HELPING THE INJURED WORKER
RETURN TO WORK
Understanding the role of Work
Conditioning/Hardening programs
and FCE’s
MATTHEW A. COHEN, Med, CERT FCE, CEAS
INDUSTRIAL REHABILITATION MANAGER
DEEP RIVER REHABILITATION
WORK CONDITIONING
VS.
WORK HARDENING
MATTHEW A. COHEN, Med, CERT FCE, CEAS
INDUSTRIAL REHABILITATION MANAGER
DEEP RIVER REHABILITATION
FUNCTIONAL CAPACITY
EVALUATION
MATTHEW A. COHEN, Med, CERT FCE, CEAS
INDUSTRIAL REHABILITATION MANAGER
DEEP RIVER REHABILITATION
BACKGROUND
 12
YEARS OF EXPERIENCE
INDUSTRIAL REHAB
 CERTIFIED FCE EVALUATOR
(BLANKENSHIP)
 CERTIFIED ERGONOMICS SPECIALIST
 BACHELORS SPORTS MEDICINE
 MASTERS EXERCISE PHYSIOLOGY
 FATHER OF 2 (KIDS)
OUTLINE
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INDUSTRIAL ATHLETE
COMPONENTS OF WORK COND. & WORK HARD.
CRITERIA TO DETERMINE WHO IS APPROPRIATE CANDIDATE.
GOALS OF PROGRAM (FUNCTIONAL VS. SUBJECTIVE).
WHAT IS AN FCE?
TYPES OF FCE’S
VALID VS. INVALID
WHAT NEXT?
USING OUTCOMES OF WC/WH AND/OR FCE FOR RETURN TO
WORK.
OPEN DISCUSSION
Work Disability Cycle
EMPLOYEE INJURED
RTW
ER
REHAB
Care
Manager
OMC
PT
SPECIALIST
PCP
POOR TECHNIQUE
POOR POSTURE
POOR DECISIONS
Bad Decisions
www.medicine-in-motion.com
INDUSTRIAL ATHLETE

As time off work is inversely correlated to the
rate of return to work, early intervention is
strongly recommended.

WHY WE NEED RTW
PROGRAMS
Research shows



employees receiving disability benefits recover
less quickly and have poorer clinical outcomes
than those with the same medical conditions,
who do not receive disability benefits.
employees that had no lost time from work
had better outcomes than employees who lost
some time from work.
odds for returning to full employment
decreases 50-50 after six months of absence.
Costs of Work Injuries
 $142
billion annual Worker Compensation
costs in 2009.
 Per
claim cost average $7,000 to $30,000
 There
is a wide range in cost per claim
among companies (how managed)
EDUCATION OF EMPLOYEE

80 to 95% of injuries are due to poor choices and habits.

Liberty Mutual study found that 68% of accepted claims
are related to ergonomics and/or body mechanics.

Industrial Rehabilitation goes beyond just treating the
injury it also includes vital safety information to the client.
MYTHS

The 100 Percent or Nothing Myth:
 Employees must be able to do 100 percent of
their job tasks before returning to work.
 Reality
 Not so. Employees regain their ability to work
incrementally and can therefore transition back
into the workplace gradually. In most cases,
work tasks can be modified for short periods of
time without reducing the overall productivity of
an organization.
MYTHS




The Light-Duty Myth
Light duty is an effective way to return employees to their
full productivity.
Reality
Light duty can be static and open-ended. Uncontrolled or
poorly managed light duty can encourage an employee
to remain in a reduced-productivity position too long, or
indefinitely. Without a planned transition back to full
productivity, employees will not become reconditioned or
build up the tolerance they need to resume full job
duties. And if appropriate expectations are not
established on the front end, miscommunication between
the employer and employee can occur. DISGRUNTLED
MYTHS





The Total-Disengagement Myth
People who are ill or injured need total rest and removal from
everyday life in order to recover.
Reality
People heal from illnesses and injuries incrementally. Getting back
to normal daily activities, including work, is part of that process.
Recovery progresses quickly and successfully when there is a
combination of early mobilization treatment and increased
transitions back to a normal way of living. Rehab team plays a key
role in the recovery process when they involve the physician and the
employee in return-to-work planning and a discussion of the need
for temporary modifications in the workplace.
NEED TO AVOID SICK MENTALITY
MYTHS





