WORK CONDITIONING AND WORK HARDENING

1. WORK CONDITIONING AND WORK
HARDENING
- NITHIN NAIR
• UNDER GUIDANCE OF DR. POTHIRAJ P. (PT)

2. LEARNING OBJECTIVES
• After this session students will have in-depth knowledge
about Work Hardening and Work Conditioning.

3. INJURY ACUTE
CARE
FCA
JOB
ANALYSIS
WORK
HARDENING
JOB
MODIFICATION
CONDITIONING
WORK
CONDITIONING
RETURN
TO WORK
EXIT
ASSESSMENT
TERTIARY PREVENTION

4. FCA
MEET JOB
REQUIREMENTS
RTW
CAPABILTY
BELOW AVERAGE
CONDITIONING &
RTW
DOES NOT MEET
JOB
REQUIREMENTS
VALID
POOR POSTURE &
BODY MECHANICS
TRAINING
MEETS JOB
REQUIREMENTS
RTW
DOES NOT MEET
JOB
REQUIREMENTS
WORK
CONDITIONING
RTW
WORK
CONDITIONING
JOB
MODIFICATION
RTW
JOB
MODIFICATION
RTW
CONDITIONALLY
VALID / INVALID
WORK
HARDENING
RTW
INVALID
FCA RTW
REDUCE OR TERMINATE
WORKERS’
COMPENSATION BENEFITS

5. SIGNIFICANT DIFFERENCE BETWEEN A PERSON WHO IS
MEDICALLY HEALED & A PERSON WHO IS PREPARED FOR
RETURN TO WORK AT FULL JOB FUNCTIONS.
 Physical strength to perform work – declined due to inactivity.
 Individual’s physiological resources have been depleted – Energy
level & Endurance.
 The person’s psychosocial equilibrium unsettled – Fear of reinjury
& other anxieties.
 The body part “healed” in medical terms may still be vulnerable to
reinjury when subjected to job demands.
LITERATURE SUGGEST THAT THERE ARE A NUMBER OF
MEASURES REQUIRED, BEYOND HEALING IN ORDER TO
ACCOMPLISH A SAFE AND SUCCESSFUL RETURN TO FULL
PRODUCTIVITY.
 Physical strength – Built up & maintained.
 The injury or illness – induced physiological & chemical changes
that impact energy levels & endurance must be reversed.
 The capability in strength and endurance depleted by inactivity
must be restored..

6. STRENGTH
EDURANCE
FLEXIBILITY
MOBILITY
SYSTEMATIC APPROACH
PREVENTIVE EDUCATION
WORKERS’ COMPENSATION UNDERSTANDING
HEALTH CARE
KNOWLEDGE OF OPTIONS
HONESTY & TRUST
WELL DEFINED GOALS
PACING MECHANISM
COPING SKILLS
CO – WORKER INTERACTION
EMPLOYEE / EMPLOYER COMMUNICATION
PAIN MANAGEMENT SKILLS
WORK HABITS
MOTIVATION / CONFIDENCE
PHYSICAL CAPABILITIES
SUPPORT STRUCTURE
SELF MANAGEMENT SKILLS
SPECIFIC RTW REQUIREMENTS

7. WORKRETRAINING
OPERATIONS
ASSESSMENT AND
EVALUATION
GOAL SETTING
PROGRAM DAY
LENGTH
PROGRAM
DURATION
PROGRAM
PLANNING
PROTOCOL
GUIDELINES
SIMULATION
GUIDELINES
Provides a baseline of comparison for goal setting,
planning and progress monitoring
Goals are determined by rehabilitation team and
should be SMART
Previous → Later
(8 hours → 6 hours → 4 hours)
Determined using Predictive Index
Determined using FCA results, return to work job
demand, injury profile, validity index result,
litigation status
Should be consistent, standardized and flexible
No need have exactly duplicate, just simulate
relevant portions of it

