June 2006

Studies Show Poor Results for Work Restrictions

The Back Letter – Volume 8, Number 6, 1993

The rationale behind limiting the type of work done by back-injured patients is fairly familiar. Certain forms of labor are more stressful to the spine than others. Therefore, eliminate them and allow the patient to continue working productively. 

The theory is fine, but do work restrictions actually permit greater numbers of patients to return to their jobs? Two studies – one retrospective and one prospective – presented at the International Society for the Study of Lumbar Spine (ISSLS) meeting in Marseilles, suggest they don’t. 

An American study of a 20,000 employee metropolitan utility company showed that about two-thirds of patients who were granted work restrictions returned to full employment, while almost nine out of ten unrestricted workers returned to work. Meanwhile, a review of the cases of 1,400 Canadian workers receiving Workers Compensation for injuries showed that patients who don’t have restrictions enjoy a statistically greater chance of returning to work than those with restrictions. 

Epidemiologist Mary Louise Skovrin, PhD and colleagues from the Hospital of Joint disease in New York City identified and reviewed 420 patients who visited the Occupational Health Service for back pain, back strain, backache or lumbago during1987. More than half of the afflicted workers (263) received work restrictions at some time during their bout with back pain. 

Illness episodes, which were defined as having ended when the employee returned to work without a recurrence of back pain for at least eight weeks, lasted an average of 65 days in the restricted group.  There was no significant difference between restricted and non-restricted workers in the likelihood of suffering a recurrence of back pain.   

The Canadian Worker’s Compensation system recommends that approximately 60% of back-injured employees be returned to work with restrictions. 20% be returned with restrictions, and 20% be referred for further medical intervention, psychological counseling, retaining, or vocational rehabilitation.  However, in a study led by Hamilton Hall, MD. Of the Canadian Back Institute in Toronto, only 44% of 700 injured workers returned to work without restrictions, while 38% were restricted by medical evaluators.  

Using this sample as a control group, Hall and his colleagues attempted to determine whether a more stringent standard for issuing work restrictions would lead to a greater number of workers returning to full employment, without any changes in the way therapy was handled. 

“We just told the therapists that is they were going to give restrictions, they had to submit a form to us for medical review,” said Greg McIntosh, a collaborator on the stuffy.  “If you have a patient who needs restrictions, you must write us and tell us why they’re getting it.  We won’t necessarily dispute your reasons, we just want to know what your reasons are.”  Subjective complaints of pain alone, McIntosh added, didn’t qualify as a valid reason for work restriction.  

When these requirements were added to the application of work restrictions, the number of workers returning to work without restrictions almost doubles, to 80%. 

Four months later, 74% of the unrestricted group continued to work, and 9% required modifications in their duties.  In the group with restrictions, only 53% were working after four months, and only a third without restrictions. 

“Requiring clear objective evidence an removing pain as a reason for recommended job restriction resulted in an increase in the return to full duty from 37% of all patients in phase 1 to 59% of all patients in phase 2,” the authors concluded. 

The study indicates that unrestricted patients have a much better chance of getting back to work than restricted patients, McIntosh says, and hints that it may be preferable to attempt to rehabilitate all workers to the point where they can go back to work without work restrictions, rather than sending them to work in a state of partial impairment. 

“We thinking several things may come into play here,” McIntosh said.  “Employers aren’t always eager to accommodate employees with restrictions, because new jobs may need to be created to accommodate them. 

“From the patient’s side we conclude that the process of giving restrictions can be a barrier to recovery.  We may be implying to the patient that they are incapable of doing full duty.  They may see the restricted environment as a negative thing, a barrier.”