Welcome to Module 2, Session 2, Work Restrictions. My name is Arlene Guzik. I am currently board certified as an adult nurse practitioner. After spending time in my early nursing career in critical care and nursing administration, I completed my master's degree as a nurse practitioner. It was during my thesis research on community health that I stumbled upon this little specialty of occupational health. I then completed my thesis on the principle of employee health and wellness, and I fell in love with this specialty. It has been my passion since 1988. I have had the fortunate pleasure of working on both the employer side of the specialty as a company-based occupational health nurse and on the specialty provider side where I was the vice president of operations for a large multi-clinic specialty practice in Florida. In the company nurse role, I assumed responsibility for managing the health, wellness, safety, disability, and workers' compensation benefits. It was during this time that I was able to interact with employees, injured workers, human resources professionals, benefits specialists, as well as leaders in the areas of company operations, finance, and legal departments, all of whom had varying perspectives on the specialty of occupational health. In my role as vice president of operations for the occupational health clinics, I led the company's growth strategy from one clinic to 18 clinics covering five Florida counties. During this time, I interacted with employer stakeholders from various disciplines representing a multitude of specialties such as local and county governments, school districts, manufacturing and distribution centers, retail operations, healthcare, construction, and many other specialties. With each interaction, I learned more and more about the specialty of occupational health and its impact on workers and their employers. I am here now to share some of this wisdom with you as it relates to rendering care under the benefit of workers' compensation. I have no conflicts to disclose as it relates to this presentation. Our objectives include your ability to list the relevant regulatory statutes related to workers' compensation care, to define the importance of assigning realistic and relevant work restrictions for workers, to discuss the provider's responsibility of medical decision making regarding workers' compensation case management, and to explain the value of the use of the medical decision making process using objective relevant evidence. Workers' compensation medical care has been around since the early 1900s and covers the cost of medical care and benefits for workers who become injured or ill as a result of their job. Since that time, the role of the occupational health clinician has greatly evolved. We now have occupational health registered nurses, licensed practical nurses, paramedics, physicians, nurse practitioners, and physician assistants in various roles rendering care to injured workers. In 2020, ACOM published a guidance statement regarding workers' compensation elements in different jurisdictions in the United States. One of the principles discussed in the paper was the fact that the rendering of care to injured workers is quite diverse. First, the fact that workers' compensation care is offered in a variety of settings is most important to note. Care is often rendered at the work site by trained emergency medical personnel, safety specialists, first aid responders, occupational health nurses, and in some cases, the company will have an on-site employer-based medical clinic to handle first-line treatment. Outside the workplace, the injured worker can have health care encounters in the emergency department, the urgent care setting, the primary care setting, and in a variety of specialty clinics by a variety of providers, such as orthopedics, neurology, spine specialty, pain management, dermatology, cardiology, ophthalmology, and even dentistry. The paper goes on to discuss the fact that most of these providers have little or no formal training in the specialty of occupational medicine. So one may ask themselves, why do I need special training? What competencies do I need beyond diagnosing and treating injured workers? And why do I need these competencies? The answer is simple. In this specialty, you are dealing not only with the injured worker who is your patient, but you will be dealing and interacting with a variety of others who have a stake in the workers' compensation claim, such as human resources professionals, safety specialists, operations managers, company owners, claims adjusters and case managers, and workers' compensation attorneys. So beyond your clinical expertise, other qualities need to shine through. Occupational health clinicians should have a working knowledge of the workers' compensation laws and regulations, which are different in each state, knowledge of the regulatory statutes that come into play at times, and a broad breadth of knowledge and expertise, solid decision making, and a willingness to collaborate with other stakeholders in the workers' compensation claim. What is competence as it relates to workers' compensation? In another of ACOM's guidance statements, these are defined as physical, intellectual, and behavioral qualifications that are common to other stakeholders in the specialty. As mentioned earlier, each state has established regulations guiding their workers' compensation benefits. So, as we are rendering medical care under a regulatory statute, it is critically important that we have a good working knowledge of the statutes that will guide our decision making. For example, certain injuries and conditions may be covered while some are not. The clinician is always asked to render opinion of work-relatedness of the condition, so it is quite important that you are familiar with the state statute. You can only do this by researching the web for workers' compensation statutes for your specific state. Although the statute addresses a wide breadth of legal issues, be sure to read the section on medical care. The statute likely will have a specific form that is completed at the medical visit as this is the primary way of communicating your opinion in a structured fashion with the employer, the adjuster, and the case manager. Your ability to make sound decisions as a clinician is vital to the decisions surrounding how the claim is managed. This affects the outcome of the claim and benefits for the injured worker. The statutory regulations address the fact that the clinician rendering medical care is competent in the understanding of the state's workers' compensation statutes. So again, one must be mindful to understand that although care is being rendered in one