Cover StoryPublication Exclusive

Bias, expectations are among challenges in management of workers’ compensation patients

Orthopedic surgeons are often called upon to care for injured workers; however, these cases can present with many unique challenges.

“[Workers’ compensation patients] are in a unique environment,” John D. Di Paola, MD, an orthopedic surgeon with Occupational Orthopedics in Tualatin, Oregon, told Orthopedics Today. “They are affected by multiple factors that are the result of that environment, which is created by the workers’ compensation system.”

In this Cover Story, Orthopedics Today explores the biggest clinical and practice management obstacles presented by this patient population and how surgeons can best manage these patients.

One challenge for the surgeon is to navigate the nature of the workers’ compensation environment. Workers’ compensation insurance covers only those injuries that occur in the workplace or as a direct result of the patient’s work, Di Paola said. When a worker is injured, the employer begins an investigation, which can be intrusive, he said.

“Sometimes that will make some workers feel as though they are not trusted or that they are not being honest,” Di Paola said. “That can sometimes immediately set up a negative environment of suspicion or fear or anxiety about the whole process.”

John D. Di Paola, MD, noted that although some published studies point to workers’ compensation patients having more negative outcomes after treatment compared with non workers’ compensation patients, this finding has not always manifested in real-life practice.

Image: Lori Di Paola

Throughout the process, workers’ compensation patients receive many legal notifications from their insurance carriers, which are typically written in legal jargon.

“When patients get these notifications, they do not know what [they] mean and that can also make them feel as if they are in a hostile environment,” Di Paola said.

“There are several publications that show that the treatment response is not as good in workers’ compensation patients as in patients with commercial insurance,” said Gunnar B.J. Andersson, MD, PhD, who is professor and chairman emeritus in the department of orthopedic surgery at Rush University Medical Center in Chicago. “And the reason why that is the case is not always entirely clear.”

Poorer outcomes

From the trauma literature, findings from the Lower Extremity Assessment Project (LEAP) indicate that patients who filed workers’ compensation claims had poorer outcomes, according to Lisa K. Cannada, MD, an associate professor of orthopedic surgery at Saint Louis University, in St. Louis.

Results from the Spine Patient Outcomes Research Trial (SPORT) also demonstrated that workers’ compensation patients did have not results equal to non-workers’ compensation patients, she said.

Lisa K. Cannada

Furthermore, a recent meta-analysis by de Moraes and colleagues showed that patients receiving workers’ compensation who underwent orthopedic procedures had a two-fold greater risk of negative outcomes. These findings do not always transfer to real-life practice, however.

“Although this has been put forth in the literature, I do not believe it is true because that has not been my experience after doing this for 30 years,” Di Paola said. “Most of the workers want to get better and get back to work, and they will cooperate.

“Nonetheless, that bias appears in the medical literature, and so it affects the way the patient is treated by the health care providers,” Di Paola continued.

New research, different findings

Newer research may help dispel that notion. Benjamin G. Domb, MD, who is the medical director of the American Hip Institute and clinical assistant professor at Loyola University in Chicago, and colleagues compared the 2-year outcomes of workers’ and non-workers’ compensation patients undergoing hip arthroscopy following labral tears. The investigators matched the patients in each group (21 hips each) for age, surgical procedures, degree of arthritis, gender and various radiographic findings.

The researchers assessed patients preoperatively and 2-years postoperatively with the modified Harris Hip Score (mHHS), the Non-arthritic Hip Score (NHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL) and the Hip Outcome Score-Sport-Specific (HOS-SS) Subscales. Preoperatively, workers’ compensation patients had significantly lower scores for all measures.

The results showed that both groups had significant improvement in all patient-reported outcome measures, according to Domb. In the workers’ compensation group, scores improved from preoperatively to 2 years postoperatively as follows: mHHS, 46 to 67.7; NHS, 39.3 to 66; HOS-ADL, 39.7 to 69.5; and HOS-SS, 15.3 to 49.8.

For the non-workers’ compensation group, scores increased 67.9 to 85.8 for mHHS, 62.6 to 84.4 for NHS, 69.8 to 86.9 for HOS-ADL and 41.9 to 73.8 for HOS-SS subscales.

“They were dramatic improvements; both groups benefited greatly,” Domb, who is also an attending surgeon at Hinsdale Orthopedics, told Orthopedics Today.

It is important to note the functional level of the workers’ compensation group started out lower and it ended lower; however, their improvement was equal to the non-work comp group, according to Domb.

This showed that “work comp patients can benefit equally to a non-workman’s compensation group, but given their lower starting and ending points using patient-reported outcome functional measures, their expectations the expectations of the surgeon should be adjusted accordingly,” Domb said.

Although this study focused on hip arthroscopy, “I think the findings extend beyond hip arthroscopy because this is one of the few level 2 studies that have been done on work comp patients for any kind of surgery,” Domb said.

