Product lines of Industrial rehabilitation by Hemant Nandgaonkar

iNdUsTrIaL rEhAbIlItAtIoN sErViCeS Product lines 1. Functional Capacity Evaluation

12. Hand therapy

2. Work hardening therapy

13. Post offer job evaluation

3. Work conditioning

14. Prevocational Evaluation

4. Ergonomic consultation

15. Physical Injury Prevention Programme

5. Work site health promotion

16. Expert Witness Testimony

6. Wellness program

17. Impairment Rating

7. Job analysis

18. Vocational Rehabilitation &

8. Job simulation

19. Vocational Evaluation

9. Job modification

20. Vocational Training

10. Occupational therapy

21. SyMpToM mAgNiFiCaTiOn

11. Physical therapy FUNCTIONAL CAPACITY EVALUATION -

FCE = is the broad umbrella term applied to work assessment & can be delineated into physical capacity evaluation and work capacity evaluation

One- time evaluation

Measures a patient’s performance against criteria to predict potential to engage in work

Criterion =

May be job specific → injured worker who may return to job OR

General classification of work levels → general work level in which patient may successfully function is identified

Reasons for referral

Physician → disability rating,

Objective performance data → for prescribing appropriate treatment

Insurance carrier → for settlement of worker’s compensation claim

Attorney in personal injury litigation → may seek a clear definition of patient’s ability to function normally

Rehabilitation counselor → physical performance parameters →to develop an individualized employment plan

To make a decision that requires clear delineation of the worker’s abilities & limitations Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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iNdUsTrIaL rEhAbIlItAtIoN sErViCeS Preparing for evaluation -

Begins several days in advance of the actual evaluation

Review of medical records

Records of the therapy received relative to the reason for evaluation

Therapist should be acquainted with three factors from patient’s perspective

What the patient perceives has happened

What the patient recognizes has been done about it

What the patient expects will happen in the future with regard to recovery & return to work

Telephone contact

Mailed questionnaire → thoughtful response, permits the patient to consider the questions carefully, to refer to the records

Educational & work history

The evaluation process -

Interview

15 to 30 minutes

Subjective information from the patient

Objective evaluation = sitting tolerance for the duration of the interview

Direct measures

MMT, ROM, sensibility, coordination, balance, functional mobility & endurance

Computerized equipment for use in measuring lifting, pushing, & pulling strengths

Contributes to the overall objectivity

Standardized tests

Grip strength, MRMT, the Jebson-Taylor Test of Hand coordination, or any combination

Normative data for comparison

Add strength to overall test findings → If patient is member of the reference group on which the norms were based

Job simulation

FCE has work sample or simulated job task components= job simulation

Individualized for each patient

When patient’s job is specified

Select factors essential for the job Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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iNdUsTrIaL rEhAbIlItAtIoN sErViCeS -

Same motion, pace, resistance required on the job

Challenge patient’s performance ability based on the information concerning nature & extent of injury

Test that give a good idea of the cognitive & physical function are included

When no specific job targeted

General FCE

Subjective, direct & standardized measurements

For the job simulation component -

Evaluation designates several tasks as at the Sedentary work level ↓

After completion of sedentary level → advanced through tasks at successive work levels ↓ -

Until patient’s performance reaches plateau ↓

The level at which the patient can safely & comfortably perform both the frequent lifting & the maximal lifting requirements specified ↓ -

At that work level the patient reasonably may seek gainful employment

Evaluation findings -

FCE → data regarding limits of the patient’s functional performance for the day of testing

Review → identify strengths & weaknesses for job performance

Identify Primary limiting factors = factors that impede the patient’s return to work at the time of testing

Determine extent to which these prevent form performing the job

Judge which limiting factors may be responsive to remediation, adaptive devices & adaptive environments

Identify skills which patient can offer labor market

Identify skills on which alternative work may be based

Discussion with the patient

Written report to referral source

Recommendations

Course of action to enter or reenter the work force Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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Course of acute PT or hand therapy, WC, WH

Estimated length of time WORK CONDITIONING

Natural extension of a physical or occupational therapy program

Forms a natural bridge b/w acute OT/PT and WH

Typically provided as a unidisciplinary or bidisciplianry,

Half-day program that Exercise, aerobic conditioning, education & limited work tasks ↓ Restore an individual’s systemic & musculoskeletal function ↓ Client can return to work or become physically reconditioned ↓ So vocational services can commence

When a client has an uncomplicated injury but physical limitations preclude return to work