state, the injured worker may be employed by an employer in a different state, and that state's regulations guide the management of the claim. That state may require completion of paperwork that is different than that of the state in which the care is being rendered. The greatest expectation of clinicians is that we provide medically appropriate care in a cost-conscious manner, providing injured workers with nothing more and nothing less than what is medically appropriate. Because there are state variations in workers' compensation laws and guidelines, it is strongly recommended that providers become familiar with the workers' compensation laws for the specific states in which they are working. For those working on borders of states, if you work in clinics in different states, you need to have familiarity with the workers' compensation statutes of each of those states. For example, if my employer has a clinic in West Virginia and another clinic across the border in Ohio, I must be familiar with both state statutes. So once we have clinical competency under our belts and we are now familiar with the state statutes, it's equally important for workers' compensation clinicians to be familiar with other statutory regulations that come into play with workers' compensation. These include the Occupational Safety and Health Administration, or OSHA as we know it, because our medical decisions influence the employer's obligations under this law. The Occupational Safety and Health Administration also provides regulatory guidance in regard to hazards and exposures in the workplace. So when a worker comes to your clinic and says, I've been exposed to benzene, OSHA becomes a point of reference. The Equal Employment Opportunity Commission, or EEOC, is concerned that employers treat all workers as equals, including access to workers' compensation benefits. The ADA, or Americans with Disabilities Act, holds employers accountable to providing workers with reasonable accommodations regarding health issues. The Family Medical Leave Act, or FMLA, requires employers to provide time off for employees with their own serious health conditions or those of their family members. So under workers' compensation, if a period of incapacitation leads to time away from work, the injured worker may ask the clinician to complete appropriate paperwork required by the employer to justify their entitlement to this benefit. I think we as clinicians are most familiar with the Centers for Disease Control, or CDC, and its guidance surrounding certain communicable exposures and diseases, and we do often see many of these conditions in the occupational health setting. The National Fire Protection Association, or NFPA, has clear medical guidance regarding firefighter fitness, as well as those conditions that are deemed compensable as being related to their work as a firefighter. And there are many, many other regulations that may come into play, but I just wanted to touch on those that are most common. So now that I'm an occupational health clinician, or I find myself in a job that requires me to evaluate and treat workers' compensation patients, what specifically is my role and what am I responsible for? First and foremost is to evaluate, examine, and diagnose. Everything else that occurs down the line in the management of the workers' compensation insurance claim is based on the diagnosis or the diagnoses. If an incorrect diagnosis is made and becomes part of the permanent medical record, the financial set-aside on the claims end may be inappropriate. The claim may actually be denied because the diagnosis does not equate with what actually happened at work. A common example of this is the patient who presents with low back pain, indicating it is from lifting heavy boxes at work. Upon exam, the clinic's exam for musculoskeletal injury is negative. However, the patient has positive flank tenderness and is actually diagnosed with nephrolithiasis. The patient's complaints are then deemed to be not work-related and they are referred to their personal treating provider for further evaluation and care. So making the correct diagnosis the first time is critical. You can always add diagnoses later in the course of the medical management, but the initial diagnosis is key to incident investigation and claim set-up. Your diagnosis will then influence the medically appropriate work restrictions you assign during the clinic visit, and it is also affecting how the employer will provide accommodations to allow the worker to work within the assigned work restrictions. Speaking of work restrictions, the assignment of medically appropriate work restrictions is a quality that is valued by injured workers, employers, adjusters, and case managers. The clinician who takes time to discuss work restrictions with the injured worker or actually discusses accommodations with the employer is held in high esteem. The collaboration amongst injured worker, the employer, and the clinician most always leads to the ability for the injured worker to remain productive in the workplace. And another ACOM guidance statement tells us that better claims outcomes are actually achieved when this occurs. This means the injured worker gets appropriate medical care that leads to recovery, and this actually has a positive effect on the cost of the claim and influences the worker's compensation insurance costs for the employer. All of what we've covered so far is leading up to the provider's role in assigning work restrictions for injured workers. The foundations of knowing the laws, making the correct diagnosis, tying that diagnosis back to the work incident are all initial key setups in the medical visit. Once the diagnosis is made and appropriate treatment is rendered, we then address work status. We ask the question, can the injured worker go back to work? And when they go back, what should they be stricted from doing in order to avoid harm or exacerbation of their symptoms? The clinician then is responsible for making the medically appropriate referrals and assigning the appropriate level of impairment at the time of discharge. Another ACOM study on preventing needless disability found there is only a small fraction of medically excused days off work that are actually medically necessary. Most injured workers can generally return to work with assigned work restrictions that allow them to remain productive. In most cases, this is greatly appreciated by both the injured worker and their employer. So our role as workers' compensation health care providers is to provide the injured worker with exactly what they need, nothing less and nothing more than what is medically necessary. Now it's time to get to how we manage work status