This Series consists of five (5) separate articles and is worth ten (10) Credit Hours.  Each article has corresponding questions that can be found be clicking on the "Questions" link.

Article 1: Job Analysis & Job Accommodation
Article 2: Increasing Company Profits Through the ADA
Article 3: Analyzing & Describing Jobs
Article 4: Pain as a Disability // Issues in Pain as a Disability (two-part article)
Article 5: A Pain in the Back // Back Problems: Specific Issues // "Well-Managed" Companies & Return-to-Work Programs (three-part article)

While the Americans with Disabilities Act (ADA) addresses a number of issues under five¹ separate "Titles." The Title that most directly impacts employers is Title I. The essential idea of "Title I: Employment" is the requirement that employers make reasonable accommodations that are not an undue hardship so that any qualified individual with a disability can perform the essential functions of a job.

What this means to employers who want to comply with Title I is that they need to know precisely what the "essential functions" of the jobs in their companies are. In cases that go to either mediation or litigation on a Title I complaint against an employer, the issue of the essential functions of the job in question will be central to the case.

Many employers, of course, have always had "Job Descriptions" for their jobs. Unfortunately, in most cases these traditional Job Descriptions do not specifically identify the essential job functions in terms of the precise physical demands of the job, the environmental conditions under which the job is performed, and/or the minimum general educational development level required for the job. Further, traditional Job Descriptions rarely make a distinction between those functions of the job that are "essential" and those that are tangential or "non-essential" functions.

To create a meaningful, comprehensive, and defensible Job Description (or Job Content²) document, employers must do a "Job Analysis." The Job Analysis process is a close observation and documentation of the actual functions of each specific job to identify the physical requirements of the job. Physical requirements analysis includes the percent of time on the job involving each of the following:

Each of these physical requirements has to be measured in terms of the specifics that are present in a job. For example, if a job requires lifting, carrying, and pushing, the pounds to be lifted or carried have to be determined, and the percent of time each of these physical requirements occurs in a work period has to be determined.

The environmental conditions inherent in a job are also measured in the percent of time involved. Environmental conditions that are significant to the essential job functions include: exposure to weather; extreme cold; extreme hot; dust, fumes, and gases; wet and/or humid weather; noise; and vibration.

Cold and hot conditions are measured in terms of temperature ranges. Potential hazards are also identified and documented in the Job Contents. The machines, tools, equipment, work aids, materials, and products used in the job functions are also identified.

Finally, the mental requirements of a specific job are established in terms of the ability needed on the job to reason, to use math, and to use language. The Dictionary of Occupational Titles (or DOT), a publication of the U.S. Department of Labor, provides a scale for employers to use to determine mental requirement.

With this understanding of the details that go into producing a valid job description, we can take a look at what it means for employers. Title I of the ADA says that an employer needs to base a job offer on the applicant’s qualifications to perform the essential (not the marginal or non-essential) functions of a job, with or without accommodation. The ADA does not require that employers do job analyses or have job descriptions or list job contents for the jobs in their companies.

But any case of discrimination under Title I (as opposed to the other titles of the act) that reaches litigation will revolve around what the essential functions of the job are and whether or not the particular applicant is qualified for the job on the basis of his or her ability to perform the essential functions, with or without accommodation. And employers will not be permitted, in litigation, to determine the essential functions after the fact. The essential job functions and their documentation must have existed at the time of the application and have served as the basis on which the employer decided the applicant was not qualified for the job or could not perform, with or without accommodation, at least one of the essential functions of the job in contention.

All employers with 15 or more employees, who are interested in complying with the provisions of Title I of the ADA, should have job descriptions that were created using methods discussed above. To do this, they will need to make a commitment to do job analyses and to create job descriptions based on the essential functions of each job.

Since the analysis is based on actual observations and the measurements of specific job functions (as opposed to someone’s creative listing of what the employer would like the job applicant to accomplish), employers will need to train the appropriate staff professionals in the job-analysis process. It is important to note, however, that the employer gains much more than simply compliance with Title I by producing job descriptions based on analysis. For one thing, when employers hire new employees, whether they are individuals with disabilities or not, they now have a detailed description of the job to share with the applicant at the time of employment. Expectations for both the employer and the new hire are now based on detailed measurements of the actual events of a job. This serves as a basis for the hiring decision, the decision of the applicant as to whether or not to take the job, and as a basis for the evaluation of job performance after employment.

Additionally, essential-job-function descriptions become tools with which employers can manage disability resulting from occupational injury or lost-time illness. Job descriptions permit employers to more effectively communicate with treating physicians about essential job requirements, and job descriptions serve as a framework from which job modification might be made to quickly re-employ a worker who is temporarily or partially disabled as a result of accident or illness.

For their part, job applicants with disabilities need to be aware of the Title I provisions so that they can compete for a job based on the essential functions of that job. Job applicants with a disability need to insist, at the time of application, that the employer produce the essential functions (in the form of a job description or job contents form) for the job in question. Applicants failing to do so will not have met their obligation under the ADA to compete in the marketplace. When the employer does produce a job description based on job analysis at the time of application, the burden is on the applicant with a disability to demonstrate that he/she can perform, with or without accommodation, the essential functions of that job.

Job Location (Place where work is performed): Mold Press Department

Equipment: Compound loading board; compound stripper plate ring; lube (water and mold release solution); lube sprayer, attribute chart, heat press; and air hose.

As disability-management consultants to business and industry, our experience over the last two years has been that company officials too frequently view the Americans with Disabilities Act (ADA) as another piece of social legislation designed to get in the way of company profit. From that perspective, compliance with the ADA becomes an effort to "dodge the bullet," or to do what is necessary to avoid litigation. With regard to the latter position, we often hear company managers say, "Well, we want to see how the courts are going to decide on the vague language in the Act." This implies that those managers will not pursue full compliance until lawsuits and court decisions further refine ADA language, but this ignores the fact that much of the ADA is already based on legally defined and redefined language.

