IN THE BEGINNING
The first description of a work hardening program came in an article published in 1985 by Leonard Matheson and colleagues that described the program Matheson developed in 1977 in California.7 Work hardening was defined as:

a work-oriented treatment program that has an outcome of improvement in the client’s productivity . . . Work hardening involves the client in highly structured, simulated work tasks in an environment where expectations for basic worker behaviours (e.g., timeliness, attendance, and dress) are in keeping with workplace standards.7

Work hardening guidelines were then published in 1986 by the American Occupational Therapy Association’s (AOTA) Commission on Practice.2 The Commission defined a work hardening program as “an individualized, work-oriented activity process that involves a client in simulated or actual work tasks.”2 To develop work standards, the Commission for Accreditation of Rehabilitation Facilities’ (CARF) National Advisory Committee expanded the AOTA’s definition by defining the concept as:

a highly structured, goal oriented, individualized treatment program . . . which [is] interdisciplinary in nature [and] use[s] real or simulated work activities in conjunction with conditioning tasks that are graded to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, and psychosocial functions of the individual. (as cited in Lepping5)

However, due to the difficulties and costs associated with the CARF’s administrative and organizational standards, only a small percentage of work hardening programs have become CARF accredited.5 Due to these difficulties, the Industrial Rehabilitation Advisory Committee of the American Physiotherapy Association (APTA) developed guidelines in 1991 for small clinics that could not afford the costs of providing the administrative and organizational structure required by the CARF. It was at this time that APTA introduced “a program with an emphasis on physical conditioning that addresses the issues of strength, endurance, flexibility, motor control, and cardiopulmonary function.”1 This new concept was termed work conditioning and was designed for those individuals with less complex conditions or chronic conditions.1

WORK CONDITIONING VERSUS WORK HARDENING
The APTA clearly differentiates between a work conditioning program (WCP) and a work hardening program (WHP). WCPs deal with physical and functional needs that can be provided by one discipline, whereas WHPs address these needs as well as behavioral and vocational needs while utilizing many disciplines (interdisciplinary). WCPs employ physical conditioning and functional activities while WHPs use real or simulated work activities. Both WCPs and WHPs are provided up to five days per week for up to eight weeks, but WCPs run for a maximum of four hours per day, versus a maximum of eight hours per day for WHPs.1
Furthermore, APTA set guidelines for those individuals eligible for WCPs and WHPs. Injured workers should be placed in a WCP if they:

1) have a job goal
2) have a willingness to participate
3) have diagnosed systemic neruomusculoskeletal physical and functional     deficits that disrupt their work
4) are at the point of resolution of the initial or principal injury at which     participation in the WCP would not be prohibited.

Injured workers should be placed in a WHP if they:

1) have a targeted job goal
2) have a willingness to participate
3) have recognized physical, functional, behavioral and vocational deficits that     limit their work
4) are at the point of resolution of the initial or principal injury at which     participation in the WHP would not be prohibited.

These guidelines do not suggest whether the potential patients should meet all or merely some of these criteria before being placed in a WCP or WHP.1

SUCCESS RATES
Depending on the study analyzed, various success rates have been published. The study by Hazard and associates (1989) is by far the most convincing for the efficacy of WHPs in returning patients with chronic conditions (off work for more than four months) back to work. In their well-designed study this group of researchers found that WHPs increased the rate of return by 52%.4 Other studies dealing with this patient group documented a 31%13 to 39%8 improvement in the rate of return to work. WCPs studies dealing with patients with less chronic conditions, such as those examined in 1990 by Mitchell and Carmen (patients off work for an average of 41 days) and Lindstorm et al (1992) (patients off work for an average of two months) found similar results as those with chronic conditions.10,6 These studies all suggest that well designed WCPs and WHPs are effective in returning an increased percentage of individuals back to work.

COST EFFECTIVENESS
Other research has shown that these programs are cost effective. Mitchell and Carmen (1990) found that workers’ compensation costs were lower for clients who participated in WCPs, compared with clients who received other forms of treatment. The researchers reported that the program attended by their subjects resulted in an increase in medical costs of approximately $400 per patient. However, this was offset by a savings in workers’ compensation expenses of approximately $2,000, resulting in a net savings of $1,600 per subject.10 Greenberg and Bello (1996) concluded that at least $44,000 was saved by using a WHP in their case example. This is assuming the insurance company would have paid out an estimated $40,000 for the indemnity settlement plus at least $4,000 in additional medical costs.3 According to The Washington Business Group on Health, an investment in return to work strategies, such as using WCPs or WHPs, can result in a return of $8 to $10 for every $1 invested (as cited in Lepping5). These studies clearly indicate that WCPs and WHPs can drastically reduce the financial burden placed on an already troubled workers’ compensation system.

