Recently**, a physical therapist who I’ve known for years reached out to me for some advice. She had two patients that were being sent for “work conditioning” to her. The problem was that job descriptions weren’t provided for either of the two patients. She knew that the “I only have to do this…..I never have to do that” wasn’t the whole story. She also knew that I had been involved in writing job descriptions for those positions for some of our clients. Having performed Functional Capacity Evaluations with us in the past, she also knew that having a solid job description is key in matching up demonstrated performance to essential physical and postural demands.
Work conditioning is defined by the American Physical Therapy Association as “work related, intensive, goal-oriented treatment program specifically designed to restore an individual’s systemic, neuromusculoskeletal and cardiopulmonary functions. The objective is to restore the injured employee’s physical capacity and function for return to work.”
Without understanding what the functional demand is for a specific position, it is difficult to define the goals of a work conditioning program. One of the patients that she had inquired about was a school bus driver. He had told my friend that he “really didn’t have to do much beyond sit in the driver’s seat and drive. Maybe, open the door every so often to let the kids on in the morning or off in the afternoon.” He was returning to work from a lower extremity injury that resulted in a joint replacement. Having performed FCEs for school bus personnel before, she knew that the demands were more but was unsure of the other tasks.
School bus drivers are tasked with performing pre- and post- inspections of their vehicles. This involves checking in and around the vehicle, checking storage compartments (if the bus has one), ensuring that all emergency exits (including the roof exits) are operational, and being able to check under the seats for both children and their belongings. Also, in some districts, bus drivers may be switched to different routes based on employer needs. Switching routes may require drivers to pick up students who may be in wheelchairs. When the wheelchair lift malfunctions, drivers use a manual, hydraulic pump to elevate and lower the lift as needed. This task requires the driver to be able to squat or kneel to a level to operate the manual pump. Drivers, if an aide is not present, may have to secure wheelchairs to floor mounted devices, which requires the ability to kneel while reaching. With demands such as those listed, she needed to work with this patient on being able to step up/down to get into and out of the bus, to be able to kneel to perform tasks, and make sure that the driver demonstrated the ability to perform the overhead tasks of checking the emergency exits. The ability to perform these demands are even more important as a result of the NTSB school bus driver recommendations that I mentioned in a January blog post.
Based on the APTA definition, work conditioning covers a larger swath than when the patient was being treated solely for the injury that brought them to physical therapy. During that initial portion of the treatment, therapy focused on the needs of healing for the specific body part along with improving range of motion and strength as appropriate based on the healing process. Work conditioning helps to pick up to make sure that the other aspects of the injured worker such as their cardiovascular endurance, strength, power, and muscular endurance are not impaired when they are returned back to work. As a result, work conditioning includes activities to improve physical capacity in all of these areas. When an individual begins a work conditioning program, their initial status in these components should be documented – both as a baseline as well as for comparison to the essential postural and physical demands. This will help the therapist communicate to the patient, the case manager, the physician, and the employer as to where the patient is in regard to return to duty.
When quarantine/shelter in place orders begin to be lifted, work conditioning is going to play an important role in returning workers that had been out on workers comp prior to the pandemic to their previous roles. For many of these patients, they may have been shifted over to telerehab as clinics closed for safety issues. Telerehab and “virtual physical therapy” are great for keeping in contact with the worker and moving them along in their rehab journey as best as can be done in these circumstances. However, they may not have access to the resources or guidance to recondition themselves for work prior to returning to their job. Correcting this deconditioning is going to be vital to their success upon return to work as well as for reducing their risks for suffering another injury after return to work.
** – I had started writing this several weeks before all of the “shelter in place” orders started to come down from the different states and it sat in a draft folder for a while. As I revisited the draft after a little over 3 weeks in quarantine, it made me think about the fact that some injured workers currently in PT may be deconditioned if not by now, but definitely by the time the shelter in place orders are lifted. Getting these workers into a work conditioning program at the soonest appropriate time point may be the best chance for a successful return to work process.