Industrial Rehabilitation

1. Industrial Rehabilitation George T. Edelman MPT, MTC Rick Hayward MPT, OCS, OMPT

2. Scope of the Problem • 5.7 Million injuries and illnesses reported in private industries in 1999 • Of those, about 2.7 million were lost workday cases • Of those 5.7 M, 5.3 million were accidents • Injury rates higher for those mid-sized companies employing 50-249 workers.

3. INJURY COSTSMedical CostsEmployee WagesBenefit Package PaymentsSalary of Replacement PersonnelTraining of Replacement PersonnelOvertime Payments for Current Personnel

4. What do I need to know? • Acute care management of patients with musculoskeletal dysfunction • Functional Capacity Evaluation • Job Demands Analysis • Ergonomics, hazard identification and abatement • Pre-employment Screening • Information management

5. What do I need to know? • Work conditioning • Work simulation • Injury Prevention Education • Fitness • Governmental agencies • Regulatory issues • Reimbursement issues • Marketing

6. Players • Worker/patient • Employers • Physician • PTs/OTs/ Exercise physiologist • Vocational Rehab consultant • Psychologist • Attorney • Case manager

7. Scope of Practice Most Common • Treating acutely injured workers in outpt setting • Return to Work Screens (mini-FCE) • Functional Capacity Evaluation (FCE) • Job Demands Analysis (JDA) • Post-Offer / Pre-Placement Screens • Worker Education • Ergonomics • Fitness/Wellness

8. Overview of Lecture • History, Regulations, and Agencies • The Continuum of Care and Services • Functional Capacity Evaluation: The Well Designed Test • Job Demands Analysis • Post Offer Screening • Marketing & Selling Your Services to Business & Industry

9. History, Regulations, and Agencies

10. History - 3 Major Areas • Workers Compensation • Social Security • Employment Selection

11. History: Workers’ Compensation • Early 1900’s - trend toward awareness of rehab of physically disabled • Prior to 1910 the only recourse to bring a suit against their employers in court to claim damages for work related injuries

12. Workers’ Compensation Law • Early 1900’s increasing number of claims being settled in favor of plaintiff but many did not have resources to go to trial • only 6% workers received financial relief • employers risk of liability in isolated cases was astronomical - out of business in single claim

13. History - Workers’ Compensation • State Workers Compensation Law • 1910 New York • 1911 Wisconsin • mandated employer-financed insurance programs • created a “no fault system” where workers gave up right to sue and employers accepted limited liability • purpose was prevention of poverty, not disability prevention

14. Workers’ Compensation Law • varies from state to state • costs are paid by employer to state fund or insurer • each state determines specific benefits received

15. History: Workers’ Compensation • By 1920, 42 out of 48 states & DC had WC laws • has been called the “most dramatic event in 20th century of American civil justice”* • for 25 years was the only social disability income program in the US *Darling-Hammond L, Keisner TJ: The law and economics of workers’ compensation, Santa Monica CA, 1980, Rand Publications.

16. Understanding Workers Comp • Who pays and why? • Every employer except • family business, only family employees • self-insured • Point is to spread risk • riskier industries pay more • higher injury rates pay more

17. Who is Covered • Everyone except • Baby-sitters • Temporary agriculture • Religious school teaching • Part-time domestic help • Family members in family business

18. What is Covered? • Work-related injuries or illnesses • must “arise out of and in the course of employment • Includes • organized recreational functions • travel • homework • unauthorized presence in workplace

19. Pre-existing Conditions: Pre-disposing to Injury • If it occurs at work, it arises out of employment as far as the law is concerned • does not matter if the injury occurs during an activity that would not have been injurious but for the preexisting sensitivity • Employers must “take employees as they find them”

20. Pre-existing Conditions: Causing Injury • When cause is unclear, law will not attribute it to work unless evidence points in that direction • King v. TTC Illinois Inc., Montana, 2000 • Truck driver, smoker, HBP, high cholesterol • died in cab of truck after handling tarps • medical examiner concluded death caused by preexisting heart condition • court sided with med examiner

21. History - Workers’ Compensation • 1920’s saw decline in the workers compensation system • Disputes arose over whether injuries were work-related and the extent of disability • By mid-1930’s debate began over whether to add disability to the social security system

22. History: Social Security Disability • Social Security system added disability coverage in increments: • ‘54 disabled exempt from making social security payments • ‘56 disability benefits began for those between 50 and 65 were unable to work due to disability • ‘58 monthly benefits paid to dependents • ‘60 age limitation of 50 years removed • ‘65 12-month requirement added • ‘72 benefits increased & Medicare benefits available to those whose disability lasted for at least 2 years

23. SSA’s Definition of Disability • The inability to do any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

24. SSA’s Definition of Disability • Impairment must be so severe that person is not only unable to do past work but considering age, education, and work experience engage in any other substantial gainful work which exists in the national economy

25. Five Step SSA Disability Determination Process • Is the individual engaged in SGA? • Does the individual have a severe impairment? • Does the impairment meet the listings? • Can the individual do past relevant work? • Can the individual do other work?