by assigning medically appropriate work restrictions. I am a firm believer that if we maintain a focus on what a person is able to do, they can remain a productive member of the workforce despite their injury or physical limitations. Despite popular thought that workers use the workers' compensation system to get out of work, most workers actually want to and are anxious and happy to return back to work. Experience tells me that more than 90% of the injured workers file legitimate claims for legitimate injuries, and these workers want to remain at work. State workers' compensation statutes have stipulations on how the injured worker gets paid for time away from work, and most have a certain waiting period before the injured worker gets compensated for time off or lost time. This means during that waiting period, the injured worker does not get paid and must use accrued paid time off, such as vacation or sick time. So keeping the injured worker at work is therapeutic for their wallets as well as their health. A swift return to work should be considered therapeutic, as it keeps the injured worker productive, keeps them amongst their comrades at work as a support system, and keeps them engaged with their employer. Now, in regard to the provider's responsibility, as if I haven't already given you a long list of responsibilities as a workers' compensation health care provider, let's talk about managing work status. Essentially, the work restriction should be assigned commensurate with the severity of the injury or illness. We are now focusing on what activities would cause an aggravation or exacerbation of the condition. Our goal is to maintain productivity of the injured worker while supporting a swift recovery. Stay at work, return to work. This is a common phrase used in our industry. This term has been embraced by workers' compensation health care providers, as well as employers, health adjusters, case managers, and workers' compensation attorneys. By this concept, the mission is to avoid taking the injured worker off work unless absolutely medically appropriate. Of course, there are exceptions to this philosophy. These would include injured workers with contagious infectious diseases, injured workers on safety-sensitive medication, and those whose acute injuries are in need of imminent intervention. Also, those who would be a threat to themselves or others in the workplace. But for the most part, most injured workers may return to work with assigned restrictions. A best practice to develop is to hold a discussion with the injured worker about their job duties before assigning restrictions. And better yet, when in question, phone the employer representative to have the same conversation. Both the injured worker and the employer will be very appreciative of your efforts. Of course, there are times when the injury is acute or the injured worker really should not return to work that same day of the injury. The plan of care would be to allow the injured worker to go home for the remainder of the workday, allowing them to apply modalities, start medications, and rest. My favorite assignment of work status in this case is to use the phrase, home for the remainder of the day. By now, you may be asking yourself, gosh, how can I possibly know what kind of work every injured worker does? And how can I possibly know what they do at work that may exacerbate or aggravate their injury? One of the most effective ways I have learned is to simply ask the patient, what do you do at work? This is a question that can be asked during the examination that may better engage a patient provider relationship and lend an intent of compassion as well. Most injured workers are happy to talk about their jobs and are happy to share information with you. If you find they are not, then this is your sign, as they say, that there may be confounding issues surrounding the case, a disgruntled employer-employee relationship, or other intents on the part of the injured worker. Managing work restrictions is a dynamic process. Once the initial restrictions are assigned, on subsequent visits, always ask, how is it going at work? Have you been able to do your job? I have found that the injured worker is most always willing to have this conversation. Once you have re-examined the injured worker, review the restrictions that were assigned at the previous visit to determine if they are still medically appropriate. This is vitally important if this is your first visit with the patient, as you want to be consistent from visit to visit with the assigned restrictions. The goal at all subsequent visits is to advance work status toward the aim of achieving regular duty status, meaning there are no longer restrictions to the injured worker's work activity. A best practice I implemented many years ago was to assign a few days of regular duty without restrictions before discharging the patient from my care. This gives the injured worker time to resume all work activities and all life activities to assure there is no re-aggravation or exacerbation of symptoms before releasing the injured worker from your care. The timeframe for follow-up after the assignment of regular duty would be three to five work days. If the injured worker tolerated regular duty, it's now safely time for discharge. I have talked about the role of the workers' compensation health care provider from the perspective of the injured worker and somewhat from the employer's perspective as well. But another favorite concept of mine is that we as workers' compensation health care providers serve multiple masters. Unlike in the world of private medical care, where it is highly unusual to involve others beyond the patient and their family or significant other in the plan of care, workers' compensation statutes define the employer's right to review the medical records of workers' compensation visits and have open discussions with the injured worker's workers' compensation medical providers. The employer representatives typically include representatives from risk management, safety, human resources, and operations managers or supervisors. It is not unusual for these representatives to accompany the injured worker to medical visits as well. This provides the perfect opportunity to include the company representative in the discussion of work status in order to gain their support for the needed accommodations. Workers' compensation adjusters and case managers also have the right to the medical records and the right to discuss the case with the health care provider. Case managers will often attend medical visits with injured workers to assure they are familiar with the plan of care. Their role is to facilitate the medical needs and referrals