Concentrates on physical components of flexibility, strength, coordination, motor control & endurance for return to work

Behavioral & vocational components of return to work process are NOT integrated

Circuit training & aerobic conditioning activities

Program of choice

More rigorous exercise than typical therapy set up

Preceded by a brief course of therapy (OT.PT)

Prescribed within first few weeks of injury

If client does not require job simulation activities before returning to work

WC integrated into WH program if the patient has been off work for an extended period

Transfer or reassign worker to different jobs

Result of downsizing, retooling, automating a job

Employees work in several different jobs during the course of a day or week

To provide work conditioning to help employees prepare for the physical demands of the new job

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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iNdUsTrIaL rEhAbIlItAtIoN sErViCeS WORK HARDENING PROGRAM -

Definition

WH = A multidisciplinary, comprehensive program combining work simulation with strengthening & behavioral components.

WH programs, which are interdisciplinary in nature, use conditioning tasks that are graded to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic & psychosocial functions of the person in conjunction with real or simulated work activities

WH provides transition b/w acute care & return to work while addressing the issues of productivity, safety, physical tolerances, and worker behavior

WH is highly structured, goal oriented, individualized treatment program designed to maximize the person’s ability to return to work

WH is a work-oriented treatment program, the outcome of which is measured in terms of improvement in the client’s productivity

Ultimate goal→ to help the person achieve a level of productivity that is acceptable in the competitive labor market

Uses grade work simulation

Who benefits?

Who are seriously deconditioned after an impairment caused by an injury or disease

Those who have major discrepancies b/w their symptoms & objective findings

Improvement in productivity is achieved through graded activity

To ↑ work tolerances, improve work rate, master pain, improve work habits, ↑ confidence & proficiency with work adaptations or Assistive devices

Worker behaviors = timeliness, attendance & dress →workplace standards

Duration varies from 2 to 12 weeks with daily participation ranging from 2 to 8 hr

Use a variety of tools, equipment, work samples &

Work capacity evaluation devices → allow presentation of tasks that simulate job tasks & that can be graded in difficulty or length of time involved

Homemade devices, commercially available

Traditional craft activities

WH program for Chronic back pain (example) Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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Favorable environment → practice & improve the execution of work related activities needed to perform their jobs → while learning to live with, or control, symptoms

Monitors & workstations → to evaluate & develop work tolerances

Treatment → education through discussion, demonstration, active participation & visual aids

Topics → anatomy of spine, body mechanics, ECT, weight reduction &

Relaxation techniques → progressive relaxation techniques, meditation, increased body awareness, control of breathing & muscle tension

Begin with activity that simulate the work

Treatment time gradually ↑ed to equal person’s premorbid work schedule

Modalities = balance monitor → provide feedback on weight bearing & symmetry of posture

Multi work station → simulate construction jobs

Truck simulator → uses truck cab along with a computerized video screen → to simulate & measure driving process

Computerized pneumatic lift → to simulate lifting process

UE work simulator → to simulate various UE work tasks

Maintain an activity log to develop a sense of responsibility for their own rehabilitation & pain control

Effectiveness of WH program

Program accreditation

Hospital based, medically affiliated or independent free standing facilities, within industry organizations

Commission of Accreditation for rehabilitation facilities (CARF) → Quality of program structure & content

Program entry

Immediately after an injury

Some time after the injury

Preferable to follow closely the completion of acute phase of rehabilitation

So becomes progressive step in total rehabilitation

If little time is allowed to elapse b/w →changes in life roles for the patient & family members are likely to occur Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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Evaluation

Baseline evaluations→ functional ability to perform work activities, physical demand factors

Job capacity evolutions→match b/w patient’s abilities & critical demands of specific job

Occupational capacity evaluation→match b/w patient’s capabilities & critical demands of an occupational group

Work capacity evolution→match b/w patient’s capabilities & demands of competitive employment

Evaluation time = half day to week

Depends on question concerning rehabilitation

Preparation for treatment

Formulate measurable, work related rehabilitation goals

Long & short term goals

Goal = realistic, attainable & focused on patient’s reentry into work force

WH → to challenge the patient to higher level of physical or cognitive demand than demonstrated in the evaluation,

Appropriate for patient’s who have not yet selected or targeted a specific vocational or job goal

WH → job specific

In c/o work injury = patient usually attempts to return to the former job

Patient knows requirements of that job well

Employer → provide the information about the job, therapist visit the workplace, see worker actually performing the job

Treatment process

Graded activity → to ↑ strength, aerobic capacity, tolerance for tasks & postures required on the job

Exercise, activity & simulated work tasks

Designed to require the patient to move in the same planes across the same distances &use the same muscle groups at the same pace & frequency required at the job

Simulated work tasks → lift & carry materials of the same size & weight for the same distances as the job demands

Lend significant items at the daily work from the employer → job tasks closely simulated & practiced for WH

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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When it is safe to do → Guide the patient to progress to the next higher level of physical performance

Guiding Principle of rehabilitation → returning injured worker to work as quickly & safely as possible

Psychosocial considerations

May become a significant block

Fear of reinjury or returning to the same job

Concerns about supervisory response

Concerns from peers regarding patient’s competence to perform job duties adequately, to carry a fair share of the work load

Diminished financial settlement if the patient returns to work

Concerns regarding the performance of the job if patient returns to work

Concern regarding change in the role assignments within family structure if the patient returns to a worker role

WH therapist should provide with sensitive assistance in working through these concerns

Referral to psychotherapist or more specialized source

Discharge

When the patient has demonstrated proficiency in accomplishing the job requirements over a 3to 5-day period → released to return to the physician for final disposition

Therapist’s Recommendations →

Return to full duty without restrictions = if ability to do so

Return to restricted work =

If not successful in meeting return to work requirements

Specify = demonstrated limitations or restrictions that will enable the patient to perform at maximal job capacity

Visit the job site → meet the supervisor → together design equipment or work station or task modifications → enable the worker to do the job

Possibilities of work modifications

Instituting rest pauses

Job rotation

Relieve the worker of a task that the worker cannot yet perform,

Reassign it to another employee on a temporary basis Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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If Return to former or modified work is deemed impractical

Referral to vocational rehabilitation counselor

Aim → assist in retaining gainful employment at maximal functional level ERGONOMICS CONSULTATION

Rapidly becoming a popular specialty

Ergonomics = “the study of the interaction or fit between workers & their total work place environment” with the overall goal of improving worker safety & performance by maximizing this fit

Role at the work site → to provide guidance in the physical arrangements of the various job components so that workers can perform all parts of their jobs with minimal physical stress

Advice for appropriate height of work surface → task is done without workers having to bend too far or reach too high

Suggest ways of adjusting the height of the work surface so that both short & tall people can perform the job without undue physical stress

Work in good visual alignment

Altering the positioning of the job task

Changing the handle of a tool so that the UE may be well aligned while performing a task

Recommend chairs or stools that provide the worker with optimal back support

May work with industrial engineer, industrial hygienist &

Management & labor in designing equipment lay out, work flow, or work stations

Work station = physical space & equipment required by a worker to perform the duties of the job

OTst follow an injured or disabled worker into the workplace to recommend ways that the individual job, tools, or work station may be modified to enable the worker to attain or retain competitive employment

Ergonomist makes recommendations to companies on behalf of apparently healthy workers in the plant

Suggestions are focused on preventing injury & minimizing physical discomfort for all employees

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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iNdUsTrIaL rEhAbIlItAtIoN sErViCeS PHYSICAL THERAPY -

Injuries to lower back, neck, shoulders, elbow, hand, hips, knees & ankles

Sprains, strains & fractures most frequently diagnosed problems

Early referral is important for rapid return to work

Musculoskeletal injury – start first week after injury →faster recovery at low cost

If patient has not recovered sufficiently within few weeks to return to work ↓ Reevaluate medically ↓ Transfer the patient to more aggressive rehabilitation ↓ Work conditioning or work hardening

Close communication with the physician → helps the therapist know how hard to push the patient toward recovery HAND THERAPY

Hand injuries constitute a large percentage of worker’s compensation claims

Hand rehabilitation can effect an optimal return to work

If management is started in early stage of injury

Type of injuries vary from region to region depending on the risks of industries located in the geographic area POST OFFER JOB EVALUATION

New employee, transfer to another job within the organization

Evaluation for matching the worker’s capabilities & specific requirements of the new job

To reduce risk of injury by ensuring that the worker is physically able to perform the most strenuous parts of the job PREVOCATIONAL EVALUATION

Helps patients achieve a level of mastery of self-care or general work skills before determining the job placement

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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School based OT programs, head trauma centers, pain management units, rehabilitation centers provide a first step toward the long term goal of entry or reentry into the work force JOB MODIFICATION

