Return to work after traumatic injury or a long absence requires a strategy

Co-worker support, gradual re-entry can make return smoother

It’s a common observation when the discussion is about return-to-work plans: "Every return to work plan is different because every employee/patient is different."

But what about cases that are really different — when the employee has been off work for five years, or is returning to work after a traumatic injury that not only affected the employee, but also the co-workers who witnessed it? In cases like these, neither the employees nor their workplaces are the same as they were before the employees went on leave.

"Successful return to work in these cases demands a combination of knowledge, experience, and creativity," says Jeanne Griffin, MS, CDMS, a disability management specialist and director of the Return to Work Center, a division of the Peoria, IL-based Institute of Physical Medicine and Rehabilitation. "When someone has been off work for years, or has had a catastrophic injury, each of those presents with its own set of problems."

A one-size-fits-all return to work approach doesn’t work in general, she points out, and especially not when dealing with an employee whose biggest problems may not be just the injury or illness that put him or her on leave to begin with.

Issues beyond injury or illness

A clinician working with an employee who has been off work for years may find that the employee is reluctant to come to work, but not necessarily because he or she still is bothered by the initial injury. "I recently worked with someone who had been off work for about five years," Griffin explains. "That was long enough that the employee was bored at home and really wanted to go back, but after that period of time, you aren’t just looking at the injury anymore."

In cases in which employees are off work for years, they change, their health alters, and their job and workplace change. Technological advances in the workplace may leave the employee feeling that he or she doesn’t know the job any more; his or her supervisor might feel the same way. Especially in the cases of employees who are near or in middle age, intervening health problems can arise to cause problems that were not there at the time the employees went off work. "What has this person being doing? Inactivity can have an effect on health," Griffin says. "Also, sometimes other conditions have developed in that time away from work. That makes it so important to identify all barriers to returning to work."

In the case of traumatic injuries, Griffin says the employee also is battling fears that stem from the event or its aftermath. "Of course, they are worried about reinjury," she says. "Someone who has been in a serious motor vehicle accident may be very fearful about returning to work and driving a truck. What helps that situation are things like work hardening, work conditioning — a brief period where they have a neutral environment, when they can get confident, and with a brief oversight of that transition period [by a disability manager or nurse], you can get through that and smooth away the fear of reinjury, and reassure them that what they’re doing at work is within their capabilities."

Education on all levels urged

When an employee is ready to go back to work after an extended leave, his immediate supervisor "can be a great help by letting the other workers know that this person will be back, and what his limitations are," says Mary Patt Scanlon, division chief in the Civilian Personnel Management Services, Injury/Unemployment Compensation, U.S. Department of Defense in Arlington, VA. "If the co-workers buy in — they may have to do some of this person’s heavy lifting, for example — the return will go much more smoothly."

When the employee in question is someone who has been off work for a number of years, he or she might be coming back into a workplace that has changed; both the work and the co-workers might not be the same. Accordingly, other employees will be asked to make concessions for and assist a new worker they have no ties to.

"We get everybody on board, so everyone’s working toward the same goal of getting a person back to work. That may mean some education for that first-line supervisor as to what this person can and cannot do, and for the [case manager] to act as a mediator to help in the transition."

When an employee who suffered a serious injury on the job comes back to work, not only is the occupational health manager faced with helping the worker overcome fears of being reinjured and the emotional and physical toll of regaining the comfort and proficiency of doing the job he or she was doing before the accident, but also the case manager finds other employees needing help, as well.

"The impact is on everyone at the workplace, especially those who witness a catastrophic injury," says Griffin. "It impacts the whole workplace, from preparation for the employee to come back, to how far this person is going to integrate back, to the emotions that they might be feeling."

Griffin says she once managed a worker who was seriously burned on the job. The employee’s co-workers "never imagined he would be able to return to work, ever." When he did, "There wasn’t a dry eye in the house." The tears were not just from happiness, Griffin says; the injured worker’s experience brought home to his co-workers the realization that what happened to him could happen to them.

"The more that employers can understand that [an injured employee’s] co-workers see how that person is treated while they are off, and how they are treated when they return, that’s an opportunity for employers to raise their own awareness and to think of the things they can do to make transitions easier and make the environment safer for all their employees," she points out.

Same ideas, modified

Traditional tools for re-integrating an employee into the workplace — work hardening, work fit testing, modified or light work — are important components of getting a long-disabled employee, or a seriously injured one, back to work. The trick is using those tools in the right way. "On-site work hardening, by itself, can be too costly. Modified work, by itself, does not advance the worker to the pre-injury job level," Griffin says. "There isn’t just one solution."

Sometimes, it’s easy. "One of our goals is to change managers’ attitudes," Scanlon says. "A lot of times, accommodating an injury can be simple. By removing one piece of a job description, the employee can do the rest of it. He may not be able to lift 50 pounds anymore, but he certainly can work."

Modified work can be a very good way to ease an employee back to his pre-injury levels. However, modified work can appear to be too simplistic to the experienced employee; if the employer has been forced to come up with "busy work" for the employee to do when he returns to work, the employee can feel guilty.

Griffin says that if the case manager can come on-site and oversee the employee’s transition period — in as unobtrusive a way as possible — he or she can get an accurate picture of whether the modified work is enough to help harden the employee and foster his return to his previous work levels, or if it is so far behind what the employee is capable of that it actually sets his rehabilitation back. "But there is something to remember about on-site supervision — it needs to be for as short a period and as nonintrusive as possible," she advises. "That person is going back as a whole person, and doesn’t want to be identified as someone with special needs."

Devising a successful return to work plan must be done with input from the employee’s physician. "You need to get them to write a prescription that really means something, not no use of right arm,’ but something that really helps the employer understand the tasks the employee can do." (For the American College of Occupational and Environmental Medicine’s guidelines for making useful return-to-work recommendations, see box.)

A mistake some case managers make on the employee’s behalf is not giving the physician enough of the right information he or she needs to write a return-to-work prescription. The physician should be given detailed descriptions of the work — including, for example, what kinds of hard labor are involved or what repetitive tasks are done. The physician also should evaluate what the patient is able to do at the time of the initial return to work.

The physician and case manager should be creative at times, to ensure that the return-to-work actually does prepare the employee to return safely to his or her former work. For example, an employee might need to be restricted to lifting 25 pounds; but if medically appropriate, the prescription could specify that the employee can lift more weight when the case manager is present. In that context, the employee and case manager can see what he is capable of, in a controlled setting.

"If you can do it in as nondisruptive way as possible, individual case management [on site] can get the employee back to work more quickly," Griffin says.

This on-site work hardening requires considerable communication among the worker, employer, physician, and case manager to obtain the desired results, authorization for compensation, and scheduling of site visits. Depending upon the workplace, there may be other considerations: safety equipment or special attire for the case manager, hours of supervision, and confidentiality issues for the worker.

For more information, contact:

Jeanne Griffin, MS, CDMS, Director, Return to Work Center, Institute of Physical Medicine and Rehabilitation, Peoria, IL. Phone: (309) 692-8155. E-mail:

Mary Patt Scanlon, Division chief, Civilian Personnel Management Services, Injury/Unemployment Compensation (CPMS ICUC), U.S. Department of Defense, 1400 Key Blvd., Suite B200, Arlington, VA 22209. Phone: (703) 696-1986. E-mail: