While worksite programs have a positive impact on the reduction of employee injuries, physical therapists and other rehab professionals are challenged to get those workers who do suffer an injury back to work as soon as possible. This becomes even more important for patients in these currently uncertain economic times.

The recessionary era we all now deal with has demonstrated that workers' compensation is a tumultuous arena for policymakers and elected officials. Battle lines get drawn between political parties as well as among health care practitioners, attorney groups and organized labor opposing organized business associations. Most of the feuding concerns cost and utilization containment. However, what seems surprisingly conspicuous by its absence is that when most politicians and business leaders speak of outcomes, they are almost exclusively and uniformly referring to fiscal outcomes, not clinical.

No Patient is an Island
Economic as well as humane concerns arise as well, and it becomes incumbent on physical therapists to provide proper care vis-à-vis the injury and its sequelae. However, in this process, other aspects of the patient/person also undergo a healing process. While the focus of care is on the injury, physical therapists know that patients are not a collection of symptoms, but rather a complex and dynamic system.

While we obviously understand this biomechanically, those treating injured workers also come to understand this system to include the psychological (e.g., self-esteem, self-efficacy, depression, anxiety), familial (e.g., sexuality, activities with children, caretaking of aged parents), social (physical activities with friends, role-identity to a physically demanding profession, loss of status), economic (diminution of income while simultaneously having an increase in medical expenses), and many other aspects.

All of these issues can conspire to create poor outcomes by any measure-economic, personal or professional-for both employee and employer. They are literally life changing for the injured worker.

Thus, in our practice, we feel it is important for health care to be integrative. Far too often, health care specialties become insular and siloed, resulting in care that is likewise narrow or limited. Being empirically oriented, we wanted to conduct an investigational study to probe and thus better understand the impact that our rehabilitative services may concomitantly influence other aspects of health status as well as perceptions concerning returning to work, such as being fearful to return to the site where they were injured.

While multiple studies have shown that patients with a high level of fear avoidance do much better in a supervised physical therapy exercise program, we found that no one has investigated the impact of an evidence-based, sports performance-based work conditioning/hardening (SPWC/H) program on fear avoidance beliefs and general health perceptions of injured workers. Thus, we set out to examine the outcomes and impact rehab has not only on healing the injury and expediently returning the injured worker to work, but also how participation in such a program may impact fear-avoidance beliefs as well as other health and well-being perceptions.

An Examination
In order to do this, we used standardized measures (the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Medical Outcomes Study 36-Item Short-Form Health Survey, or SF-36) and surveyed 206 patients from 37 of our clinics in Illinois, Wisconsin and Delaware. All patients provided informed consent.

Seventy-nine percent of the patients were male. Their average age was 43.2 years and the females' average was 43.4 years. One hundred and nine (53 percent) patients had undergone surgery. The majority of respondents (66.5 percent) had been injured over six months prior to their participation in the program. Most patients had only one injury (91.7 percent) and 8.3 percent had two or more injuries.

The Approach
Driven by the necessity for a far more effective option than standard rehabilitative programs, this program was developed with input from a review of the literature, consensus guidelines, and expert opinion of orthopedic surgeons, physical therapists, athletic trainers, exercise physiologists and biomechanists to create an optimal, evidence-based return to work program (Functional Integration of Rehabilitation and Strength Training, FIRSTTM). The program is group-based and conducted with multiple people attending the program simultaneously.

The result of the positive peer milieu/culture provided within the SPWC/H program is similar to the finding that a strong social support group is influential in successfully returning injured workers to their jobs. The proxy of work via participation in a work conditioning/work hardening program, along with the kinship experienced by those in such a program, appears to provide the necessary peer support that fosters mitigation of fear-avoidance beliefs as well as improving overall health perceptions.

The Findings
The SF-36 is a commonly used measure that examines eight areas of health. It is a psychometrically rigorous and reliable tool for examining health-related quality of life aspects. The Fear-Avoidance Beliefs Questionnaire aids in quantifying levels of a person's fear of pain and the beliefs associated with avoiding such pain. These items are specifically related to current and future disability in the work environment along with work loss concerns.

Findings for the entire population sampled indicated that pre- and post-program scores improved at a statistically significant level (P<.0.01). The findings generally suggest that participating in an evidence-based sports performance-based work conditioning/hardening program can significantly mitigate participants' fear-avoidance beliefs about work as well as other physical activities. Similarly, when comparing patients' health perceptions and attitudes prior to beginning the program and upon completion, across-the-board improvements at a statistically significant level were also discovered. That is, patients' perspectives concerning their personal health quality and expectation for the future also improved.

Results indicate that patients herein had greater confidence in performing various physical activities of daily living, as well as more vigorous actions. Likewise, positive feelings about work and other daily activity abilities vis-à-vis physical health status increased significantly, along with an improved emotional perspective as well. Social functioning without interference due to physical or emotional problems was improved along with general mood state and greater frequency of positive moods. The absence of severe and extremely limiting pain increased for these patients, and they reported experiencing higher levels of vitality and energy.

What We Learned
It is important to understand these findings in the context of comprehending the additional therapeutic impact of an injured worker participating in a SPWC/H program. From the perspective of the rehabilitation professional, there is a successful completion of rehabilitation.

Part of this is not just the physical healing and conditioning, but also the psychological as well.

While dynamics limiting strength production such as physical factors or biomechanical efficiencies can be dealt with via proper exercise and training, the fear of pain and the fear of injury may also be key factors in optimal functioning.

Pain and injury (and fear thereof) occur with every patient going through the workers' compensation process-exacerbated by social and monetary stresses that naturally occur.

Other studies have examined the role of injured workers' expectations on clinical outcomes, as well as how fear avoidance beliefs can prolong work restrictions.

Herein, we were interested in learning whether clinical outcomes could be optimized and fear avoidance beliefs mitigated regardless of patient injury or demographics if they participated in a sports performance-based work conditioning/hardening program.

Moving Forward
The results are promising that completing such a program yields manifold benefits that go beyond returning to work and extend into other areas of physical and emotional function.

Indeed, if patients' fear avoidance beliefs dominate their ability to confront their symptoms in treatment, they are much less likely to be active. This lack of activity can further contribute to progressive disability.

In the adapted stress process model, a control variable-fear of work-played a predominant role in the prediction of work status. The adapted stress process model suggested that psychological variables act differently according to the variable predicted and to the period of time considered.

Use of such theoretical models could lead to a better understanding of the development of long-term disability and to improvement of our capacity to predict this complex phenomenon, and thus are important for physical therapists to also be mindful of.

It is incumbent on all rehabilitation professionals to remember, if not emphasize, that we are health care professionals dealing with the complexities of not only the physical, but the psychological-and the days of antiquated Cartesian models are long past.

Patients function as a system, not a set of symptoms. Systems are complex and integrated. We can be leaders in the provision of health care to all those with physical injuries and serve as role models for understanding the complex interplay of physiological, psychological and social aspects in the rehabilitative process.

Brent Mack is regional vice president of clinical operations at ATI Physical Therapy, Bolingbrook, IL. Chris Stout is director of research at ATI Physical Therapy and clinical professor at the University of Illinois at Chicago, College of Medicine.