8. FCA
VALIDITY
COMPLIANCE
HISTORY
LITIGATION
STATUS
TIME OUT OF
WORK
JOB ANALYSIS
VALIDITY
DETERMINATION
PHYSICAL
CAPABILITY
PREDICTIVE
INDEX
α
β
γ
CONDITIONING
2 WEEKS
6 WEEKS
4 WEEKS

9. WORKRETRAINING
STRUCTURES
SPACE
REQUIREMENTS
EQUIPMENT
REQUIREMENTS
EQUIPMENT
SELECTION
LOCATION
SELECTION
SPACE
SELECTION
PATIENT MIX
STAFFING
3 primary determinants: Type of work, Population
of workers types and injury types, program
protocols (hours per day and days per week)
Average size space is 2,500 sq. feet
Functional, manufacture warranted, multi – user
capable, multi – occupational flexible, durable, space
efficient, client and therapist friendly, non trendy
Nearby locations, easily accessible from major
highways, within 30 min drive
Warehouse buildings, medical buildings, should
meet ADA requirements
Severely impaired mixed with later stage recovery
client
Depends on the client caseload and the protocols

10. PT / OT (Program Director)
Assumes managerial role +
supervises + presides over
staff meetings
Add work trainer (Exs.
Physiologist, Athletic
training , PT / OT assistants
or Kinesiologist
NUMBER OF STAFF
<10 clients
Single therapist (4
weeks, 4 hours/day)
More staff required
(6 – 8 hours
program)
>10 clients
Work trainer
should be added
and staff of 2 can
manage up to 20
new clients
Staff Increases
Case load increases

11. APTA WORK CONDITIONING DEFINITION:
Work Conditioning is a work related, intensive, goal-oriented
treatment program specifically designed to restore an
individual’s systemic, neuro, musculoskeletal (strength,
endurance, movement, flexibility and motor control), and
cardiopulmonary functions. The objective of the work
conditioning program is to restore the client’s physical capacity
and function so that the client can return to work.
APTA WORK HARDENING DEFINITION:
Work Hardening is a highly structured, goal-oriented,
individualized treatment program designed to return the person
to work. Work Hardening programs, which are interdisciplinary
in nature, use real or simulated work activities designed to
restore physical, behavioural and vocational functions. Work
Hardening addresses the issues of productivity, safety, physical
tolerance, and worker behaviours.

12. CONDITIONING
WORK
CONDITIONING
WORK
HARDENING
FLEXIBILITY / MOBILITY   
STRENGTHENING   
CONDITIONING   
OUTCOMES   
ASSESSMENTS  
JOB SIMULATION  
FUNCTIONAL CIRCUIT  
EDUCATION  
VOCATIONAL REHABILITATION 
PSYCHOSOCIAL REHABILITATION 
COMPARISON OF THE TERMS WORK HARDENING, WORK CONDITIONING, AND CONDITIONING.

13. WORK CONDITIONING / WORK HARDENING
 Frequency – 4–8 weeks, 5 days/week, 4 hours/day
 Movements required in work place – used as treatment plan
 Initiated and supervised by professional therapists
 Work simulation included
 Structured body mechanics
 Preceded by FCA
 Uses job requirements as objectives
 Incremental task achieved – progress measure
 Capability level based on safe performance of job tasks & job site
ergonomics
CONDITIONING
 Frequency – 2-4 weeks, 3-5 days/week, 2-4 hours/day
 Movements required in work place – used as treatment plan
 Initiated and supervised by professional therapists
 Work simulation not included
 Structured body mechanics
 Preceded by traditional clinical evaluation
 Uses fitness level as objectives
 Fitness goal attained – progress measure
 Capability level based on physical fitness

