HELPING THE INJURED WORKER RETURN TO WORK Understanding the role of Work Conditioning/Hardening programs and FCE’s

1. HELPING THE INJURED WORKER RETURN TO WORKUnderstanding the role of Work Conditioning/Hardening programs and FCE’s MATTHEW A. COHEN, Med, CERT FCE, CEAS INDUSTRIAL REHABILITATION MANAGER DEEP RIVER REHABILITATION

2. WORK CONDITIONINGVS.WORK HARDENING MATTHEW A. COHEN, Med, CERT FCE, CEAS INDUSTRIAL REHABILITATION MANAGER DEEP RIVER REHABILITATION

3. FUNCTIONAL CAPACITY EVALUATION MATTHEW A. COHEN, Med, CERT FCE, CEAS INDUSTRIAL REHABILITATION MANAGER DEEP RIVER REHABILITATION

4. BACKGROUND 12 YEARS OF EXPERIENCE INDUSTRIAL REHAB CERTIFIED FCE EVALUATOR (BLANKENSHIP) CERTIFIED ERGONOMICS SPECIALIST BACHELORS SPORTS MEDICINE MASTERS EXERCISE PHYSIOLOGY FATHER OF 2 (KIDS)

5. OUTLINE 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

6. Work Disability Cycle EMPLOYEEINJURED RTW ER REHAB Care Manager OMC PT PCP SPECIALIST

7. POOR TECHNIQUE

8. POOR POSTURE

9. POOR DECISIONS

10. Bad Decisions www.medicine-in-motion.com

11. INDUSTRIAL ATHLETE • As time off work is inversely correlated to the rate of return to work, early intervention is strongly recommended.

12. 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.

13. 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)‏

14. 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.

15. 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.

16. 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

17. 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

18. 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 well-informed 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.

19. 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.

20. 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

21. 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)

22. 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

23. 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 Work Cond. Vs. Work Hardening

24. 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). 

25. 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.

26. 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.

27. What is Work Conditioning? It is a structured program of PHYSICALCONDITIONING, 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 INDUSTRIALATHLETE.

28. 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

29. It All Begins With anInjured Worker

32. 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.

33. DO YOU KNOW WHAT YOUR INJURED EMPLOYEE IS DOING?

34. 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)

35. 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.

36. 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 INADJUSTING WORK RESTRICTIONS)

37. 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.

38. 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.

39. TREATMENT PROGRAM 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)

40. 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.

41. Muscle Physiology

42. Work Conditioning

43. WORK CONDITIONING

44. Work Conditioning

45. Don’t Lift With Your Back!

46. Benefits of Work Conditioning 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

47. 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

48. 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.

49. 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);

50. Ideal Situation • Combining Limited Duty and Work Conditioning will maximize the worker’s Musculoskeletal, functional and worker performance.