for the injured workers and to be a liaison amongst the workers' compensation carrier, the employer, and the medical provider. We've covered a lot of responsibilities of the health care provider, so let's now cover the responsibilities of the employer. There are a number of administrative responsibilities an employer has in setting up the workers' compensation claim and directing medical care, but a key responsibility is determining the ability to accommodate work restrictions. The employer is also accountable for the reasonable accommodation and assuring the injured worker abides by the assigned restrictions. An astute employer will already have a stay-at-work, return-to-work plan in place that will accommodate reasonable restrictions. When the injured worker returns to work, the employer will be responsible for ensuring that the injured worker has access to work. The employer representative will assist in assigning work by removing essential functions of the job consistent with the assigned work restrictions or providing alternate work assignments within the assigned work restrictions. Best practices that support on-the-job recovery include keeping the injured worker engaged and productive, supporting an attitude of caring, and keeping the injured worker engaged with co-workers. We have found that the concept of providing an environment of social support that surrounds the injured worker leads to positive case outcomes. Waddell and Burton published a study in 2006 that looked at this concept. Their findings tell us that just as important as appropriate medical care, work is therapeutic. It aids in recovery and leads to better outcomes. It minimizes the harmful physical and mental effects of absence. It reduces long-term incapacity and actually improves quality of life for injured workers. Thus, the focus on a strong stay-at-work, return-to-work philosophy by both the health care provider and the employer is a winning combination. This concept is also supported by the National Institute for the Prevention of Sexual Abuse This concept is also supported by an ACOM guidance statement published in 2020 that tells us the longer a worker remains out of work, the likelihood of them returning to work diminishes quickly. This happens for various reasons. They lose interest in the job. They become complacent. They think their workers' compensation claim will provide a big payout. Perhaps they find another job. Or worse yet, they take on a personality of being disabled. I mentioned earlier that a key regulatory body in the workplace is OSHA. The interplay of workers' compensation and OSHA has to do with the nature and severity of incidents and injuries. When it comes to workers' compensation, the employer must log the details of all injuries and illnesses on the OSHA log. The requirements for recording include deaths at work, loss of consciousness, days away from work, restricted work, or transfers to another job, and medical treatment beyond first aid. So you can see how the decisions made in an exam room regarding diagnosis, treating, and work status have direct implications for the employer. I believe an earlier module in this bundle reviewed the concept of OSHA in detail. Let's now get to the details of assigning work restrictions. We'll just take a look at this slide. You may be asking yourself, how can I possibly know the essential functions and job tasks when there are so many jobs? From this abbreviated list, you can see there is a broad range of jobs that have varying physical demands, some more than others. If you work in an occupational health center, you may be asked, how can I know the essential functions and job tasks when there are so many jobs that have varying physical demands? If you work in an occupational medicine specialty practice, a best practice is to conduct a company walkthrough of the job sites of your key employers. There's nothing better than seeing work in progress, people doing their jobs. One of the greatest values I have found with this is being able to have a meaningful discussion with people who are amazed that I know first-hand about their job. You can always ask for a copy of the job description as well. That way you can review the essential functions and physical demands of the injured worker's job. All jobs have both essential and non-essential tasks. The essential tasks are those required to get the job done. The non-essential tasks are those that do not directly affect the core tasks. In assigning work consistent with the provider's work restriction, the employer takes these functions into consideration. And it is always valuable to have a discussion with the employer representative to get a better understanding of the work tasks and their ability to provide meaningful work for those with work restrictions. Many states have specific forms that providers are required to complete at each medical visit. This is a sample section of the Florida DWC-25 form that addresses work status. You can see under numbers 21, 22, and 23, it asks the provider to check one of three boxes. Box 21 indicates there are no assigned restrictions, meaning the worker can resume normal work duties. Box 22 indicates that the worker is unable to work until a specific date. And box 23 states the injured worker can resume work with assigned restrictions. The lower portion of the form then allows the health care provider to assign the medically appropriate restrictions. I have included here another example of the Texas workers' compensation form. Same concept, the layout is different. But it essentially allows the provider to indicate the work status and assign appropriate restrictions. As a health care provider, our role is to assign appropriate work status and work restrictions. Based on my experience, let me suggest some things to avoid. Avoid defining where and in what form the employer is required to work. And what department an injured worker can work. An example is the injured worker who works in assisted living, who tells you they can't take care of residents, but they can work in the dining room. As a provider, our responsibility is to assign the restrictions. The employer then decides where they will work. Avoid defining how many hours they work or what shift they work. Early in my career, I was fooled a few times by going along with an injured workers' recommendation that they work limited hours or certain shifts. Only to have the employer call me and tell me the injured worker was found to be working for a different employer on the days and shifts they told me that they could not work. Avoid defining what job they do. This is strictly an employer responsibility. Again, an early mistake of mine, only to have the employer tell