We try to make those managers aware that there are already nearly twenty years of legal precedents in disability-discrimination cases, generally stemming from violations of the Rehabilitation Act of 1973. But, more importantly, we attempt to make those managers aware of success stories from companies that have embraced ADA concepts as opportunities to profit by hiring the best qualified people and managing the cost of workplace disability.¹

We want to offer Title I of the Americans with Disabilities Act as a means by which organizations can select qualified individuals willing to work and as a model for reducing disability expenditures. Over the past ten years, we have found that application of ADA principles like "reasonable accommodation" actually saves companies money. Therefore, we now urge that company officials view ADA concepts as tools to increase profit by saving on the costs associated with finding, hiring, and maintaining qualified employees and reducing expenditures associated with workplace disability. Of course, we believe that those well-managed organizations that pursue application of ADA concepts also lower the probability that they will be defendants in potentially expensive federal litigation.

Qualified Applicants Who Will Work

Robert B. Reich, a U.S. Secretary of Labor, has encouraged management and labor to make the necessary adjustments to train and retrain the most highly motivated people in our country. Such adjustments would include hiring one of the best educated and most highly trained minority groups in the United States, persons with disabilities.

One of the nation’s untapped resources is Americans with disabilities, including those in our present employ. Human resource officials and workplace supervisors are continually in search of individuals who will work. It has been our experience that the vast majority of people with disabilities, representing this country’s greatest labor pool, are willing to work when provided the opportunity.

Nearly every human resource manager tells us that the pool of "qualified" applicants is evaporating.² By qualified, those company officials inevitably mean attitudinally as much as aptitudinally. Personnel officers increasingly hear supervisors complain that newly hired employees are unrealistic in terms of initial salary expectations, jaded by prior work experience, or just plain difficult. The offices of human resource managers are visited by employees who charge supervisors with being overly demanding, unfair, and in some cases, assaulting.

It has been estimated that one in five Americans have a disability, and as the workforce ages, this percentage will increase so that Americans with disabilities will no doubt become the largest "minority" group. We must turn to this so-called minority to find people who are willing to work, not simply aptitudinally qualified to fill a role. Training and maintaining those willing to work increases an organization’s profitability.

Nowhere else is the typical company spending money faster than in the area of disability. Studies have shown that the average company spends 8 percent of payroll on direct- and indirect-disability costs. Workers’ compensation and long-term disability insurance carriers are rapidly increasing premiums. Some companies have found that their workers’ compensation costs are their greatest item next to payroll.

Progressive, well-managed work organizations are using the ADA as a model for designing and implementing Disability-Management Programs. Those companies realize that current workers are valuable. Allowing these employees to "disappear" after the onset of an occupationally significant injury or illness makes no economic sense. We know that companies can reduce disability expenditures and maintain workers by providing reasonable accommodation. We have seen companies use essential-job-function descriptions not only as a method to qualify and accommodate a new hire with a disability, but also as a risk management tool to assist a physician, an employee, and a supervisor to generate ideas on how a return-to-work plan might be executed. Companies doing this are saving between $8 and $10 for every $1 invested.

We have also seen that modification of jobs produces safer and more efficient ways to work. For example, there has been a tremendous reduction in the number of incidents of repetitive-use syndromes by adapting keyboard designs that were once created for people with neuromuscular disorders affecting their upper-extremity capabilities.

Finally, when companies are proactively managing disability, employees come to believe the message that they are too valuable to waste, and the company is too committed to both survival and profitability to be held as a disability-benefit hostage. Thus, the use of wage-replacement benefits tends to go down in companies that see the ADA as a model for proactively managing workplace disability.

We are encouraged by what we see. Unlike some observers, we do not think that the number of EEOC complaints will necessarily be a reflection of how well companies are complying with the ADA. We may need to wait another twenty years to fully realize the true power of a law designed to protect qualified people who just happen to be physically or mentally different from the majority of those who maintain the profit margins in their companies.

Americans with disabilities, including those injured or ill while at work, are usually interested in being productive and helping an organization grow. We have learned that through developing ADA awareness and tapping into the power of individuals with disabilities, well-managed companies have become more viable and profitable. Understanding the Americans with Disabilities Act and the potential it holds for all current and prospective workers, as well as employers, has become a vehicle of profit for the progressive and well-managed American work organization.

1. While there are a number of studies that document the credibility of disabled employees, none are more extensive than the longitudinal studies done by the E.I. duPont Company. The duPont Company did its original study in 1973 and then followed with another in 1981. The 1981 study ("Equal to the Task") covered 2,745 disabled employees working for the company that year. In four categories (Safety, Performance of Job Duties, Attendance, and Job Stability/Turnover), disabled employees equaled or outdid their non-impaired co-workers. The duPont study is replete with interesting facts. But consider just several: 1/3 of their disabled workers were hired as such; 2/3 were disabled after employment, and 91 percent of the latter became disabled during off-duty hours.
   
2. The Workforce 2000 Study, researched and written by the Hudson Institute for the U.S. Department of Labor, clearly demonstrates the need for employers seeking a well-qualified workforce to look beyond the prevailing white, male population. The study shows that qualified workers are becoming more difficult to identify (what duPont calls "The Great American Manpower Search") and that aggressive employers need to plan for diversity if they are to remain competitive. Certainly, no single group in America represents a greater potential for high-level skills and suitability for productive employment than those with disabilities.

Analyzing and Describing Jobs: Useful Procedures in the Rehabilitation of Injured Workers

By Jasen M. Walker, Ed.D., C.R.C., C.C.M.

Title I of the ADA says that an employer needs to base a job offer on the applicant’s qualifications to perform the essential (not the marginal or non-essential) functions of the job, with or without accommodation. What this means to employers who want to be in compliance with Title I is that they first need to know precisely what the "essential functions" of jobs in their company are.

