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RETURN OF INJURED WORKER BACK TO WORK Work - includes all forms of productive activity, regardless of whether they are reimbursed. E.g. human occupations – student, homemaker, hobbyist, volunteer - Not limited to adults but is relevant through out the lifespan & can be applied to broad range of people, from school aged children with emotional or physical disabilities, to adults in rehabilitation facilities, to people with industrial injuries in a work capacity evaluation center, to disenfranchised older adults. - work is an occupational performance area that encompasses vocational & educational activities, care for others, & home management - any activity that contributes to the goals & services of a society, whether paid or unpaid, is considered a work activity - Engaging in work is a productive activity and a medium & goal of Occupational Therapy. Work – is often designated as paid employment and non-work time as time spent outside work. Work is usually defined in terms of earning a living, either in paid employment or in productive activities. Work also includes non-salaried activity that contributes to subsistence, such as homemaking, or reproduction, such as childcare. Characteristics that distinguishes work are 1. Extrinsic rewards 2. Formal duties & obligations 3. Performance within specified structure or time constraints 4. Task determined 5. Predictability Non-work includes taking care of physiologic needs, non-work obligations & leisure. Functions of work - Providing livelihood, goal achievement & production.
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RETURN OF INJURED WORKER BACK TO WORK The Meaning of work -
For some persons, work (i.e. employment) is one of the most important social roles a person fulfils in a lifetime
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Provides economic security
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Intellectual or physical challenge, & friendships
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Helps promote life satisfaction
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Helps in self definition &
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Estimating self worth
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As means to earn money to participate in other aspects of life that they find it meaningful
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NO value whatever in work
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An interruption of their true lives these easily accept the limitations of an injury relative to work & prefer to receive compensation from insurance companies
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Those who value work eager to participate in work intervention
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If they are not ready still in a period of mourning for their loss
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For some PWD, work no longer possible, despite its positive value to them
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Those with concurrent illnesses absenteeism not good candidates for work control the illness
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SCI UTI correct before seeking employment
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HI interfere with learning or appropriate social behavior NOT ideal candidates
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If unemployable teach satisfying Avocational pursuits enhance QOL
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Level of motivation = greatest determining factor concerning return to work
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Motivation = person’s determination or persistence in pursuing a goal, earning power, life satisfaction
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If NO motivation exists/can be generated training unsuccessful
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Technological advances significant employment opportunities for PWD, including severely limited physical abilities
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Job should fit a person’s realistic self-image & values regarding work
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RETURN OF INJURED WORKER BACK TO WORK -
To develop realistic attitudes & self perceptions ď‚Ž discussions during early phase of work rehabilitation concerning
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Work related issues = job versus career, pay versus personal satisfaction, office work versus physical work, small or large company
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RETURN OF INJURED WORKER BACK TO WORK Elements of work Work behavior / pre vocational readiness – are those behavior that are necessary for successful participation in a job or independent living. E.g. cooperative behavior, attention span, decision making, motivation, attendance, acceptance of supervision, appropriate appearance, punctuality, responsibility, organization & productivity. -Work behaviors are antecedents to specific skill development. Work skills, aptitudes & physical demands (vocational skills) -Required to perform the tasks of an actual job Work skills = capabilities that worker learn or has the potential to learn such as typing, welding, drafting, soldering & cooking Work aptitudes = possessed by nearly all workers. E.g. coordination, dexterity & intelligence Seven Physical demands (standing, walking, sitting, lifting, carrying, pushing, and pulling) are expressed in terms of five levels of strengths 1. S – Sedentary work – requires a maximum lift of 10-lb, infrequently and occasional lifting and carrying of papers, small tools or, file folders sedentary work may require occasional walking or standing. 2. L – Light work - requires a maximum lift of 20-1b, with frequent lifting or carrying of up to 10-1b objects. If a great deal of walking, standing or pushing and pulling of arm or leg controls is required by the job, the job is classified at the light level even though the lifting requirements do not exceed 10-1b. 3. M – Medium work - requires a maximum lift up to 50-1b with frequent lifting and carrying of weights up to 25-1b. 4. H – Heavy work - requires a maximum lift of 100-1b with frequent lifting or carrying of objects weighing up to 50-1b. 5. V – Very heavy work - – requires lifting objects greater than 100-1b with frequent lifting or carrying of objects weighing 50-1b or more.