14.  Both are work – oriented with specific work goals.
 Both are initiated with an appropriate evaluation (entry
assessment) and concluded with a return to work discharge
evaluation (exit assessment)
 Both have limited duration
 Both interface with other team members (physicians, employers,
insurance representatives, rehab. Consultants)
WORK CONDITIONING
 Addresses physical and functional
needs; may be provided by one
discipline (single discipline model)
 Requires work conditioning
examination and evaluation
 Moderate space allocation
 Utilizes more of physical
conditioning and functional
activities related to work
 Provided in multi – hour sessions
upto
4 hours / day → 5 days / week → 8
weeks
WORK HARDENING
 Addresses physical, functional,
behavioural, vocational needs;
with a multi disciplinary model)
 Requires work hardening
examination and evaluation
 Large space allocation
 Utilizes more of real or simulated
work activities.
 Provided in multi – hour sessions
upto
8 hours / day → 5 days / week → 8
weeks

15. Previous models largely ignored the role of the work place
preparedness in return to work so the newer multidimensional
definition seeks to add constructs of work place preparedness
including early return to work and a focus on decreasing lost time
with a gap analysis principle that also includes consideration of the
role of work place (barriers and facilitators) in return to work
planning and goal setting.
PREVIOUS MODELS – WORK CONDITIONING / HARDENING
CURRENT MODEL – WORK REHABILITATION
 Addresses physical, functional, behavioural, vocational needs within
a multidisciplinary model that includes medical and workplace
stakeholders.
 Requires examination and evaluation with functional testing. Also
requires communication and co-ordination with other stakeholders.
 Utilizes various therapeutic interventions with a functional
emphasis, emphasizing the role of the worker / work activities.
 Treatment session determined by situational analysis, may extend
from hour / multi – hour sessions depending on evaluation plan of
care and options / availability for work reintegration.

16. POST INJURY CARE PHASE
 TAKE THE REFERRAL
 SET UP THE FILE
 SCHEDULE THE CLIENT
 INTAKE INTERVIEW
 ORIENTATION / SIGNING
– FACILITY POLICIES
 AUTHORIZATION –
RELEASE OF
INFORMATION
 CLIENTS RIGHTS LIST
 JOB ANALYSIS OR WORK
INFORMATION REVIEW
 ASSESSMENTS
 FLEXIBILITY /
MOBILITY
 STRENGTHENING
 CONDITIONING
 JOB SIMULATION
 FUNCTIONAL CIRCUIT
 EDUCATION
 VOCATIONAL REHAB
 PSYCHOSOCIAL
 OUTCOMES
 ADMINISTER FCA
 REVIEW MEDICAL HISTORY
 COMPARE FCA RESULTS WITH
JOB REQUIREMENTS
 DEVELOP EXIT GOAL
 IDENTIFY PROGRAM LENGTH
 CONFIRM PROBABILITY OF
REACHING JOB
REQUIREMENTS LEVEL
 IF LOW PROBABILITY – JOB
MODIFICATION
 IDENTIFY STARTING POINT
 IDENTIFY WEEKLY
PROGESSION CHECK
 IDENTIFY BODY MECHANICS
ADAPTATIONS NEEDED
 IDENTIFY EDUCATIONAL
NEEDS
 IDENTIFY EXERCISE NEEDS
 PLAN JOB SIMULATION
ACTIVITIES
 IDENTIFY NEED FOR OUTSIDE
SERVICES.
SCHEDULE IMPLEMENTESTABLISHINTAKE

17. ASSESSMENT
ENTRY
ASSESSMENT
INTERIM
ASSESSMENT
EXIT
ASSESSMENT

18.  Purpose: Improve client’s postural adaptability for performance of work
related tasks
 Exercises are carried out as a part of the warm-up and cool-down periods
 Clients home programs which occurs during the work retraining program
and continues after the completion of the program can be selected from
these exercises
 Each stretch is held for 5 seconds and repeated 5 times
 Benefits
 Improve circulation`
 Reduce neuromuscular inhibition
 Provide carry over to functional activities
 Improve confidence to safely move into posture