Many employers, of course, have always had "job descriptions" for their jobs. Unfortunately, in most cases, these traditional job descriptions do not specifically identify the essential functions in terms of the precise physical demands of the job, the environmental conditions under which the job is performed, or the minimal general educational-development level required for the job. Further, traditional job descriptions rarely make a distinction between those functions of the job that are "essential" and those that are tangential or "non-essential" functions.

Andrew and Dickerson¹ define the job analysis as the examination of what a worker does, why it is done, how it is done, and the skill needed. Job analysis provides systematic and detailed information about a job; what the worker does in relation to data, people, and things. The process of observation, interview, and study identifies job duties, responsibilities, purpose, qualifications for employment, equipment and materials used, relation to other jobs, training required, and physical demands.²

In a visit to a work site, the rehabilitationist who is trained in the techniques of analyzing jobs can analyze a job in a quick and informal manner. Job analysis as a technique is a major source of data and a procedure that those involved in vocational rehabilitation should know.

Once a job analysis is completed, the gathered data can be arranged in job-description form. A complete job description can:

The importance of the first two uses of the job description is self-evident. Safely returning the injured employee to gainful activity is necessarily the goal of every genuine rehabilitation effort. The third and fourth uses are adopted in contested workers’ compensation claims that require the services of a vocational expert.

Workers’ compensation litigation frequently requires that the defendant employer produce evidence that appropriate work is available to the claimant. When possible, an analysis can be conducted to ensure that the job is commensurate with the claimant’s mental and physical capabilities. From the analysis, a job description is constructed and forwarded to the physician for review and approval.

At times, this may not be necessary as the physician has clearly detailed the worker’s residual physical capacities. At other times, however, non-specific recommendations such as "no heavy lifting" or "no repetitive bending" can be clarified by the physician’s response to a job description. Notwithstanding the clarity of the physician’s recommendations, the approved job description bridges the gap between vocational and medical evidence.

Claimant counsel in Pennsylvania workers’ compensation claims may refuse to permit the direct-vocational evaluation of clients. As a result, the skilled evaluator can perform a so-called "hypothetical" examination utilizing file documentation of some sort. An alternative is to conduct a job analysis when possible.

Should claimant counsel refuse to cooperate in allowing a personal examination of the claimant, the vocational evaluator can perform an on-site job analysis. By thoroughly analyzing the claimant’s job, the vocational expert can develop at least a partial picture of the claimant’s demonstrated skills and aptitudes. A job search or labor-market survey based on this analysis and the known medical limitations would likely follow.

The ADA does not require that employers do job analyses or that they have job descriptions for the positions in their companies. However, any case of discrimination under Title I that reaches litigation will revolve around what the essential functions of the job are and whether this particular applicant is qualified for the job on the basis of his or her ability to perform the essential functions, with or without accommodation.

Employers will not be permitted, in litigation, to determine the essential functions after the fact. Documentation must have existed at the time of the application and have served as the basis on which the employer decided the applicant was not qualified for the job or could not perform, with or without accommodation, at least one of the essential functions of the job.

Since the analysis is based on actual observations and the measurements of specific job functions (as opposed to someone’s creative listing of what the employer would like the job applicant to accomplish), employers will need to train appropriate staff professionals in the job analysis process.

It is important to note, however, that the employer gains much more than simple compliance with Title I by producing job descriptions based on analysis. For one thing, when an employer hires a new employee, whether he or she is an individual with a disability or not, the employer now has a detailed description of the job to share with the applicant at the time of employment. Expectations for both the employer and the new hire are now based on detailed measurements of the actual events of a job. This serves as a basis for the hiring decision, the decision of the applicant as to whether to take the job, and for the evaluation of job performance after employment.

Additionally, essential-job-function descriptions become tools with which employers can manage disability resulting from occupational injury or lost-time illness. Job descriptions permit employers to more effectively communicate with treating physicians about essential-job requirements, and job descriptions serve as a framework from which job modification might be made to quickly re-employ a worker who is temporarily or partially disabled as a result of accident or illness.

For their part, job applicants with disabilities need to be aware of Title I provisions so that they can compete for a job based on the essential functions of that job. Applicants with a disability need to insist, at the time of application, that the employer produce the essential functions (in the form of a job description or job contents form) for the job in question. Applicants failing to do so will not have met their obligation under ADA to compete in the marketplace. When the employer does produce a job description based on job analysis, the burden is on the applicant to demonstrate that he or she can perform, with or without accommodation, the essential functions of that job.

More and more, job analysts are taking advantage of video technology to describe jobs. As job analysis becomes a more accurate science, the hand-held video camera increases in value as a tool for reliable communication of work-related data and the modification of work when necessary. A video sequence of a job or task can be replayed so that the employer, physician, and/or ergonomics expert can adopt methods to do the job in less taxing, safer, and more efficient ways.

Some companies that have developed their own return-to-work programs have created film libraries of their "light duty" pool for review by physicians and, at times, workers’ compensation referees. Video technology will accurately account for important considerations, such as posture and movement, when describing a job in dynamic terms.

In summary, the job analysis and the job description are useful tools to the skilled vocational rehabilitationist. Job analysis involves the examination of what a worker does and why and how it is done. The job analysis and its product, the job description, often serve as a critical step in safely returning a worker to employment. In addition, the job analysis can provide the vocational expert with an alternative to the traditional "hypothetical" evaluation when a personal interview with the workers’ compensation claimant is refused.

As job analysis becomes more commonly practiced, its usefulness will expand. Presently, job analysis and job description are integral parts of the process of vocational evaluation and rehabilitation.

1. Andrew, J.D., and Dickerson, L.R. (eds.). Vocational Evaluation: A Resource Manual. Menomonie: University of Wisconsin-Stout, Department of Rehabilitation and Manpower Services, n.d.
2. Wright, G.N. Total Rehabilitation. Boston: Little, Brown, 1980.
3. Walker, J.M. "Use of the Job Analysis in Private Rehabilitation." Unpublished, 1983.

PART I: PAIN as a DISABILITY

by Jasen M. Walker, Ed.D., C.R.C., C.C.M.