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RETURN OF INJURED WORKER BACK TO WORK Other physical demands – climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, feeling, talking, hearing, acuity (far/ near), depth perception, visual accommodation, color vision, field of vision.
PHYSICAL DEMAND CHARACTERISTICS OF WORK
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RETURN OF INJURED WORKER BACK TO WORK Level
Weight Lifted
Frequency Of Lift
Walking/
Typical Energy
Sedentary Sedentary-Light
10lbs. Or Less 15lbs.
Infrequently Infrequently
Carrying None Intermittent Self-
Required 1.5METS 2.0 METS
Light
10lbs. Or Less 20 Lbs.
Frequently Infrequently
Paced, No Load 2.5 Mph.
2.5METS
No Grade/
Light-Medium
10lbs. Or Less
Frequently
Slower Speed With
35 Lbs
Infrequently
10 Lbs. Or Less 3.0mph, No Grade/
3.0 METS
Slower Speed With Medium
20.Lbs Or Less 50 Lbs.
Frequently Infrequently
20 Lbs. Or Less 3.5 Mph, No Grade/
3.5 METS
Slower Speed With Medium Heavy
25 Lbs. Or Less 75 Lbs
Frequently Infrequently
25 Lbs. Or Less 3.5mph, No Grade
4.5 METS
With 35 Lbs Load/ 115 Lbs. 35 Lbs Or Less
Frequently
Wheelbarrow 2.5
Heavy
100 Lbs
Infrequently
Mph, No Grade 3.5mph With 50
6.0 METS
Very Heavy
50 Lbs Or Less In Excess Of 100
Frequently Infrequently
Lbs./Less Load 3.5 Mph With 50
7.5 – 12.0 METS
Lbs.
Frequently
Lbs./More Load
50 Lbs To 100 Lbs
Work Assessment uses
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RETURN OF INJURED WORKER BACK TO WORK 1. Review of medical, educational & vocational records 2. Interview with the patient, family, employer, teachers & other personal 3. Observation 4. Inventories & checklists 5. Standardized and non standardized evaluations In an attempt “to predict current & future employment potential by evaluating mental, emotional & physical abilities along with limitations & tolerances. It focuses on the identification of a person’s strengths & weaknesses in relation to general employability factors & specific vocational skills.”
Work assessments -
Begins the rehabilitation process for individuals injured on the job
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Provide foundation for the development & provision of comprehensive intervention
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Numerous work assessments available
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Should be reliability, validity, sensitivity, and objectivity in measurement tools
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Timely, clear & logical report formats
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Maki et. al. (1979) described work assessment as a four step process based on system approach
1. Formulation of objective of the assessment= whether client will be able to return to work 2. Definition of content to be addressed = what the client’s existing physical capacities are following injury 3. Selection of appropriate strategies, inventories, checklists, & standardized measurement instruments = WEST 7 – Bus Bench for a client who has LBP 4. Analysis & interpretation of data to formulate recommendations for intervention = WH for client with Carpal Tunnel Syndrome
FUNCTIONAL CAPACITY EVALUATION
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RETURN OF INJURED WORKER BACK TO WORK -
Include tests of manual material handling capabilities, aerobic capacity, posture & mobility tolerance, anthropometric measurements, ADL, ECT, need for adaptive devices & technology
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EPIC FCE system = commercially available
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Provides six modules that evaluate lift capacity, motor coordination, finger & hand dexterity, standing whole body ROM, balance while walking, carrying & climbing, industrial pushing & pulling
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Formalized training & certification required
PHYSICAL CAPACITY EVALUATION -
Typically assess isolated body parts of the body or functional units e.g. lumbar region
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High tech instrumentation = Cybex Sagittal Strength Device
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Smith physical capacity evaluation 154 performance items, 86.5 accurate in predicting reemployment of workers with physical disabilities
WORK CAPACITY EVALUATION -
Residual physical disability requires the person to either change his type of employment or to resume previous employment using adapted tools or methods
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In either case ability work safely & efficiently must be determined
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Definition= comprehensive process that systematically uses work, real or simulated, to assess & measure an individual’s physical abilities to work
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Certifies that person possesses those basic attributes necessary for employment somewhere in the labor market, which can buoy spirits during subsequent repeated unsuccessful attempts to secure employment
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Primary evaluation general work ability employment feasibility & work tolerance
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Feasibility = concerned with those basic factors that affect work acceptability to an employer in the labor market; worker productivity, safety & interpersonal behavior
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Functions as a gatekeeper to triage clients into those who are able to profit after using prevocational services designed to optimize their potential
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Work tolerance evaluation
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After feasibility has been determined
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RETURN OF INJURED WORKER BACK TO WORK -
Include the general factors that affect the worker’s physical competence to perform basic work tasks
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Strength, energy reserve, flexibility, & effect of pain & other limiting factors on task performance
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Considers aptitudes, interests, & vocational skills as secondary factors
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WCE results are compared with demands of the job Action plan WH or WC WORK EVALUATION TOOLS
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Four categories
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Used independently or as a part of work assessment On the job, or work site evaluations
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Done to determine whether a PWD can return to his old job or can apply for a particular new job
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Clinical assessment of the client’s abilities & physical status are compared with the physical demands of the job
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For efficiency’s sake, the analysis should be limited to critical work demands of a particular job as they may be affected by client’s diagnosis & limiting symptoms Situational assessments
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Involves placing an individual into a realistic work situation & systematically altering variables, such as physical demands or stress factors, to ascertain the person’s performance each circumstances
