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The medical advantages of returning to work as part of the healing process are well documented. According to the "Foreword" for the Fifth Edition of The Medical Disability Advisor: Workplace Guidelines for Disability Duration (2005), Dr. Jennifer Christian, MD, MPH writes:
In recent years, the disability "paradigm" has begun to shift. The traditional medical thinking that recovery from illness or injury requires rest and withdrawal from work is becoming passé. It is rapidly being replaced by the idea that people recover better and faster if they stay active and engaged in life as much as possible during and after the medical episode. A growing body of medical evidence supports this new approach. In contrast, when people are treated the old way, they tend to recover more slowly and sometimes fail to heal due to the negative physical, emotional, and social side-effects of the disruption in their normal routine.
According to the new way of thinking, an injury, illness or surgical procedure, even a serious one, need not automatically lead to significant absence from work. A period of disability can often be shortened or prevented entirely by keeping daily routine as normal as possible and arranging for on-the-job recovery. Support from the employer may be required in order to arrange appropriate work site accommodations to keep an injured or ill person safe, comfortable, and successful at work during recovery and beyond. When both the employer and the employee work to make this process successful, both short-term as well as long term returns are usually the result. (xvii)
The aim of The Medical Disability Advisor (MDA) has always been to recommend the physiologically optimum duration for injury or illness recovery, assuming that unusually early or delayed return to work is bad for the individual. In addition, it has stressed treating the individual humanely, so that the "emotional, and social side-effects" mentioned by Dr. Christian do not impair long-term recovery.
The new paradigm is that returning to work can assist or help maintain the healing process. Many refereed articles over the last five years continue to document the propitious effects of engaging in appropriate levels of activity as part of rehabilitation. For acute back pain, it has been found that the resumption of activity as tolerated is superior to bed rest. For certain types of back surgery, those patients who intend to return to work after the surgery have a shorter recovery period than those patients who do not plan to return to work. To the extent that disability leave also disrupts social stability, return to work offsets some of the psychological effects that may protract a leave. Finally, there is strong evidence that workers who are compensated for disability have significantly slower recovery rates than workers who are not. This relatively new approach then encompasses physiological, psychological, and institutional dimensions, each requiring attention in order to obtain optimum recovery.
The following publications argue that timely return to work will benefit the recovery process. These represent a small sampling of publications that deserve to be collected in a more comprehensive bibliography at a later date. It would be a mistake, of course, to draw the conclusion that every injury or illness should be subjected to any simple return-to-work recommendation; the specifics of each case must be considered carefully.
From "Preventing Needless Work Disability by Helping People Stay Employed"
This article, recently published in The Journal of Occupational and Environmental Medicine, deserves attention because it provides a balanced context for the uneasy relationship between the injured worker and the oversimplification of current disability assessment models. It asserts in several places that a speedy return to work has health benefits. While it does not focus exclusively on the health benefit of early return to work, it places that one factor in the broader context of how disability should be prevented rather than managed:
"Preventing Needless Work Disability by Helping People Stay Employed." Stay-at-Work and Return-to-Work Process Improvement Committee - J Occup Environ Med - 01-SEP-2006; 48(9): 972-87 (From NIH/NLM MEDLINE)
The article attempts to dislodge the assumption that employees on medical leave necessarily have a medically viable reason for being on leave. The section, "Increase Awareness of How Rarely Disability is Medically Required" states, "Only a small fraction of medically excused days off work is medically required, meaning work of any kind is medically contraindicated" (975). The majority of "medically" excused days off arise from institutional and communication barriers.
A section entitled "Urgency Is Required Because Prolonged Time Away From Work Is Harmful" stresses that the net effects of delayed activity, coupled with social and psychological hindrances, militate against the best recovery times for workers on disability leave. "Early intervention is the key to preventing disability. Research confirms that people who never lose time from work have better outcomes than people who lose some time from work" (976).
Similarly, the section, "Address Behavioral and Circumstantial Realities That Create and Prolong Work Disability," touches on the social elements the prolong disability, once the standard definitions of work leave have been applied. "Those who have trouble coping with their circumstances are likely to resist relinquishing those roles [of being the "dependent patient"] . . . ." long after the normal period for physical healing ends (977). While this point is tangential to the key issue, it answers the negative circumstance: how does failing to return to work reinforce disability?