The Physician-as-Occupational-Expert Myth
Physicians always offer work restrictions based on solid knowledge
of job demands and know when a patient is ready to return to work.
Reality
Physicians are experts in the field of diagnosis and treatment of
disease and disability, but need objective data in order to make wellinformed return-to-work assessments. A physician isolated from this
data may unnecessarily limit the patient’s work options. Usually, this
is unintentional and the result of inaccurate or incomplete
information.
In some cases, a physician's training and work focus may not
provide the best skills and clinical setting to assess functional
capacity and make return-to-work plans.
CONT.
 50% of injured workers who remain off
work 6 months or more never return to
work
 75% of injured workers who remain off
work 12 months or move never return to
work
 We need to treat them like athletes and
give them every opportunity to succeed
and return to work.
What is Work Conditioning?
“a work related, intensive, and
goal-oriented treatment program
specifically designed to restore an
individual’s systemic, neuromuscular
(strength, endurance,
flexibility, etc.) and
cardiopulmonary function.” The
objective of the work conditioning
program is to restore the client’s
physical capacity and function so
the client can “return to work”.
APTA
What is Work Hardening?
“a highly structured, goal
oriented, individualized
treatment program designed to
return the person to work.” Work
hardening programs use real or
simulated work activities
designed to restore physical,
behavioral, and vocational
function.
CARF (Provider Accreditation)
Work Cond. Vs. Work Hardening




Work Conditioning
2 - 4 hours a day
3-5 days a week
3-4 weeks
Addresses systemic,
neuromuscular,
cardiopulmonary, and
function




Work Hardening
4-8 hrs.
5 days a week
4-8 weeks
Addresses physical
behavioral and
vocation function
Work Cond. Vs. Work Hardening
Work Conditioning
Easier to get Worker
Comp approval.
Due to the lower cost
and number of
days/wk usually can
get more visits.
Work Hardening
More expensive
Harder to get
approval for initial
visits and continuation
of program.
Both programs effective
RESEARCH

Function-centered treatment involved work simulation
combined with cardiovascular workouts and
strengthening exercises. Pain-centered treatment
involved stretching combined with passive and active
mobilization .

The study concluded that function-centered rehabilitation
is recommended more than pain-centered treatment.
FCT decreased work-related disability and were part of
the larger return to work group.

2005 study. Back Patients (Kool, Oesch, Bachmann,
Knuesel, Dierkes, Russo, de Bie, van den Brandt).
RESEARCH



Research shows that problem-oriented rehabilitation can
significantly reduce long-term sick leave (Streibelt,
Blume, Thren, Reneman, & Meuller-Fahrnow, 2009).
Consistent with that research, work conditioning
programs are problem-oriented programs with the intent
to return the individual to normal work function ASAP.
High correlation between the patient’s attitude and
success of returning to work.
WHAT IS WORK
CONDITIONING?
*Work Conditioning is not just a continuation of
physical therapy.
*Work Conditioning is an effective adjunct to a
comprehensive physical therapy program and
effective RTW program.
*Work Conditioning is entirely focused towards
returning the injured worker back to work quickly
and safely.
What is Work Conditioning?
It is a structured program of PHYSICAL
CONDITIONING, ERGONOMICS training and
EDUCATION in safe work practices.
It addresses the individual needs of the injured
worker as it relates to their return to a specific
job or job type.
It is a training program for the INDUSTRIAL
ATHLETE.
When is it Appropriate?







Client requires progression from skilled PT (d/c from
acute)
Option if insurance will not pay for FCE
Client currently unable to RTW & perform required job
demands
Strength/Endurance Deficits
Per therapist's recommendation
Per doctor's order
Treatment option as result of FCE to increase ability to
RTW
It All Begins With an
Injured Worker
Very Appropriate
 Not
Working.
 Working Light Duty.
 Inconsistency Demonstrated in PT.
 Attempted return to work and failed
without WC.
 FCE shows strength as primary limitation.
 Non-compliant with HEP.
DO YOU KNOW WHAT YOUR
INJURED EMPLOYEE IS DOING?
Acute Therapy is Complete, What
next?