Introduction

Pain is a complex human experience that is seldom completely understood, and too frequently a problem for not only patients and their physicians, but work organizations that wish to keep employees productive.  Pain is a mental event that cannot be appreciated solely in terms of tissue damage.  Chronic pain, pain that continues for more than three months, is one of the most serious international health care problems, and it has enormous economic consequences. 

It has been estimated that one-third of the American population experiences chronic pain.  Musculoskeletal conditions, such as low-back pain, joint pain, arthritis, and rheumatism, are the leading causes of disability in people during their working years.  Complaints of back pain are second only to upper respiratory conditions in accounting for work absenteeism.  Pain is undoubtedly a major contributor to the cost of disability, which has been estimated as approximately eight percent of payroll for the average American company.

Pain is the most common presenting complaint seen by physicians.  Pain behavior in the presence of a physician is a very important form of social communication, one that may intend to invite the physician’s declaration of total disability.

Nonetheless, is pain inevitably a disability that requires time off from work?  As a clinical manifestation, pain, particularly chronic pain, is often elusive, intractable, and inextricably intertwined with social, psychological, cultural, and economic factors.  As a problem potentially reducing occupational capability and productivity, pain is difficult to assess in an efficient, fair, and reliable manner.  Pain is inherently subjective; there are no thoroughly reliable ways to assess it; and the correlation between the pain experience and occupational disability is a substantial measurement challenge to all professionals who are charged with the responsibility of assisting people back to work.

Work disability can be thought of as the inability to perform the essential functions of a job in  multiple ways, including the job’s mental, emotional, and/or physical demands.  In this paper, we will address how the rehabilitation professional can help to determine if an individual’s chronic pain experience causes disability from work.  Therefore, functional, multifactorial assessments of pain are required in determining if pain truly causes vocational disability.

Defining Pain

Stedman’s Medical Dictionary (26^th Edition, 1995) defines pain as “an unpleasant sensation associated with actual or potential tissue damage, and mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors.”  Acute pain is pain for which there is a readily available biological explanation.  Acute pain is associated with trauma, illness, or disease.  To the extent that there is an emotion associated with acute pain, it is usually anxiety.  Acute pain should be treated aggressively by health care providers, and there is no contraindication to using narcotic analgesics for pain relief.  Chronic pain continues long after the biological explanation is over.  Chronic pain remains after tissue damage should have healed and is frequently associated with depression and helplessness.  Chronic pain probably should not be treated with narcotic analgesics and frequently must be managed because it is not amenable to relief with purely medical interventions.  Moreover, individuals should be encouraged to deal with their chronic pain and to remain productive.

Thus, pain lasting longer than the time expected for biological healing is a mental event that cannot be understood solely in terms of tissue damage.  Pain is a perception, an experience, and the continuation of pain perception with associated thoughts and emotions once tissues have healed can be thought of as pain behavior.  In Behavioral Methods for Chronic Pain and Illness, Fordyce (1976) has shown how pain behavior can be modified in clinical rehabilitation settings.  Fortunately, the vast majority of individuals who sustain painful injuries recover spontaneously within a matter of weeks or months.  For too many individuals, however, the onset of pain, whether traumatic or insidious, marks the beginning of a slow but steady dissent into total and permanent vocational disability. 

Pain, however, need not become disability.  The longer pain lasts, the greater its intensity, the more it, as a balance, is allowed to impact the psychosocial aspects of living, to influence or manipulate others for example, and the more it can become vocationally disabling.  However, occupational disability need not be the inevitable result of chronic pain.  One way of understanding pain in the contexts of time, intensity, and functionality is to fully appreciate the difference between medical impairment and occupational disability.

Medical Impairment and Vocational Disability

The American Medical Association draws a distinction between medical impairment and occupational disability.  Medical impairment is a physical or mental defect at the level of a body system or organ.  The official World Health Organization definition is “any loss or abnormality of psychological, physiological, or anatomical structure or function.”  Simply speaking, impairment is what is wrong with the individual.

Occupational disability, however, is any restriction or lack of ability to perform an occupational activity in a manner that is expected.  The term disability reflects the consequences of impairment in terms of an individual’s functional performance and activity in a social context.  Occupational disability relates to work exclusive of the social consequences of impairment, and vocational disability can be mitigated or fully eliminated by modifying employee behavior and/or employer prejudices.

Job accommodations in many instances have been found to not only enhance the productivity of people with impairments, but make work safer and more predictable for employees without medical impairments.  For example, industrial lift equipment alone has made it possible for all people with limited physical strength to increase their work capacities.

With regard to pain, it need not be a disability.  Individuals in chronic pain can work if they are willing to do so and accommodated at work with manageable tasks.  Frequently, however, chronic pain is mismanaged by the patient, health care provider, and employer, so that eventually the chronic pain sufferer no longer has the will to work.  In this case, the difference between ability and will is critical.  Time out of work is inevitably a key factor.  For years, it has been known that only 50 percent of individuals with low-back pain who are out of work for six months return to gainful activity.  After 12 months of lost time, the return-to-work percentage drops to only 20 out of 100.

Obviously, early intervention is key.  However, the rehabilitation professional charged with the responsibility of assessing vocational disability and residual employability must be prepared to evaluate the capacity to work at any time following the onset of a painful injury or disease.  In a vocational rehabilitation evaluation, the ability to work with pain can be addressed by measuring the key traits that are most often affected by the pain experience.  These traits include physical capacities, mental capabilities, and emotional status.

Measuring Work Ability

Pain can affect cognitive ability, temperament, and physical capability.  Individuals in acute pain can potentially perform in ways that would suggest that the pain actually enhances each of these domains.  For example, people in crisis situations, such as a burning building, often respond cognitively, emotionally, and physically in ways that surprise them retrospectively.  Science has shown that this is probably the result of adrenaline surging through the body.  However, when the adrenaline rush is over, tissue pain can be debilitating.  Once the tissue is afforded the opportunity to heal, one would expect the pain to end.  Unfortunately, that has not proven to be the case, and injured or ill individuals can experience so-called chronic pain.

