WorkAbility.us

By: Rick Wickstrom, PT, DPT, CPE, CDMS

The American Psychological Association (1994) reports that "failure to change despite the overwhelming positive benefit is considered the cardinal characteristic in defining addiction." According to Reed Humphrey, PhD, PT: "The most significant threat to prevention or rehabilitation from chronic disease and disability on earth today is not obesity, not diabetes, not metabolic syndrome. It is quite simply, physical inactivity." He advocates for addressing physical inactivity in a paradigm that is more similar to other forms of addiction.

Goetzel et al reported that physical inactivity is a modifiable behavioral risk factor that relates to five of most costly physical health conditions for US Employers (angina pectoris [chest pain], diabetes mellitus, acute myocardial infarction, chronic obstructive pulmonary disease, and back pain). The evidence is quite compelling about the protective effects of good cardio-respiratory fitness (or high physical activity) on all-cause and cardiovascular disease (CVD) mortality. A sampling of noteworthy evidence includes:

• A recent systematic review by Fogelholm reported that good cardio-respiratory fitness (or high physical activity) has a very positive effect on mortality even in the face of obesity. All-cause and CVD mortality risk was lower for individuals with high BMI and good aerobic fitness compared to individuals with normal BMI and poor fitness.
• Blair et al studied the impact of physical fitness on all-cause mortality in healthy men and women and concluded that higher levels of physical fitness as measured by aerobic capacity testing appear to delay all-cause mortality primarily due to lowered rates of cardiovascular disease and cancer.
• Fang et al studied the relationship of BMI and physical activity to CVD mortality and concluded that lower levels of physical activity and obesity were independently associated with decreased cardiovascular disease survival.
• Wei et al studied the influence of low cardiorespiratory fitness (an objective marker of physical inactivity) on CVD and all-cause mortality in normal-weight, overweight and obese men compared to other mortality predictors and concluded that low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with diabetes mellitus and other risk factors of CVD.
• Sui et al studied the impact of cardiorespiratory fitness and adiposity as mortality predictors in older adults and concluded that cardiorespiratory fitness is a significant mortality predictor, independent of adiposity, baseline health, or smoking.

Occupational health professionals such as physical therapists can positively impact physical fitness of workers by objective monitoring of physical fitness and coaching higher risk workers to adopt more active lifestyles. For employers, workers with poor physical fitness (or physical inactivity) have more on-the-job injuries, lost productivity, absenteeism and healthcare costs. Well-designed, employer-based programs to address poor physical fitness and physical inactivity should include three key components:

• MANDATE baseline physical fitness measures during post-offer screening of all new hires. The post-offer phase of employment is the only when participation can be mandated for entering workers and the scope of medical inquiry and tests is relatively unrestricted. Additional cost savings from work injury prevention many also realized by including job-relevant work samples such as lifting in the post-offer Worker Fitness Screen (WFS) to verify the applicant’s ability to safely perform more physically-demanding job tasks.
• CONDUCT periodic physical fitness screens with incentives for participation by all workers.  Soler et al conducted a systematic review that identified strong evidence of Assessment of Health Risks with Feedback as a gateway intervention to health promotion intervention that includes health education lasting at least one hour or repeated multiple times over one year.
• PROVIDE coaching on physical activity/exercise progression to higher risk workers. Soler et al found that higher risk persons appreciate greater health gains; therefore, workers with poor fitness, absenteeism, work restrictions, or excessive healthcare utilization should be encouraged to access individualized counseling for lifestyle intervention.

One of the primary goals in the Healthy People 2010 initiative was to increase the proportion of work-sites offering employer-sponsored physical activity and fitness programs to a national target of 75%. Although 66.1% of large employers with 750 or more employers were close to this objective in 2004, this percentage drops rapidly to only 16.4% in employers with 50-99 employees. The HIPPA exemption for wellness programs that allows employers and coverage provider to offer rewards or penalties as long as this does not exceed 20 percent of the cost of employee-only coverage under the health plan. Smaller employers that can’t afford to have an on-site fitness facility may want to consider other innovative practices such as consulting with a physical therapist for work-site screening and coaching of higher risk persons, peer-led walking clubs, making arrangements for discounts or free access to community-based fitness facilities, and permitting FMLA or paid leave for participation in prescribed wellness interventions.

In summary, for most high risk persons with the "addiction" of physical inactivity, success may be impacted by a report card of objective measures to reinforce accountability, individualized coaching to address specific problems areas, and incentives to motivate healthy lifestyle choices. A limited budget for health promotion needs to be focused more on objective bench marking, financial incentives to motivate behavior and removing access barriers for individuals with poor fitness to adopt a healthier lifestyle.

References:

Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA. 1989 Nov 3;262(17):2395-401.

Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA. 1989 Nov 3;262(17):2395-401.