Is the employee physically ready to return to
work SAFELY?
 Depends on number of days not working
regular duties?.
 What were they doing for light/modified duty?
 Are they still having pain that limits function?
 What is their confidence level?
 Are they professional W/C patients? (Need
Motivation)
AFTER PHYSICAL THERAPY
 INITIAL
EVALUATION
 EVALUATE FUNCTION AND
DETERMINE DEFICITS
 LIFT/PUSH/PULL, GRIP, CLIMBING,
POSITIONAL TOLERANCE, ETC.
 MATCH TO PHYSICAL DEMANDS OF
JOB (JOB DESCRIPTION/ANALYSIS)
 DEVELOP PROGRAM WITH
FUNCTIONAL GOALS.
STRUCTURED PROGRAM
 3-5X
PER WEEK
 3-4 WEEKS(STRENGTH CHANGES)
 2-4 HOURS PER SESSION
 CONSTANT MONITORING
 RE-EVALUATE EVERY 3-4 VISITS
(ASSISTS IN ADJUSTING WORK
RESTRICTIONS)
GOALS
 Functional
Goals vs. Subjective Goals
 Pain is not the focus
 Can you do more, and be productive?
 During initial Eval the client signs a
consent which states intent for RTW.
 Try to establish 4-5 functional goals.
 Pain is monitored but not the focus.
GOALS

Clients focusing on pain should learn to accept
that a quick resolution of their pain problem is
not realistic, and that the primary goal of WC is
restoration of function. In order to change the
focus from pain towards function, weekly
assessment of functional evolution and a formal
feedback of the results for the client is critical.
 The clients should learn to really appreciate their
functional improvements in spite of the fact that
some pain is persisting.
TREATMENT PROGRAM

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CARDIOVASCULAR COMPONENT (You lose it if you
don’t use it)
GENERAL CONDITIONING EXS.
FLEXIBILITY EXS.
JOB SPECIFIC WORK SIMULATION
PATIENT EDUCATION (Body Mechanics, Posture,
Pacing, Symptom Management)
COMMUNICATION (Update MD on progress, case
manager, plant nurse, HR)
NEED TIME!
 All
three parameters (intensity, duration,
frequency) contribute to the training
volume.
 The volume should exceed that which the
muscles normally encounter. This
“overload” induces muscles to adapt and
progressively increase their ability to
generate force.
Muscle Physiology
Work Conditioning
WORK CONDITIONING
Work Conditioning
Don’t Lift With Your Back!
Benefits of Work Conditioning


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An earlier, safer return to work
A daily program that gets the injured worker “out of the
house” and more focused on a daily program of work
Self-imposed competitiveness among the participants,
which motivates them to reach beyond their goals
Increased socialization and less focus on pain and
disability
Increased confidence in returning to a job they once
feared as a possible source of re-injury
Documentation of inconsistencies
Benefits of Work Conditioning

Improves musculoskeletal status
ROM, strength, endurance
 Increases functional abilities
physical demand level, abilities,
workplace tolerance
 Improves worker performance
 symptom management, symptom
magnification, worker traits
WORK SIMULATION
 Work
simulation is the crucial part in the
functional training of a WC program.
 It mimics many job situations, functional
postures and tasks, so offering clients the
opportunity of practicing work activities
and procedures in a “therapeutic”
framework, in order to train job-specific
deficits step by step.
Work Simulation

The client is deconditioned: there is a big gap
between actual functional capacity and the
physical demands of the specific job;
 – lack of work-oriented goals in usual care and
physical therapy (these treatments often are
pain oriented and do not focus on prompt
increase of work related functional capacity, nor
do they include work simulation tasks, and they
are usually not intensive);
Ideal Situation
 Combining
Limited Duty and
Work Conditioning will
maximize the worker’s
Musculoskeletal, functional
and worker performance.
RETURN TO WORK

Success less than 50% if off work greater than 6
months

25% if off greater than 1 year

Nearly 0% if return to work has not occurred within 2
years

The longer someone stays home the more severe they
feel their injury is.
THE CHALLENGE
 If
patients do not come into Industrial
Rehabilitation with the mindset of receiving
care and returning to work as soon as
possible, they are more likely to fail in
attempts to complete a work conditioning
program and return to full active duties.
 Try to establish positive mindset in acute
phase.
GOOD REHAB IS WORKING
“Work is the grand cure of all maladies and
miseries that ever beset mankind”
Thomas Carlyle, 1866
“As long as we still get weekends off!”
Matthew Cohen, 2008
SOMETIMES THE EMPLOYEE STILL ISN’T
EAGER TO RETURN TO WORK WHEN
THEY ARE READY
PAIN
When time of inactivity is kept short and use
of passive modalities (physical agents,
manual therapy, massage, etc.) is limited,
individuals are less likely to develop
symptom magnification and to assume a
“sick role”.
PAIN