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E.g. how will a client’s performance be affected by ng the distance a box must be transported Psychometric instruments
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Include numerous pencil-and-paper & apparatus instruments used for measuring general intelligence, achievement, abilities, & related characteristics
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Kuder Occupational Interest Survey, the General Aptitude Test Battery
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RETURN OF INJURED WORKER BACK TO WORK Work samples -
Well defined work activity involving tasks, materials & tools which are identical or similar to those in an actual job or cluster of jobs
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Are the primary technique of work evaluation
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Evolved to meet the growing demand for vocational & special services to variety of disability group in traditional rehabilitation settings, clinics & public schools
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Used to access an individual’s vocational aptitude, worker characteristics & vocational interests
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Advantage of resembling actual work & providing an opportunity to observe work behaviors & physical functioning & variety of work areas
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Four types of WS corresponds to actual job
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Actual job samples= they are samples of work that have been taken in their entirety from an employment setting & brought to a testing environment for the purpose of evaluating a patient’s interests & aptitude.
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Pipe fitting, refrigeration, electronic assembly, baking & cooking, cosmetology, TOWER, Valpar Component Work Sample Series
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TOWER = the testing, orientation & work evaluation in rehabilitation
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Oldest complete work evaluation system
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Originally developed for use with people with physical disabilities
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Now for other clients mental illness
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Contains 110 work samples organized into 14 training areas
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Clerical,
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Drafting,
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Drawing,
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Electronics Assembly,
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Jewelry Manufacturing,
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Leather Goods,
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Machine Shop, Lettering,
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RETURN OF INJURED WORKER BACK TO WORK -
Mail Clerk,
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Optical Mechanics,
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Pantograph Engraving,
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Sewing Machine Operating,
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Welding & Workshop Assembly
WORK -
Within each major area WS are graded in complexity
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The recommendations that can be derived from the results are limited to jobs that relate to the WS & DO NOT relate to DOT classifications
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Normed on PWD
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NO industrial norms available
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Useful for thorough evaluation in limited areas
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Each facility must build its own WS, following the instructions in the manual
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Assembly of WS is at the evaluator’s discretion
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NOT all samples are administered to each client because not all are appropriate
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The completion of the entire TOWER system takes 3 weeks
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Simulated job samples= is representation of the common critical factors of a job
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Differs from AJS in that all factors affecting job are not replicated for example, environmental stress
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Baltimore Therapeutic Equipment Work Simulator,
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Computerized measuring device that allows measurement of repetitive upper extremity motions against measurable resistance over a specified amount of time
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Composed of an adjustable shaft that accommodates a variety of tools that simulate jobs (e.g., shoveling) & can be adjusted to different angles & heights with computer console that displays the amount of resistance programmed by the therapist
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Quantitatively documents the work output of the user
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After completion of an activityprintout with data (amount of time spent on the activity, force exerted on the tool
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Used to estimate work tolerance & cardiac & pulmonary stress & for WH with feedback
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The interchangeable handles simulate the physical demands of most jobs such as grip, pinching, lifting, carrying & reaching
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Cluster trait samples= assess a number of traits inherent in a job or various jobs
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Strength, endurance, ROM, speed, dexterity
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Work evaluation system technology (WEST; WEST 7, Bus Bench), VCWS#4, UEROM
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WORK
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Single trait samples= assess a single worker trait
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Psychological tests of vocational aptitudes
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DexterityPurdue Pegboard Test, Minnesota Rate of Manipulation Test, Crawford small part dexterity test, O’Connor Dexterity Tests, Pennsylvania Bimanual Work Sample, Bennett Hand Tool Dexterity Test
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Jacobs Prevocational Skill Assessment (JPSA)
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Therapist designed work sample
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For learning disabled adolescent population
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Low cost
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15 task battery
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Relies heavily on observational skills to provide a profile of patient’s skills & behaviors
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WORK
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WORK CONDITIONING Natural extension of a physical or occupational therapy program
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Forms a natural bridge b/w acute OT/PT and WH