Importance of safe, efficient placement or location of job components in the design of a job to prevent occupational injuries

Recommend job or equipment modification to reduce physical or psychological stress imposed on the worker

Adjustment of height of the work surface, distance or angle of reach, seating arrangement PHYSICAL INJURY PREVENTION PROGRAMME

Back schools =

Safe lifting techniques & methods of handling materials associated with specific job,

Emphasize biomechanically & physiologically safest movement,

Lifts for the employee to use in a particular job

Cumulative trauma prevention program=

Are the diseases that result from physical stress to the Musculoskeletal or PNS over a period of time

Repetition, force, vibrations & cold temperatures are recognized as primary factors

Fine hand & finger movements in electronic industry

Carpal tunnel syndrome

Extensive use of computers & video display terminals

Educational programs

Encourage the worker to identify & avoid positions & movements that are likely to result in physical injury

Emphasize the importance of seeking medical treatment at the earliest sign of discomfort

Enables to manage problem before it develops into an injury of major proportions EXPERT WITNESS TESTIMONY

In a court of law

Therapist may be hired by either plaintiffâ&#x20AC;&#x2122;s or defendantâ&#x20AC;&#x2122;s attorney to assess functional limitations & capabilities

Based on functional capacity evaluation, documented Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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Objective & unbiased WORK SITE HEALTH PROMOTION & WELLNESS PROGRAMS

Wellness = is perceived as a dynamic way of life in which good health habits are incorporated into one’s lifestyle to improve both health & QOL

Short training programs for employees → to assist in taking responsibility for their own health behavior

Objective = to provide information & assistance in developing healthy lifestyles that minimize time lost from work due to physical or emotional stress

Stress management,

Development of leisure skills,

Relaxation, smoking cessation,

Energy saving techniques for home or work management,

Personalized exercise program with emphasize on flexibility, muscle balance & cardiovascular fitness

Assessment of daily living skills for maintenance of productivity, leisure, home & family management

Assessment of & recommendations for adapting work & home environments to improve health & well-being

Task analysis & instruction in work simplification to ↓ stress & strain on body parts

Conservation of energy & time to improve job performance

Identification of architectural barriers

Instruction in the use of adaptive devices

Promotion of a milieu supportive of occupational role performance through interpersonal skill development

Development of support groups & activities for health & fitness promotion

Stress reduction

Retirement & leisure planning

SyMpToM mAgNiFiCaTiOn -

Is usually misrepresentation of the patient’s symptoms, feigned for secondary gain

Very difficult assessment Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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iNdUsTrIaL rEhAbIlItAtIoN sErViCeS -

Most common in setting of workers compensation & personal injury cases

Secondary gain may not be financial alone

Effort to impress staff with greater than actual impairment, intensity of the injury

If individual desire a less strenuous job at work

Prolong the time away from the job or

To increase the worker’s compensation case settlement

May gain control over fellow workers or family members

The injured party may allow others to do work that the patient would normally do

Examples=

Patient clings to the banister during direct testing of stair climbing but walks down stairs without holding hand rails at the end of the evaluation or the simulated work

Who can not bend forward on direct testing but does so to obtain a soft drink from the soda machine

Symptom magnification assessment

Possibility =

When major discrepancies or inconsistencies appear in patient’s condition

May be noted in history & physical examination

Examples=

Dramatized complaints → vague & global

Overemphasized gait or postural abnormalities

Resistance to evaluation / rehabilitation

Lack of motivation to develop new skills or

Lack of treatment compliance

Few cases →totally without pain or fear of being placed in a job perceived as potentially harmful

Second opinion are quite useful

Concurrence by more that one is prudent in these cases

Clinical signs & symptoms

Discrepancy b/w patient’s presentation & degree of reported pain

Negative work up for organic problems by multiple physicians Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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Dramatized complaints that are vague & global

Overemphasized gait or posture

Resistance to evaluation

Resistance to rehabilitation

Hoover’s Sign

With patient supine, instruct ti lift the affected leg while you place one hand ↓ the heel on the unaffected side

Will not raise the affected leg

No posterior pressure will be put on the unaffected heel

Burns’s bench test

Kneel on the examination table, bend at the waist to touch the floor while examiner stabilize the legs

Patient with LBP will be able to perform → no strenuous activity of the back

Stress is on the posterior leg muscles

Magnuson’s test

Instruct the patient to point at the site of the pain → distract by performing irrelevant test →point the site again

