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Injured Workers:Takin’ Care of Business

WORK & INDUSTRY OOTA REHAB SIS WEBINAR

AMY SMITH, OTR/L, CEAS, CWE

Objectives:1. Recognize the unique role of occupational therapy in the return to work process.

2. Understand the types of evaluations used in work and industry and incorporate considerations in selecting the appropriate tools.

3. Identify how ergonomic principles and implementation, job analysis, and modifications help to safely return individuals to the worksite.

Work RehabilitationWORK REHA BILITATIO N IS A BROA D TERM THAT ENCOMPA SSES MA NY A SPECTS OF INTERVENT IO N, A LL GEA RED TOWA RD FA CILITATING PA RTIC IPATION IN WORK A ND SATISFA CTORY FULFILLM EN T OF THE WORKER ROLE. – A OTA FA CT SHEET

Goals of Work RehabilitationMaximize levels of function following injury and/or illness to maintain a desired quality of life for the worker

Facilitate the safe and timely return of individuals to work following injury and/or illness

Remediate and/or prevent future injury or illness

Assist individuals in retaining or resuming their worker role, which can contribute to self-confidence and a view of self as a productive member in society, and prevent the negative psychosocial consequences of unemployment.

Approaches to Goal Achievement:1. Acute Injury and Illness Management

2. Work Conditioning

3. Work Hardening

4. Functional Capacity Evaluation (FCE)

5. Environmental Modification

6. Transitional Work Programs

This Photo by Unknown Author is licensed under CC BY-SA-NC

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Acute Injury and Illness Management:The occupational therapist works with the client to determine any gaps between the demands of the job and the individual’s existing performance abilities, and remediates or compensates for the differences in a timely manner. The occupational therapist will determine the history of the current condition or injury, consider any potential change in the condition over time, develop a comprehensive and individualized intervention plan to address problem areas, help to implement the plan, and evaluate its effectiveness.

Work Conditioning:The occupational therapist uses a systematic approach to restore the performance skills of workers recovering from long-term injury or illness. There is a focus on restoring musculoskeletal and cardiovascular systems, as well as safely performing work tasks. This is typically achieved through work simulation and individualized interventions to improve physical capacity that occur 3 to 5 days per week for 2 to 4 hours per session.

Work Hardening:This approach is similar to work conditioning; however, it is multidisciplinary and can involve psychomedical counseling, ergonomic evaluation, job coaching, and/or transitional work services. Treatment is typically provided 5 days per week for 2 to 4-plus hours per day. Clients in work-hardening programs may progress to transitional work programming by actually performing job duties at their place of employment. If necessary, final adaptations and/or reasonable accommodations can be determined during this period of transition.

Functional Capacity Evaluation (FCE):The occupational therapist uses standardized and validated advanced testing in order to (a) determine safe job matches for return to work; (b) determine the level of reasonable accommodations necessary for reinstating an injured worker; and (c) make recommendations regarding future interventions. The results of the FCE may be used by the physician to make a disability rating for insurance purposes.

Environmental Modification:The occupational therapist, together with the worker and the employer, makes recommendations for modifications to the workplace environment to facilitate successful employment performance. Examples of environmental modifications include raising or lowering the lighting, creating a new layout of the workspace, modifying work-related tools and devices, and minimizing distractions.

Transitional Work Programs:Transitional work uses the actual work tasks and environments as a form of rehabilitation. After becoming familiar with the individual’s job requirements and measuring the individual’s functional abilities, the occupational therapist determines tasks that the individual can safely and dependably perform at work. The occupational therapist works with the employer to identify environmental and task modifications that will support work performance, and makes detailed recommendations to the treating physician, who releases the individual to modified work within these parameters. Work performance is closely monitored and discussed among the occupational therapist, employer, and individual, and modifications change as the worker develops more skills.

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Occupational Therapy’s RoleOccupational therapy practitioners, through their education and training, have the skills to evaluate worker capacities, task performance, and the work environment, and to provide interventions related to these areas.