Chronic pain may be thought of as a psycho-physiologic impairment, but it need not be an occupational disability.  Like acute pain, chronic pain (pain lasting more than three months) can affect occupationally relevant characteristics such as cognitive ability, temperament, and physical capability.  Indeed, one might claim to be in chronic, intractable, disabling pain, but that person’s capacity to function or work is measurable beyond subjective complaint alone.  Standardized measures of cognitive (mental) ability, temperament, and physical strength can greatly assist those concerned with the occupational consequences of chronic pain.

Assessing Pain’s Effect on Mental Ability

Individuals in chronic pain frequently report that they cannot think, concentrate, problem-solve, and otherwise work as efficiently as they did before the onset of their pain.  People who report that chronic pain disables them occupationally often declare that they have trouble functioning cognitively as they did previously.

Despite an individual’s report of pain, he or she can nearly always be tested with standardized measures of academic achievement, vocational aptitude, and intelligence.  If the individual scores well (or as expected given his or her pre-morbid background), can we logically conclude that the pain is disabling in terms of negating cognitive ability?  For example, the Working Memory Index (WMI) of the Wechsler Adult Intelligence Scale-III provides reliable information on how well an individual can attend to and concentrate on orally presented information (i.e. solving problems without the benefit of paper and pencil).  Utilized in a battery of other tests measuring cognitive capability, the WMI can offer the vocational evaluator specific information about how the rehabilitation client functions with regard to attending, concentrating, and freeing oneself from distraction.

Thoughts, beliefs, attitudes, and self-expectations are all examples of cognition that can be assessed in relation to pain.  Objective personality testing, however, can yield much more reliable data regarding how pain may be affecting an individual’s temperament and work personality.

Measuring Temperament

Affective assessment of those who are thought of as vocationally disabled secondary to chronic pain is important because people reporting chronic pain frequently describe depression and anxiety.  Moreover, nearly all workers must relate to others in some fashion while at work.  Emotional deficits can interfere with an employee’s interpersonal communications.  Interactions with people at work can vary from highly demanding and refined mentoring and negotiating to simply speaking and/or signaling to others to carry out job functions.

Objective personality testing is available through a variety of measures, from the very detailed Minnesota Multiphasic Personality Inventory-2 to the 16 Personality Factor Questionnaire, both of which include validity checks to determine how genuine the examinee was in responding to test items.  In terms of assessing an individual’s psychodynamics after the development of chronic pain, objective personality testing can provide valuable information as to how pain perception and perhaps illness behavior potentially affect the rehabilitation client’s capacities to interact with others in the workplace.

Measuring Physical Capacity

Chronic pain may be disabling if it negates or diminishes an individual’s capacities to sit, stand, walk, lift, carry, bend, and otherwise perform physical work.  The Functional Capacity Evaluation (FCE) is a specialized form of assessment that is usually performed with biomechanical hardware and by a certified assessment specialist, usually a physical therapist.  The FCE is performed to quantify functional capabilities and limitations for physical work.  When the FCE shows that the essential physical abilities are present to match a job description, then the individual with chronic pain, despite his/her complaints, can meet the exertional demands of a particular vocation.

Sometimes, of course, chronic pain can affect work tolerance or endurance, and the FCE becomes the best available evaluation to indicate whether work hardening is necessary and appropriate.  In addition to showing deficiencies of physical ability, a good FCE will show the physical reasons for those deficiencies, and those physical reasons may very well be addressed in work hardening and/or by job accommodation.  For example, if a person with chronic back pain cannot sit or stand for prolonged periods, then the job accommodation of allowing the person to change his/her posture to find comfort may very well be considered reasonable depending on the job and the employer.

Symptom Magnification and Observation

None of the assessment tools mentioned above are more important than the qualitative data that employment of these methods can supply to the trained observer.  According to Matheson (1982), symptom magnification is a complex pain behavior that involves a “constellation of reports or displays of symptoms which functions to control the environment,” usually in a manipulative or maladaptive manner.  However, as with any human behavior, pain behavior is meaningful and purposeful.  Therefore, a trained observer must be present and willing to look for consistencies and inconsistencies in what a person reports or displays, and how the individual actually functions in relation to measures of mental ability, temperament, and physical capacity.  Otherwise, the symptom magnifier will display symptoms (real or imaginary) in an effort to secure social reinforcement, generally by manipulating his or her performance.

In the evaluation context, those reported symptoms can be misleading without the observer recognizing that critical behaviors must also be measured and evaluated concurrently.  Thus, one might find the symptom magnifier actually performing a work-like task completely, while at the same moment complaining that he/she cannot do it.

Summary and Conclusion

Chronic pain (i.e. extended pain) is a serious health care problem.  The estimate of the prevalence of chronic pain in the general population is that as many as one-third of all Americans experience it.  When chronic pain is examined in the context of return-to-work programming, the cost factors to employers can be substantial if not addressed knowledgeably.

What vocational rehabilitation professionals – working from medical research models – have found is that chronic pain need not be a work disability.  Using FCE outcomes and the results of standardized instruments, experienced Vocational Counselors are competent to overcome the return-to-work obstacles that chronic pain often presents.  The methods of rehabilitation appropriate for employees manifesting chronic pain symptoms are “job accommodation” and “transition-to-work programs.” 

PART II: ISSUES IN PAIN AS A DISABILITY

by Jasen M. Walker, Ed.D., C.R.C., C.C.M.

A Definition of Chronic Pain

This article focuses on the concerns of chronic pain and Transition-to-Work programming.  The working definition of chronic pain that CEC Associates used in preparation of this article is:

Chronic pain is pain that persists after adequate medical treatment has been administered, traditional medical treatments have been exhausted, and a normal period of time has passed during which a cure or healing might have been expected.

