Vol. 19 •Issue 11 • Page 56
Work Conditioning, Work Hardening-What's the Difference?
After a month of rehabilitation, a worker is making great progress and can't wait to get back to work.
Not so fast.
Although traditional therapy has done its part, the patient isn't quite ready to return to part-time or full-time duties. To help him get there, you have two choices: work conditioning or work hardening. Both programs possess components of cardiovascular fitness, strengthening and work simulation. But which one is appropriate for your patient? And what's the difference between these options?
Although they take different approaches, the goals are similar: Return the worker to full duty as quickly, safely and efficiently as possible.
Work conditioning uses strengthening and conditioning tasks to restore function. These individualized programs use hourly sessions, up to five days a week, for one to three months. Depending on the level of a patient's deficiencies, each session lasts one to three hours.
During an initial evaluation, gather current baseline information and functional data about the worker's physical abilities. With these baseline numbers, you can more easily track progress and improvement. You should compile a history, assess manual material handling, determine positional tolerances, take grip measurements and conduct a metabolic equivalence test (MET). This information enables you to see a patient's current functional abilities.
For instance, to test manual material handling, have the patient lift and carry boxes around the clinic. After each lift and carry, add more weight to the boxes and observe performance to determine his current baseline for safe limits.
To test positional tolerance, place the patient into a position (bending at the waist, kneeling, reaching above the shoulders) while doing a task that he'd handle in a work environment. For example, a carpenter should get on his hands and knees and pick items off the floor or pound nails into a board. Look for signs of discomfort. How long can he perform those tasks?
A MET measures cardiac stamina and exercise tolerance. During the MET, a patient wears a heart rate monitor while stepping up and down to the beat of a metronome. After three minutes, record the heart rate. Then, raise the step height for another three minutes and take the heart rate again. The two heart rates determine the patient's MET level, the baseline and high-end cardiac capabilities.
In most cases, workers lack conditioning to complete necessary job functions safely and effectively. Strength and endurance deficiencies can lead to other injuries-back strains, meniscus knee tears or a rotator cuff tear-if they return to work too soon.
Strength exercises should focus on the entire body, including biceps curls (arms); bench press (chest); military press (shoulders); abdominal crunches; seated or prone rows (back, shoulders) and squats and calf raises (legs). Cardiovascular options can include a stationary bike or treadmill. Ask the patient if he prefers to sit or stand. If he prefers to sit, suggest riding a stationary bike. If he says walking makes his stiff back feel better, then direct him to a treadmill. (If you're not sure about cardiovascular ability, contact the physician for clearance.)
I usually have patients walk at regular speeds or faster to build endurance. Running or jogging can be too taxing on joints and ligaments. (And most patients don't run at work.) If a job requires them to walk long distances outside on uneven surfaces, take them outside with a 5- or 8-pound weighted vest to move around for 15 to 20 minutes. Check with the physician about weight amounts a patient is permitted to lift, if he's permitted to bend at the waist or use the involved body part.
If patients experience pain or other symptoms, such as numbness, during any tasks, stop and evaluate why they're experiencing discomfort and determine whether it's safe to continue. A patient may still be assuming a poor position or be more deconditioned than originally thought. If you're in doubt, consult a physician.
For cardiovascular exercises, be careful with people who smoke, are over 45, have high blood pressure or take cardiac medication. Watch for signs of pain, dizziness or a drastic rise in blood pressure during strengthening or cardiovascular exercises. In addition, make sure people don't exceed their maximum safe heart rate.
Education is another key to helping people get back to work. In the work conditioning program, education should consist of instruction on proper body mechanics and manual material handling.
If workers go back to a job without altering basic mechanisms of accomplishing tasks, they'll stand a high risk of reinjury, more than likely to the same body part. A rehab team should educate patients on the correct way to lift and carry objects or teach proper positioning while sitting at a desk. Reinforcing and monitoring these body mechanic techniques during a work conditioning program will eliminate bad habits.
Unlike work conditioning, work hardening is a more aggressive approach. With work hardening, a worker attends daily sessions (Monday through Friday) for four consecutive hours during the first week. With each week of progress, he adds one more hour to daily sessions until he's worked up to eight hours-a full workday.
These treatment sessions should be held at your clinic with equipment and tools similar to the job site. A member of the rehab team should always supervise the patient. Some employers may allow part of the program to occur at the work site. But conducting the entire program at a work site is rare, unless the company is a large, self-insured business with its own therapists and programs.
Work hardening focuses on the functional aspects of a job. These sessions consist of work simulation tasks, with small components of strength and conditioning blended in. This option is appropriate for workers who can't tolerate various positions or job demands, but who also lack strength and endurance.
After collecting basic information during the evaluation (similar to work conditioning requirements), you should conduct a functional capacity evaluation (FCE). During an FCE, a worker tests his abilities with essential job functions by performing tasks that simulate a work environment.
For example, I recently treated a refuse worker with work hardening. His FCE included box lifting and carrying to determine the safe amount, as well as an MET. Tests also included tasks in standing. During the work circuit portion, he had to lift a garbage can loaded with 60 pounds, carry it around the clinic, set it down, climb up a few steps on a ladder and jump down.
By watching these motions, I observed activity tolerance over time, body mechanics, and lifting and carrying capacities, as well as tolerance to standing, walking and climbing. The FCE identified areas in which he was having trouble, so we could focus on those components during work hardening.
After the initial evaluation, a patient will spend a majority of time practicing work simulation tasks. For two of the four hours each day during the first week, he should practice work simulation tasks. Strength and conditioning exercises fill the rest of the time. Toward the end of the program, a patient should eventually spend almost 30 hours performing these tasks. This gives workers the chance to practice appropriate movements and body mechanics.
As a result, you can reinforce certain movements as the program progresses, such as lifting with the legs instead of the back, turning the whole body instead of twisting with the trunk or legs, and pushing instead of pulling.
The best simulated tasks resemble the actual job, so you may need to have equipment available. For instance, construction workers can carry small beams outside in the parking lot, lift and carry bags of cement or garbage cans, or crawl on the floor. Secretaries can play computer games to practice using the keyboard. People who stand and sort items can put together a puzzle at a table. And workers with janitorial duties can climb a ladder to change light bulbs, wash windows in the clinic, vacuum, dust or mop. For all of these workers, monitor the level of pain and heart rate, which is similar to the work conditioning program.
Remember minor details. The closer the task is to the actual job demand, the better it is for the worker. For example, if a construction worker wears a hard hat and tool belt, then make sure he wears those items during work simulation tasks. This will give you a better handle on the worker's ability to perform the job.
The educational component for a work hardening program should cover body mechanics and manual material handling. But you also should stress how the injury could affect activities of daily living. For instance, a low back injury can prevent someone from putting on socks and shoes or picking up the soap he dropped in the shower.
In certain situations, you can blend work conditioning and work hardening. For instance, if referral sources know a worker needs a work hardening program, but he isn't yet ready for the four-hours-a-day requirement, the clinician may suggest work conditioning first. Then, after several weeks of work conditioning, the worker will be prepared for the more rigorous demands of work hardening.
Work conditioning and work hardening programs have different fees and rates, depending on the state or practice location. Usually, work conditioning is less expensive because the program is shorter. Work hardening programs are more expensive because a worker spends more time in treatment.
Nevertheless, each program is cost-effective and can facilitate a safe, speedy return to full duty.
Jon Harrison, OTR/L, is coordinator of industrial rehab services for Cascade Summit Physical Therapy/Work Force in Yakima, WA. He can be reached at (509) 248-6113, ext. 17, or at Jon.Harrison@juno.com