Using a client-centered perspective, occupational therapists evaluate the impact of wellness, cognition, physical disabilities, psychosocial factors, and medical conditions on work performance. In particular, occupational therapists possess the distinct ability to evaluate the intersection of an individual’s work demands and the work environment through evidence based task analysis. The occupational therapy evaluation can identify supports and barriers to success in the work environment, including work culture, that can be addressed in the intervention plan to enhance work performance. The occupational therapist also considers other contexts and environments that may support or hinder the ability to fulfill the worker role, such as access to transportation and the ability to dress oneself in a timely manner for the work day. These specialized evaluation skills allow the occupational therapist to understand and deliver results in the complex psychosocial and physical work environment (American Occupational Therapy Association, 2017).This Photo by Unknown Author is licensed under CC BY-NC-ND

Transitioning Back to Work

Accidents HappenAccidents HappenAccidents HappenAccidents HappenDespite Safety Practices

Equipment Malfunctions

Employees get distracted

Body parts wear out

/

What happens when an injury occurs

Injury reportingMedical

Treatment

RTW with restrictions or

taken off of work

Receives therapyTransitions to full

dutyReleased back to

work

What is Transitional Work Therapy?

Real work tasks within the worker’s restrictions that are

used to progress the employee to full duty job tasks.

Therapist uses body mechanics, ergonomics, pacing, stretching, posture, etc. to gain endurance, flexibility and strength for the worker to tolerate the physical

job demands.

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Where and How Are Services Provided?

Possible Location of Services: Outpatient rehabilitation centers, hospitals, private industry (e.g., on-site clinics), private practices, community-based centers

Referral Sources: Medical providers, insurance case managers and adjusters, attorneys, state agencies, rehabilitation team members

Payer Sources: Workers’ compensation carriers, state and local agencies (e.g., Bureaus of Vocational Rehabilitation), legal settlements, private insurance, private pay

Comparison of Clinic-Based OT vs Onsite/Transitional Work Therapy

CLINIC BASED OCCUPATIONAL THERAPY

1. Completes full evaluation based on diagnosis

2. Provides therapeutic intervention to return the client back to 100% in order to return to work

3. Simulates work tasks within the clinic to insure that the client has the strength and coordination to return to work safely

4. Makes recommendation to the POR for release to full duty

5. Average LOS 4-6 weeks

ONSITE/TRANSITIONAL WORK THERAPY

1. Completes full evaluation based on diagnosis but in relation to work demands/JA

2. Compares the restrictions, physical abilities of the client, physical job demands and works with the employer to identify “transitional duty” work tasks that the IW can do while rehabilitating

3. Observes the IW performing job tasks and progresses the tasks within the POR restrictions towards full duty release

4. Makes recommendation for full duty release

5. Average LOS 4-6 weeks if no lost time

Players on the Team

• Occupational Therapy• COTA –clinic only• Physical Therapy• Case ManageroNurse Case ManageroVocational Rehabilitation Case Manager

• Physician of Record (POR)• Employer – HIPAA• MCO – Managed Care Organization

This Photo by Unknown Author is licensed under CC BY-SA

Specialized Training for RTW Services

CWE – Certified Work Evaluator

CEAS – Certified Ergonomic Assessment Specialist (Can be general, office only, aging workforce)

CETS – Certified Employment Testing Specialist

TWD - Transitional Work Developer

CPE – Certified Professional Ergonomist

CDMS – Certified Disability Management Specialist

The Injured WorkersTAKIN’ CARE OF BUSINESS

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Functional Job Analysis

IT’S NOT JOB DESCRIPTION

Job AnalysisJob AnalysisJob AnalysisJob Analysis

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Job Analysis: How is it used?