Returning to Work with Pain

Returning employees to work after an injury or illness is a process in which most employers have experience.  Frequently, the return occurs before complete recovery has occurred, but the prognosis is for eventual near-total recovery. 

When the return to full employment is complicated by continuing pain (real or perceived), the solution is compounded.  That is, a return to work is not absolutely contingent on the employee being pain free, either at the time of the return or in the future.  The issue then becomes one of finding ways to accommodate the employee with continuing pain and keeping him/her productive.

The single most important aspect of a return to work for all employees is that the return is developed as a transition.  There are few, if any, cases (with pain or pain free) where an abrupt re-entry to work will be as successful as a planned, incremental return.  The term used by rehabilitation professionals for this process is a Transition-to-Work (TTW) program. 

The primary issue with pain is to determine whether it is an “impairment” or a “disability.”  If the pain is determined to be an impairment, then a decision may be made as to whether the pain will preclude the employee from performing tasks other than his/her pre-injury/illness work.  For example, an employee whose pre-impairment assignment involved a physical activity (e.g., walking, standing, and lifting) that now cannot be achieved because of attendant pain might be assigned to a new work activity in which the specific physical activity that caused the pain has been reduced or eliminated.  In this case, the impairment is “accommodated,” and there is no absolute disability.  One deemed disabled in a specific activity is not necessarily disabled in all other activities. 

Medical experts are responsible for determining what physical (or psychological) impairments an individual may have.  Such medical diagnoses are called “functional capacity evaluation” reports.  Given the medical knowledge of the specific impairment, it then becomes the responsibility of the employer (through vocational rehabilitation professionals) to determine the level of disability of the individual.  If, in fact, the impairment precludes the employee from doing any tasks in the work organization—with or without accommodation—then the employee may be determined to be disabled.  If, on the other hand, the employee can be productive in a different work assignment, or the same assignment with appropriate accommodations, then the individual can be classified as not being disabled in all possible work assignments. 

The most frequent causes of workplace injuries that result in post-treatment pain are:

Chronic and persistent pain may be the direct result of work-related injuries (or post-trauma or surgery complications), but they may also be the result of personal and psychological stressors, such as:

Interventions

The most effective interventions are proactive.  That is, employers need to develop strategies that will prevent and reduce injury/illness occurrences.  The single most effective strategy is creating a Safety and Wellness (S/W) program.  The function of an S/W program is to educate employees on ways to eliminate, or at least limit, accidents and avoidable illnesses.  Work-risk analysis is the basis for determining the concepts to be inculcated.  The safety aspects of this kind of program are closely tied to proven job redesign and ergonomic models.

When an individual identifies pain that persists after curative medical treatments, there are pain rehabilitation methods that can be applied.  These include, especially:

Since TTW programs are predicated on planning and incremental steps, this approach to return to work is ideal for managing pain.  In a TTW program, on-the-job training is meshed with pain treatment in steps.  Each day is divided between actual pain abatement training and work assignments that are incremental, from limited time on the work task to eventual integration into full-time work and the phasing out of training.  Specific training on the non-work, pain-reduction aspects will include:

Traditional TTW programs are developed by a team of appropriate persons.  At minimum, the team will include a medical professional (a physician or a Case Management Nurse) and the supervisor of the employee after he/she returns to work.  Needless to say, the plan also requires the input and approval of the employee for whom the program is being designed.  The TTW plan should also include projected milestones to evaluate the employee’s progress and follow-up schedule, which could include visits to the medical professional assigned to the case.

Self-Management Treatments for Chronic Pain

The scientific and medical professions have, in the past several years, invigorated their interest in that part of patient care that focuses on pain relief.  Two recent professional studies on pain, conducted under the auspices of the International Association for the Study of Pain,¹ relate to the responsibilities of Vocational Rehabilitation professionals.  These findings are relevant to “pain as a disability” and “pain as an aspect of return to work.”

One study suggests that an “increased commitment to a self-management approach to chronic pain may serve as a mediator or moderator of successful treatment.”  An instrument, Pain Stages of Change Questionnaire (PSOCQ), was developed to “assess readiness to adopt a self-management approach to chronic pain.”  That is, Vocational Rehabilitation Professionals may have a new tool to assist employees in returning to work and making the transition more smoothly.

A second study found that an original study done on animals is also true for humans.  In that study, the researchers found that “fear inhibits pain” but “anxiety enhances pain.”  The ultimate value in vocational rehabilitation is in finding ways to identify and lessen the anxiety factors associated with a return to work. 

The outcomes of both of these findings undoubtedly hold significance in vocational rehabilitation, and it will now be up to professional Vocational Experts to work out strategies to apply the findings.

Assessment of Pain and Pain Behavior²

Since pain is a perceptual event, it cannot be measured in terms of the presence or absence of tissue damage.  Rather, evaluation must develop around knowledge of the kind of pain that is present.

Aspects of pain classification would include, but not be limited to the following:

To measure the intensity of pain, the professional could use one of the following methods:

Physiological evaluations are used to examine the relationship between the behavior of the individual with pain and the physical responses that may accompany pain.  The three most common forms of physiological assessment in chronic pain are:

Behavioral assessments may be defined as personal reactions to impairment.  There are three approaches to behavioral assessment, ranging from direct behavior observations (generally of videotaped samples) to self-administered questionnaires.  The direct observation method is preferable to a self-administered approach, but it also requires greater resources for the activity.  Somewhere between the observation and the self-reported methods is the pain behavior checklist.  The most widely used checklist is one developed by the University of Alabama-Birmingham called the Pain Behavior Scale (PBS).  This checklist contains 10 pain behaviors (e.g., grimaces, downtime, and medication use) that are rated on a 3-point scale.  Checklists come as either administered or self-administered instruments.

