special populations

what is worker’s comp

It is a form of insurance providing wage replacement and medical benefits to employees injured during the course of employment.

who is financially responsible

- If you are injured at work, your employer is responsible for covering your medical expenses and compensating you for lost wages as a result of your injury.
- There are a few exceptions based on the size and type of business. Exceptions vary from state to state (sole proprietors, family farms, etc)
- Businesses are required to demonstrate that they can afford to cover these expenses if/when they arise. Employers two choices:
 1) get an insurance policy or
 2) set aside a funds to be used as needed (self-insure) – Self insured companies use third party administrators (TPAs) to handle payment and manage care
- Same rules apply to either arrangement. The only difference is who is financially responsible

REPORTING REQUIREMENTS

• Worker must report the injury within 120 days of occurrence
• Insurance carrier is allowed 21 days from notice by employer of disability to decide to accept or deny a claim
• May require an independent medical exam (IME) by a physician of the insurer’s choice

work flow

1. Injury is reported (accident or cumulative trauma) to a supervisor.

2. A claim is filed (“This is what happened to me...”)

3. A medical evaluation in scheduled
   - Compensability is determined (is this work related?)
   - Treatment plan is developed
   - Work ability determined
   - Referrals to other providers made (diagnostics, pharmacy, rehabilitation, specialist, etc)

4. Employer investigates the claim

5. Adjuster is assigned
   - Employee outreach
   - Additional resources considered (case manager, transportation, translation)
   - Referral are coordinated and care is scheduled

6. Ongoing care is authorized and coordinated by the adjuster

7. Work restrictions are managed by the employer

Provider responsibilities

• Schedule ongoing care

• Return injured worker to prior functional status

• Identify and manage barriers

• Communicate with stakeholders (restrictions, prognosis, barriers, etc)

Adjuster responsibilities

• Coordinate referrals

• Timely care (authorization)

• Timely payment (provider and patient)

• Resources identification

• Disability prevention

Injured worker responsibility

• Compliance

• Effort

Employer responsibility

• compliance

• accomedation

PT RESPONSIBILITIES

- Understanding mechanism of injury
- Understanding pre-injury job duties- “job description”
- Orienting the patient toward a full return to work
- Orienting the treatment plan towards a full return to work
- Identifying recovery barriers
- Communicating with unique stakeholders

why is there a decrease in overall injuries at work but an increase in nonfatal workplace injuries?

the normal strains have decreased due to AI and technology, but the dangerous jobs have been maintained.

who gets hurt the most?

manual heavy labors

what is the average expense per injury

On average, it costs 45$/month to provide workers compensation for an employee. This vary on the risk associated with the position

what is the most expenive body region

head/CNS

WHAT IS COVERED?

• Injury, illness, or disease caused by a work duty or environment
• Starts day 1 of employment
• Occupational diseases are covered if caused or aggravated by employment
• Reasonable cost for surgical and medical services, medication, supplies, hospital services, orthopedic appliances and prostheses, without any balance billing to the worker

WHAT IS NOT COVERED?

Self-inflicted injury
• Employee violation of the law, including illegal use of drugs (or alcohol intoxication)
• Not caused or aggravated by a work duty or environment
• Employer has up to 90 days to provide temporary compensation benefits without accepting the claim

evaluation

• data point

• screening tools and outcome measures

• physical exam

work status

• full duty

• light duty

• modified duty

• transitional programs (progressive increase in physical demandds)

work classifications

• how much

• how often

HOW DOES THE INJURED WORKER GET TO PT?

• Referred from a physician

• Authorized by an adjuster (x visits over x weeks)

• Initially scheduled by an adjuster, a network or a medical practice

• Follow-ups are scheduled by your practice

• What if you need more than x visits?

  • Request additional authorization – (new physician referral typically required by the payor)

BARRIERS

• Perceptions that work involves heavy physical demands
• Stressful work demands
• Lack of workplace social support
• Job dissatisfaction
• Inability to modify work
• Poor expectation of recovery and return to work
• Fear of re-injury
• Perceived injustice

privacy

Privacy and HIPAA in Workers’ Compensation Employer/insurance provider is entitled to monthly reports from health care providers
• Attendance
• Progress
• Prognosis/return to work
• Only for the current course of current injury

who has access to the medical record

whoever the patient allows

who are they expected to allow

payer and those acting on the payor’s behalf

PAYMENT

- The employer is ultimately responsible but payment of medical expenses and lost wages are almost always handled by an insurance company or other third party.
- Medical expenses outside of the claim expense (injury prevention, ergonomics training, new equipment, job modification, etc) are handled by the employer.

HOW MUCH DOES WC PT COST?

