The therapist said, “I didn’t know there was so much legal stuff involved with Industrial Rehab.  I don’t think I want to do it….”  This was a statement made by a FCE course attendee in 2011.  While a seasoned Industrial Rehab (IR) OT or PT practitioner may view this position as overcautious, conservative, or naïve, this is an attitude pervasive in the therapy community at large.  No one  entering the helping professions wants or expects to be involved with lawyers and worried about the potential for litigation so the very thought of having to do so just doesn’t seem worth the hassle.  Many therapists working in Industrial Rehab switch specialty areas because of potential legal entanglements.  No one leaving the Industrial Rehab specialty ever considered the possibility of burning out on OT or PT and then having to re-ignite skills long since dormant like in home health or working in a hospital. 

In my 26 years of practice, I have experienced temporary burnout, I have seen other OT’s or PT’s leave the IR specialty area after limited or long-term exposure.  I decided to write an article in an effort to provide some perspective so practitioners could see just how rich a specialty area and how rewarding the field of Industrial Rehabilitation (IR) can be.  To do this, I would outline the many service offerings it includes as well as some factual information about the recipients of the service.

To the experienced IR practitioner hopefully this article will remind them of why they have remained, and to the neophyte why they should consider starting down this road.  To do so we will first outline what Industrial Rehab is and what services the specialty includes.  Then we will explore 4 basic myths that will address the recipients of IR services, validity and reliability of IR services, potential for legal involvement, skill level of IR therapists.

First, what is Industrial Rehab?  No standardized definition exists, but most rehabilitation providers would state that IR is a comprehensive set of services that is designed to study work and also to prevent and/or mitigate the effects of work-related injury.

Industrial Rehab includes the following services:

• Functional Capacity Evaluation
• According to Matheson (2003), the FCE is a systematic method of measuring an individual’s ability to perform meaningful tasks on a safe and dependable basis.
• While no accepted standardized method for performing FCE’s exists or is mandated by the States or the Federal Government, the existing medical research provides guidelines for the practitioner to enable them to provide a reasonably valid and reliable evaluation system.
• Employment Testing
• Employment Tests (ET’s) or Post-Offer (or Pre-Placement) Employment Tests are used to match physical capabilities of prospective new hires with the physical demands of a specific job (Harbin, 2005).
• Reductions in employee turnover, frequency and severity of injury, and lower workers’ compensation costs are just some of the benefits realized by employers after implementing ET programs.
• Ergonomics
• The applied science of equipment design, as for the workplace, intended to maximize productivity by reducing operator fatigue and discomfort (American Heritage Dictionary, 2011).
• Blake McGowan, managing consultant and ergonomics engineer at Humantech concluded, “To reduce or eliminate exposure, effective ergonomic practices need to be addressed. Risk factors need to be quantified and the root causes need to be identified. By using engineering controls, practices and methods it is then possible to reduce or eliminate the exposure.” This method appears to have a greater effectiveness, both from a cost and risk reduction perspective, he says (2011).
• Work Hardening/Work Conditioning
• This is a treatment program that uses graded real or simulated work activity and/or graded conditioning exercise based on an individual’s tolerances to provide a bridge between traditional physical rehabilitation and return to work (WA Dept of Labor and Industries, 2011).  Both the American Occupational and Physical Therapy Associations provide guidelines for both Work Hardening and Work Conditioning Programs.
• These programs have shown favorable sustained return to work statistics in follow-up studies, (Johnson et al, 2001).

Clearly, IR Programs are popular and effective media and provide the OT or PT clinician a richly creative and stimulating outlet in which to practice.  So why are some therapists averse to work in this interesting specialty area?  We will next explore the main objections or myths pervasive in the helping professions.

Myth 1:  “Workers’ comp patients all just want to sue you.”

There are difficult patients seen in industrial rehab clinics.  But they represent a small number.  Only a small percentage of the general medical population are Symptom Magnifiers and only a small percentage of Symptom Magnifiers are true malingerers.  Mittenberg et al (2002) published a study on base rates of malingering and symptom exaggeration in various samples.  Note only 8% of medical cases were in this category.  However, in cases in which there is a higher potential for litigation the percentages are higher such as chronic pain, disability, or personal injury.

While workers’ compensation was founded in part to avoid litigation between employers and employees, litigation is very much part of the system. Moreover, the Equal Employment Opportunity Commission (EEOC) is on pace to set another record in 2010 because of the expansion of the legal environment, including ADA (Americans with Disabilities Act) amendments, and other laws.  The Cambridge, Mass. Workers’ Compensation Research Institute published a valuable study in 2010, Avoiding Litigation: What Can Employers, Insurers, and State Workers’ Compensation Agencies Do? The study found that workers were more likely to seek attorneys when they felt threatened (Diamond, 2011).

