By John Duncombe, DPT, OCS, CIMT, and David Ensign, MA, ATC, CWcHP

According to the Bureau of Labor Statistics, there were 2.9 million non-fatal, recordable injuries in 2015. More than 320,000 involved some type of sprain, strain, or tear; 155,740 involved injuries to the back; and the more than 900,000 of the total cases involved days away from work.

In many cases, these work-related injuries impact not only the worker, but also the worker’s family. A recent study noted in a 2015 OSHA report found that workers in New Mexico, for example, earn 15% less over 10 years than they would have earned, following an injury. The economic costs of these injuries to the United States economy are trending in the same stratosphere as dementia and diabetes. The National Safety Council estimates these type of injuries cost the US economy $198 billion in 2012. This compares to $159 billion and $245 billion for dementia and diabetes, respectively.

Physical therapy rehabilitation is generally effective for injured workers who are not performing manual labor (eg, office work, sales, education, etc), about 80% of the injured population. For the remaining 20%, such as manual laborers, carpenters, ironworkers, roofers, etc, physical therapy rehabilitation often falls short and leaves them unable to return to their occupations.

[sidebar float=”right” width=”250”]Product Resources

The following companies offer products and services that can be helpful for industrial rehabilitation and work injury assessment:


DSI Work Solutions Inc



Hoggan Scientific LLC

JTECH Medical


Rehab Management Solutions

Spirit Medical Systems Group


WorkWell Prevention & Care

Above and Beyond Physical Therapy

A lesser-known rehabilitation option—Work Conditioning/ Work Hardening (WC/WH)—is one recommendation that fills this void. The challenge is that many physicians and even workers’ compensation professionals do not know about this option, or understand the difference between it and physical therapy.

The differences between physical therapy and work conditioning/work hardening are quite significant. Physical therapy for an acute injured worker is typically two to three times per week, with each treatment lasting approximately 60 minutes. Physical therapy treatments commonly contain a warm-up, therapist and/or patient-guided stretching, joint and soft tissue mobilizations, and various strengthening exercises using resistance bands, stability balls, dumbbells, machines, and the patient’s own body weight.

Work conditioning/work hardening is a more intensive, highly structured, goal-oriented, and individualized intervention designed to return the injured worker back to the previous level of work. Work conditioning/work hardening programs are designed to restore physical and vocational functions. These programs utilize various types of equipment (free weights, weight machines, dumbbells, medicine balls, sleds, ladders, weighted boxes, etc) and are combined with total body stretching and cardiovascular training to prepare an injured worker’s entire body for the rigors and demands of a full day of work.

Currently, physicians prescribe physical therapy with the expectation that insurance companies will continue to reimburse for those services because the patient has not improved sufficiently to return to work. Yet based on national statistics, injured workers would be better served by a safe and appropriate transition from physical therapy to a WC/WH program because of the program’s return to work success rate and end objective. This is particularly important in today’s changing healthcare marketplace and the rising cost of workers’ compensation insurance for employers. Based on national figures, workers’ compensation costs have more than doubled in the last 20 years in terms of percentage of payroll.

The Return-to-Work End Goal

ATI Physical Therapy, headquartered in Bolingbrook, Ill, developed the Functional Integration of Rehabilitation and Strength Training (FIRST) program based on extensive research and input from orthopedic surgeons, physical therapists, athletic trainers, exercise physiologists, and bio-mechanists. The FIRST program combines sports performance-based methodology and physical therapy principles, with the ultimate goal to safely return the injured worker back to the workplace as quickly and safely as possible. It is a customized program based primarily on the patient’s current level of function with an identified return-to-work end-goal in mind. The FIRST program is typically 4 to 6 weeks long, with 4- to 5-hour sessions per day. However, modifications can be made to fit a patient’s specific needs.

The referral pathway for an injured worker to become a FIRST candidate typically follows physical therapy treatment and if he/she has:
• Reached a plateau in physical therapy,
• Has insufficient strength/tolerance compared to his/her prior functioning level, and
• Cannot meet his/her occupational physical demand level because of remaining deficits.


Pivotal Products: Cardio, Strength, and Rehab

A typical FIRST program session consists of cardiovascular training, total body stretching and mobility work, core stabilization activities, total body strength and functional training, and work simulation activities. Within the FIRST program, patients utilize a number of product technologies to build strength, endurance, flexibility, and functional capacity.