me the injured worker did not like the job they were hired to do and found the injury a convenient way of getting assigned to a different job. The injured worker might tell you what days of the week they want to work. What I have heard from the injured worker is, I can't work weekends because they can't accommodate my restrictions on those days. This turned out to be a good one. When I learned that the injured worker was trying to manage working two jobs, one during the week and another on the weekend. Some other tips based on my experience as mentioned earlier. The assignment of home for the remainder of the day is great to use on the day of injury to aid recovery. When assigned on the date of injury, it does not constitute lost time under OSHA. Be mindful that when this restriction is used on any day other than the day the injury occurred, it constitutes lost time for the employer and becomes OSHA recordable. Another favorite restriction of mine when dealing with lower extremity injuries or even low back injuries is seated duty only or seated duty preferred. The employer can then assign job duties that can be performed in the seated position. Know that there are some restrictions that employers find too ambiguous or difficult to manage. Examples are to limit something such as limit lifting. The question at the work site becomes, who determines the limit? The injured worker or the employer? How much is the limit? The injured worker and the supervisor may disagree on the limit. So always assign a defined amount of weight. Always clearly define in objective terms the details of the restriction, such as limit lifting to 20 pounds or limit walking to 30 minutes per hour. If it is medically necessary to take the injured worker off work, be sure to keep a short follow-up interval. See them back in two or three days for reevaluation. If the injury is acute, such as in the case of a head injury or multiple trauma, or if they are injured or ill enough to be taken off work, then our intention to follow them medically at short intervals is also important. The next one is a really important tip. Maintain consistency of restrictions from visit to visit and from provider to provider. It drives a supervisor and an injured worker crazy when the restrictions keep changing. This tends to happen a lot when the injured worker is seeing different providers at each visit. Always refer to the previous visit's work status to see what was assigned and stay consistent with those restrictions unless you are intentionally adding more limits because the condition is worsening or because you are advancing work status by removing restrictions because the injured worker is recovering. Make it a point to talk to the patient at each visit about the work restrictions. As the condition improves, we want to start peeling away some of the restrictions, increasing weight limits, or advancing activity at each visit. As mentioned earlier, before discharge, always assign a few days of regular duty to assure it is tolerated before assigning MMI and discharge. So let's take a look at a few cases to show you examples of restrictions that are over-restrictive and difficult to comply with. These are real case examples. We will then look at a more realistic assignment of work restrictions for these same cases. Better for the worker to comply with, better for the workplace to accommodate. Additionally, we need to also keep in mind that the restrictions we assign truly are intended to be in effect both at work and away from work in order to avoid exacerbation and promote recovery. This first case is a 45-year-old female with right wrist sprain due to repetitive scanning and filing. The patient states that she has been assigned to scanning and filing forms for the past several days. Her wrist began to hurt a few days ago and she has been using Tylenol for the discomfort. On exam, there is no swelling or discoloration. There is tenderness on palpation over the dorsal aspect of the wrist and the discomfort is aggravated with flexion of the wrist. Carpal tunnel exam is negative. The diagnosis is a sprain of the right wrist and a wrist splint is applied. This is a work status form that was completed at the initial visit. I will give you a few seconds to review the form asking yourself, what work could I assign for this worker if I were their supervisor? You see that the provider assigned limits of five pounds for less than five minutes at a time for less than five minutes at a time for the activities of carrying, lifting, pushing and pulling while wearing a splint. There is also a five pound limit to grasping, avoiding use of the right hand, but the right hand can be used to write for less than five minutes at a time. If she must avoid grasping, this is very difficult in the sense that she cannot grasp a piece of paper, a fork, a door handle or a cup. Let's look at these examples and ask, are these restrictions realistic? Are they manageable? Put yourself in the supervisor's place and ask yourself, what is it that she could do at work? I would find this quite confusing and very difficult to manage. The employer did as well. Let's now reassign the work restrictions in a way that is more reasonable for the injured worker and more manageable for the employer. Instead of five pounds, I think that 10 pounds is more realistic while she's wearing a splint and using both hands. Simply assigning limit use of the right hand gives the worker the option of what tasks she can perform to protect the hand and wrist while wearing the splint. And this allows the injured worker to use discretion, maintain productivity and do what they can reasonably do. You will find that this restriction of limiting use of the hand is accepted well by both the patient and the supervisor. Add to that that the form looks a whole lot better. Other reasonable restrictions for wrist sprain or other hand or arm injuries would include avoiding repetitive use and limiting lifting and carrying. Consider using 10 pounds as your lowest limit unless the injury is acute. Based on my experience, most injured workers can manage 10 pounds of force without difficulty. Our next case is a 36-year-old male construction worker who stepped into a hole on the construction site and sprained his right foot and ankle. On exam, he has gross swelling of the right angle and foot, tenderness over the lateral aspect of the foot and around the lateral malleolus. X-ray is negative for fracture. The diagnosis is sprain of the left foot and ankle. An elastic wrap, ankle splint and post-op shoe are applied. He was provided crutches with gait training. Just look at the list of restrictions that were initially assigned. There are restrictions that address