How Work Capacity Evaluations and Work Hardening Can Expedite Case Closure PRESENTED BY RICHARD CHAU, D.C. QME

How Work Capacity Evaluations and Work Hardening Can Expedite Case Closure

PRESENTED BYRICHARD CHAU, D.C. QME

AGENDA

• What is a Work Capacity Evaluation (WCE)• How Long Does it Take• When is a Work Capacity Evaluation (WCE)

Appropriate• FCE vs. WCE differences• Work Hardening program• Case Studies

• WCE uses advanced work simulation testing equipment for measuring body movement.

• Evaluation helps determine pathology, pain response, and emotional reactions to injuries that are affecting patients recovery.

WHAT IS A WCE?

WHAT IS A WCE (cont.)?

Comprehensive examination using multiple scientific standards to objectively and accurately separate:

• Muscle strength & endurance from pain reactions.

• Motivational Interferences


Only physical performance test that is able to do this type of detailed separation Work is backed by the complete evidence- based scientific and outcome studies. Our program holds the highest published

return to work and restoration outcomes in the industry that leads to significant cost savings for employers/carriers.


Physical performance testing measured using either :

muscle force contraction graphs for static strength work motions . or time motion studies for dynamic strength work motions

Both systems record an examinees performance at a minimum rate of 16 measurements per second.


Examinee is instructed to perform each test using maximum voluntary effort

Examinee is tested twice for same biomechanics: One time when they know what the activity target is Second time when they don’t know they are being

retested for the same motion, also known as blind testing


If examinee uses submaximal effort, graphs and report will flag under performance

Data is analyzed and will provide information that the employee was trying to avoid disclosing true work capability


Patient behaviors fall into 3 broad categories:

1)Physiological – behavioral pain responses – “a body mind tug-of-war”

2)Work-related psychosocial suffering reactions or failure to cope with pain & motion due to other factors.

3)Motivational interferences “nonorganic attempts to obstruct testing efforts.”

THREE RESULTS OF WCE

1) True work effort that is compared to their job standards to determine their safe & sustainable work tolerances.

2) Self-limited effort sorted out to determine the cause of limitation. Cross validation allows us to recapture their true work tolerances and sort out behaviors for remediation if needed.

3) Test will objectively reveal examinee’s performance as malingering

HOW LONG DOES IT TAKE?

Work Capacity evaluation - 5-6 hours (entire body, checks all functions)

Work tolerance testing - two hours ( specific activity or motion related to injury)

Work hardening - 2 to 4 hour sessions 2x per week

WHEN TO ORDER A WCE

Lost time from work exceeds 30 days & no surgeries planned

Modified duty longer than 90 days Full duty not reached in six months from date

of injury/surgery Permanent impairment expected Subjective reports not supported by objective

findings

WHEN TO ORDER A WCE

Patient not progressing as expected Patient has emotional reactions to pain that

interfere with recovery Poor patient compliance/attitude with

treatment

FCE vs. WCE

3 Components to tests

1) Data Collection2) Analysis Methods3) Scientific Content

FCE DATA COLLECTIONWHAT CAN THE EMPLOYEE DO?

• Test length: 1-3 hours• Deliberately simplified evaluations based on

multiple assumptions and subjective factors• Manual observation test• Inconsistent controlled test administration• No cross validation• Little or no occupational/job standard

correlation

DATA COLLECTIONWHAT CAN THE EMPLOYEE DO? - WCE

• Test length: 5 hours• 350-450 activity test trials• Criterion-based work simulation test• Standardized computer-based protocols• Digitally measures all performance activities

at a rate of 16 measurements per second• Cross validation• Occupation/job standard specific

FCE ANALYSIS METHODSHOW CAN YOU KNOW IF ITS EMPLOYEE’S BEST EFFORTS?

• Normative performance comparisons (age, gender, disability biased)

• Functional results based on discomfort and behavioral interferences

• Doesn’t separate “what they actually can do” from “what they want or feel they can do”

• Relies on evaluator “guesstimate” of performance results

WCE ANALYSIS METHODSIS IT THE EMPLOYEE’S BEST EFFORTS? -

• Cross-validation • Uses ONLY objective performance metrics• Consistent• Court tested using international standards of

work, speed & efficiency• Muscle contraction graphs validate

maximum voluntary effort levels• Separates physical work capabilities from

employee’s perception of pain

FCE SCIENTIFIC CONTENTCAN YOU DEFEND IT IN COURT?

• Vulnerable to criticisms of poor validity and reliability• Not compliant with ADA standards for disability• Almost universally “understates” worker capabilities• Tests for “maximum” momentary lift capabilities; not

“safe & sustainable work levels• Can’t determine 8-hr workday capacity or effects of

fatigue• Easily defeated in court• Opens liability for claims discrimination

SCIENTIFIC CONTENTCAN YOU DEFEND IT IN COURT?

WCE

• Complies with ACOEM, CA MTUS & ODG recommendations for proper physical performance testing and addresses deficiencies & limitations of FCEs

• Concurrent validity study (mitigates single day & good-day/bad-day maneuverings)

• Reliability & reproducibility studies (eliminates evaluator bias)

• Clinic studies completed (multi-use tested)• 600 cases/7 year longitudinal study underway

WCE SCIENTIFIC CONTENT

• Most robust type of physical performance testing available including 8-hr workday capabilities

• Provides physicians with accurate defensible scientific-based medical conclusions.

