervisor can facilitate finding modified work and access to health
resources, interpret workplace policies, monitor the worker’s function, and
express support.
 RTW after Musculoskeletal disorders
• A no of factors prolong musculoskeletal pain. Some are obviously related to
the individual, others to the workplace or to compensation systems.

• Multidisciplinary interventions comply with the possibility that barriers to

work-participation exist at multiple levels and have proven beneficial to
facilitate RTW in low back pain.

• As psychosocial factors predict the long-term incapacity of musculoskeletal

disorders, interventions focusing on these aspects should be of clinical
value.
• Musculoskeletal disorders (MSDs) may interfere not only with function but also
with sleep, leading to fatigue and difficulties in sustained concentration, which
may lead not only to safety issues but also are certainly likely to have an adverse
effect on performance.

• Matters can be compounded by the side effects of medications, thereby decreasing

the likelihood of early and sustained RTW after injury.

• McDonald et al. ( 2011 ) found that workers with arthritic back pain and
fibromyalgia had significantly higher levels of work productivity loss than
workers without musculoskeletal pain, even after adjusting for demographic and
health characteristics.
• Evidence-based review of the literature on the relationship between
musculoskeletal conditions and work, Waddell et al. ( 2003 ) concluded :

Musculoskeletal symptoms, whatever their cause, may certainly make it

harder to cope with the physical demands of work, but that does not
necessarily imply a causal relationship or indicate that work is causing
(further) harm.
Certain physical aspects of work are risk factors for the development of
musculoskeletal symptoms.
Psychosocial factors (personal and occupational) exert a powerful influence
on musculoskeletal symptoms and their consequences.
 RTW after Stroke
• In a study from the stroke registry in Thiruvananthapuram, India, the stroke
incidence was 135/100 000; mild disability was seen in 42% and moderate
disability in 43% of the patients.
• Successful return to work after stroke has been shown to improve quality of life
and overall life satisfaction as well as economic circumstances.
• Worldwide, the number of stroke patients who return to work varies significantly
from 14% to 73%.
• A recent study conducted in south India showed that, amongst stroke survivors,
62% were employed before the stroke but only 20% were still working after the
event, with half changing jobs after stroke.
• The severity of stroke, the extent of disability, rehabilitation and the type of employment
all play important roles in the ability of patients to return to work.

• In addition, anxiety and depression following stroke may be as debilitating as any physical
disability. Therefore, mental health and social support factors may also play an important
role in the successful return to work, but few studies have addressed the role of
psychosocial factors in this regard.

• In India rehabilitation centers are few and most of the time rehabilitation is caregiver
based, and this affects functional recovery after stroke.

• There are no data available regarding the work situation following stroke disability in
India.
 RTW after Cancer survivors
• Cancer survivors typically suffer from impairments in physical and psychosocial
functioning, which may last several years after treatment.
• Consequently, 1.5 years after diagnosis, only two thirds of cancer patients have
returned to work, and the rate of unemployment is significantly higher in cancer
survivors when compared to noncancer controls.
• Additionally, work performance, e.g., the ability to perform and complete work
accurately, is often lower than before diagnosis.
• To facilitate RTW and work performance, workplace support and workplace
accommodations are often required
• Physical exercise may facilitate RTW by reducing cancer-related fatigue and
improving physical functioning although exercise-induced fatigue might
inhibit RTW.

• The number of cancer survivors of working age is growing, and an increasing

proportion will be offered the opportunity to participate in physical exercise
because evidence of its safety and efficacy has been increasing.

• Applying physical exercise to enhance RTW and ensuring that RTW is not an
obstacle to participating in physical exercise would be logical steps in cancer
rehabilitation.
• Cancer survivors experienced a positive influence of physical exercise on
RTW and work performance and a positive influence of RTW on physical
exercise.

• When stimulating and facilitating physical exercise during and after RTW,
the time to lasting RTW may be shortened, work performance may be
optimized and sustained participation in physical exercise may be achieved.
• Most cancer survivors will want to resume work after treatment but not all
survivors are able to do so and find the process of return to work difficult.

• Returning to work is important for cancer patients, their families, and society.

• Patients often regard returning to work as a sign of complete recovery and

regaining a normal life.
• Numerous studies have been conducted since the year 2000 assessing return-
to-work rates of cancer patients in many countries.

• A recent review by Mehnert analyzed 28 of these original studies. Overall, an

average of 63.5 % of cancer survivors (range 24–94 %) returned to work
depending on the time from diagnosis to work.

• Studies indicated a steady increase of return to work from on an average 40 %

at 6 months post-diagnosis to 62 % at 12 months, 73 % at 18 months, and to
89 % at 24 months after cancer diagnosis.
Cancer
and
work
model
 RTW Following Major Limb Loss

• Rehabilitation following amputation focuses on restoring body function (with

prosthetic replacement if possible), decreasing limitations in activity, and facilitating
participation and reintegration to community, which includes return to work.