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Typically provided as a unidisciplinary or bidisciplianry,
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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
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When a client has an uncomplicated injury but physical limitations preclude return to work
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Concentrates on physical components of flexibility, strength, coordination, motor control & endurance for return to work
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Behavioral & vocational components of return to work process are NOT integrated
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Circuit training & aerobic conditioning activities
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Program of choice
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More rigorous exercise than typical therapy set up
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Preceded by a brief course of therapy (OT.PT)
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Prescribed within first few weeks of injury
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If client does not require job simulation activities before returning to work
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WC integrated into WH program if the patient has been off work for an extended period
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Transfer or reassign worker to different jobs
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Result of downsizing, retooling, automating a job
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Employees work in several different jobs during the course of a day or week
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To provide work conditioning to help employees prepare for the physical demands of the new job
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WORK
WORK HARDENING PROGRAM -
Definition
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WH = A multidisciplinary, comprehensive program combining work simulation with strengthening & behavioral components.
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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
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WH provides transition b/w acute care & return to work while addressing the issues of productivity, safety, physical tolerances, and worker behavior
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WH is highly structured, goal oriented, individualized treatment program designed to maximize the person’s ability to return to work
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WH is a work-oriented treatment program, the outcome of which is measured in terms of improvement in the client’s productivity
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Ultimate goal to help the person achieve a level of productivity that is acceptable in the competitive labor market
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Uses grade work simulation
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Who benefits?
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Who are seriously deconditioned after an impairment caused by an injury or disease
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Those who have major discrepancies b/w their symptoms & objective findings
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Improvement in productivity is achieved through graded activity
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To work tolerances, improve work rate, master pain, improve work habits, confidence & proficiency with work adaptations or Assistive devices
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Worker behaviors = timeliness, attendance & dress workplace standards
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Duration varies from 2 to 12 weeks with daily participation ranging from 2 to 8 hr
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Use a variety of tools, equipment, work samples &
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Work capacity evaluation devices allow presentation of tasks that simulate job tasks & that can be graded in difficulty or length of time involved
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Homemade devices, commercially available
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WORK
WH program for Chronic back pain (example) -
Favorable environment practice & improve the execution of work related activities needed to perform their jobs while learning to live with, or control, symptoms
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Monitors & workstations to evaluate & develop work tolerances
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Treatment education through discussion, demonstration, active participation & visual aids
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Topics anatomy of spine, body mechanics, ECT, weight reduction &
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Relaxation techniques progressive relaxation techniques, meditation, increased body awareness, control of breathing & muscle tension
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Begin with activity that simulate the work
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Treatment time gradually ed to equal person’s premorbid work schedule
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Modalities = balance monitor provide feedback on weight bearing & symmetry of posture
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Multi work station simulate construction jobs
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Truck simulator uses truck cab along with a computerized video screen to simulate & measure driving process
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Computerized pneumatic lift to simulate lifting process
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UE work simulator to simulate various UE work tasks
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Maintain an activity log to develop a sense of responsibility for their own rehabilitation & pain control
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Effectiveness of WH program
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Program accreditation
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Hospital based, medically affiliated or independent free standing facilities, within industry organizations
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Commission of Accreditation for rehabilitation facilities (CARF) Quality of program structure & content
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Program entry
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Immediately after an injury
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Some time after the injury
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Preferable to follow closely the completion of acute phase of rehabilitation
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If little time is allowed to elapse b/w changes in life roles for the patient & family members are likely to occur
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Evaluation
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Baseline evaluations functional ability to perform work activities, physical demand factors
