Every injured employee must be treated with dignity and respect and provided with the required treatments, including time off work when warranted. However, when there is no clear rationale, persistent delay of an employee to return to work, even to modified duties, is a denial of evidence-based occupational medicine.

Furthermore, unnecessary delay in the return to work (RTW) of injured employees causes tremendous financial loss for employers. It increases the cost of health care and encourages the disability mindset.

Certain misconceptions act as barriers in decision-making by those who provide healthcare to injured workers. We will clarify six of these common misconceptions.

1. THE TREATING DOCTOR IS NOT RESPONSIBLE FOR AN RTW DECISION.

Many treating providers hold the misconception that the RTW of an employee is not their concern. They believe it to be an issue that employees, insurance carriers, and employers will settle between themselves. Therefore, they consider their job to be limited to the employee’s treatment.

In fact: An essential function of the treatment provider is the planning of RTW as part of the management of the injured employee. The treating provider (along with the insurance carrier and employer) is part of a team, all of whom have responsibilities for ensuring the employee's successful return to work. Treating providers have a pivotal role in minimizing adverse outcomes, including prolonged disability or complete failure to return to work.

Treating providers are trained to focus on assessing and treating symptoms rather than determining their patient's ability to function in their occupation. However, understanding the job responsibilities of the injured employee, with an objective functional assessment of the employee's current capabilities, should greatly help in the RTW determination.

2. THE FIRST IMPRESSION IS NOT THE LAST.

Treating providers frequently underestimate the importance of the first clinical encounter as a crucial determining factor in the recovery and RTW of the patient.

In fact: The initial clinical encounter sets the tone for future events, including RTW. Exaggerating the patient's condition by using medical jargon, over-treatment, and inappropriate certification of disability, are all factors that may delay RTW.

For many injured workers, recovery may take longer than can be explained by physical symptoms alone, which suggests the presence of psychological and social issues that prolong the disability. Therefore, clinicians must be aware of the pathology and mindful of psychosocial problems hindering their motivation to return to work.

Treating providers should refrain from using a specific diagnostic label for non-specific symptoms. Instead, a better choice is to use a descriptive term for the symptoms, such as “back pain” or “unspecified disorder of muscle and ligament” (Talmage, 2000).

Inappropriate diagnostic labels provide an ominous impression of common, self-limiting conditions and create psychological barriers to recovery. Lastly, the providers should not inadvertently give their patients the impression that work would be harmful or impede their recovery.

3. THE EMPLOYEE NEEDS TO BE SYMPTOM-FREE FOR RTW.

Treating providers may misconstrue the presence of an employee’s common symptoms, without objective findings, as an incapacity for work.

In fact: Symptoms are subjective complaints, such as aches and pains, which concern the worker. Many symptoms are self-limiting, an everyday fact of life, and related to daily living, but some represent the clinical presentation of the disease. Contrary to the common belief of patients and health professionals, symptoms do not necessarily mean incapacity to work.

Clinical management of common occupational health problems, such as back pain, is often about sufficiently managing symptoms to allow the patient to return to normal activity levels.

Workers gradually heal from injuries and illnesses, and research shows that recovery is faster when there is an early mobilization and transition back to normal living activities. In some cases, if necessary, modifying workers' tasks for a short period will allow injured employees to take time to recover without complete loss of productivity.

4. EARLY RTW INCREASES THE RISK OF RE-INJURY.

Many treating providers delay the return to work or prolong the work restrictions of an injured employee based on their perception of the risk of re-injury.

In fact: Except in rare cases, there is no scientific evidence that returning to work after appropriate treatment increases the likelihood of re-injury of the employee.

Also, most published literature on injury risk assessment is based on consensus and not on established research findings.

Lastly, one should be cautious; occasionally, a worker might attempt to attribute residual symptoms or the recurrence of symptoms of a previous injury to some new questionable incident.

5. LIGHT DUTY ENSURES RETURN TO FULL DUTY.

Often, treating providers believe that light duty is an effective way to return employees to regular duty.

In fact: Temporary restrictions may be recommended for a short duration to enable the worker to return to modified duty. However, long-term restrictions will significantly diminish the chances of a successful recovery and return to full duty.

According to a Canadian Back Institute study, workers who returned to work without restrictions had a higher success rate than those who returned with restrictions (84% compared to 47%). As a result, the study’s authors believe that "an unwarranted restriction implies disability and may become a self-fulfilling prophecy" (Hall, 1994).

6. RTW DETERMINATION IS A PERFECT SCIENCE.

Treating providers believe that RTW determination, including work restrictions, is based on firm scientific knowledge. They also think that occupational health experts know precisely when a patient is ready to return to work.

In fact: There is no straightforward method for return-to-work assessment, but the following approach should help reach justifiable recommendations for returning to work:

• Evaluate the employee's current abilities (strength, flexibility, and endurance) to perform functional tasks of the job.

• Estimate the claimant's tolerance for sustained work at a given level. It should be based on motivation, symptoms, and functional capacity evaluation.

• Estimate the risk of subsequent injury or worsening of symptoms from RTW. Base this decision on the claimant's job description.

• Recommend a reasonably tolerable level of work activity if there are no excessive risks at work that pose a direct threat to the worker. Restrictions should be based on experience, knowledge of biomechanics, and an estimate of the risk of injury from published medical studies.

Understanding these six common misconceptions should help you make proper RTW decisions for injured employees. The timely return to work prevents the unnecessary lost time and wage and mental distress of workers. It also favorably affects overall productivity and workers’ compensation cost.

Bogduk N. “What’s in a name? The labeling of back pain (editorial).” Medical Journal of Australia, 2000; 173: 400-401.)

Talmage JB. Assessment and Management of Upper and Lower Extremity Impairment and Disability. Occupational Medicine: State of the Art Reviews. 2000; 15(4): 771- 788

Hall H, McIntosh G, Melles T, Holowachuk B, Wai E. Effect of discharge recommendations on the outcome. Spine,1994; (9):2033-7