A physiatric approach to disability management in the workplace

Disability management has been recognized in rehabilitation literature since the 1980s yet remains an elusive and often abstract concept that is difficult to fully put into operation. At a basic level, disability management is a process to minimize impairment to allow for maximization of activities. Fundamental to the practice of physical medicine and rehabilitation is reducing the impact a medical condition has on an individual’s functions and productivity. When applied in the workplace, disability management maximizes productivity and reduces absenteeism costs.

The physiatrist is a patient-health advocate who seeks to establish an evidence-based medical diagnosis. Patient management goes beyond the traditional focus on pharmacological and/or surgical approaches. After the patient has healed, rehabilitation plays a critical role in managing the underlying disorder. For example, a patient with a healed fracture can be left with residual functional limitations. Restoration of function is often a much more complex process than medical treatment of the condition.

After a work injury, a critical first step is to identify the loss in function, which may be directly caused by the underlying condition and/or secondary effects of the injury. A spectrum of disorders, from nonspecific low-back strain to complex polytrauma or limb loss, may need to be considered. The relationship between the severity of the condition and the impact on function is often imprecise. A classic example is the pianist who permanently injures a single finger but whose career is compromised as a result. Influencing factors include the environment and activities the worker is returning to, in the home, community, and workplace.

Initially, the physiatric approach involves recognizing underlying impairments from anatomical or structural as well as functional perspectives. Next, loss of normal activities such as self-care or ambulation is determined and assessed. Finally, the physiatrist should identify the resulting disadvantages the individual may experience, in the home and in society, such as a handicap or the assistance required with instrumental activities of daily living (IADL).

Minimizing impairment is associated with reduction in disability. Similarly, interventions to reduce disability are associated with improvements toward normalization of activities. In addition to the direct impact the condition has on the patient, the physiatrist should recognize and manage focal comorbidities, such as contractures after a fracture, and generalized factors, such as deconditioning, depression, or generalized pain.

Specific rehabilitation strategies include physical therapies and modalities, with therapeutic exercise receiving special emphasis. Bracing or orthotics is often underappreciated. Environmental barriers need to be overcome. Objective outcome measures are well defined for diseases but less so for disability status, and are weak for reintegration in the home and community. Valid tools are needed to determine fitness to resume usual activities at home and work. An understanding of the previously held roles to which the injured worker can return, as well as a valid job description and an analysis of work demands, is critical.

Physiotherapy, occupational therapy, and speech and language pathology are valuable disciplines when working in an interdisciplinary fashion with common patient-focused goals. Kinesiology, recreational therapy, and vocational rehabilitation are playing increasingly important roles in the rehabilitation process.

Disability management is not a new concept. It is a philosophy and formal approach directed at assisting an injured worker to restore function and reintegrate into the workplace. From a vocational-rehabilitation perspective, restoring lost function and ability is critical to maximizing outcomes. Comprehensive efforts to restore lost function and/or develop compensatory strategies benefits workers and their families, co-workers, and employers. When considering the principles associated with disability management, the physiatrist is a critical resource through the continuum of care, including workplace reintegration.

Call your nearest WorkSafeBC office for physiatrist referral information.
—Elliott Weiss, MD, FRCPC, MBA
WorkSafeBC Physical Medicine and Rehabilitation Consultant

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.