Download Work Capacity Evaluations and Work Hardening

How Work Capacity Evaluations
and Work Hardening Can
Expedite Case Closure
PRESENTED BY
RICHARD 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
WHAT IS A WCE?
• 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 (cont.)?
Comprehensive examination using multiple
scientific standards to objectively and
accurately separate:
• Muscle strength & endurance from pain
reactions.
• Motivational Interferences
WHAT IS A WCE (cont.)?
 Only physical performance test that is able
to do this type of detailed separation
 Work is backed by the complete evidencebased 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.
WHAT IS A WCE (cont.)?
 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.
WHAT IS A WCE (cont.)?
 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
WHAT IS A WCE (cont.)?
 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
WHAT IS A WCE (cont.)?
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 Collection
2) Analysis Methods
3) Scientific Content
FCE DATA COLLECTION
WHAT 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 COLLECTION
WHAT 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 METHODS
HOW 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 METHODS
IS 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 CONTENT
CAN 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 CONTENT
CAN 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.
FCE vs. WCE CONCLUSION
• Subjective manual
• Objective
testing that
comprehensive
estimates work
testing with exclusive
performance based
use of evidenceon evaluator and
based scientific
discriminatory biases
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 STATISTICS
Sample 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.)
Before Work Hardening
• Lifting Bench Height
(Occasional)
• Lifting Shelf Height
(Occasional)
40 Lbs Up to 20 Min
40 Lbs Up to 20 Min
CASE STUDY #1 (cont.)
After Work Hardening 2X per wk
4 hour sessions for 5 weeks
• 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.
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.
CASE STUDY #2 (cont.)
• 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.
CASE STUDY #2 (cont.)
Before WH limits:
Biomechanic
Frequency
Lbs
•Lifting Bench Height
Occasional
•Lifting Shelf Height
Occasional
40 Lbs Up to 20 Min
20 Lbs Up to 20 Min
CASE STUDY #2 (cont.)
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.
CASE STUDY #3 (cont.)
•
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.
CASE STUDY #3 (cont.)
TREATMENT RECOMMENDATIONS
• WORK:
RETURN TO FULL DUTY WORK TRIAL
• TREATMENT:
NO WORK RESTORATION REQUIRED
• TREATMENT:
PERMANENT & STATIONARY STATUS
MAY BE CONSIDERED
Questions?
Thank you
Richard Chau D.C. QME
Alliance Occupational Medicine
1901 Monterey Rd. Ste 10 San Jose, CA. 95112
2737 Walsh Ave. Santa Clara, CA. 95051
315 S. Abbott Ave. Milpitas, CA. 95035