Another approach to pain evaluation is through cognitive and affective assessments.  Thoughts, beliefs, attitudes, self-statements, and expectancies are all examples of cognition used to assess pain.  The primary instruments used in this approach are:

In addition to the specialized assessment instruments listed above, there are also “inventories” that can be used in the vocational rehabilitation process.  For example, the two most used pain-specific inventories are:

Most Vocational Counselors trained in assessment methods and materials are familiar with the Minnesota Multiphasic Personality Inventory-2 (MMPI-2).  This is the most prevalent standardized inventory used for evaluating patients with pain.  Other psychological inventories include the Million Behavioral Health Inventory (MBHI) and the Million Clinical Multiaxial Inventory.  These latter two inventories were standardized on a medical basis rather than on the mental health population of the MMPI-2.

Vocational Rehabilitation Professionals will need to recognize that pain is an impairment and, as such, can be managed in a way that will provide an opportunity for the employee to return to productivity.  To succeed in returning injured workers to productivity, Vocational Counselors will need to be trained and certified in the methodologies and materials of vocational evaluation.

Tolerance for Pain

One of the most important studies on pain and disability was conducted by the Committee on Pain, Disability, and Chronic Illness Behavior at the Institute of Medicine.  The study was published as Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives in 1987 by the National Academy Press in Washington, D.C. 

In a subsection titled Medical Definitions Versus Functional Concept, the study addresses the issue of tolerance for pain:

…there is substantial individual variation in terms of tolerance for pain…  Many factors interact in complex ways to influence individual tolerance, motivation, and functional capacities such that some people are able to work in the face of severe symptoms and others are unable to work when confronted with less severe symptoms  (pp. 69-70).

The reality of a disparity in tolerance levels creates a difficulty for employers trying to distinguish between those who will benefit from a Transition-to-Work (TTW) program and those who are truly incapacitated.  Generally speaking, workers who can be engaged in TTW programs are more likely to have positive outcomes than those who resist the effort.  At least three studies³ indicate that employed patients have better treatment outcomes than unemployed workers.

Commitment to a Return-To-Work Program

Numerous studies show that companies interested in the cost effectiveness of their operating procedures will have a strong management commitment to a Return-to-Work program for employees who have suffered injury/illness.

A certain and early return to work is one of the most successful strategies that employers can use to control their workers’ compensation and other insurance costs.  The commitment to return to work includes the following components:

 References:

1.      Kerns, Robert D., and Rosenberg, Roberta, Predicting responses to self-management treatments for chronic pain: application of the pain stages of change model.  International Association for the Study of Pain.  (www.elsevier.nl/locate/pain)

Rhudy, Jamie L., and Meagher, Mary W., Fear and anxiety: divergent effects on human pain thresholds.  International Association for the Study of Pain.  (www.elsevier.nl/locate/pain)

2. Cushman, Laura A., and Scherer, Marcia J., Editors, Psychological Assessment in Medical Rehabilitation: Chapter 7: “Assessment of Pain and Pain Behavior.”  American Psychological Society, Washington, D.C., 1995.

3.      Catchlove R., and Cohen, K., “Effects of a directive return to work approach in the treatment of workmen’s compensation patients with chronic pain.”  Pain 14:181-191, 1982.

Newman, R.I., Seres, J.L., Yospe, L.P., and Garlington, B., “Multidisciplinary treatment of chronic pain: long-term follow-up of low back patients.”  Pain 4:283-292, 1978.

Seres, J., Painter, J.R., and Newman, R.T., “Multidisciplinary treatment of chronic pain at the Northwest Pain Center.”  NIDA Research Monograph 36, Rockville MD, pp.41-65, 1981.

PART I: A PAIN IN THE BACK

by Jasen M. Walker, Ed.D., C.R.C., C.C.M.

Introduction

The most frequent and costly cause of lost work time is, to no one’s surprise, back problems.  Back problems cost employers an estimated $75 billion per year in direct workers’ compensation costs alone (Source: HR Magazine Online, 9/5/01).  And, the real cost, the total cost, to employers is even higher.  The cost of lost productivity due to back problems is even more than the total cost of workers’ compensation for this specific problem.

Are there strategies and methods that employers might use to address the issue?  This article will focus on some ideas for employers to control the reality of back problems.

As with any injury or illness leading to lost time at work, the key to ameliorating the high cost of back problems is prevention.  There are two basic aspects of prevention that employers need to address:

1. Creating and conducting safety and wellness programs, including exercise, weight loss, and stress-reduction sessions.

2.  Conducting ergonomic surveys of the workplace and redesigning work tasks to conform to the results of these surveys.

The single most effective strategy is to train and educate employees on prevention.  Employers need trainers who have been trained to teach others how to avoid injuries and prevent illnesses, as well as how to prevent back problems specifically.  In small companies, the trainers might be individuals assigned the responsibility as a supplement to their regular duties, or by contracting for outside trainers to do part-time training.

In larger companies, safety and wellness programs are essential.  These programs need to be carefully structured and documented, facilitated by competent individuals, pressed to remain vital by achieving positive results, and continued over time by offering fresh issues to examine.  In addition to general principles of health, wellness programs should especially include weight loss, stress reduction, smoking cessation, and nutrition.

It is also important to note that training need not be focused on the lowest level of employee.  In fact, training supervisors will produce a higher return on investment than direct training of employees on the lowest level.

Back problems, more than any other injuries with the exception of repetitive motion injuries, lend themselves to prevention and reduction through ergonomic redesign.  (Back problems can, of course, result from tasks with high incidences of repetitive motion.)  Engineers specifically trained in ergonomics and safety can make work-site adjustments that will return several times more in cost savings than the amount spent.

Another aspect of ergonomics is what is known in business management case studies as the “Hawthorne Effect.”  Named for an experiment more than 50 years ago in a manufacturing plant in Hawthorne, New Jersey, the “effect” is achieved when modifications that workers perceive to be to their benefit are made in the physical environment.  That is, even if the ergonomic redesign does not in reality produce a desirable effect, if it is perceived to do so by the worker, the desired result will be realized.

After all the preventive measures have been implemented, the next most cost-efficient practice is a commitment to a return-to-work program.  A return-to-work commitment manifests itself through a Disability Management (DM) program.