Physician to set restrictions

Vocational Rehabilitation Case Manager to determine job goals

•SJSE, DJSE, SJDE, DJDE

Employer to Identify Transitional Duty Tasks

**Transitional work versus Light Duty

Functional Capacity Evaluation

History of the FCEA functional capacity evaluation is set of tests, practices and observations that are combined to determine the ability of the evaluated to function in a variety of circumstances, most often employment, in an objective manner

1970’s beginning

2001 criticized as not being job specific

What is an FCE• A functional capacity evaluation (FCE)

evaluates an individual's capacity to perform work activities related to his or her participation in employment (Soer et al., 2008).

• Consists of standardized assessments• Administered with care and safety in

mind

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Testing With a Purpose

Functional testing by therapists continues to be important in objectively matching workers and their jobs. By understanding the need to choose the correct test and provide nondiscriminatory information, the therapist takes on broader professional responsibility consistent with laws and nondiscriminatory return to work.

Susan J. Isernhagen, PT

Why are FCEs orderedBaseline

Pre employment

Job Specific

Medical/legal

Assisting with case closure

Who Benefits From aFCE?

Individual injured on the job

Applying for Social Security Disability

Seeking to return to work after extended leave

Someone seeking vocational rehabilitation

Transition from school to work setting

FCEs are done on a one-on-one basis and may range in length from 4 to 6 hours.

The FCE may take place over 2 consecutive days.

Uniqueness of Billing Code 97750

OOTA and BWCDEFENDING BILLING PRACTICEDEFENDING BILLING PRACTICEDEFENDING BILLING PRACTICEDEFENDING BILLING PRACTICE

Types of FCE’sMatheson

Ergo Science

ARCON VERNOVA FCE

Isernhagen Work System

Blankenship

Ergos Work Simulator and Ergo Kit Variation

Hanoun Medical

WEST-EPIC

Key

AssessAbility

Workability Network

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In developing diagnostic tests, we must remember that it is better to miss an insincere individual than to classify a sincere patient as insincere. Tests must be chosen carefully, and if multiple tests are used, they must be administered in a logical order.

Ahmer, 2007

Components of a FCE

History review –medical,

vocational, social

History review –medical,

vocational, social

Screening tests –musculoskeletal

Screening tests –musculoskeletal

Physical functional

testing – based on DOT

Physical functional

testing – based on DOT

Job simulation – when

identified job is known

Job simulation – when

identified job is known

Behavior assessment

Behavior assessment

Results, data compilation, and

recommendations

Results, data compilation, and

recommendations

COGNITIONCOGNITION

Less than Full Effort Performance Matheson, 2003

1. Medically determined impairments

2. Malingering

3. Factitious disorder

4. Learned illness behavior

5. Conversion disorder, pain disorder

6. Depressive disorder

7. Test anxiety

8. Fear of symptom

exacerbation or injury

9. Fatigue

10. Medication &

psychoactive substance

effects

11. Lowered self-efficacy

expectations

12. Need to gain

recognition for symptoms

/

Non-Organic Signs

Pain Questionaire

Waddell

McGill Pain Questionaire

Ransford

Numeric pain scale

Million Visual Analogue

Reliability

Intra-rater ReliabilityIntra-rater Reliability

Test-Retest ReliabilityTest-Retest Reliability

Reliability of Predictability of RTWReliability of Predictability of RTW

Reliability with Different DiagnosesReliability with Different Diagnoses

Physical Demand Characteristics of Work

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AMERICANS WITH DISABILITIES AMENDMENT ACT and RTW

This amendment went into effect January 1, 2010. It broadens the definition of disability to include people with chronic illnesses that affect life and work. The exact scope is not yet clear, but the intent was to allow more people to fall under the definition so they could receive protection. Behavior change is expected from employers, away from challenging whether a person has a disability and instead focusing on reasonable accommodations. There is an increased opportunity for therapists to identify job modifications in a positive way. With the accommodation, the worker must be able to perform the essential functions of the job, thus not harming an employer’s need for a capable and productive worker.