Finally, the section "Increase 'Real-Time' Availability of On-the-Job Recovery, Transitional Work Programs, and Permanent Job Modifications" (980) describes the need for getting workers back to work as quickly as possible to ensure they reach the greatest physiological and psychological health. While the recommendations are directed toward changes in organizational policies, they assume that in the majority of cases, true medical disability will be resolved more quickly if individuals are accommodated at work rather than perfunctorily put on medical leave.
Below are two links that allow non-members to download the article. If the first link doesn't work, the second link should.
First link
Second link
- Click on www.joem.org (Non-Members)
- At the new window, paste the text "Preventing Needless Work Disability by Helping People Stay Employed" into the search form
- That one article will be the only search result.
- Click on the "PDF" link to the right of the search result, and the article will load or prompt the user to save it.
Additional Articles
Most of these articles focus on back pain or back surgery. Back pain is considered the second leading cause (after the common cold) for absenteeism from work and therefore merits this focus (Amundson).
Amundson, Glenn M. "Low Back Pain." Spine Universe. 11/13/2006. http://www.spineuniverse.com/displayarticle.php/article216.html
Atlas, Steven J., et. al. "Long-Term Disability and Return to Work Among Patients Who Have a Herniated Lumbar Disc: The Effect of Disability Compensation." The Journal of Bone and Joint Surgery 82:4-15 (2000).
Conclusions: Even after adjustment for the initial treatment of the sciatica and for other clinical factors, patients who had been receiving Workers' Compensation at baseline were more likely to be receiving disability benefits and were less likely to report relief from symptoms and improvement in quality of life at the time of the four-year follow-up than patients who had not been receiving Workers' Compensation at baseline. Nonetheless, most patients returned to work regardless of their initial disability status, and those who had been receiving Workers' Compensation at baseline were only slightly less likely to be working after four years. Whether or not they had been receiving Workers' Compensation at baseline, patients who had been managed with an operation reported greater relief from symptoms and improvement in functional status at the time of the four-year follow-up compared with patients who had been managed nonoperatively, even though the outcomes with regard to disability and work status in these two groups were comparable.
Bellamy, Ray MD. "Compensation Neurosis: Financial Reward for Illness as Nocebo." Symposium: Clinical Orthopaedics & Related Research. Chronic Pain, Secondary Pain, and Somatization. (336):94-106, March 1997.
"Financial reward for illness thus functions as a powerful nocebo, a nonspecific force creating and exacerbating illness. Solutions require recognition that judging disability and work incapacity in others is an unscientific process and that adversarial systems rewarding permanent illness or injury, particularly self reported pain, are often permanently harmful. The remainder of the solution must be political" (Abstract).
Clermont E. Dionne, et. al. " A Clinical Return-To-Work Rule for Patients with Back Pain." CMAJ. 2005 June 7; 172(12): 1559-1567.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?
artid=558170
PDF version (preferable)
See figure 3 in particular — return to work expectations is one of seven critical elements in the predictive model developed through the study.
CSI Work Group. "Adult Low Back Pain." Institute for Clinical Systems Improvement. Sept. 2006. http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=149.
"Patients with acute low back pain should be advised to stay active and continue ordinary daily activity within the limits permitted by the pain. For chronic back pain, there is evidence that exercise therapy is effective (4).
Rainville, James MD, et. al. "The Effect of Compensation Involvement on the Reporting of Pain and Disability by Patients Referred for Rehabilitation of Chronic Low Back Pain." Spine. 22(17):2016-2024, September 1, 1997.
Results. The compensation group included 96 patients; these patients reported more pain, depression, and disability than the 96 patients without compensation involvement. These differences persisted when baseline differences were controlled for with multifactoral analysis of variance models. Treatment recommendations and compliance were not affected by compensation. For patients completing the spine rehabilitation program, length of treatment, flexibility, strength, lifting ability, and lower extremity work performance before and after treatment and patient satisfaction ratings were similar for the compensation and non-compensation groups. At 3 and 12 months, improvements in depression and disability were noted for both groups, but were statistically and clinically less substantial for the compensation group. At the 12 month follow-up visit, pain scores improved for the noncompensation group, but not for the compensation group.
Conclusions. In chronic low back pain, compensation involvement may have an adverse effect on self-reported pain, depression, and disability before and after rehabilitation interventions.
Future Research
The foregoing should alert us to the need for a comprehensive understanding of the advantages of earlier return to work (as well as the advantage of staying at work, when appropriate). While low back pain is common, and commonly documented, other diagnoses invite further research. This article will be expanded in the future, and any suggestions to relevant studies are welcomed: lburkhardt@rgl.net.
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