walking, standing and climbing using crutches with no weight bearing which are appropriate for a foot and ankle sprain. But look at the restrictions assigned for carrying, grasping, kneeling, lifting, pushing and pulling, reaching, squatting and twisting. A lot of these words have none assigned to which means he cannot perform these functions such as carrying and pulling. These restrictions do not seem applicable to a foot and ankle injury because he's still able to use his arms and hands. And it is quite difficult to get along in daily living without being able to do these tasks. If you were the supervisor, what work could you assign within these restrictions? They seem a bit overwhelming at first glance and they are overwhelming. Take a few seconds to look at this. Decide for yourself, what could I have this injured worker do? When we readdressed the case, we found the restrictions were quite unrealistic. The employer had actually called the clinic on this case and asked that the restrictions be readdressed in attempt to be more realistic. We went back and looked at the case and assigned restrictions of no climbing, no kneeling, no squatting, no standing or walking. These are essential functions of the work. We addressed the fact that he must wear a post-op shoe and use crutches. Additionally, we have assigned no driving at work since this was a core essential responsibility and he is at risk wearing a post-op shoe on his right foot. We also looked at some alternate options on this case. This would be a perfect case for assigning the work status of one of my favorite restrictions and that restriction is seated duty only. This means that the injured worker can only be assigned work that they can do in a seated position. This pretty much takes care of all of the other restrictions that were assigned. We did, however, add no climbing, no standing and the fact that he must use crutches and wear a post-op shoe. Some other options for work restrictions for use with foot and ankle injuries include seated work only, limit standing to a defined timeframe. For example, limit standing to 15 minutes per hour. And as recovery progresses, you can increase the timeframe for standing at longer intervals of time at subsequent visits, increasing to 30 minutes per hour and 45 minutes per hour and eventually remove the restriction for standing. Another restriction is to alternate sitting and standing for comfort. This can easily be achieved at the work site by providing a chair at the workstation. No or limited squatting, no or limited climbing of ladders and stairs, no working at heights and elevate the leg while seated. The next case is a 57-year-old female with low back strain due to lifting boxes at work. On exam, she admits to no prior history of back problems. She states her job involves lifting boxes that weigh about 20 pounds off a conveyor belt onto a cart, stating, I think I just twisted the wrong way. She came to the clinic immediately from work shortly after the injury. She has muscular tenderness and palpable spasm over the lumbar area bilaterally. She has trigger point tenderness over the right sacroiliac joint. X-ray is negative for fracture or any significant degenerative disease or other acute findings. The assigned restrictions included just about everything on the list at none or a five pound limit. She could not carry or lift anything according to these restrictions. This would mean she could not lift her pocketbook or lift her toothbrush. However, carrying limit is five pounds. Ask yourself, how can you carry five pounds if you are not permitted to lift anything? So what is it she can do at work with these restrictions? The supervisor just told her to stay home because they were unable to accommodate all these restrictions. This then resulted in a lost time case or the employer. When we looked at modifying the restrictions, it seemed reasonable to assign a 10 pound limit for carrying and lifting. We then limited pushing and pulling to 20 pounds. We assigned no lifting overhead and no climbing ladders since these were essential functions of her job. The employer was then able to accommodate the restrictions and provide her with productive work. Some additional suggestions for restrictions for back injuries include seated work only, limiting lifting to 10 pounds, limiting pushing and pulling to 20 pounds. And again, at each visit, the amount of weight can be increased as recovery progresses. And as in our previous example for foot and ankle injuries, limit standing to a certain number of hours, alternate sitting and standing, no or limited squatting and bending, no or limited climbing of ladders, and no working at heights. What happens when you find yourself faced with a supervisor or safety representative saying, just send him back to regular duty, we'll take care of him? Well, this comment is usually motivated by the need to avoid the mandatory recording of restricted duty on the OSHA log. This does happen and will happen to you one day. In reviewing your state workers' compensation regulations, you will find that most states expect the medical provider to assign the medically appropriate restrictions. Your response to this company representative is a comment about your legal responsibility under the state's workers' compensation regulations to assign medically appropriate restrictions. Here are some other concepts to keep in mind when assigning work restrictions. Your assignment of realistic work status and work restrictions is intended to keep the injured worker at work and productive. I learned early in my career, based on feedback from an employer, to avoid using the phrase as tolerated as a work restriction. An example would be lifting as tolerated regular duty as tolerated. The employer taught me that the term was really ambiguous and hard to manage. She said, on the job, it becomes a question of whose tolerance it is, the tolerance of the injured worker or the tolerance of the supervisor. This was a great lesson learned. As I mentioned previously, consistency matters from visit to visit and from provider to provider. When assigning restrictions, put yourself in the role of the supervisor and ask yourself, what could this person reasonably do within these restrictions? If the answer is nothing, you have likely assigned too many restrictions. Make a habit to ask the injured worker their suggestions for work restrictions. I guarantee that at least 80% of the time, they are honest and helpful. And remember to always keep your goal on the return to regular duty. Let's now talk about the frequency of follow-up visits. I always suggest having an initial follow-up visit two to four days following the initial visit. This will give you an