19.  The selection of the exercises is based on the results of the FCA, the job
requirements, and the specific body part that is injured
 Strengthening exercises should be a part of each day of treatment (20-30
minutes). They should be mixed in with work conditioning and work
hardening components. (Part – Whole Concept)
 Some strengthening exercises will be taxing so it is important to space
them out, allowing ample rest and recovery between exercises.
 Equipment & Exercise Selection – Isometric & active exs, free weights,
dumbbells, and weight cuffs, Resisted exercise machine, hydraulic
resistance, isokinetic equipment, thera band, gymnastic ball, WH & WC
equipment
 Objectives of the strengthening components
 Develop strength in selected areas of the body
 Work through specific areas of deficits
 Support general improvement
 Improve client’s ability to perform job simulation
 Strengthen body parts to accommodate mechanical stresses
 Increased localized strength for maintaining static posture

20.  It involves overloading the aerobic system, stressing it beyond its current
limits to gain improvement in aerobic capability
 Benefits
 Improves Endurance
 Improves Cardiovascular efficiency
 Facilitates weight loss
 Reduces pain and enhances well being
 Guidelines
 Intensity – Determined by Karvonen formula , 60 -80% of HRmax is
taken
 Frequency – 3 – 5 times / week, minimum 15 – 30 minutes of
continuous activity
 Type of Exercise – Must involve large muscle group, be repetitive in
nature, and maintained over a period of time. It can be walking,
running, biking, rowing, cross country skiing (simulated), stepping or
swimming. Upper body ergometers can also be used.

21.  Job simulation can be defined as putting a worker in a similar or mock
situation that closely resembles the task or tasks that the worker
performs on the job
 Work stations that simulate dynamic job functions should match
individual’s job classification, postural treatment needs, body part injured
 Break tasks into smaller independent component → Learn them in safe
manner → Combine them again to resemble actual job
 Approaches : General Simulation → Specific Simulation
 Benefits of Job Simulation
 Case resolution and return to work
 Reduces fear of injury
 Improves confidence in performing tasks
 Determines client’s job task capabilities
 Provides a safe and controlled environment
General Simulation Specific Simulation
Work on a part of the body / task Involves whole body / task
Uses simulated physical demands Uses actual job task
Works primarily on one physical
demand at a time
Involves multiple physical demands
simultaneously
Precedes specific simulation Succeeds general simulation

23.  Activities included are meant to be a distraction from pain while the
individual is carrying out increased level of postural complexities.
 Activities need to be short in duration (3 mins each), rapid paced and
enjoyable to bring about a positive attitude
 Total time devoted – 30 mins / day
 Functional circuit activities should be based on “SAID” principle and
should target postures and movements that are in need of rehabilitation
and strengthening.
 Monitoring Functional Activities: Direct observation and Indirect
observation
 Direct observation includes: Activities in standard FCA (kneeling,
crawling, stooping, bending, squatting, reaching and grasping), Eye-hand
co-ordination, Mobility, Reports and behaviours, Hearing and seeing.
 Indirect observation includes: Pacing, Sequencing, Ability to follow
multiple instructions, Partner and group responsiveness, Consistency,
Motivation and Co-operation.
 It can be considered as a good opportunity to develop client’s adaptations
to immediate demands.

24. Main Objective: Educate clients on the proper use of their body to
perform job comfortably, and to prevent re-injury.
 Educational information should be consistent and on-going throughout
the program
 Educational sessions can be either individual sessions or group sessions.
 Primary topics : Presented during group sessions (For a 6 week WH
program – select 3 topics and rotate every week
 Secondary Topics: Interspersed with primary topics. And can be covered
as group sessions or individual sessions
Topics
Primary
The injury (back, neck,
upper extremities)
Prevention
Pain management
Stress management
Secondary
Dependencies
Nutrition
Fitness
Getting and Keeping a job
Pain and Interpersonal
relationships
Others

