Michigan Hand & Sports Rehabilitation Centers Quarterly

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Michigan Hand Sports Rehabilitation Centers
Quarterly Roundtable Review

• Richard M. Singer, MD
• Kimberly M. Pace, OTR
• Lori Sweeney, OTR

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Industrial Rehabilitation Current Issues Trends

• Functional Capacity Evaluation
• Work Conditioning
• Job Analysis
• Pre-Work Screen

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Functional Capacity Evaluation Defined

• Functional Purposeful activity that is an actual
  work movement. Functional implies a definable
  movement and result that can be measured.

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Functional Capacity Evaluation Defined

• Capacity Existing abilities for activities
  including the maximal function able to be used.

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Functional Capacity Evaluation Defined

• Evaluation Observation, reasoning, conclusion.
  Objective measurement of the activity.

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Functional Capacity Evaluation
Isernhagen Work System

• Comprehensive, objective, standardized test
• 2 day testing
• Abilities and physical limitations identified
• Matching the worker to the work

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Functional Capacity Evaluation

• Design of the IWS
• Total body function
• Focus on function, not pain
• Kinesiophysical approach

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Functional Capacity Evaluation

• Kinesiophysical Approach
• Definition The study of physical movement at
  all levels of work SEDENTARY, LIGHT, MEDIUM,
  HEAVY and VERY HEAVY

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Functional Capacity Evaluation

• Attributes of the Kinesiophysical Approach
• Maximum function
• Safety
• Physical musculoskeletal findings correlate with
  the functional findings and observations

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Functional Capacity Evaluation

• Testing Format Day 1
• History
• Musculoskeletal exam
• Lifting (floor to waist, waist to overhead,
  horizontal)
• Static dynamic push/pull
• Unilateral bilateral carry
• Elevated work
• Trunk Flexion (sitting standing)
• Unweighted Trunk Rotation (sitting standing)

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Functional Capacity Evaluation

• Testing Format Day 2
• Lifting repeated
• Low level activities (crawl, kneel, crouch,
  repetitive squat)
• Ambulation activities (walking, stair climbing,
  step ladder climbing and balance)
• Static work (sitting standing)
• Upper extremity activities (grip coordination)
• Job Simulation

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Functional Capacity Evaluation

• Job Description Explored
• Usual customary job demands identified
• Avenue to perform a functional job analysis
• Dictionary of Occupational Titles
• Client/Employer Interview

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Functional Capacity Evaluation

• Results
• To determine an individuals ability to safely
  return to work full-time or on a modified basis
• -Case Closure-

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Functional Capacity Evaluation

• Results cont
• To determine work limitations, job modification
  or reasonable accommodation to prevent injury
• -Case Closure-

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Functional Capacity Evaluation

• Results cont
• To determine the extent to which impairments
  exist or the degree of physical disability for
  compensation purposes
• -Case Closure-

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Functional Capacity Evaluation

• Results cont
• To predict the potential ability to perform work
  following acute rehabilitation or a work
  conditioning program
• -Case Closure-

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Maximum Voluntary Effort

• MVE Tests
• A series of evaluations used to determine if the
  client is exerting full effort or demonstrating
  inconsistencies
• 5 Test Protocols

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Maximum Voluntary Effort

• Test Protocols
• Grip strength
• Jamar Dynamometer
• 5 handle positions (3 trials at ea. level)
• Determine optimal grip level
• Bell-Shaped Curve

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Maximum Voluntary Effort

• Test Protocols cont
• REG (Rapid Exchange Grip)
• Tested at optimal grip level
• Compare to grip strength in initial Dynamometer
  grip test
• REG result should be less than static grip
  strength

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Maximum Voluntary Effort

• Test Protocols cont
• CVs
• Co-efficient of variation (use scientific
  calculator to determine )
• Jamar grip strengths all 5 levels
• Total 10 CVs
• Cut-off 12

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Maximum Voluntary Effort

• Test Protocols cont
• CVs
• Co-efficient of variation
• BTE/Primus with tools 162, 601, 701
• Total 10 CVs
• Cut-off 12

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Maximum Voluntary Effort

• Test Protocols cont
• Cross check of the BTE/Primus static grip
  strength results with the results of the Jamar
  Dynamometer grip strength testing
• 10 Cut-off with R/L L/R comparison

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Maximum Voluntary Effort

• Test Protocols Review
• Review Results Determine
• Acceptable effort
• Less-than-maximal effort
• Questionable effort

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Work Conditioning

• Work Conditioning
• Treatment option as result of FCE to increase
  ability to RTW
• Per doctors order
• Per therapists recommendation
• Referral from case manager
• Client requires advanced therapy (d/c from acute)
• Option if insurance will not pay for FCE
• Client currently unable to RTW perform required
  job demands

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Work Conditioning

• One Day Evaluation (2-3 hours)
• Medical history
• Job history/demands (attain job description)
• Push/pull ability
• Material handling (determine required physical
  demand level)
• Grip/prehensile strength
• Coordination
• Low-level activities crawl
• Sit/stand/walk
• Climb ladder/stairs

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Work Conditioning

• Structured Program
• 3-5 x per week
• 2-4 weeks
• 2-4 hours per session
• Certified Occupational Therapy Assistant (COTA)
• Facilitates daily treatment protocols and
  performs re-eval