• Amputation results in a permanent change in body structure, which may or may not
be partially compensated with prosthetic rehabilitation.

• The goal after amputation is to reduce activity limitations and increase participation,
of which return to work is an integral component.
• The time taken to return to work following amputation ranges from 9 months
reported after transtibial amputation (Bruins et al. 2003 ) up to 2.3 years in the
study by Schoppen et al. ( 2001a ), independent of the amputation level.

• Age is a well-known predictor of outcome following amputation, and studies

confirm that persons with amputation who are over 45 years of age have higher
unemployment rates (48 %) compared to those under 45 years of age (22 %
unemployment) (Millstein et al. 1985 ) and most that did not return to their job
after amputation were older than 45 years.
• Most authors indicate that the need to change jobs after return to work is high;
Datta et al. ( 2004 ) suggested that 67 % of the 73 % of their upper limb
amputees who returned to work had to change their job; other reports have
indicated only 5 % of their population retaining the same job, but 59 %
returned to the same company in a different post.

• In lower limb amputation, the more proximal the loss, the greater the mobility
restriction.
• The level of amputation does not affect return to work, but if a person is
successfully fit with a prosthesis, this procedure has a positive impact on
return to work.

• In general, persons with amputation are noted to be more successful if they

return to less physically demanding jobs and are offered retraining and
educational opportunities and adaptation to the workplace to accommodate
their functional change to allow them to return to productive employment.
 Ergonomic Accommodation in Return to Work
Accommodation
• The term accommodation basically means “ something supplied for convenience or
to satisfy a need ”

Ergonomic Accommodation
• “any adjustment in the way the work is performed in order to fit the characteristics
of the individual following an injury or illness.”
• This adjustment may take different shapes: change the sequence of job activities,
duration of exposure to a particular task, withdrawal or addition of a task or tool or
substitution or redesign of tools, equipment or layouts from those normally provided
to employees.
• Medically followed RTW processes need to consider the following behavioral
facilitators which were deemed efficient by employers (IWH 2007b ):
1. Having a commitment to safety and health
2. Offering modifi ed RTW
3. RTW process involves consideration of preventing overburden for
coworkers and supervisors
4. Supervisors are involved in RTW planning and trained in work disability
prevention
5. Early contact with injured/ill worker
6. One person devoted to the RTW coordination
7. Communication occurs among employers, health care providers, and the
employee with the worker’s consent.
Purpose of Ergonomic Accommodations
• improve worker performance by increasing safety, comfort and productivity in
work execution and output.
• Workplace modifications target different time lines in the job design and
implementation process: before the work task is designed or after.
• As a preventive measure, ergonomics are involved in design of original tasks,
choice of furniture or tool purchase
• Rehabilitation ergonomics generally take place once there is an identified
overexertion occurrence in an existing task, usually aimed at one particular
worker.
When Should Ergonomic Accommodations Be Considered?

• Ergonomics can be used as primary, secondary and tertiary prevention of

injuries or illnesses, work-related or not.
• In rehabilitation, ergonomic accommodations are used in secondary and
tertiary prevention, typically in form of assistive devices or tool
modification.
• When appropriate, réhabilitation ergonomists should consider factors
beyond the immediate person–task interaction including environmental,
organizational and administrative factors.
 Integrated Return-to-Work Programs
• According to Bose ( 2008 ), a key objective of an RTW program is to facilitate
return to employment as soon as possible, thereby helping an injured person regain
a sense of importance and worthiness; key corporate elements include
(1)early injury and illness management
(2)Accident prevention
(3)active safety program
(4)Ongoing review of workplace design and process
(5)Proactive claims management
(6)employee assistance and corporate wellness
 The Scope of Return-to-Work Programs: Illustrative
Examples

1. A Preventative Approach with Absence Management

2. A Job Placement Program
3. A Functional Restoration Approach
4. A Staged Approach
5. A Comprehensive Strategic Approach to Return to Work
 REFERENCES
• Escorpizo R, Brage S, Homa D, Stucki G. Handbook of vocational rehabilitation
and disability evaluation. Springer International Pu; 2016
• Brassil EB. AMA Guides™ to the Evaluation of Work Ability and Return to Work,
edited by James B. Talmage, J. Mark Melhorn, and Mark H. Hyman: chicago:
American Medical Association, 2011. 510p. ISBN: 978-1-60359-530-8
• Brownson RC, Proctor EK, Luke DA, Baumann AA, Staub M, Brown MT. IWH
Research Alert August 25, 2017
• Schultz IZ, Gatchel RJ, Asih SR. Handbook of return to work. From research to
practice. 2016
• Dejours C, Deranty JP, Renault E, Smith NH. The return of work in critical theory.
InThe Return of Work in Critical Theory 2018 Sep 24. Columbia University Press.