- Each state has an established fee schedule.
- Typically a multiple of the Medicare fee schedule.
- Many insurance carriers and third party administrators partner with networks to deliver care. Different rates (typically lower rates) may be negotiated to join a network.

COMMUNICATION

- Communication must be timely to allow to allow for stakeholder decision making
- What should be communicated?
 Attendance
 Compliance
 Effort
 Clinical progress
 Prognosis
 Functional capacity relative to job demands
 Material handling
 Positional tolerance
- Information often must be suitable for consumption by a non clinical audience

GOAL SETTING

- The goal is almost always a return to prior functional status at work
 That is different than a full functional recovery
- Job description is critical
 What do they have to do and how often do they have to do it?
- The larger the employer, the more likely there is a formal job description with the necessary information.
- Job descriptions range in detail.
- An employee can not be relied upon to supply the information needed for goal setting

other considerations in goal setting

• Job modifications

• Light duty

• Other services
   Work hardening/ conditioning
   Functional capacity evaluations
  Job site analysis may be needed to quantify goals and inform recommendations

MOTIVATION

- Not everyone wants to get better. Some have more to gain by not improving.
 Secondary gains

terminolgy for motivation

 Submaximal effort
 Feigning
 Malingering
 Inconsistent effort

IDENTIFYING SUBMAXIMAL EFFORT

- Performance consistency
 ROM – consistency over multiple trials
 Strength – Rapid Exchange Grip Test
 Function – lift capacity testing, Minnesota Rate of Manipulation Testing
 Physiological response to pain – HR changes, BR changes
 Observation – Cervical extension when drinking, UE function when dressing/grooming, transferring in and out of a vehicle

STRATEGIES

- Focus on function
- Communicate clearly
 Needs
 Deficits
 Potential / prognosis
- Objectivity whenever possible
 Effort
 Attendance
 Performance
 Progress
- PTs are the experts in functional assessment but not always the best at managing PT utilization.

ADVANCED WORK REHABILITATION

Some injured workers are able to remain in the workplace with graded workplace activities (light/modified duty) and supplemental physical therapy, while other workers may require more advanced work rehabilitation to return to safe and productive work

• The purpose of these more intensive return-to-work programs is to help progress an injured worker’s tolerance of job or occupation-specific physical stresses.

• Under these return to work programs it is critical that the treatment should emphasize restoration of work-related function and reconditioning.

• For the patient/clients with behavioral and vocational limitations, multi-disciplinary intervention may be indicated.
   Work Conditioning - 4 hours/day, 3-5 days/week, 4-8 weeks
   Work Hardening - 8 hours/ day, 5 days/week, 8 weeks.

factors to consider in non-specific LBP

o Posture
o Lack of Skeletal Maturity
o Hypermobility and Flexibility
o Activity Participation
o Strength and Neuromuscular Control

Spondylolysis

o Isolated defect in Pars Interarticularis
o Bone stress injury – continuum
o Bilateral > Unilateral
o Most common on L5
o Males > Females

MOI of spondylolysis

chronic overload or acute overload

factors for spondylolysis

• biological

• mechanical

biological

increased risk for development with
▪ Spina bifida occulta at S1
▪ Scoliosis
▪ Scheuermann's disease (hyperkyphosis)
▪ Cerebral palsy
▪ Excessive lumbar lordosis

mechanical

axial load with lumbar extension with or without rotation

how does sport participation impact spondylolysis

higher incidence rates
▪ Dancers, divers, weightlifters, football linemen, wrestlers, throwing sports, and rowing
▪ 50% incidence rates have been reported in gymnastics

clinical presentaition of spondylolysis

• Gradual onset of back pain.
• Mean age of 15-16 years old.
• Pain is central to lumbar spine.
• Worse with:
o Activity
o Lumbar extension
• Activity modifications.
• Systems: Dietary and Nutritional Screening

3 clinical presnetation types of spondylolysis

1. Dancer/Gymnast, Female, Hypermobile, Hyper Lordotic
2. Strong male athlete, Decreased Flexibility, Peak Growth Velocity
3. New Athlete in a Deconditioned State

physical exam for spondylolysis

• Palpation
• Range
• Flexibility
• Strength
• Special Testing
• Functional mobility

Diagnostic Imaging of spondylolysis

• Little consensus on appropriate imaging pathways
• Radiographs
o Standard (AP)- poor reliability
o Lateral- potential translation
o Oblique- Scotty Dog Sign
• MRI: gold standard.
• CT and SPECT: used to identify appropriate treatment decisions

conservative management of spondylolysis

• Rest from Activity:
o 2-6 months
• Physical Therapy
• Bracing
• Vitamin D and Nutrition