Clients focusing on pain should learn to accept
that a quick resolution of their pain problem is
not realistic, and that the primary goal of WC is
restoration of function. In order to change the
focus from pain towards function, weekly
assessment of functional evolution and a formal
feedback of the results for the client is critical.
 The clients should learn to really appreciate their
functional improvements in spite of the fact that
some pain is persisting.
PAIN
 Important
core messages to give the back
pain client are:
 – chronic pain does not mean harm! It is
not dangerous to move and stress your
body when you are in pain! In fact, this is
necessary in order to escape from the
vicious circle of avoiding physical activity,
loss of fitness and pain;
PAIN
–
chronic pain usually cannot be reduced
in a short time. However, it is possible to
increase performance capacity with
intensive training despite pain. In many
cases, a reduction in pain will then occur
in the long term;
In Workers Compensation
Life-Altering Decisions Are Made !
Safe Return to Work?
Employability?
Continuation of
Treatment?
Disability
determination?
Residual Functional
Capacity?
Implications of these decisions are enormous!
Functional Capacity Evaluations

FCE can help you make appropriate RTW
decisions
 Objective Measures


Provide Critical Information
Save You Time
Looks great! Does it have an
engine??
ENTIRE MISSION OF
TESTING IS:

To prevent injuries

To protect
employer/employee

To provide the best
possible RTW conditions

To maintain productivity
FCE?

Functional Capacity Evaluation, FCE, is a systematic
evaluation process designed to document a person’s
current work ability from a physical ability and
motivational perspective with consideration given to any
existing medical impairment and/or pain syndromes. It’s
primary purpose is to determine a worker’s ability to
return to work following a job related injury, to help
determine an injured worker’s medical impairment to
assist with the settlement of their case, to determine a
person’s functional loss following a personal injury, and
other elements dealing with the decision of an injured
worker’s ability to work at certain levels of stress.
TYPES OF FCE’s
 UEE
 JOB
SPECIFIC
 NON-JOB SPECIFIC
 FORENSIC (All incorporate this)
 BASELINE FCE
 DISABILITY
Without FCE...
RTW Decisions Require a Lot of Guesswork!
 Client

self-report
Do you think you are ready to go back to
work?
 Impairment/diagnosis-based



Imaging studies
Range of motions
General impressions
decision
Problems with This
Approach
 Self-report

Is influenced by motivation
• job satisfaction
• financial incentives
 Impairment

information
Not equal to function
No objective information about patients’
functional abilities!
An FCE Can Help You….







Progress Treatment
Match Abilities to Job Demands
Make RTW Decisions
Determine Work Restrictions
Make Reasonable
Accommodations
Evaluate Performance
Inconsistencies
Facilitate Case Closure
FCE Benefit to the Physician
 Provides
an accurate summary of physical
capacities
 Saves time
 Improves communication



patient,
employer,
other providers
 Can
be counted on in court
FCE Benefit to the
Case Manager
 Objective
 Reliable
data to facilitate case closure
 Expedites
work
information for the rehab plan
safe, productive return to
How does the FCE report assist me
with my patient’s case?






Overall level of work
Tolerance 8 hr day
Level of cooperation
Specific limitations
Job match
Interventions






Job placement
Work transition
Barriers to address
Modified duty needs
Return to work
decisions
Program planning
DISABILITY
 The
World Health Organization defines
disability as “any restriction or lack of
ability to perform an activity in the manner
or within the range considered normal for
a human being” (resulting from an
impairment). Disability is also the "gap
between what the individual could do prior
to the injury and is currently able to do".
Disability represents the Functional Loss.
IMPAIRMENT
A permanent impairment according to the
definition is “one that has become static or
stabilized during a period of time sufficient
to allow optimal tissue repair and one that
is unlikely to change in spite of further
medical or surgical therapy.”
ROLE OF THE FCE