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Work Conditioning

• Treatment Program
• Cardiovascular component (bike, treadmill)
• General conditioning exercises
• Flexibility exercises
• Pre-conditioning stretches
• BTE exercises
• Job-specific work simulation
• Patient education (body mechanics, posture,
  pacing, symptom management)

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Work Conditioning

• Treatment Program
• Re-eval every 10 sessions
• Check progress against required physical demand
  level
• Continue tx good progress
• Look ahead alternate career, Voc. Rehab
• Job coach
• Job analysis
• Case closure by D/C

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Functional Job Analysis

• Defined
• An evaluation which identifies physical
  functional aspects of work
• Worker
• Work
• Worksite

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Functional Job Analysis

• Worker
• Gender
• Age
• Anthropometric measure
• Skill level
• General health conditioning
• ROM strength

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Functional Job Analysis

• Work

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Functional Job Analysis

• Worksite
• Work area flooring, dimensions, heights, etc.
• Seating/standing supports
• Space design organization
• Environment lighting, temperature, noise, air
  quality, etc.

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Functional Job Analysis

• Tools Equipment Used
• Video camera
• Tape measure
• Scale
• Dynamometer/pinch meter
• Goniometer
• Stop watch

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Functional Job Analysis

• Videotape Format
• If a picture is worth 1,000 words, a moving
  picture/video must be worth at least 5,000 words.

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Functional Job Analysis

• Critical job demands identified
• Rarely 0-5 (up to ½ hour)
• Occasionally 6-33 (up to 3 hours)
• Frequently 34-66 (up to 5 1/2 hours)
• Constant 67-100 (8 hours)

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Functional Job Analysis

• Job modification
• Worker modification posture, pace, work method
• Worksite modification job rotation, workstation
  adjustability, etc.
• Equipment needs tools, gloves, etc.
• FJA in conjunction with FCE Case Closure

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Job Coach

• Defined
• An on-site visit with the employee at the place
  of employment (approx. 2 hours)
• Physician ordered
• Case manager referral
• Therapists recommendation (often at the end of
  work conditioning and with release to RTW)

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Job Coach

• Purpose
• Gives the therapist ability to view client in
  actual setting performing required job demands
• View interactions with employer (management)
  employees
• Provide support as client RTW (decrease anxiety,
  fear)
• View analyze work setting for
• Physical layout
• Physical demands
• Equipment
• Potential risks
• Client concerns

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Job Coach

• Summary
• Make recommendations
• On-site
• In report
• Recommendations for
• Ergonomic setup
• Ergonomic equipment
• Assistance to perform physical demands
• Body mechanics/ posture
• Safety
• RTW (yes, no, restrictions?)
• Case closure

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Pre-Work Screens

• Overview
• Source of income
• No workers comp involvement
• Post-offer pre-work screen
• Hired under condition of passing physical
  test/screen

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Pre-Work Screens

• Development
• Obtain critical demands from a functional job
  description
• Evaluate critical demands for requirements of
• Lifting carrying
• Push/pull
• Positional tolerance
• Ambulation
• Climbing/balance
• Coordination

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Pre-Work Screens

• Test Protocols
• Develop test protocols to evaluate critical
  demands
• i.e. sandbags lifted from floor and carried 10
  ft. occasionally (8 at a time, 10x per week)
• Use actual sandbags
• Gradual increase in weight pass each level
  before continuing (i.e. 10, 20, 30 lbs.)
• Incorporate heights/distances into test protocol

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Pre-Work Screens

• Test Protocols cont
• i.e. Isernhagen Swift account trucking
  company (2 jobs flat bed/dry van)
• Went out and physically assessed job demands
• Developed test protocols actual reflection of
  job demands (weights, heights, reps, etc.)
• Set up test sights at Swift terminals (30 minute
  test)
• 28, 670 tests
• Fail both, 6
• Fail flat bed, 27
• Pass both, 65
• 54 decrease in new driver reported MSDs
• Swift estimates average WC claim - 32,000

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Home Evaluation

• Traditional scope of Industrial Rehabilitation?
• NOT

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Home Evaluation

• Overview
• 4 cases within the last year
• COPD / emphysema
• Traumatic hand amputation / replant
• Spinal cord injury / MVA
• Fusion lumbar spine

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Home Evaluation

• COPD / Emphysema
• Long-term disability
• Dependent on amigo wheelchair
• Identified accessibility constraints in home with
  amigo wheelchair
• Ramps
• Thresholds
• Doorways

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Home Evaluation

• Traumatic Hand Amputation/Replant
• Dominant Hand
• Current workers compensation claim
• Attending acute O.T. treatments
• Assessed need for adaptive equipment with meal
  preparation, feeding, dressing, bathing,
  grooming, housecleaning, leisure time interests,
  etc.
• Goal increase ease and independence with ADLs
  and reduce the number of home healthcare visits

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Home Evaluation

• Spinal Cord Injury / MVA
• Assessed caretakers need for personal assistance
  in caring for her quadriplegic brother
• Identified equipment needs for caretakers safety
• Identified equipment needs for patients safety

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Home Evaluation

• Fusion Lumbar Spine
• Long-term disability
• Assessed need for in home personal assistant
• Addressed all aspects of ADLs

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Home Evaluation

• Non-traditional view of the injured worker
• Another avenue for case closure

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