Advanced Rehab Helps Prevent Delayed Recoveries

Sarasota, FL ( – Returning injured employees to work can potentially save their lives. Research conducted during the pandemic found being out of work was associated with conditions ranging from poor mental health, and chronic and disabling low back pain, to increased risks for hypertension, heart attacks and stroke, among other things.

“Not working is probably the single biggest risk factor for poor health and poor outcomes with injured workers right now,” said Anne Marciniak, Clinical Services Department team lead for MedRisk. “Being out of work kills people … the best thing that we can possibly do is get people back to work.”

During a recent webinar Marciniak explained various facets of advanced rehabilitation and how and when they can be used to help injured workers recover and return to work.

Advanced Rehab

Most injured workers have a fairly smooth transition from initial injury to returns to function and work. But for some, their recoveries are such that they have some improved function but cannot carry out the duties of their jobs. They may have regained their strength and range of motion, for example, but cannot lift the weight and/or number of loads required for their work.

This ‘gap’ can cause these workers’ compensation cases to go off the rails, leaving the worker on disability duration for the long term. As research has proven time and again, the longer a worker is out of work, the less likely he is to return to the workforce. Providing treatment during these gaps is crucial for best outcomes.

Prior timelines were 6 to 12 months as critical benchmarks to identify risks of long-term incapacity. But recent research has led to changes in treatment models.

“Now we’re finding 4 weeks to 4 months is the most critical time where the risk of long-term incapacity increases substantially,” Marciniak said. “This is usually a critical time where you want to be identifying risk factors, you want to make sure that they are progressing through treatment. If they need work conditioning or [work] hardening, that they are getting in. That helps them to avoid a disability mindset.”

Work Conditioning/Work Hardening

Advanced rehabilitation occurs after the initial physical therapy. It is designed specifically to help the person return to work.

Work conditioning occurs for up to 4 hours a day, for three-to-five days per week, and between four and eight weeks. It is an ‘intensive, work-related, goal oriented conditioning program.’ It is specifically designed to restore:

  • Joint mobility and muscle flexibility, beyond just the injured body part
  • Muscle performance, including strength, power and endurance
  • Motor function, including motor control and motor learning
  • Cardiovascular/pulmonary functions, such as aerobic capacity/endurance, circulation and ventilation and respiration/gas exchange

Work hardening is more intensive. It typically lasts longer each day – up to 8 hours, for five days a week up to eight weeks. It is a highly structured and individualized intervention program and typically involves providers from multiple disciplines. “Work hardening addresses the issues of productivity, safety, physical tolerances and worker behaviors,” Marciniak said.

Some states require special accreditation from the Commission on Accreditation of Rehabilitation Facilities for work hardening. In others, however, the terms work conditioning and work hardening are often used interchangeably by prescribing physicians. The CPT billing codes for them are identical.

Both work conditioning and work hardening involve work simulation. They also focus on the whole body.

“In work conditioning and work hardening you don’t just lift with your hands, or lift with your back or your shoulder,” Marciniak said. “You lift, and push and pull, and do your work activities with your entire body. If they’ve been out for an extended period of time you are looking to condition the whole body to get back to work.”

It’s important to distinguish work conditioning and work hardening from physical therapy. Unlike PT, work conditioning and work hardening are:

  • More goal oriented
  • No longer focused on managing pain
  • Involving whole body treatment
  • Including work simulation
  • Containing functional activities

“Work conditioning should not be PT with a few box lifts,” Marciniak said. “Be wary of that. It’s a red flag.”

Work conditioning and/or work hardening are most effective when used on appropriate injured workers. The best criteria is that they are unable to work at the moment; there is some component of the job they cannot do. It may be a lack of endurance, for example. Additionally, the injured worker:

  • Should have no pathology that would contraindicate participation
  • Must have no severe psychopathology
  • Must have a job goal and be motivated to RTW
  • Have all non-related medical problems stabilized
  • Have a physician’s referral

Sending someone for work conditioning or work hardening too soon is expensive and unnecessary. Sending them in too late may be a wasted expense.

It’s imperative that those doing the work conditioning/work hardening have a clear understanding of the injured worker’s job demands. Getting accurate and thorough job descriptions and pictures of their work-stations can be “a recipe for success!” Marciniak said.


In some instances, functional capacity evaluations will aid the RTW process. The FCE is “an objective measure of the current level of function compared to the physical job demands,” Marciniak explained. “The functional capacity evaluation predicts the potential to meet and sustain work tasks.”

These typically take anywhere from a couple of hours to days. They identify things such as tolerance of various postures, movements, repetition and other body stressors. The injured worker is tested for balance, carrying, climbing, lifting, pushing, pulling, reaching, sitting, standing and other job-specific simulations.

The timing for a FCE depends on the worker and the circumstances. They can be used for

  • Intervention and treatment planning
  • Disability evaluation
  • Job placement decisions
  • Identifying accommodations or supporting lite duty solutions
  • Supporting RTW decision and planning

Someone who has good range of motion and strength but is not quite able to meet the job demands would not necessarily need a FCE, Marciniak said. On the other hand, a patient who is new to the provider may be a good fit.

FCEs also do not need to be overdone. “I see very little benefit in doing a FCE at the beginning and one at the end,” Marciniak said. “There is no reason to do two FCEs within 6 weeks.”

While potentially valuable, Marciniak points out that the FCE is just “one piece of the picture for RTW.”