What’s the Difference Between Standard PT and Work Conditioning When It Comes to Return-to-Work Success?

Physical therapy is great. But work conditioning and work hardening are the true champions when it comes to rehabilitative care in workers' comp.
By: | April 12, 2022

Physical therapy has long been heralded as a highly effective treatment for injured workers with musculoskeletal injuries. And it’s considered one of the primary rehabilitation techniques used by the industry.  

But even though PT may get a lot of attention, lesser known rehabilitation techniques are still helping injured workers get back to pre-injury levels of function every day.

In a recent webinar, MedRisk, a provider of managed physical medicine for the workers’ comp industry, dove into several of these physical rehabilitation techniques, including work conditioning, work hardening and functional capacity evaluations.  

Presenter Anne Marciniak, with MedRisk, has a background in overseeing all three techniques over the course of her 20-year career as a physical therapist.  

Marciniak described advanced work rehabilitation techniques as a tool that allows workers to dip their toes into the water before fully returning to work.  

While physical therapy can help immensely for some jobs, especially after surgery, the basic tests of full strength don’t suffice, and the patient can regress. She recommends these advanced methods as a way to keep the patient from veering off course and never returning or returning after a lengthy and potentially damaging period of disability.  

“Physical therapy and these advanced techniques should flow together. Case velocity is a big thing throughout the research in the last five to ten years … four months is the most critical time,” she said 

Work Conditioning Vs. Work Hardening 

At first blush, work conditioning and work hardening may seem similar. Both are physical rehabilitation techniques designed to help a patient return to specific vocational functions. They may use simulated or real activities to increase a worker’s musculoskeletal function.  

 “What I can tell you from treating countless patients myself is that work conditioning and work hardening are used interchangeably. The CPT codes are the same,” Marciniak said, although she noted work hardening is multidisciplinary and should include “a healthy portion of work simulation.” 

Classic definitions of work conditioning and work hardening cite the intensity and length of the programs as the key distinguishing factors, according to Marciniak.  

Work conditioning is typically four hours a day, three to five days a week, for a month of two. Work hardening builds on the gains made in physical therapy to a greater extent, increasing sessions to a full eight hour day, five days a week, and continuing for a full two month period. 

Work hardening programs may also be tailored to fit an individual position’s needs. Marciniak gave an example of a flight attendant who may not need a full five-day-a-week program.  

“It always should vary based on what your injured worker needs,” Marciniak said.  

“We have flight attendants who get into work hardening programs. Flight crews typically don’t work five days a week — they work two to three days on and then they’re off. So it doesn’t make sense to put somebody who does shift work or split shifts to do a five-days-a-week program.” 

Or a worker may need a more vigorous work hardening program, as is common for people with jobs in heavy industry or those who have been out of work for longer than six months.  

Despite these differences, both techniques share the objective of restoring physical capacity and function, and both must build on the simple exercises preferred for physical therapy.

“It shouldn’t look the same. You shouldn’t look at these notes and think, ‘I can’t tell if it’s PT or work conditioning.’ If that’s the case, it isn’t work conditioning,” Marciniak said, adding that claims handlers should be aware of red flags where the only additional tasks seem to be box lifts or other minor adjustments.  

Next Steps

After and throughout successful completion of both work conditioning and work hardening programs, functional capacity evaluations (FCEs) come into play.

“There are a lot of different things that go into returning to work,” Marciniak said. “Looking at job demands and looking at work capacity, the FCE is measuring whether those two things match.” 

A typical FCE will include a wide variety of activities, from balancing to walking, and it is considered to be objective, but “branded” ones will tout an evidence-based approach, and the options can be overwhelming.

A 1999 study from the American Institutes for Research found that there are over 800 different types of FCEs, and that has only expanded with the growth of PT as a portion of medical spend. 

Job placement is one of the key areas where an FCE can benefit both the employee and the employer to determine fit for job placement, if the injured worker’s former job is no longer available.

“I did a lot of work for Honda and they had one job title — production associate — but there were 600 different areas of the plant that they could work in,” Marciniak recalled.

“So after surgery, we would do a test and see where they match.” 

The timing of an FCE is varied, and Marciniak said it all depends on the reason.

“If you have somebody going from acute PT and the therapist says their range of motion and strength are normal, but they aren’t quite meeting their job demands, so they might be a candidate for work conditioning/work hardening, there’s almost no reason to do an FCE beforehand,” she explained.  

Marciniak reiterated the lifesaving benefits of work, citing the oft-cited statistic that 50% of people who are out of work for six months never return.  

She emphasized the harm associated with unemployment, citing research that shows a lack of meaningful employment is associated with substance abuse and increased risk of chronic low back pain.

It’s also associated with negative psychosocial outcomes, such as divorce and child abuse. 

“Being out of work kills people,” Marciniak explained.  

“Getting people back to work … it’s for the patient and the injured worker’s survival.” &

Nina Luckman is a business journalist based in New Orleans, focusing primarily on the workers' compensation industry. Over the last several years, Nina has served as Editor of Louisiana Comp Blog, a news site she started in 2014 under the auspices of a group self-insurance fund. She can be reached at [email protected].

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