The solution for the OT or PT is to minimize the likelihood of litigation by removing the “threat” in your clinic.  Fortunately, these patients feel threatened mostly by their employer and the insurance company.  But the healthcare provider can be lumped into “the conspiracy” many workers’ compensation patients feel exists to rush them back to work and deny them benefits – a perception cultivated by attorney TV commercials (421-HELP).  Stay above the fray.  Explain your role in the process and always consider safety first in patient evaluation and treatment.  Explain forms and procedures thoroughly and elicit patient feedback often to gauge the level at which you challenge a patient to perform in the clinic.  Control the evaluation and treatment process based on external signs of effort.  Provide the patient with an environment that encourages questions.  Finally, debrief the patient fully after an evaluation or treatment session and provide them with a mechanism for contacting you if complications should arise after an encounter.

Myth 2:  “I’ll always be in court.”

There are no easily available data for how often an OT or PT must testify in a deposition or in court.  I can tell you that I testify anywhere from 4-6 times per year mostly in depositions but occasionally in court.  The therapist may be called to testify as a Fact Witness by subpoena or be retained as an Expert.  Attorneys are increasingly looking at PT’s and OT’s as expert witnesses especially given the newly required Doctorate or Masters in the therapy professions (Bucklin, 2011).

As a practical matter, I can tell you that it doesn’t happen that often.  About 80% of the time that I am called, the case settles before the date of the appearance.  The good news is that the clinician can charge for their professional time and mileage, though the amounts differ depending on how they are called and this varies by state.

Myth 3:  “Where’s the research?”

In short, the research is everywhere if you know where to look.  Check the websites for Matheson, Blankenship, Isernhagen, and others.  Entrez PubMed is an excellent source for the latest research on FCE’s, Employment Tests, Ergonomics, and Work Hardening/Work Conditioning from a huge variety of professional journals.  The BIO-ERGONOMICS FCE protocol is supported by over 200 research references alone.  Similar research supports the BIO-ERGONOMICS Employment Testing protocols and the other IR courses available through Back School of Atlanta.  Just remember, the medical professions are as much art as science and there are differing opinions on validity and reliability.

Myth 4:  “IR Therapists are poor clinicians.”

Some of the best clinicians I have met work in Industrial Rehabilitation.  IR is the applied distillation of many of the skills learned in Physical Dysfunction and Behavioral Health.  Also, the supremely satisfying aspect of IR is that the boundaries between the OT and PT professions seem to blur making the clinician more of a hybrid, “Industrial Therapist”.

Therapists will grow outside of their comfort zone as OT’s learn to assess the spine and PT’s learn to incorporate worker behaviors into their assessments.  Both clinicians learn other valuable skills such as job analysis and workstation modification ultimately discovering they can be part of a bigger picture in improving worksite safety and employee retention.

Is there an “ideal” Industrial Rehab clinician?

The specialty area of Industrial Rehab is a rich and fulfilling experience.  It is not for the faint of heart, however.  The decision to spend 5, 10, or 20 years in this field should be made with eyes wide open as there are potential stressors related to the probability of legal involvement.

Character traits I have seen in successful IR therapists are fairly universal:

• A successful IR therapist is an evidence-based clinician.
• A successful IR therapist is a good writer.
• A successful IR therapist is a good speaker.
• A successful IR therapist is assertive but is also a good listener.

If you have any questions regarding Industrial Rehab Services or Courses, please visit our website at www.backschoolofatlanta.com.

References:

Matheson, L. (2003). The functional capacity evaluation.  In G. Andersson & S. Demeter & G. Smith (Eds), Disability Evaluation. 2^nd Edition. Chicago, IL; Mosby Yearbook.

Harbin G, Olson J.(2005). Post-Offer, Pre-Placement Testing in Industry.  Am J Ind Med,   47(4), 296-307.

The American Heritage Dictionary online available at:  http://education.yahoo.com/reference/dictionary/entry/ergonomics.

Is the Million-Dollar Cost of Some Workplace Stretching Programs Worth It? EHS Today, 2011 available at:  http://ehstoday.com/health/ergonomics/stretching_programs_too_costly_0926/

State of Washington Department of Labor and Industries,  Work Hardening Program Standards available at:  http://www.lni.wa.gov/ClaimsIns/Files/ReturnToWork/WhStds.pdf

Johnson LS, Archer-Heese G, Caron-Powles DL, Dowson TM.   Work hardening: Outdated fad or effective intervention?  Work. 2001;16(3):235-243.

Diamond, Preston (2011).  11 Workers’ Compensation Issues Sure to Impact 2011.  Available at:  http://www.propertycasualty360.com/2011/01/17/11-workers-compensation-issues-sure-to-impact-2011

Bucklin, Leonard (2011).  Bucklin.org., The Bucklin Organization.  Don’t miss considering the use of a physical therapist as an expert medical witness in bodily injury cases.  Available at:  http://www.bucklin.org/litigation-tip-physical-therapist.htm

Mittenburg, W., Patton, C., Canyock, E. M., Condit, D., C., Base rates of malingering and symptom exaggeration, J Clin Exp Neuropsychol 24 (8) 2002.