26. History - Rehabilitation • World War I - disabled veterans’ vocational needs • 1920 - Passage of Vocational Rehab Act - Provided funds for vocational rehab • veterans WWI • industrially injured • Amendments in 1943 & 1954

27. History - Employment Selection • Americans with Disabilities Act (ADA) July 26,1992 • extended legal protection from employment discrimination to handicapped Americans • goes beyond traditional equal employment law and affirmative action by requiring individualized treatment on a better-than-equal basis • tests cannot be used to screen out disabled individuals unless they are job-related

28. ADA • All employers of 15 or more people • protects “qualified persons with a disability” • physical or mental impairment substantially limits one or more major life activities • “record of” • “regarded as having” • has requisite skills, experience, education, & other job-related requirements • able to perform essential functions with or without reasonable accommodations

29. ADA - Substantial Limitation of Major Life Activity • Caring for self • Performing manual tasks • Walking • Seeing • Hearing • Speaking • Breathing • Learning • Working • Participating in community affairs

30. ADA - Essential Functions • Job function considered essential if: • reason job exists is to perform function • limited number of employees available among whom performance of function can be distributed • highly specialized so that the incumbent is hired for the ability to perform the function

31. ADA - Reasonable Accommodations • modifications or adjustments to job to enable impaired person to enjoy equal employment • job application process • work environment • benefits & privileges

32. ADA - Undue hardship • If necessary modifications create “undue hardship” employer does not have to provide • Factors considered: • nature and cost • financial resources of employer • effect on the operation of the facilities/business

33. History - Injury Prevention • Williams-Steiger Occupational Safety & Health Act 1970 • assure safe and healthful working conditions for men and women • no specific ergonomic standards • ergonomic considerations covered under the general duty clause • employers responsible for furnishing employees a place of employment free from recognized hazards that are likely to cause death or serious physical harm to employees

34. OSHA • Regulatory body • Employers of 11 or more people • Reduce hazards/comply with standards • Conducts inspections • Issues fines • No ergonomic standards per se

35. History - Injury Prevention • 1991 - OSHA published “Ergonomics Program Management for Meatpacking Plants” covering primary components of an effective ergonomics program: • Worksite Analysis • Hazard Prevention & Control • Medical Management • Training & education

36. NIOSH • set up by same act that established OSHA • directed by Secretary of Health & Human Services • authorized to develop standards & conduct research • Work Practices Guide for Manual Lifting including formula for calculating recommended weight limit for lifting tasks

37. Governmental agencies • Department of Labor • description/classification of work • Social Security Administration • disability determination • NIOSH • research • OSHA • regulatory

38. Overview of Course • History, Regulations, and Agencies • The Continuum of Care and Services • Functional Capacity Evaluation: The Well Designed Test • Job Demands Analysis • Post Offer Screening • Marketing & Selling Your Services to Business & Industry

39. The BIG PICTURE... • Continuum of Care • Medical Model vs Work Recovery Model • Acute, Subacute, Chronic • medical management • work recovery management • Role of assessment • Importance of function

40. Medical Model Acute Sub-acute Chronic Work Recovery Model Off Work Transitional modified duty Return to full duty Permanent modified duty New permanent position Disability Continuum of Care

41. Acute Care: Medical Side • Acute • promote healing of tissue • minimize symptoms • maximize function • Important to begin asking about job tasks and demands early! • usually patient or employer self-report • can explore occupational information • DOT • Job Exploration Software

42. Work Related Function • Early emphasis on work-related function is one of the hallmarks of a holistic clinician!

43. Acute Care: Work Recovery • Acute- Off work – Begin by asking about home function • Be specific • activity • duration • performing functional activities at home • sitting • standing • walking • lying • light materials handling

44. Acute Care: Work Recovery • Aim for graded progression of home function • Scheduled and structured • As a measure of outcome • Set stage for • problem solving • pain management • exercise • positioning

45. Work Function • Based on demands of job • Work simulation • Work conditioning exercises • Graded with specific goals

46. Acute Care: Work Recovery • Acute -Transitional modified work • original job • new temporary job • meaningful work is optimal • guided by functional testing • communication with supervisory personnel is essential • progression

47. Importance of Function • Only way we have of knowing whether we are making a significant difference in the lives of the patients we treat is to find out about function of patient & work demands • self-report • accuracy • motivation • observational measurement is preferable

48. Importance of Work-Related Functional Assessment • Only objective means of determining whether patient abilities meet functional demands of work is to evaluate • asking patient to perform functional task • measuring physical demands of work • match? • yes return to work • no further treatment or modified work

49. Appropriate Measurement for the Acute Stage • Not full blown FCE • Not formal job demands analysis • Instead: • informal visit to the job site • observe the job • use the information to develop a brief screen of the most demanding aspects of the job

50. What does the informal job site visit accomplish? • Increases your • comfort level with the industrial environment • credibility in the eyes of your patient • patients’ level of trust • ability to market other industrial services • value in the scheme of treatment • physicians • case managers