opportunity to assess the condition, assess compliance with the treatment plan, and to discuss tolerance of any assigned work restrictions. A weekly visit thereafter is most beneficial. An exception to this would be eye injuries, where I suggest daily visits until the condition is resolved or the worker is referred to ophthalmology. And simple sutured wound checks, see them back in two days for a quick follow-up assessment than a subsequent visit for suture removal. Another pearl regarding follow-up visits is that you continue to schedule regular follow-up visits when physical therapy or occupational therapy is ordered. This gives you the ability to assess the worker's compliance and tolerance to the therapy, their progress, and to make the appropriate referral to specialists if there is no improvement. It also provides the opportunity to advance work status as they improve with the expectation that they will be at regular duty at the completion of therapy. Too many times I find providers who schedule the next follow-up visit weeks out after therapy is expected to be completed. The risk with this is losing touch with what is happening with the worker's compensation claim, how the injured worker is tolerating therapy and the assigned work status, and what is happening with the clinical status of the patient or the status of the worker's compensation claim. At one time, I had a client tell me that I was not authorized to see their workers back in our clinic during the course of therapy. I complied with their request on a case involving a work-related motor vehicle accident. I ordered physical therapy and saw the patient at the next scheduled clinic visit in three weeks. It was then I found out that the patient had actually not been participating in the prescribed physical therapy because she had been involved in another motor vehicle accident on her personal time. She had filed a claim through her motor vehicle insurance and had secured the services of an attorney. So now from the claims perspective, it was far gone and things were out of control and being directed by her attorney. Had I scheduled that follow-up visit at an intermediate interval after ordering physical therapy, this would have been caught early on and appropriate steps taken to mitigate the situation from the claims perspective. When referring to specialists, I also suggest you continue regular follow-up visits until the injured worker has actually had their first visit with the specialist. Of course, this assumes you are able to continue your care consistent with the referral process in your state's workers' compensation statutes. Too many times we find the patient lost in follow-up because of delays in adjuster authorization of the referral or other mitigating circumstances such as plaintiff attorney involvement. As medical providers, we often do not know what is happening behind the scenes of a workers' compensation claim. Incident investigation may be happening in order to validate an incident or accident that the worker claimed had occurred. Plaintiff attorney involvement may cause delays or simply the worker or employer failed to file a claim. Beside the medical perspective, there are several steps in the evolution of a workers' compensation claim that we may never be aware of. So, it is best that you keep the patient under your care until a known transfer of care is completed, avoiding an abandonment of care situation. How do you respond to this if you walk into an exam room and the injured worker says, just take me off work? Your response would be to explain to the patient that unless there is a medical rationale for taking them off work, our obligation is to continue to assign medically appropriate restrictions. From the first medical encounter to the time of discharge, our sights should be on bringing the workers' compensation claim to maximum medical improvement or MMI. In some cases, the patient may not be fully recovered or may still have some limitations or activity restrictions. MMI indicates that the patient's condition is as good as we expect it to get. So, it is vitally important that we have realistic expectations focused on function and capabilities. Who doesn't love having some great spice in our food or even having some good spice in our lives? I'm going to now throw a little spice into this presentation by giving you some background on what is known as the spice model in occupational medicine. Many years ago when I was first introduced to these concepts, they provided such clarity to my role as an occupational health provider and really helped me maintain objectivity and focus when managing workers' compensation claims. As the saying goes, if it starts out wrong, it will likely end up wrong. Your greatest opportunity to influence the outcome of a workers' compensation claim starts early on in the case. Just as in cooking, when the right spices are added early in the cooking process, it often influences the flavor of our dish. College and Johnson published a paper in 2000 that describes certain principles that when applied to management of cases resulted in positive outcomes. These principles are based on the military's forward treatment methodology and extensive experience in managing trauma. The model addresses both biological and psychosocial components of managing cases. The military leaders found that when injured soldiers were kept on duty in close connection with their comrades, they seemed to experience a quicker and less complicated recovery. When applied to workers' compensation, the intent is to establish interventions aimed at reducing claims cost by dealing with them in an efficient, fair, and timely manner and keeping the injured worker at work as much as possible. Known as the SPICE model, this concept has proved effective in both medical management and claims management of a workers' compensation case. The acronym SPICE stands for the concepts of simplicity, proximity, immediacy, centrality, and expectancy. Simplicity means that when we tend to overemphasize the potential seriousness of an individual's case or symptoms, it may have a negative effect on their recovery. College and Johnson described it this way. When simple, benign conditions are treated in a complicated fashion, they simply become complicated. And in keeping it simple, diagnostics, prescriptive medications, splints, and physical restrictions should be reserved for medically necessary purposes and not implemented simply at the injured worker's request or as a matter of habit. A focus on maintaining a regular work schedule with assignments within the assigned restrictions is therapeutic. So, as a clinician, our focus should be on keeping it simple, realistic, and optimistic. College