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Job capacity evolutionsmatch b/w patient’s abilities & critical demands of specific job
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Occupational capacity evaluationmatch b/w patient’s capabilities & critical demands of an occupational group
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Work capacity evolutionmatch b/w patient’s capabilities & demands of competitive employment
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Evaluation time = half day to week
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Depends on question concerning rehabilitation
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Preparation for treatment
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Formulate measurable, work related rehabilitation goals
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Long & short term goals
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Goal = realistic, attainable & focused on patient’s reentry into work force
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WH to challenge the patient to higher level of physical or cognitive demand than demonstrated in the evaluation,
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Appropriate for patient’s who have not yet selected or targeted a specific vocational or job goal
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WH job specific
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In c/o work injury = patient usually attempts to return to the former job
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Patient knows requirements of that job well
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Employer provide the information about the job, therapist visit the workplace, see worker actually performing the job
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Treatment process
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Graded activity to strength, aerobic capacity, tolerance for tasks & postures required on the job
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Exercise, activity & simulated work tasks
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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
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Simulated work tasks lift & carry materials of the same size & weight for the same distances as the job demands
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Lend significant items at the daily work from the employer job tasks closely simulated & practiced for WH
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When it is safe to do Guide the patient to progress to the next higher level of physical performance
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Guiding Principle of rehabilitation returning injured worker to work as quickly & safely as possible
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Psychosocial considerations
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May become a significant block
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Fear of reinjury or returning to the same job
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Concerns about supervisory response
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Concerns from peers regarding patient’s competence to perform job duties adequately, to carry a fair share of the work load
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Diminished financial settlement if the patient returns to work
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Concerns regarding the performance of the job if patient returns to work
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Concern regarding change in the role assignments within family structure if the patient returns to a worker role
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WH therapist should provide with sensitive assistance in working through these concerns
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Referral to psychotherapist or more specialized source
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Discharge
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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
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Therapist’s Recommendations
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Return to full duty without restrictions = if ability to do so
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Return to restricted work =
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If not successful in meeting return to work requirements
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Specify = demonstrated limitations or restrictions that will enable the patient to perform at maximal job capacity
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Visit the job site meet the supervisor together design equipment or work station or task modifications enable the worker to do the job
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Possibilities of work modifications
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Instituting rest pauses
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Relieve the worker of a task that the worker cannot yet perform,
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Reassign it to another employee on a temporary basis If Return to former or modified work is deemed impractical
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Referral to vocational rehabilitation counselor
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Aim assist in retaining gainful employment at maximal functional level
VOCATIONAL TRAINING -
Refers to the actual training program that the worker will undergo to learn the trade or profession that he has decided on
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Prepares the person for competitive job seeking
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Done by the persons expert in the trade or profession
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Vocational specialist finds the training program, to suit the client’s need & may help place the client in a job, once trained
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OTst role=
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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 Nandgaonkar Hemant (2004, 2005, 214) Do Not Reproduce
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WORK 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
•
Develop pre placements, post job offer screenings
•
Write job description
•
Describe and advertise jobs
Essential functions of a job – are job tasks that are fundamental, not marginal, to the job. E.g. a job description for a secretarial pool of 20 workers lists a driver’s license as requirement, but the job entails no driving. A driver’s license would not be an essential function of the job & could no longer be included in the job description. Reasonable Accommodation – is any modification or adjustment to a job or work environment that will enable a qualified applicant or employee with a disability to perform essential job functions. -
E.g. restructuring a job, modifying work schedules, adapting equipment, or providing an interpreter. Nandgaonkar Hemant (2004, 2005, 214) Do Not Reproduce
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A reasonable accommodation could be as simple as allowing an employee to wear sneakers instead of shoes.
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