Fang J, Wylie-Rosett J, Cohen HW, Kaplan RC, Alderman MH. Exercise, body mass index, caloric intake, and cardiovascular mortality. Am J Prev Med. 2003 Nov;25(4):283-9.

Fogelholm M. Physical activity, fitness and fatness: relations to mortality, morbidity and disease risk factors. A systematic review. Obes Rev. 2010 Mar;11(3):202-21.

Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the "top 10" physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003 Jan;45(1):5-14.

Groeneveld IF, Proper KI, van der Beek AJ, Hildebrandt VH, van Mechelen W. Lifestyle-focused interventions at the workplace to reduce the risk of cardiovascular disease--a systematic review. Scand J Work Environ Health. 2010 May;36(3):202-15. Epub 2010 Jan 12. Review.

Soler RE, Leeks KD, Razi S, Hopkins DP, Griffith M, Aten A, Chattopadhyay SK, Smith SC, Habarta N, Goetzel RZ, Pronk NP, Richling DE, Bauer DR, Buchanan LR, Florence CS, Koonin L, MacLean D, Rosenthal A, Matson Koffman D, Grizzell JV, Walker AM; Task Force on Community Preventive Services. A systematic review of selected interventions for worksite health promotion. The assessment of health risks with feedback. Am J Prev Med. 2010 Feb;38(2 Suppl):S237-62. Review.

Sui X, LaMonte MJ, Laditka JN, Hardin JW, Chase N, Hooker SP, Blair SN. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA. 2007 Dec 5;298(21):2507-16.

Wei M, Kampert JB, Barlow CE, Nichaman MZ, Gibbons LW, Paffenbarger RS Jr, Blair SN. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. JAMA. 1999 Oct 27;282(16):1547-53.

Rick Wickstrom, PT, DPT, CPE, CDMS Rick is a Doctor of Physical Therapy, Certified Professional Ergonomist, and Certified Disability Management Specialist. As President of WorkAbility Systems and WorkAbility Network, he has served industry for over 25 years as a consultant in occupational health and ergonomics. He has provided expert testimony and published many articles and technical reports related to worker fitness screening, functional capacity evaluation, work injury management and ergonomics. WorkAbility Network is committed to preparing occupational health professionals such as physical therapists with skills needed to evaluate worker fitness and motivate successful transitions from medicine or therapy care to self-directed wellness programs.

For more information, phone 866-772-1026 or email rick@workability.us

By: Rick Wickstrom, PT, DPT, CPE, CDMS

Traditionally, employers have limited their medical screening of new hires to persons entering physically-demanding or safety-sensitive jobs where the program is justified to prevent work injury claims in physically-demanding jobs or to protect the health and safety of the public. Employers are legally permitted to condition a job offer on the results of an employment entrance medical exam that has a similar scope for all entering employees in the same category. This is the only phase of employment when the scope of medical inquiry and tests are relatively unrestricted, provided that health-related information is maintained in a confidential record (separate from the personnel file) and that withdrawal of the job offer is based on medical information that is job-related and consistent with business necessity.

A well-designed post-offer WorkAbility Fitness Screen by a physical therapist has important benefits that justify this investment in human resources for all categories of new hires:

1. Reduces recovery time and costs of future health claims by establishing an objective, pre-injury baseline of musculoskeletal status, health and fitness.

It has been often said that anyone can slip & fall on the employer's premises, regardless of the level of work strenuousness. Having a pre-injury baseline of physical fitness helps deter inappropriate work-related injury claims, shortens recovery time, and reduces claims costs because pre-injury data may be used to determine the functional impact of injury and realistic recovery expectations. When prior health and fitness status is unknown, most of the worker's alleged problems are attributed solely to the work-related injury claim.  

2. Improves job placement safety and efficiency. 

Harbin¹ conducted a prospective 3-year study of new-hires in Food Production and Electrical Manufacturing that received a comprehensive medical history and 20 different anthropometric, isometric strength and dynamic lifting tests. Isometric strength testing alone was of no predictive value for work injury incidence. There was a strong correlation between dynamic lifting tests and physical job requirements. Well-matched workers had 3% incidence of lower back injury compared to a 33% incidence of injury if the workers did not demonstrate adequate physical capacities. Workers with history of prior back surgery or low back pain at the time of hire had a 35% incidence of back injury (these workers were analyzed separately). Cost savings of $690 per employee tested and hired were projected based on direct costs alone. The importance of physical capacity screening on job assignment was critical for Medium, Heavy and Very Heavy physical demands based on percent of physically qualified food production workers for jobs at different DOT Physical Demand Strength Categories: 

DOT level                                     Male (%)         Female (%)

Sedentary up to 10 lbs.               99                    99

Light 11-20 lbs.                            95                    90       

Medium 21 to 50 lbs.                   66                    50

Heavy 51 to 100 lbs.                    33                    10

Very heavy over 100 lbs.             10                     0

Rosenblum et al.² investigated effects of pre-employment physical ability screening in the building supply industry and found that non-screened applicants 2.38 times more likely to experience a MSD-related overexertion injury and had 4.33 times higher costs for work-related injury claims. Average direct cost for MSD injuries of $422.76 per year for non-screened workers versus $97.63 for screened workers. There was also a significantly lower cost of non-MSD claims expense among screened workers, with 10-fold reduction in average loss accident costs.