With real pain, point to the specific site both times

Otherwise does not indicate exact same site

Mannkopf’s Maneuver

Seated patient → resting radial pulse rate → irritate the patient’s complaint bt poking with finger → take the pulse rate

Sympathetic system controls vasoconstriction & HR

When area of pain provoked → true pain → undergo flight & fight phenomenon → ↓ HR & BP

Pulse rate = ↓ by 10% or >

Reaction carried out below the conscious level

Not under patient’s control

Behavior should be documented for referral & payment sources

Must not make assumptions about motivations for the patient’s behavior

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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iNdUsTrIaL rEhAbIlItAtIoN sErViCeS IMPAIRMENT RATING -

After injury, rehabilitation, & recovery & stabilization

Assignment of percentage rating of residual functional limitation sustained by the worker

Monetary statements made on this basis

Physicians rely on data obtained from an FCE or from a course of WH

This allows to consider the patent’s strengths & assets for job performance as well as limitations or disabilities when assigning an impairment rating

VOCATIONAL REHABILITATION & VOCATIONAL EVALUATION -

Sometimes patient’s job performance ability is permanently affected by accident or disease to the extent that patient is unable to return to the previous work or modified work

E.g. the construction worker whose back is broken in fall resulting in partial paralysis of both LE.

May be Immediately obvious or

Sometimes limiting factors that prevent return to previous work may not show up until FCE or

Until WH has been accomplished → functional limitation is consistently shown to interfere with the performance of simulated tasks ↓

Refer to vocational rehabilitation counselor or vocational evaluation ↓

Identify & match the patient’s transferable skills with opportunities for employment in the local community VOCATIONAL TRAINING -

Refers to the actual training program that the worker will undergo to learn the trade or profession that he has decided on

Prepares the person for competitive job seeking

Done by the persons expert in the trade or profession

Vocational specialist finds the training program, to suit the client’s need & may help place the client in a job, once trained

OTst role= Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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To evaluate the client’s need for, or design necessary reasonable accommodation that the person will need to have to do, the job for which he is training JOB ANALYSIS

A job analysis is a systematic evaluation of the job that identifies its physical, cognitive, social, and psychological requirements. Conducting a job analysis entails going to the job site, observing workers performing their tasks, measuring equipment and equipment placement, and interviewing those who perform the job and their supervisors. Some of the tools employed in the job analysis are video cameras, tape measures, scales, goniometry, stopwatches, dynamometers, still cameras, and strain gauges. The results of a job analysis can be used in several ways. Basic Components of Job Analysis Components of any job analysis include the job title, basic description or objectives of the job, number of employees performing the job, the work and break schedule, a description of any rotation or enrichment program, and output requirements for the workers. A description of the environment should include temperature, available space, a list of fixed and movable equipments, personal protective equipments, and a sketch of the area. A sequential description of each task (essential function) and the component steps to complete it is also necessary. This should include measurements such as heights, weights duration, distances and so on.

Rationale for conducting job Analysis The reason for conducting the job analysis dictates its questions and procedures. Purposes of conducting a job analysis include returning a disabled person to work, identifying musculoskeletal risk factors, matching a rehabilitated or new worker with job demands and developing assessments such as Functional Capacity Evaluations and pre placement screening tests. Ways to Use Job Analysis Data •

Develop Functional Capacity Evaluation

•

Match injured workers’ capabilities to job task requirements

•

Place workers on light duty

•

Return previously injured workers to work

•

Identify risk factors associated with work-related musculoskeletal disorders Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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iNdUsTrIaL rEhAbIlItAtIoN sErViCeS •

Develop pre placements, post job offer screenings

•

Write job description

•

Describe and advertise jobs EDUCATION & TRAINING

Job specific rather than generalized

Teaching methods = lecture, use of visual aid (model of back), actual practice of the principle during a lift, a videotape of the lift, group critique of the tape

Ideally Should occur in the actual environments & ↓ actual work conditions in which the worker will be expected to use such learning

Improves knowledge & productivity

↓ The days lost b/o injury

Demonstration & practice of biomechanically correct techniques (lecture & discussion)

Feedback to worker at work site

Positive reinforcement regarding use of body mechanics & safe work postures

Done few weeks after classroom presentations

Give the worker time to practice new methods

Follow up to the on-site coaching

Training sessions to mangers & supervisors

Safe work habits are continually reinforced

Nandgaonkar Hemant (2004, 2005) Do Not Reproduce

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