25. The role of vocational rehabilitation consultant (VRC) organised into 5
major categories
1. As a referral source: Recommends providers for assessments and programs of
treatment. Options available for referring clients.
2. As a communication and information facilitator: handles - sensitive issues,
workers compensation benefits complications, transportation issues, job
modifications, current information on job availability, accessing needed
records / results.
3. As a source for speciality testing and needs: can recommend medical,
standard capability test, psychological tests.
4. As a provider of guidance and advisory: assist with consultation, provide
assistance in compliance issues, can advise if psychological intervention is
needed, safe guard legal rights.
5. As a paperwork and payment facilitator: can intervene on behalf of client for
expediting paperwork or processing bill.
Why VRC referrals important ?
 Prompt admission (FCA, RTW program)
 Prompt , clear and responsive reporting
 Clear recommendations
 Congruent goal setting
 Clear delineation of time frames
 Solution –oriented approach
 Defensible assessment and treatment
 Standardized and consistent approach and outcomes
 Flexibility

26. o Psychological component is one of the primary defining differences
between Work Hardening and Work Conditioning
o Program Director should select appropriate professionals (Psychologist /
Psychosocial specialist)
Identify triggers that indicate a potential need for psychosocial intervention
 Conditionally valid or invalid determination
 Little or no communication with co-workers / employer
 Compliance issues
 Being disruptive
 Negative thoughts (Suicide, Violence)
 Old pain/problems reappear shortly before discharge
 Inability to work with equipment which had caused injury
Psychosocial specialist should be prepared to address following topics
 Pain management
 Dependencies
 Fear of return-to-work
 Employee / employer relationship issues
 Managing family and work issues,
 Co-worker issues
 Anxiety and stress management techniques
 “Injured” self image syndrome

27. Ultimate Goal : Increase Productivity and Reduce Costs
Hence, there is a growing demand of outcome studies – with it they can
provide better tailored treatment, improve assessment procedures, support
treatment and reimbursement, market industrial therapy services to new
prospects
3 categories of outcomes should be measured to fully evaluate work
retraining program
 Clinical solutions: Return to work and reinjury percentages
 Satisfaction survey: Client and Referral source
 Follow-up client reports: 6 and 12 months post RTW
Specific measures worth including
 Length of time between injury – start of work retraining – return to work
 Program components administered
 Return to work status
 Same employer – same job
 Same employer – modified job
 Same employer – modified job
 Different employer – same job
 Different employer – modified job
 Different employer – different job
 Not re-employed
 Reinjury rates

28. PAIN ISSUES
CLINICAL AND PHYSICAL ISSUES
MOTIVATIONAL & MENTAL ISSUES
COMBINATION CLINICAL & MOTIVATIONAL ISSUES

29. Pain
 First determine whether the pain is simply discomfort from
exertion or actual damage to the muscle tissues.
 Remedies may include individual educational sessions, pain
coping strategies, buddy activities, psychologist intervention.
Clinical and Physical issues
 Client pacing too fast – use reference points such as heart rate
 Inexperience with equipment / exercises – provide accurate
instructions, provide encouragement and observe and address
incorrect techniques
 Pain while performing exercise – differentiate between tissue
damage pain and conditioning discomfort and then address
each separately

30. Motivational and Mental Issues
 Exhibits Depression – Document observations, report to the
physician and other team members → professional
consultation
 Prior experience with exercise has been ineffective – Explain
the work related reasons and science behind exercise, use
outcome studies (evidences) for support
 Blames trainer for consequences they anticipate – help them
realize that he or she is the beneficiary of the program, not the
victim
Combination of Clinical and Motivational Issues
 Evidences fear of reinjury - document the observation and
discuss issues with the client, educating the client so that
knowledge can overcome fear of the unknown.
 Reports minor injury from the previous day – Injury however
minor should be documented when they occur.
 Doesn’t take some of the activities seriously – Certain
activities are interim steps in the part to whole progression
toward dynamic work function.

32. 1. INDUSTRIAL THERAPY – GLENDA KEY (1ST EDITION)
2. TEXTBOOK OF PREVENTION PRACTICE AND COMMUNITY
PHYSIOTHERAPY (VOLUME: 1) – Dr. BHARATI BELLARE
(1ST EDITION)
3. PHYSIOTHERAPY IN COMMUNITY HEALTH AND
REHABILITATION – WAQAR NAQVI (1ST EDITION)