• Subjective manual testing that estimates work performance based on evaluator and discriminatory biases

FCE vs. WCE CONCLUSION

• Objective comprehensive testing with exclusive use of evidence-based scientific performance metrics

WORK HARDENING (WH)

• WH is a severity-based rehabilitative exercise program that uses rigorous muscle strength and endurance mobilization exercises to advance a worker’s deficient biomechanical capabilities to their full duty work levels or to maximum medical improvement, in the shortest amount of time possible.

• Motion is Lotion principle.

WCE STATISTICS

• 52% of WCE patients return to work full duty with no additional treatment

• 31% are found to be in need of work hardening after WCE eval

• 17% of them are not remediable – meaning that 1) their pain is too high or 2) just trying to get something “else” out of system

WORK HARDENING STATISTICSSample Size of 103 Patients

• 10% failed the trial WH program• 14% did not actively participate, so

stopped the WH program and the PTP made patient P&S

• 79 cases did complete the full program

WORK HARDENING STATISTICS Cont.Of 79 Patients Who Completed WH

• 100% of patients that did participate in full program showed increased improvement when finished. Showed measurable strength greater than when started

• 71% of patients went back to full duty• 29% had lower permanent disability ratings and

lower impairment ratings which means lower settlement costs

WORK HARDENING STATISTICS (Cont.)

• Out of the 31% are found to be in need of work hardening after WCE eval , only 58% are getting authorized

• 42% of patients that could benefit from WH are being lost in system

STATISTICS

• By adding the full duty WCE and WH patients that fully participated together = total of 63% of cases went back to full duty as a combined percentage

CASE STUDY #1

• Pt. works for moving company. Had rotator cuff surgery 6 months postsurgical PT. Then had WCE & entered WH program

• • Pt. is a 52-year-old male who injured his right shoulder in work

related injury. While lifting he sustained a massive rotator cuff tendon tear. He states he is now able to lift up to 40 pounds

• • Based on WCE eval: Pt. is qualified injured worker. He cannot lift

over 40 pounds above his shoulder, which prevents him from doing his work and he has permanent work restrictions. Based on the work capacity evaluation, he will require future medical treatment which include follow-up visits, inflammatory medications, and cortisone injections and allotment should be made for future right shoulder surgery.

CASE STUDY #1 (cont.)

• Lifting Bench Height 40 Lbs Up to 20 Min (Occasional)

• Lifting Shelf Height 40 Lbs Up to 20 Min (Occasional)

Before Work Hardening


• Re-testing was completed; patient achieved full duty work levels; Reached 100 lbs bench height and 50 lbs shelf height, however, these do not interfere with his ability to safely perform his usual and customary work duties as per the job description provided by the employer.

After Work Hardening 2X per wk 4 hour sessions for 5 weeks

CASE STUDY #2

• Pt. is an LVN who works in the Mother/Baby Unit who injured her upper back, mid back and neck areas. It is progressively worse with tingling of her left arm.


• Pt. is a 41-year-old female with compensable neck and upper back discomfort arising out of employment on 09/07/2012. The patient is permanent and stationary with respect to cervicothoracic pain syndrome, with access to future medical. Her PTP then ordered a WCE.


Before WH limits:Biomechanic LbsFrequency •Lifting Bench Height 40 Lbs Up to 20 Min

Occasional•Lifting Shelf Height 20 Lbs Up to 20 Min

Occasional


After 2x per wk for 5 wks of WH:

•50 lb bench constant•30 lb shelf constant

•This pt has successfully completed her authorized WH sessions and is full duty capable with excellent biomechanical strength reserves. The pt reports she is ready to resume her full duty work.

CASE STUDY #3

Sample report:

MUSCLE STRENGTH & ENDURANCE

This examinee presents with TRACE overall biomechanical (STRENGTH, BODY DEXTERITY) deficiencies in comparison to the full duty physical demand requirements of his usual and customary job assignment, as defined by the EMPLOYER job description.

– This examinee did demonstrate a MILD (16.7%) biomechanical deficiency for CROUCHING, however, there was no organic basis to explain this deficiency other than the examinee not wanting to complete the test protocol properly.

– Even so, the examinee is able to use alternate biomechanical postures (stooping and kneeling) so as to render this biomechanical physical demand non-contributory to his usual and customary job standard.

– Correspondingly, while this deficiency may be considered with regards to impairment (MMI) it DOES NOT affect work disability (RTW) at this time.

It should be noted this examinee SEVERELY catastrophizes the physical demands of his usual and customary job.


• Sample report cont.

– There is also some evidence of maneuvering as it is noted he reported to another clinic that the need to lift to 100 lbs; to his neurosurgeon the need to lift to 200 lbs, and to the Work Capacity Evaluation evaluator the need to lift to 160 lbs.

• – Upon contacting the employer to discuss this job demand it was

learned that the examinee is required to lift only to a maximum of 40 lbs and that it is company policy that employees are to obtain assistance in lifting animals greater than this weight.

• – The employer reports that of the 4,000+ dogs that they have taken care

of over the years that very few are above the 40 lb weight mark, with the majority weighing less than 20 lbs.

• Work Hardening restoration IS NOT NEEDED.


TREATMENT RECOMMENDATIONS

• WORK: RETURN TO FULL DUTY WORK TRIAL

• TREATMENT: NO WORK RESTORATION REQUIRED

• TREATMENT: PERMANENT & STATIONARY STATUS MAY BE CONSIDERED

Questions?

Thank youRichard Chau D.C. QME

Alliance Occupational Medicine1901 Monterey Rd. Ste 10 San Jose, CA. 95112

2737 Walsh Ave. Santa Clara, CA. 95051315 S. Abbott Ave. Milpitas, CA. 95035

Documents

How Work Capacity Evaluations and Work Hardening Can Expedite Case Closure PRESENTED BY RICHARD CHAU, D.C. QME