PT for spondylolysis

• Pain modulation
• Improving core stability
• Improving flexibility deficits
• Restoring extension range of motion
• Restoring functional mobility
• Return to sport testing

surgical managemetn of spondylolysis

• Greater than 6 months of failed conservative management
• Fusion of facet joints vs. Direct pars fixation
• Highest success rates:
o L5/S1 location
o Athletes <25 yo
o Unilateral lesions
• Return to sport 6-12 months with a 90% success rate

Spondylolisthesis

o Progression leading to "Slipping"
o Same MOI as spondylolysis
▪ More common bilaterally
▪ Most common at L5 on S1
o Males > Females
o 10-15 year olds

Clinical Presentation of Spondylolisthesis

• Similar to Spondylolysis
• Lower extremity symptoms!
o Pain will present more distally into buttock and posterior thigh.
o May have lower extremity radicular/neurological symptoms
• Step off deformity

Diagnostic Imaging of spondylolisthesis

• Similar to Spondylolysis
o Lateral views will show degrees of slippage
• Classifications:
o Grade 1: < 25%
o Grade 2: 26-50%
o Grade 3: 51-75%
o Grade 4: 75-99%

treatment of spondylolisthesis

• Low grade lesions are treated similarly to spondylolysis
• Grade II and lower = Success
• Surgery:
o Higher grade
o Neurological symptoms
o Persistent pain after conservative management

RTS for apindylolisthesis

• No consensus on Return to Sport after surgery
• ~60% of surgeons allow return to low impact and non-contact sports by 6 months
• 50% return to sport after 1 year
• Discouraged return to contact or high force sports.

scoliosis

Complex 3D deformity of the spine
o Vertebral wedging
o Lateral translation (>10 degrees)
o Axial rotation

• structural

• nonstructural

structural scoliosis

o Idiopathic
o Congenital
o Syndromic
o Neuromuscular
o Tumors, Chiari Malformations and other diseases
o Post-Surgical or Post traumatic
o Adult-onset degeneration

nonstructural scoliosis

Leg length discrepancy, postural, muscular asymmetries

Idiopathic Scoliosis

• Most common type: 75-80%
• Incidence: 2-3% of the general population
o 3:1 female to male

how is idiopathic scoliosis defined

by age of onset

o Adolescent : > 10yo and prior to skeletal maturity
o Juvenile: 4-9yo
o Infantile: 0-3yo

theories in Idiopathic Scoliosis

o Vertebral Body and Growth Plate Pathology
o CNS and ANS

idiopathic scoliosis

• Cause remains unknown.
• Multifactorial
• Moment of Failure During Growth
o Vertebral Body and Disc Deformity

sagital plane

Relative Anterior Spinal Overgrowth

frontal plane

lateral wedging

transverse plane

vertebral torsion

pathomechanisms

• mechanical torsion

• biomechanical torsion

mechanical torsio

The spine twists around its own axis. This is related to the structural changes that occur within the spine itself
o Intravertebral torsion: within a vertebra
o Intervertebral torsion: between vertebra of the spine

biomechanical torsion

Twisting with translation into space causing change to the whole 3-D shape of the spine

screening for idiopathic scoliosis

o ½ of US schools require scoliosis screening
o Ages 9-14
o Referred to PCP

diopathic Scoliosis: Clinical Presentation

• screening

• Incidental findings due to non-specific LBP
  o There is no correlation between back pain and curve severity

Orthopedic Examination

o Spinal Range of motion
o Strength assessment
o Core endurance testing
o Hypermobility Assessment: Beighton Scale

Scoliosis Specific Assessment

o Adam’s Forward Bend test
o Modified Adam’s Bend Flexion test
o Scoliometer
o Postural Assessment

Idiopathic Scoliosis: Diagnostic Imaging

• Radiographs
• MRI
• EOS
• DIERS Formetric 4D

to measure Cobb angle

1. identify most tilted vertebra for each curve

2. draw parallel to top of UEV and bottom of LEV

3. drae perpendicular to those

4. measure angle where perpendicular lines bisect

Idiopathic Scoliosis: Treatment

• General Treatment Guideline:
o Observation - <25 degree curves
o Bracing – 25-40 degree curves
o Surgery - > 45 degree curves
• Physiotherapeutic Scoliosis Specific Exercise (PSSE)

Idiopathic Scoliosis: Physical Therap

• Avoid single plane stretching
• Focus on postural correction and elongations
• Strength and core stabilization in neutral positions
• Address strength imbalances in lower and upper extremities.

Idiopathic Scoliosis: Outcomes

• 10% of patients diagnosed with scoliosis require bracing
• .1-.3% of patients diagnosed with scoliosis require surgery
o Limited return to sporting activities as discussed in previous slides regarding return to sport after posterior spinal fusion.
o No return to contact sports.