ADA and Prevention of Discrimination Based on Injury

The FCE needs to be job specific or generic with an objective summation of the IW’s ability to do their job

Job-specific:

◦ measure job demands and design a job-specific test

◦ test only to the specifics of the job(s) required;

◦ match the worker’s abilities to the job tasks. Indicate if there is a match or not.

Make suggestions for accommodation/modification.

◦ don’t make employment decisions.

Employers are the final decision makers.

Ergonomic Assessment

Benefits of Workplace Ergonomics

1. Ergonomics reduces costs

2. Ergonomics improves

productivity

3. Ergonomics improves quality

4. Ergonomics improves employee

engagement

5. Ergonomics creates a better safety culture

What is an Ergonomic Injury?

Pain and dysfunction as a result of static and/or awkward

postures especially when there is FORCE, REPETITION,

VIBRATION, or CONTACT STRESS involved.

Most often involves muscles, nerves, tendons or fascia

Ergonomics injuries are the result of a

problem, not the Source

Ergonomic Risk FactorsErgonomic Risk FactorsErgonomic Risk FactorsErgonomic Risk Factors

High Task Repetition

Forceful Exertions

Repetitive/sustained Awkward Postures

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High Task RepetitionControl methods to consider:

Engineering Controls – Eliminating excessive force and awkward posture requirements will reduce worker fatigue and allow high repetition tasks to be performed without a significant increase in MSD risk for most workers.

Work Practice Controls – Providing safe & effective procedures for completing work tasks can reduce MSD risk. In addition, workers should be trained on proper work technique and encouraged to accept their responsibilities for MSD prevention.

Job Rotation – Job task enlargement is a way to reduce duration, frequency and severity of MSD risk factors. Workers can rotate between workstations and tasks to avoid prolonged periods of performing a single task, thereby reducing fatigue that can lead to MSD.

Counteractive Stretch Breaks – Implement rest or stretch breaks to provide an opportunity for increased circulation needed for recovery.

Forceful ExertionsControl methods to consider:

Engineering Controls – Eliminating excessive force requirements will reduce worker fatigue and the risk of MSD formation in most workers. Using mechanical assists, counter balance systems, adjustable height lift tables and workstations, powered equipment and ergonomic tools will reduce work effort and muscle exertions.

Work Practice Controls – Work process improvements such as using carts and dollies to reduce lifting and carrying demands, sliding objects instead of carrying or lifting, and eliminating any reaching obstruction to reduce the lever arm required to lift the object.

Proper Body Mechanics – Workers should be trained to use proper lifting and work techniques to reduce force requirements.

Repetitive/Sustained Awkward PosturesControl methods to consider:

Engineering Controls – Eliminate or reduce awkward postures with ergonomic modifications that seek to maintain joint range of motion to accomplish work tasks within the mid-range of motion positions for vulnerable joints. Proper ergonomic tools should be utilized that allow workers to maintain optimal joint positions.

Work Practice Controls – Work procedures that consider and reduce awkward postures should be implemented. In addition, workers should be trained on proper work technique and encouraged to accept their responsibility to use their body properly and to avoid awkward postures whenever possible.

Job Rotation – Job rotation and job task enlargement is a way to reduce repeated and sustained awkward postures that can lead to MSD.

Counteractive Stretch Breaks – Implement rest or stretch breaks to provide an opportunity to counteract any repeated or sustained awkward postures and allow for adequate recovery time.