Predictive validity studies by Anderson et. al.³ on hire food distribution workers that passed physical ability test had 47% lower workers compensation injury rate and 21% higher retention.

Sluiter^4-5noted that in general, specific demands of high-demand jobs are more likely to tax capacities of older workers than younger workers, but that effect varied enormously within age cohorts. She recommended development of functional tests for high demand jobs due to such an extent of age-related diversity.

3. Raises employee awareness of interventions to maintain or improve safety, health & fitness. 

A mandatory post-offer fitness screen may be only opportunity to evaluate persons who don’t participate in health promotion programs. One of the criticisms of health promotion programs has been that program resources are largely consumed by the "worried well" who don't benefit as much from the programs. 

55% deaths strongly impacted by four modifiable behavioral factors (tobacco use, poor diet, physical inactivity, and alcohol use).⁶ These factors relate to five of most costly physical health conditions for US Employers (angina pectoris [chest pain], diabetes mellitus, acute myocardial infarction, chronic obstructive pulmonary disease, and back pain).⁷ Individuals with multiple health risks tend to be less productive than peers with better profiles, with estimated productivity impact of two times the medical costs.⁸ These risk factors can be reduced through participation in worksite health promotion interventions. Rula⁹ reported that 47.4% of workers under-reported/unaware of 3 or more risk measures…this reinforces need for objective health metrics to motivate higher risk workers to improve their health and fitness.

Soler et. al.¹⁰ identified strong evidence of effectiveness of Assessment of Health Risks with Feedback as a gateway intervention to a broader worksite health promotion program that includes health education lasting at least one hour or being repeated multiple times over one year. Evidence suggests that higher risk person have greater health gains, with more evidence of effectiveness for some outcomes and insufficient evidence for changes in body composition or intake of fruits and vegetables.

Yen¹¹ determined that excess costs related to smoking were $466 per year and for high blood pressure were $1644 per year. Schultz¹² evaluated impact of metabolic syndrome (3+ risks) and demonstrated excess costs for

1. Blood Pressure => 130/85 or meds: $2011
2. BMI > 30: $627
3. Fasting glucose => 100 or meds: $1682
4. Triglycerides => 150: $ 1474

Note: Total costs included costs for health care, pharmacy and STD for persons at risk minus costs for persons not at risk.

References

1. Harbin G, Olson J. Post-offer, pre-placement testing in industry. Am J Ind Med. 2005 Apr;47(4):296-307.
2. Anderson C, Briggs J. A study of the effectiveness of ergonomically-based functional screening tests and their relationship to reducing worker compensation injuries. Work. 2008;31(1):27-37.
3. Sluiter, JK. High-demand jobs: Age-related diversity in work ability? Applied Ergonomics. 2006; 37: 429-440.
4. Sluiter JK and Frings-Dresen. What do we know about ageing at work? Evidence-based fitness for duty and health in firefighters. Ergonomics. 2007 November; 50 (11): 1897-1913.
5. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004 Mar 10;291(10):1238-45. Review. Erratum in: JAMA. 2005 Jan 19;293(3):298. JAMA. 2005 Jan 19;293(3):293-4.
6. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the "top 10" physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003 Jan;45(1):5-14
7. Loeppke R, Taitel M, Haufle V, et al. Health and productivity as a business strategy: a multiemployer study. J Occup Environ Med 2009; 51: 411-428.
8. Rula EY, Hobgood A. The impact of health risk awareness on employee risk levels. Am J Health Behav. 2010 Sep-Oct;34(5):532-43.
9. Soler RE, Leeks KD, Razi S, Hopkins DP, Griffith M, Aten A, Chattopadhyay SK, Smith SC, Habarta N, Goetzel RZ, Pronk NP, Richling DE, Bauer DR, Buchanan LR,Florence CS, Koonin L, MacLean D, Rosenthal A, Matson Koffman D, Grizzell JV,Walker AM; Task Force on Community Preventive Services. A systematic review of selected interventions for worksite health promotion. The assessment of health risks with feedback. Am J Prev Med. 2010 Feb;38(2 Suppl):S237-62. Review.
10. Yen L, Schultz A, Schnueringer E, Edington DW. Financial costs due to excess health risks among active employees of a utility company. J Occup Environ Med. 2006 Sep;48(9):896-905.
11. Schultz AB, Edington DW. Metabolic syndrome in a workplace: prevalence, co-morbidities, and economic impact. Metab Syndr Relat Disord. 2009 Oct;7(5):459-68.