DM is an initiative designed to minimize the impact of disability (injury or disease) in the workplace.  A good DM program is the outcome of a joint effort between management and the workforce.  The objective of DM is an early return to work of employees.  (Studies reported by the UNUM/Provident Corporation put cost reduction for all disabilities, when addressed through a Disability Management program in the workplace, at 20-30% over non-managed programs.)

Why is DM a desirable process?  An employee’s chance of successfully returning to productivity (and, thereby, to the continuation of a healthy and meaningful life with self-esteem) is highest if he/she does so soon after an injury occurs.  There are significant cost savings and other considerable benefits to employers who offer DM programs.  By conducting an aggressive DM program, companies gain the respect and loyalty of their employees, and employees who participate in good DM programming are even more highly valued and rewarded by their employers.

What are the critical components of a DM program?  There are a number of components of DM, but the critical ones are having valid Job Descriptions and a Transition-to-Work (TTW) program in place.

Job analysis and job descriptions are based on the essential functions of a job.  Job analysis is an exact science that occurs by applying objective measures: pounds to be lifted, frequency of stooping, length of time to stand, repetitive motions, environmental conditions, etc.  Jobs need to be analyzed by a staff member trained in job analysis methods and materials.  Job descriptions are based on the measurable outcomes of the job analysis, and they become the blueprint that can be modified when re-employing (returning) someone with medical restrictions.

TTW programming is another essential aspect of DM.  To return employees to work at the earliest possible moment, a TTW program has to be organized and implemented.  The two basic concepts of TTW are:

1. Employees are reintroduced to work in incremental steps.

2. There are specific roles for staff and specific strategies to be used.

While DM programs are, of course, designed to work with all disabilities, they are especially effective with back problems.  Back problems can be stated in terms of statistical realities.  According to Stover Snook, Certified Professional Ergonomist and lecturer on ergonomics at the Harvard School of Public Health:

And, what is even more startling is that these percentages occur with or without treatment and regardless of the type of treatment.

Given these statistical realities, it is important that employers engage their employees with back problems at the time of the injury, that they keep in close communication with the employee, and that they effect an early return to work in a TTW program structured in incremental steps.  By applying “best-practices” disability management, employers can make dramatic inroads into the intransigent nature of back problems in the workplace.

One aspect of good DM is case management.  Someone in the company needs to be assigned the responsibility of working with the injured worker from the moment of the injury until a full return to work is accomplished.  The immediate responsibility for this monitoring and support will be the injured worker’s supervisor.  In some cases, the monitoring/support function is turned over to a professional Case Manager.

Whoever is responsible, the objective is to complement the DM process, especially as that effort relates to the medical treatment plan.  Other professionals who can play essential roles in support of the DM program are Vocational Counselors.  Case Managers and Vocational Counselors are trained to work with employees who have back problems, and they have the experience to find the solutions necessary to control the back-problem aspect of returning to work.

In terms of the treatment plan prescribed for the employee with an injury resulting in a back problem, there are other professionals who may be vital to the solution.  These professionals include Physical Therapists, Osteopaths, and Chiropractors.  Physical Therapists provide strengthening and work-hardening regimens, while Osteopaths and Chiropractors offer cost-effective medical interventions to help control, and even reduce, medical costs.

The Americans with Disabilities Act (ADA) also plays an important role that can be factored into the comprehensive arsenal of strategies to deal with back problems.  The ADA requires employers to provide “reasonable accommodations” for injured workers, and there is no more important application of this concept than for employees with back problems.  Although some employers think that accommodating a worker appears to be sending the wrong message to the workforce at large, and something many employers may be unwilling to make, the outcomes of making accommodations are almost entirely positive.

Most accommodations cost very little, and making an accommodation generally will lead to the retention of a valued employee.  Accommodating an employee with a back problem is a serious tool employers can use to find relief from the debilitating costs of back problems.  Also, it is important to recognize that making a job accommodation is not the same as providing the employee with a “light-duty” assignment; these two approaches are diametrically opposed.

There is also a psychosocial factor in the mix.  That is, psychosocial dynamics are more reliable predictors of impending back-problem claims than medical factors.  CEC Associates, Inc., has long assisted employers to understand the psychosocial aspects of workplace disability through describing “learned helplessness” and “disability prone” concepts.  Again, experienced, skilled Vocational Counselors and Disability Management Specialists can assist employers to recognize these social realities and develop strategies to control and reverse them.

Employers also need to recognize an increased responsibility to deal with this problem without important assistance from the federal government.  One of the first actions taken by the Bush White House staff was to reverse a Clinton administration regulation on mandatory ergonomics under the Occupational Safety and Health Administration (OSHA).  The effect of this reversal is that employers will not receive relief in respect to ergonomics in the workplace.  That is, as OSHA now stands, there will be no federal requirement and no federal moneys to implement ergonomic reforms in the workplace.  That is not to say that employers need not, or should not, effect ergonomic adaptations; it is just that they will not be required to do so or assisted in doing so with federal funds.

Another angle of attack on the problem is through proactive claims management.  This is especially true where the responsibility for treatments and compensation are either private insurance carriers or self-insured companies.  Progressive claims management can assist employers to plan and engage “best-practices” disability management, and employers should avail themselves of these resources for program planning and implementation.

In summary, back problems are the single most significant cost factor in worker disability.  The good news is that employers can take steps to deal with this reality.  When they do so, they are rewarded with reduced costs and increased employee loyalty and dedication.

PART II: BACK PROBLEMS: SPECIFIC ISSUES

by Jasen M. Walker, Ed.D., C.R.C.,C.C.M.

Workplace Accommodations for Back Impairments

The federal government funds an enterprise that focuses exclusively on assisting employers to find suitable and cost-effective job accommodations for individuals with physical impairments.  The name of this entity is the Job Accommodation Network (JAN) located at the University of West Virginia.  JAN is a branch of the President’s Committee on Employment of People with Disabilities.  Below are some back impairment accommodations developed by JAN.