Cardiovascular activities, for example, are supported by treadmill training, stationary bicycles, and elliptical machines. At various clinics, commercial treadmills from Life Fitness, Rosemont, Ill, are used to help build cardiovascular fitness for patients participating in the program. The Life Fitness Activate Series Treadmill provides good shock absorption and also has a console that is programmable and easy to use for staff and patients. The console monitors can provide training data or be used for entertainment purposes. They can also provide data about equipment use for facility managers to track and maintain. Several manufacturers offer treadmills to the PT market designed to provide similar types of features, including the MT200 Gait Trainer Treadmill from Spirit Medical, Jonesboro, Ark, built with three motors to provide bidirectional training for uphill or downhill applications. This treadmill also has a display console and an instrumented deck that can provide basic gait assessment and training. The MT200’s features can be useful in rehabbing patella femoral conditions, arthritic conditions, and tendonitis. Woodway, Waukesha, Wis, also offers a line of treadmills for commercial and medical use, including split-belt models aimed at gait rehab.

Stationary bicycles and ellipticals from Life Fitness, again, are some of the go-to technologies used for the clinic’s FIRST program. The consoles on both types of devices help provide data that is helpful in managing equipment and can support managers in planning preventive maintenance. Elliptical technologies from other manufacturers designed to provide similar utility include Spirit Medical Systems Group’s MS300 Semi-Recumbent Stepper, which offers graphical biofeedback that can help patients self-correct symmetry between both legs as well as heart rate monitoring via the device’s hand grips. The Woodway Wattbike Trainer is an indoor bike that can provide a range of data about the user’s performance such as leg balance, cadence, and heart rate, and has adjustable resistance from low to medium to high.

Free weights and resistance products are also part of the tool set commonly used in the FIRST program. For patient use the clinic is stocked with a variety of free weights and kettlebells from Rogue Fitness, Columbus, Ohio, as well as various weights of Dura-Bell Dumbbells from Ventura, Calif-based Hampton Fitness. The Dura-Bells have a urethane casing over the heads that make them less damaging to floors and other surfaces in which they come into contact. The Xertube resistance band from SPRI Products, Louisville, Colo, is also a tool that provides resistance training for our FIRST program patients, and are used in progressive levels of resistance. The Xertube provides a versatile range of therapeutic activities for patients to perform, and the foam-padded handles make them comfortable for patients to use. The clinic also uses a Free Motion cable resistance machine that provides movement across multiple planes. The Hammer Strength from Life Fitness and Cybex weight machines are also among the strength-building equipment the clinic uses in addition to TRX suspension trainers. Rounding out the equipment used in the FIRST program are traditional work hardening weight sleds and lift boxes that therapists use to restore patients’ physical and vocational functions.


Healthy Habits Develop

Around 6 weeks, physical demand levels tend to plateau for program participants and there does not seem to be a significant improvement in function. This finding is consistent with what is seen in the FIRST program when patients are prescribed more than 6 weeks of work conditioning/work hardening. Patients may improve occasionally past 6 weeks, but generally, that occurs less frequently. A positive side effect of the FIRST program is the modification of behavior for fitness for many of its participants. For 6 weeks, patients have been involved in a workout regimen for the better part of 4 hours each day. Another benefit of the program is creating a healthy habit of working out with cardiovascular equipment, free weights, dumbbells, etc. Many patients stick with the routine beyond their treatment.

While FIRST targets all injured workers, it is particularly helpful for those with permanent partial disability (PPD) because it is customized for each patient’s current functional level. For example, in ATI’s home state of Illinois, PPD settlements represent approximately 28% of the claims filed, but account for nearly 63% of the total workers’ compensation costs. This means the majority of costs to the workers’ compensation system result from a relatively small number of challenging cases.

In a study on improving injured workers’ lifting abilities by Cole, Keith et al, 80% of FIRST patients achieved the medium physical demand level (able to lift up to 50 lbs occasionally, or better) and 37% met the heavy physical demand level (able to lift up to 100 pounds occasionally) in order to return to work.1

Improving Return-to-Work Outcomes

Patients also were assessed 1 and 2 years post-program completion to determine if their improved physical abilities increased their return-to-work rates. The results showed 97% of those in the FIRST program returned to work, and half returned to their former occupation. Reinjury rates were rare and occurred less frequently with greater physical abilities.

Together, these studies validate the FIRST program’s approach that improves outcomes by increasing physical capabilities, which then improves return-to-work rates and decreases reinjury rates. During the past 18 years, the FIRST program has successfully returned more than 10,000 patients to work.

With the success of the FIRST program, the changing healthcare marketplace, and the rising cost of workers’ compensation insurance for employers, incorporating a work conditioning/work hardening element into the system not only makes sense, but ultimately can save money, return more workers to their jobs, and help ensure that those who return are physically prepared for all required activities. PTP

John Duncombe, DPT, OCS, CIMT, is manager of clinical operations at ATI Physical Therapy, Bolingbrook, Ill.

David Ensign, MA, ATC, CWcHP, is director of workers’ compensation at ATI Physical Therapy, Bolingbrook, Ill. For more information, contact [email protected].


1. Cole K, Kruger M, Bates D, Steil G, Zbreski M. Physical demand levels in individuals completing a sports performance-based work conditioning/hardening program after lumbar fusion. Spine J. 2009;9(1):39-46.