The FCE process can help establish the
Disability, but it is not a medical test that
establishes a person’s Impairment.
 However, portions of the FCE process may be
used in the impairment process, for example,
Dynametric Muscle Testing may be used to
document the extent of muscle weakness in a
Shoulder Rotator Cuff injury after adequate time
for recovery has taken place.
IMPAIRED VS. DISABLED
 An
impaired person may not be disabled.
For example, a laborer may sustain an
amputation of two fingers on his dominant
hand, but may be able to perform their
original job as a Machinist. But the same
impairment on a Hand Surgeon or a
Concert Pianist may be disabled from
pursuing their vocations.
FCE LOOKS AT











NON-MATERIAL
HANDLING
Balancing
Climbing
Crawling
Crouching
Feeling
Fingering
Kneeling
Reaching
Sitting
Standing
Stooping
Walking
MATERIAL HANDLING

Carrying

Handling

Lifting

Pulling

Pushing
FCE INCLUDES
 The
FCE should include the identification
of client behaviors that interfere with the
client’s physical performance.
FCE INCLUDES

The DOT Categories of Work include: SEDENTARY
(Up to 10 lbs.), LIGHT (Up to 20 lbs.), MEDIUM (Up to
50 lbs.), HEAVY (Up to 75 lbs.) and VERY HEAVY
(100+ lbs.)

The Frequencies tested for are: NEVER (0%),
OCCASIONAL (0-33%), FREQUENT (33%-66% and
CONSTANT (66%-100%)



The evaluation of the biomechanical components of safe
work practices.
The purpose of the FCE should be defined
Goals of the FCE
 Answer
the questions of the referral
source:
 Can he work and at what level?
 Is there dysfunction/limitations?
 Can the worker return to a specific job?
 Was he trying his best?
What is an FCE?
A
test to assist in determining an
individual’s capacity for work.
 An
FCE is a means to assist in case
closure
 FCE’s
are in many ways a behavior test
Validity and Reliability
 Validity:
Measures what it is suppose to
measure
 Reliability:
Consistent measurement. Can
be reproduced.
RESEARCH

King et. al, identified the Blankenship method as
one of three (out of the ten they reviewed), FCE
testing systems utilizing both normative and
objective data. The Blankenship method was
also the only FCE testing system identified as
being developed based upon published medial
research. Brubaker et.al, (2007) identified four
components of the Blankenship FCE system to
demonstrated good sensitivity and specificity for
detecting submaximal effort.
No Standard in the Industry
 There
has not been one test/system that
has been proven the most reliable/valid
for FCE’s.
 Must rely on current studies/practices and
literature and utilize the best battery of
tests available to obtain a good outcome.
FCE needs to address:
 Material
handling including:
Lifting from floor to overhead
Push/pull
Carry
 Non material handling/positional
tolerances
Sit, stand, walk
Bend, stoop, kneel and squat
Performance is the key
 How
can I “force” an injured worker to
push harder than they are willing.
 When
we start the FCE, the worker is
instructed to “stay safe, work up to the
safe maximum ability”
 Thus
we are looking at behavior and
performance
I can’t say…
 Malinger
 Faker
 Symptom
magnifier
I can say…
 Acceptable
effort
 Over guarding (fearful)
 May not represent true work capacity
 Can perform work at least at this level
 Will be safe to perform work at this level
How do I determine this?
Going to look at a variety of items including:
Pain levels pre, during and post test
AROM pre and post test
Heart Rate and Rate of Perceived Exertion
Psychometric testing
Coefficient of Variance
Kinesiophysical Signs
Lifting
Pain Scales
 Simply
ask the client to report pain on the
scale.
 If they report that pain is at 6 or above, but
don’t want to take a break…
 At level 10 but still going strong?
Heart Rate and RPE
This is commonly called the BORG
 Ask client to rate exertion- “how much
work hearts and lungs are doing”
 Compare
 Must
to heart rate
be aware of medications taking.
Psychometric Tests
 Psychometric
tests are self reporting pen
and paper tests/questionnaires.
 They
give the client an opportunity to
rate/report their abilities and pain.
Psychometric Tests


