1. 2/27/2013
Feeling Disabled by Disability?:
How to Better Support Your
Patients’ Return to Work
Disclosure for Dr. Chris Stewart-Patterson:
Nothing to Disclose.
Chris Stewart-Patterson
MD, CCBOM, FACOEM Occupational
Physician
Program Director
Harvard Medical School
“Survey Says”
We asked: When are expectations for Return-to-Work (RTW) discussed?
• 32% of Injured Workers1 versus 64% of Physicians2 surveyed said RTW
was discussed at the 1st visit
What do you hope to learn by attending this webinar? 2
Most common responses to the survey were:
• Improve form completion
• Improve management of patients’ RTW
• How to perform a functional assessment/which assessment tools to use
• How to determine a realistic prognosis/recovery time
What are your challenges in regards to preventing and managing
disability? 2
Most common challenges highlighted in the survey were:
• How to support my patients’ RTW: improve motivation
• No guidelines to follow
• Too many forms!
• Giving a recovery timeframe/prognosis
1IPSIS
Occupational Medicine
REED Survey Dec 2012; 2Pre-Webinar Survey Feb 2013
Photo by: Charles Hercules Ebbets, Sr
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2. 2/27/2013
Original image
URL: http://www.flickr.com/photos/rent-amoose/5510408914/
Title: lavagna_gabri
Photo credit: rent-amoose / Foter.com / CC BYNC-SA
RTW can be Complex
Multiple psychosocial factors beyond MD’s
control
Original image
URL: http://www.flickr.com/photos/diamondmountain/2943172757/
Title: The World Needs Ditch Diggers Too
Photo credit: diamond mountain / Foter.com / CC BY
Ditch Digger to Nuclear
Physicist
Polling Question #1
• workplace relationships
• economic factors like secondary financial
gain
• compensation process
• employer policies
• social policies
Can Fam Physician 2011;57:202-9
Is Timely RTW Important?
Workmen’s Compensation Board: Vancouver, Canada (1986, unpublished data)
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3. 2/27/2013
Waddel & Burton 2006 Report
• “Strong evidence base showing that work is
generally good for physical and mental health and
well-being”
• Worklessness is associated with poorer health
• The proviso is that jobs should be safe and
accommodating
• Overall, the beneficial effects of work outweigh the
risks of work, and are greater than the harmful
effects of long-term unemployment or prolonged
sickness absence
Waddell, G., Burton, A. K., (2006). Is work good for your health
and well being? London, The Stationery Office.
CMA RTW Statement
Prolonged absence from one’s normal roles,
including absence from the workplace, is
detrimental to a person’s wellbeing
The Physician’ Role in Helping Patients Return to Work After an
Illness or Injury (UPDATE 2000): CMA Policy
Similar endorsements by multiple
medical associations internationally
• OEMAC, AMA, ACOEM, American
Psychiatric Association, AAOS
“First, Do No Harm”
RTW too early
• Exacerbate symptoms to point of
further impairment
• Relapse with failed RTW
• Safety sensitive work concerns
But RTW too late…
• Negative health effects of not working
on:
• daily structure & activities
• social contact
• self esteem
• financial stressors
Let’s Get This Dialogue Started!
• The role of MDs is to incorporate a timely
RTW into the care plan for their pts.
• Early in the course of treatment, the MD
should discuss expected recovery times as
well as an early, graduated increase in
activity.
• MDs should encourage a pt’s RTW ASAP
provided that RTW does not endanger the
patient, coworkers or society
The Physician’ Role in Helping Patients Return to Work
After an Illness or Injury (UPDATE 2000): CMA Policy
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4. 2/27/2013
Physician Skills & Tasks
Polling Question #2
Routine physician tasks & skills
• History, examination, investigation
• Diagnosis & treatment
Additional RTW physician tasks
• Early focus on safe RTW expectations
• Focus on function!!!
• Activity prescription
• Set limitations & restrictions
• Review the job demands
Impairment vs. Disability
Current Symptoms
Impairment is about Inability of a function
Disability is about Duty (role or job)
Case: Physician fractures an arm
Impairment: Strength, ROM, pain
Disability: Surgeon
Yes!
Medical lecturer No!
Are the symptoms impairing?
• Severity
• Intensity
• Frequency
• Duration
• Effect on functioning
• Perceived work barriers
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5. 2/27/2013
Focus on Function!
Assessing Function
• Self-reported tolerances
• Current life roles
• Description of a typical day
• Adaptations to impairment
• Observed functioning
• Physical examination
• Imaging and investigations
Original image URL: http://www.flickr.com/photos/tambako/4526323236/
Title: Huskies and sunset
Photo credit: Tambako the Jaguar / Foter.com / CC BY-ND
Physical Examination
Signs related to impairment
• Joint: reduced range of motion
• Skin: swelling & redness
• Neurological: Strength, sensory, reflex
1 Minute RTW questions
“What impact is the problem with
your…going to having your ability to do the
job in a regular way?”