and Johnson described the concept of proximity as addressing the need to keep the injured worker emotionally and geographically tied to the workforce. They proposed that social support proves to be an important component in the recovery process, along with the appropriate medical management. The injured worker benefits from the support of family and social workers benefits from the support of family and social networks, along with the support of managers and co-workers in the workplace, thus reinforcing the value of the worker and it provides psychological support. College and Johnson found that workers who return to work often displayed a more positive self-esteem that may minimize needless disability. The principle of immediacy tells us that we should deal with illnesses and injuries in a timely manner, since delays in treatment significantly increase psychosocial detriment and delayed recovery. Delays can occur on the worker's part by not reporting incidents and injuries to their supervisor. Delay can also occur on the part of the employer by not filing a timely claim and not referring the injured worker for medical care, perhaps trying to manage the injury themselves. The delay may also be on the part of the health care provider by delaying medically necessary treatment or referrals, so the focus should remain on a timely decision-making by all parties. The health care provider's intention should always be on increasing functioning to the maximum level, focusing on one's ability rather than on their disability. Centrality focuses on using the right provider at the right time. In all cases, there are several stakeholders involved in management of the claim. This includes the employer, the medical provider, the claims adjuster, the case manager, and in some cases, the workers' compensation defense attorneys. These stakeholders should share a common vision and have common goals for a successful return to work and closure of the claim. And expectancy? Well, this simply means that individuals typically will rise to our expectations. In contrast, the injured worker may also rise to fulfill negative expectations placed upon them. Expectations for treatment and recovery can be clearly outlined at each medical visit, including treatment goals and expected timelines. The experienced workers' compensation clinician The experienced workers' compensation clinician will be able to plan and facilitate a treatment strategy that supports recovery. Part of setting expectations is to assure the individual is aware of their role in complying with the treatment plan as prescribed. Please remember, the assignment of work restrictions should be based on this concept. One of my favorite principles to remember in managing workers' compensation cases is the fact that things change. Sometimes we are made aware of those changes and sometimes not. So, our medical treatment decisions can only be based on information we have at that time. And at each medical visit, we may gain some additional information from the injured worker, from the employer, or from the case manager or claims adjuster. This new information may have bearing on our future treatment plan. As a workers' compensation healthcare provider, it is vital to be open to listening to all stakeholders involved in the claim and not just the patient. As clinicians, we are educated to listen to the patient. Yet in workers' compensation, we find ourselves rendering care in a highly regulatory atmosphere with many, many barriers. We are not prepared to listen to the patient and we are not prepared to listen to the employer. We are prepared to listen to many, many stakeholders, an atmosphere that holds many dimensions that guide the claim and influence treatment decisions. The mission to support the stay-at-work, return-to-work philosophy is based on the negative impacts that can occur during the life of a claim. A work injury has a impact on family relations and household finances. The family dynamic may change. For the employer, lost time means lost productivity and in some cases, lowered profitability from less output of work and with the need to replace workers with more expensive options. Ultimately, the impact of workers' compensation costs can influence the rate of disability and reduced activity within our economy. So, our focus in the medical management of workers' compensation cases should remain true to our support for the stay-at-work, return-to-work philosophy. By keeping injured workers working as much as possible, by returning them to full productivity as soon as it is medically possible, we want to focus on reducing the cost of absenteeism and lost productivity for employers by assigning modified work status as medically appropriate. I love this quote, all humans are in essence athletes and in the case of injured workers, their jobs are their sports. Cook describes it perfectly when he states that rest leads to deconditioning. It also leads to a lack of motivation and a labile attitude. Thus, returning an injured worker back to work, even with modified duty, will keep them motivated and conditioned. In conclusion, our goal as workers' compensation health care providers is to focus on assigning meaningful work restrictions that are medically appropriate and clearly understood by the injured worker and their employer. Make it a point to avoid ambiguous terms that make it difficult for the supervisor to manage. Why are we ending with a focus on stay-at-work, return-to-work? Because your role as a workers' compensation health care provider puts you in the driver's seat. Your decisions often impact the outcome of the claim and we always want our decisions to be the correct decisions, both for the injured worker and for the employer, consistent with regulatory statutes of your specific state of practice. As we say in the development of any skill, practice makes perfect. We have the guidance of the regulatory statutes as well as our specialty practice of occupational medicine to lead us in the appropriate direction. The mission of AANP to partner with ACOM in building this specialty track of education modules fills a tremendous gap in education for the health care provider who renders care under workers' compensation. ACOM also provides excellent resources for this purpose on their website and through membership. We applaud ACOM and AANP for establishing this valuable resource to build your expertise in the specialty of workers' compensation. Thank you for your participation in this program.

Arlene Guzik

board-certified adult nurse practitioner

work restrictions

workers' compensation

occupational health

regulatory statutes

medical care

benefits

injured workers

communication

SPICE model