Modified Oswestry Low Back Questionnaire
Rates for scores are a result of study by
Blankenship:
 scores of 40-100% are considered high and
indicate significant impairment or symptom
magnification
 scores of 0-29% are considered low and
indicate non symptom magnification
 scores of 30-39% indicate an equivocal result
Ransford Pain Drawing
 Again,
another look at how this person
perceives pain
 Sometimes do pre and post drawings
Pain Drawing Score 0
Pain Drawing Score 4
Additional Questionnaires
 DASH
 SPADI
 Pain
Disability Index
 Dallas
 KOOS
 Michigan Hand Outcomes
 FAAM
Psychometric test warning
 These
 They
tests cannot stand alone.
must be used in conjunction with
each other and the rest of the test
Waddell’s Panel for Non Organic
Signs
A
group of observations taken during
specific tasks.
 These
point to the presence of nonorganic
factors causing back pain.
 Must
have three of five groups to be
considered positive.
NON-ORGANIC

Non-Organic Signs are mostly based on
objective criteria, which are documented during
a clinical musculoskeletal evaluation, based on
peer reviewed research.
 They answer the question of whether or not the
patient is cooperating with the musculoskeletal
evaluation, and whether or not they are reporting
sensory loss, weakness, tenderness and
movement dysfunction, which are simply not
present
NON-ORGANIC TESTS








1. Gordon Waddell: 3/5 Positive for Low Back Pain
2. Greg Korbon: 5/21 Positive for Low Back Pain
3. Jerry Sobel: 3/5 Positive for Neck Pain (Waddell’s
Score)
4. Modified Korbon: 5/21 Positive for Neck and Extremity
Pain (Modified
by Blankenship)
5. Additional Simulation Tests (Non-Published Placebo
Tests)
6. Additional Distraction Observations (Non-Published
and Restricted
to M-S Evaluation Only)
Movement
 Measure
range of motion at beginning
 Why would it be better or worse at the end
of the test?
 Better if need to “loosen up”
 Worse if in pain.
 What if better, but more pain?
Coefficient of Variance
 Static
 Grip
Strength testing
testing
 ROM
 Measures
consistency
Grip Testing
 Bell
shaped curved
 Rapid
Exchange Test
 Repeat
Testing
Kinesiophysical effort
 Light
Effort: no accessory muscles, natural
stance, easy movement patterns
 Moderate Effort: Involuntary recruitment of
accessory muscles, stable base,
beginning of counter balance, smooth
movements, lift takes longer
 Heavy effort: Obvious recruitment of neck
muscles, arm muscles; wider solid base;
counter balance is obvious and used
Add’m up and get the Results
 Have
to look at the big picture
 Looking for patterns
 Extrapolate
 Consistency in effort vs. non effort
 Minimum of 20 Validity Criteria are
needed.
VALID?

The percent of validity criteria passes can also provide a relative
measure of the type of effort exerted during the FCE, based on the
following algorithm.

CRITERIA PASSED EFFORT CLASSIFICATION
90 – 100% Excellent Effort
80 – 89% Good Effort } VALID FCE RESULTS
75 – 79% Fair Effort
70 - 74% Borderline Valid FCE Results: These FCE results are
probably somewhat conservative and the patient's work ability will
probably improve over the Next 6-12 Months.
65 – 69% Borderline Invalid FCE Results: These FCE results are
conservative and the patient's work ability will probably improve over
the Next 6-12-Months.
0 – 64% Poor Effort } INVALID FCE RESULTS






VALID

In summary, it is the Validity Profile which
indicates whether or not the FCE results are
valid and reliable. A worker may by classified as
a Symptom Exaggerator and he may
demonstrate some non-organic signs, but when
it comes to actually lifting boxes and exerting
force, that same worker may exert their best
effort and achieve valid and reliable FCE results
which may be used for medical and vocational
planning.
INVALID
 Inconsistent
CV’s
 Improved ROM with distraction
 Overreaction (Movements actually put
more stress on body part)
 Verbal reports don’t match
pathophysiology, distracted movement
patterns and objective measurements.
 Inconsistent Data with static strength.
INVALID?
 What
I
do you do with it?
strongly feel that the physician needs to
take all objective data and take a stand.
 The physician is at the top of the
heirarchy of care. We provide the data
and do the research and the physician
needs to use that for case closure.
Recommendations
 Return
to Work
 Return to Modified Duty if available.
 Work Conditioning
 Pain Management
 Job Analysis (If sufficient info not
available) or Evaluate alternative position
that is available.
 “You
do not get injured workers well to get
them back to work. You get them back to
work to get them well.”
 -Richard
Pimentel