1. How Work Capacity Evaluations and Work Hardening Can Expedite Case Closure PRESENTED BY RICHARD CHAU, D.C. QME

2. 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

3. 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?

4. WHAT IS A WCE (cont.)? Comprehensive examination using multiple scientific standards to objectively and accurately separate: Muscle strength & endurance from pain reactions. Motivational Interferences

5. 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 evidence- based 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.

6. 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.

7. 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

8. 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

9. 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.”

10. 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

11. 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

12. 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

13. 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

14. FCE vs. WCE 3 Components to tests 1)Data Collection 2)Analysis Methods 3)Scientific Content

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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.

22. Subjective manual testing that estimates work performance based on evaluator and discriminatory biases FCE vs. WCE CONCLUSION Objective comprehensive testing with exclusive use of evidence- based scientific performance metrics

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.

30. CASE STUDY #1 (cont.) Lifting Bench Height40 LbsUp to 20 Min (Occasional) Lifting Shelf Height 40 LbsUp to 20 Min (Occasional) Before Work Hardening

31. CASE STUDY #1 (cont.) 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. After Work Hardening 2X per wk 4 hour sessions for 5 weeks

32. 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.

33. 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.

34. CASE STUDY #2 (cont.) Before WH limits: BiomechanicLbs Frequency Lifting Bench Height40 LbsUp to 20 Min Occasional Lifting Shelf Height20 LbsUp to 20 Min Occasional

35. 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.

36. 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.

37. 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.

38. 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

39. 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