Ergonomics Improvement Process1.Facility tour and general ergonomic walkthrough audit

2.Review of injury and MSD history

3.Data and information collected from employee surveys

Manual material handling work doesn’t have to mean more injuries

#ERGONOMICS

Ergonomic Risk Assessment Tools

WISHA Lifting Calculator

WISHA Lifting Calculator

NIOSH Lifting Equation

NIOSH Lifting Equation

Rapid Entire Body Assessment (REBA)Rapid Entire Body

Assessment (REBA)

Rapid Upper Limb Assessment (RULA)Rapid Upper Limb

Assessment (RULA)

Liberty Mutual Manual Material Handling Tables (Snook Tables)

Liberty Mutual Manual Material Handling Tables (Snook Tables)

Washington State Ergonomic and MSD

Risk Assessment Checklist

Washington State Ergonomic and MSD

Risk Assessment Checklist

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Ergonomic Tools Assessments:The Details

WISHA Lifting Calculator

Developed by the Washington State Department of Labor and Industries and based on NIOSH research related to the primary causes of back injuries, this lifting calculator can be used to perform ergonomic risk assessments on a wide variety of manual lifting and lowering tasks, and can be also used as a screening tool to identify lifting tasks which should be analyzed further using the more comprehensive NIOSH Lifting Equation.

NIOSH Lifting Equation

The NIOSH Lifting Equation is a tool used by occupational health and safety professionals to assess the manual material handling risks associated with lifting and lowering tasks in the workplace. This equation considers job task variables to determine safe lifting practices and guidelines.

Rapid Entire Body Assessment (REBA)

This tool uses a systematic process to evaluate whole body postural MSD and ergonomic design risks associated with job tasks. A single page form is used to evaluate required body posture, forceful exertions, type of movement or action, repetition, and coupling. A score is assigned for each of the following body regions: wrists, forearms, elbows, shoulders, neck, trunk, back, legs and knees. After the data for each region is collected and scored, tables on the form are then used to compile the risk factor variables, generating a single score that represents the level of MSD risk.

Ergonomic Tools Assessments:The Details

Rapid Upper Limb Assessment (RULA)

This diagnostic tool assesses biomechanical and postural load requirements of job tasks/demands on the neck, trunk and upper extremities. A single page form is used to evaluate required body posture, force, and repetition. Based on the evaluations, scores are entered for each body region in section A for the arm and wrist, and section B for the neck and trunk. After the data for each region is collected and scored, tables on the form are then used to compile the risk factor variables, generating a single score that represents the level of MSD risk.

Liberty Mutual Manual Material Handling Tables (Snook Tables)

The Liberty Mutual MMH Tables (commonly known as Snook Tables) outline design goals for various lifting, lowering, pushing, pulling, and carrying tasks based on research by Dr. Stover Snook and Dr. Vincent Ciriello at the Liberty Mutual Research Institute for Safety. The tables provide weight/force values, for specific types of tasks that are deemed to be acceptable to a defined percentage of the population. This is done by comparing data for each of the specific manual handling tasks against the appropriate table.

Washington State Ergonomic and MSD Risk Assessment Checklist

This tool is designed to evaluate ergonomic risks factors including awkward postures, highly repetitive motions, high hand force, repeated impacts, lifting, and hand-arm vibration. The Caution Zone Checklist is used as a screening tool. If there are no positive findings identified, the job is regarded to be safe; otherwise a moderate risk is indicatedand the job should be evaluated further using the Hazard Zone Checklist. Positive findings with the Hazard Zone Checklist indicate immediate actions should be taken to reduce the risk.

Now that I completed the assessment, how do I fix the problems?

The 5 E’sConsiderations for treatment and implementation

Safe Lifting Education

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General Principles:

The workstation should be designed or arranged so that it allows the employee’s…

MiscellaneousInfo

Considerations:Specializing in Work and Industry

Intimidating to be on site at an employer – overhead

cranes, forklifts, large machines

Travel

Addressing needs of both client and employer –

sometimes difficult

Being onsite is the ultimate in job analysis/contextual

treatment

Blending of clinical reasoning and behavioral treatment

Making a difference in changing a culture

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Billing and Coding

CPT Codes

•97127

•97750

•97110

•97532

•97530

•97537

W Codes

Voc rehab plans

W0637

W0664

W0665

W3050

W3052

Special Interest Section:

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