Pain behaviors
“Have you figured out the way to work
around this so you can stay at work while
you recover?”
Observations of function
• Sit, stand, crouch, bend…
“Are you going to have any problems with
your boss or co-worker with that?”
Questions provided by Dr. Jennifer Christian, MD
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6. 2/27/2013
3 MD Forecasts of Function
• Out of commission
• Confined to bed or staying in the house
• OK to resume ADLs
• But with perhaps with some limitations
• Back to normal functioning
• Back to normal does not necessarily mean
all symptoms free may have permanent
loss of function and have a “new normal”
RTW is Tx! Activity Rx
•
What patients should be doing for recovery and
preserve well-being
•
What patients should not do because of medical risk
(harm or a hazard to others)
•
What patients can and cannot do given their
functional ability due to the medical condition
•
Whether or not they are willing to tolerate the activity
• ACOEM position statement The
Personal Physician’s Role in Helping
Patients with Medical Conditions Stay
at Work or Return to Work 2008
Information provided by Dr. Jennifer Christian, MD
S.M.A.R.T. Rehabilitation Goals
• Specific
• Measurable
• Achievable
• Relevant
• Time bound
Clin Rehabil April 2009 vol. 23 no. 4 352-361
Risk factors for delayed RTW
• Maladaptive beliefs around pain
• Reinforcement of pain behaviors by
family members
• Heightened emotional reactivity
• Lack of social support
• Job dissatisfaction
• Compensation issues
• National Advisory Committee Guide to
Assessing Yellow Flags in Acute Low Back
Pain. New Zealand, Ministry of Health, 1997
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7. 2/27/2013
RTW Motivation
No Graduated RTW Available?
The Obstacle Question
• What is specifically the obstacle
preventing you from working today?
Think alternate activities equal to or
close to demands of the GRTW plan:
• Increase lifestyle physical activity
• Specific home rehabilitation exercises
• Daily walks
• Volunteer work
• School & upgrading courses
The Mole Hill Sign
• When an apparently minor health
condition having a major affect on
daily life and function, there maybe a
motivational issue.
Information provided by Dr. Jennifer Christian, MD
Fibromyalgia & Lifestyle
Physical Activity
• Nightly recorded their # of steps and zeroed
their pedometer
• In a diary, categorized the types of LPA’s they
engaged in
• Over 12 weeks, LPA group increased the mean
of daily steps from 3,788 to 5,837 (± 1,770)
• LPA group reported significantly less perceived
functional deficits & pain
Basics: Work Fitness Terms
• Capacity
• Limitations
• Restrictions
• Tolerance
• Accommodation
A Physician’s Guide to Return to Work, 2nd ed. (AMA)
Fontaine et al. Arthritis Research & Therapy 2010, 12:R55
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8. 2/27/2013
Limitations or Restrictions
• Sit, stand & walk
• Lift & carry
• Stoop & crouch
• Heights & ladders
• Overhead or repetitive reach
• Shift work
• Concentration & memory
“Mom & Pop Shop” Question
If he or she
owned his or her
own mom-andpop grocery
store, would they
be able to find a
way to work
safely?
Question provided by Dr. Jennifer Christian, MD
RTW & Safety Sensitive Jobs
• Danger to self
• Danger to work mates
• Danger to general public
• Pre-placement examination
• Periodic examination
• Fitness to return to work
Medical FTW Guidelines
Available online:
• CMA Driver’s Medical Fitness
Guidelines
• Railway Association of Canada
medical guides
Book:
• A Physician’s Guide to Return to
Work 2nd edition (AMA)
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9. 2/27/2013
Temporary or Permanent?
If temporary restrictions or limitations…
• How long?
• Need reassessment?
If permanent…
• Are they at Maximal Medical Improvement?
“The condition has stabilized and is
unlikely to change substantially in the
next year…”
Employer Responsibilities
• To provide a safe workplace
• ‘Duty to Accommodate’
• To make ‘Reasonable
• Accommodation’ up to ‘Undue Hardship’
• Provide Bona Fide Occupational
Requirements (BFOR)
(Rondinelli 2008)
Confidentiality
• “Physicians should ensure that they have
received the employee's consent to provide
information to the employer or its insurer”
• “Physicians should take care not to disclose
more information than is covered by the
employee's consent or is required by the
employer's request”
• “Diagnosis and treatment information is not
normally required”
RTW Tool Kit
• Set the stage for reasonable RTW early on
• 1 minute RTW screening tests
• Activity Rx
• “Mom & Pop Shop Question”
• Mole Hill Sign
CPSBC Guideline “Medical Certificates”
9

10. 2/27/2013
RTW Assessment Review
1.
2.
3.
4.
5.
6.
7.
Diagnosis
Evidence of significant impairment ?
Is work absence medically required?
Describe any limitation
Describe any restrictions
Is there a job demands mismatch?
Are there non medical barriers?
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