Warehouse worker at 6 weeks: full-duty demand versus slow recovery
Ms. Rivera, 35, is a warehouse order picker. She sustained a lumbar sprain/strain 6 weeks ago lifting a 23 kg crate. She has completed 8 chiropractic visits and a home program. Pain is 6/10 with lifting and 3/10 at rest, and she reports fear of re-injury. Examination shows no radiculopathy, negative straight leg raise, lumbar flexion 40°, extension 15°, and pain with repeated lifting. Her job requires 8-hour shifts, lifting up to 23 kg repeatedly, and frequent trunk rotation. The employer offers modified duty at 10 kg maximum for 4 weeks; the insurer has authorized 4 more visits and is requesting a return-to-work plan. Ms. Rivera wants to return to full duty because she cannot afford reduced hours. She has no red flags and has not had a functional capacity evaluation.
1. What case-management priorities and return-to-work recommendation would you set for the next 4 weeks? Justify with functional and psychosocial factors.
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Priorities are to clarify the essential job demands, address fear avoidance, and avoid clearing full duty without evidence. She has pain with lifting and limited flexion/extension, so full duty at 23 kg is not yet defensible. Recommend modified duty at 10 kg for 2 weeks with graded work conditioning: progressive lifting from waist height, rotation control, and 8-hour tolerance. Set measurable goals: lift 23 kg from floor to waist with safe technique, tolerate an 8-hour shift, and pain ≤3/10 during work. Coordinate with the employer to confirm the modified role exists. Address psychosocial factors with education and graded exposure, not reassurance alone. Review at 2 weeks; if she meets criteria, advance to 15 kg and longer shifts. If not, consider a functional capacity evaluation. Document that reduced hours are temporary and tied to functional gains, not to her financial pressure.
2. The insurer asks whether to approve a functional capacity evaluation now or extend chiropractic care. How do you respond, and what findings would change your recommendation?
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A functional capacity evaluation is reasonable now if the question is safe lift capacity and consistency of effort, because she has plateaued and the insurer needs objective return-to-work data. It is not treatment and should not replace graded conditioning. My response: approve a focused evaluation after 2 weeks of work conditioning, or now if the employer cannot hold the modified role. Findings that would change the recommendation include submaximal or inconsistent effort, pain behaviors limiting testing, or a new neurologic deficit. If the evaluation shows she can safely lift 23 kg and tolerate 8 hours, support full duty. If it shows a gap, use the results to justify work conditioning or permanent restrictions. If red flags appear, refer medically rather than extend visits. The decision should be driven by whether the evaluation answers a specific return-to-work question.