Costs per patient enrolled in WHPs range considerably. Greenberg and Bello’s (1996) WHP cost $5,400.3 Sachs et al (1990) claimed their WHP cost as little as $1,44013, whereas Hazard et al (1989) reported WHPs ranging from $3,000 to $7,500.4 The program used by Sachs et al (1990) was less expensive than a standard WHP because it used a social worker rather than a psychiatrist or psychologist and had treatment sessions of three half-day sessions per week, with no inpatient stays.13

RECURRENCE RATES
An important factor in assessing the efficacy of WCPs and WHPs is the rate of re-injury upon successful completion of a WCP or WHP. Mayer et al (1987) reported that in their WHP 6% of their treatment group and 12% of their control group experienced a recurrence of low back pain during a two-year follow-up period.9 Lindstorm et al (1992) reported re-injury rates in their WHP of 48% and 79% for treatment and comparison groups, respectively, within the second year of follow-up.6 Due to the wide variation in the incidence of recurrence, these studies suggest that the recurrence of pain and re-injury upon successful completion of a WCP or WHP is undetermined. Hence, there may be a need for further follow up once the worker is back in the work force. This may include more ergonomic training or job-site modification.

CONCLUSION
Experience demonstrates that the longer employees are away from their jobs due to a work related injury/illness, the less likely they are to return. In an evermore competitive global marketplace, where cutbacks and downsizing have become the norm and employee productivity is constantly being maximized, the need for faster rehabilitation and earlier return to work of injured employees is crucial to the success and viability of an organization. Furthermore, the human costs for the injured worker suffering from a chronic disability are immeasurable. Thus, the use of work conditioning and work hardening programs are instrumental in facilitating the injured worker’s return to work and lessening the psychological effects of a work injury.

Reference List
1. APTA guidelines for programs in industrial rehabilitation. PT-Magazine of Physiotherapy 1993 March; 1(3): 69-72.
2. Bell E, Frazian BW, Ford L, Violette K, Smith S. Work Hardening Guidelines (prepared by the Commission on Practice. American Occupational Therapy Association). American Journal of Occupational Therapy 1986 December; 40(12): 841-3.
3. Greenberg SN, Bello RP. The work hardening program and subsequent return to work of a client with low back pain. Journal of Orthopaedic Sports Physiotherapy 1996 July; 24(1): 37-45.
4. Hazard RG, Fenwick JW, Kalisch SM, et al. Functional restoration with behavioral support: a one-year prospective study of patients with chronic low-back pain. Spine 1989 February; 14(2): 157-61
5. Lepping V. Work hardening. A valuable resource for the occupational health nurse. American Association of Occupational Health Nurses Journal 1990 July; 38(7): 313-7
6. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Physiotherapy 1992 April; 72(4): 279-93.
7. Matheson LN, Ogden LD, Violette K, Schultz K. Work hardening: occupational therapy in industrial rehabilitation. American Journal of Occupational Therapy 1985 May; 39(5): 314-21.
8. Mayer TG, Gatchel RJ, Kishino N, et al. Objective assessment of spine function following industrial injury: a prospective study with comparison group and one-year follow-up. Spine 1985 July; 10(6): 482-93.
9. Mayer TG, Gatchel RJ, Mayer H, et al. A prospective two-year study of functional restoration in industrial low back injury: an objective assessment procedure (research). Journal of the American Medical Association 1987 October; 258(13): 1763-7.
10. Mitchell RI, Carmen GM. Results of a multi-center trial using an intensive ActiveExercise program for the treatment of acute soft tissue and back injuries. Spine 1990 June; 15(6): 514-21.
11. Peters P. Successful return to work following a musculoskeletal injury. American Association of Occupational Health Nurses Journal 1990 June; 38(6): 264-270.
Sachs BL, David JF, Olimpio D, et al. Spinal rehabilitation by work tolerance based on objective physical capacity assessment of dysfunction: a prospective study with control subjects and twelve-month review. Spine 1990 December; 15(12): 1325-32.