Defining Work Restrictions, Capacity & Limitation

10 September 2012 / California Workers Compensation / Comments Off on Defining Work Restrictions, Capacity & Limitation

As doctors, we have all gotten the phone call from the either the employee or the employer asking for clarification on what the employee can and cannot do.

Often the indications for the recommended work functions are unclear, poorly described, or simply left up to the employee and the employer to figure out how to best “get along”.

The problem with this any of these options is that they leave the interpretation and necessity for work functional limitations up to interpretation. Employees and employers frequently look to us to guide the rehabilitation process, and clearly outlining the employees duty is central to that service.

The employer wants a safe return to work environment, and needs specifics to determine if return to work accommodations can indeed be made. The employee is concerned about worsening of symptoms or anticipated worsening of symptoms.

The following “word of art” discussion will aid the medical provider in clarifying the intent and medical necessity of outlining return to work instructions for the injured worker.

 

Work Restrictions:

The word work “restriction” implies that a measure of safety for the employee or the co-workers are dependent on following the instructions.

The restriction may very well be a function that the employee is capable of performing, BUT SHOULD NOT PERFORM with the risk of personal injury or injury to a co-worker.

An excellent example of a work restriction are the instructions provided for an employee with a seizure disorder not to drive or perform safety sensitive work.

If the employee were to drive and have a seizure, the consequences would be disastrous (for the employee or co-workers riding with the employee).

 

Work Limitation:

A limitation suggests that the employee cannot perform an activity as “a result of an illness or an injury” (p 121). An example of this is a worker who has had a right shoulder injury with adhesive capsulitis, firm end range of motion endpoints and capsular thickening on MRI imaging that supports the diagnosis. As a result the worker can no longer raise their shoulder above the level of the shoulder plane. The key when thinking about the use of this term is that the limitation is “measurable or objectifiable” (p 121). In the example of this worker, the shoulder has an identifiable underlying medical condition that explains and supports the limitation. The shoulder has scarred, and a reproducible measurable loss etc. The worker has a “limitation” that precludes at or above right shoulder level work. Of note, the work limitation should “be proportional” to objective findings” (p 131).

 

Work Tolerance:

Tolerance is by far the most common reason for assigning functional work instructions. “Tolerance is apsychophysiologic concept. It is the ability to tolerate sustained work or activity at a given level” (p 10).

The ability for two doctors to have agreement on issues of work restrictions and limitations are reasonably good, however, the ability to agree on issues of tolerance is much less, because of the subjective nature of the complaints and lack of objective findings.

When the subjective complaints are grossly inconsistent with the physical findings and objective imaging, however, most physician can at least agree that work activity poses no “risk” and has no clear “limitation”. In this situation, the doctor often finds him/herself functioning more as a secretary, rather than a doctor, as there are no underlying identifiable conditions.

When trying to assess “tolerance” it is important to review with the worker what they are and are not capable of performing not only at the workplace, but also at home.

The worker who presents to the clinic stating she cannot lift anything of weight, yet is carrying a six pound purse over her shoulder with apparent ease needs to be redirected in her assertions of tolerance and reasonable expectations based on the objective findings of the physical exam and imaging.

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