Another matched case-control study, this time in the shoulder, showed similar results. Holtby and colleagues reported on 220 patients who had undergone rotator cuff surgery. Their findings show that workers’ compensation patients had significant improvement 1 year after decompression or repair of their rotator cuff.

William N. Levine

Di Paola performed a literature search on medial menisectomy, the most common operative procedure performed on injured workers in the United States. He found a 50% failure rate with medial menisectomy. In contrast in his study, “We found that 98% of those patients got well, returned to work at full duty with no impairment or disability in 4 [months] to 6 months after surgery,” he said.

More and better training in the care of workers’ compensation patients may overcome the bias that exists. Currently, orthopedic surgeons receive little to no training when it comes to treating this specific patient population.

“We could probably do a better job as educators in helping our young residents understand the different challenges,” said William N. Levine, MD, who is chair of the department of orthopedic surgery at Columbia University’s College of Physicians and Surgeons, in New York City.

Pediatric, sports medicine and gerontologists all receive specialized training about the specific patient population they cover, Di Paola said.

“We do not have that same kind of training program to help doctors understand how to successfully treat injured workers,” he said.

Training in this area should be introduced early in medical education and it should be reinforced throughout residency, especially in orthopedics, Di Paola said. “I went through 6 years of residency training and I did not get 1 minute of training on how to deal with the workers’ compensation system and what to expect. The only thing I was taught was not to expect the patients to get better.”

Cannada agrees that educating residents is important.

“Workers’ compensation education should be a part of all residency programs, so that they learn from the beginning how to deal with certain issues, such as malingering, functional capacity evaluations, case managers, etc.,” she said.

There are several important factors to consider in the treatment of workers’ compensation patients. At the outset, the physician must define the mechanism of injury, which means carefully documenting the patient’s description of how the injury occurred. This will identify the positions and forces that were active during the injury.

“That will help throughout the claim to determine what was caused and not caused by the work incident,” Di Paola said. “Understanding the mechanism of injury also helps you also understand what possible and probable injuries could take place under those circumstances.”

Domb agreed. “Generally, one needs to record whether the injury caused the pathology, contributed to the pathology or was not the cause of the pathology,” he said. “It is important to note that the laws for what constitutes causation differ by state, so you have to have some awareness of what the specific laws are in your state.”

Educate the patient

Di Paola likes to take some time at the beginning of the process to educate the patient about the workers’ compensation system, its purpose and explaining the physician’s role.

“We put a lot of emphasis on reassuring patients that they are going to get better,” Di Paola said. “We see patients who have been elsewhere who say ‘Well, my doctor told me to start looking for a new job because I was never going back to the job that I had,’ which most of the time, is not accurate.”

Managing expectations in this patient population is important. “One of the dilemmas that we have is that many of these workers are heavy, heavy laborers,” Levine told Orthopedics Today. “Managing their expectations of what it means to return to the previous level of activity may be entirely different than managing the 60-year-old sedentary person whose only needs are being able to reach the top shelf, do their daily activities and may be [to] play some doubles tennis.

“I [counsel] the patients right from the start, especially if they have a significant heavy labor type position, that vocational rehabilitation is something they are going to have to consider if they are undergoing workers’ compensation surgery,” Levine, who is also the Shoulder & Elbow Section Editor for Orthopedics Today, said.

It is important to discuss medication use early on as well, Di Paola said.

“The first time that we prescribe a narcotic or sedative medication to a patient, we tell them that we are going to get them off that medicine, that this is not a permanent form of dealing with their injury,” he said. “Oftentimes, we will set a time limit.”

For the orthopedic surgeon another key factor is to remain alert for patients with secondary gain issues, Cannada said. “[The surgeon should] have some objective evaluation of [the patient’s] subjective complaints if you feel they are lagging behind,” she said.

If there are concerns about secondary gains, observe the patient’s effort in physical therapy (i.e., how many visits), examine their requests for pain medicine and carefully assess subjective complaints that are difficult to quantify, Cannada, who is also an Orthopedics Today Editorial Board member, said.

Other red flags include a history of multiple surgeries, multiple periods of being out of work due to injury and pain out of proportion to the physical presentation of the injury, Levine said.

In hip arthroscopy, objective testing such as diagnostic injections, can help identify these patients, Domb said.

Return-to-work readiness

Once patients have undergone successful treatment, the next step is to get them back to work as quickly as possible. To start, it is important to have a thorough job description, Cannada said. That description must address job requirements in terms of strenuousness (light, medium or heavy duty), the amount of lifting involved, etc. These factors influence the timing of the return to work as well as any duty restrictions, if needed, she said.

Medication use must be addressed before the worker can return to the job. “Generally, they have to be off narcotics,” Domb said. “Usually, by their first postoperative visit — 10 days to 14 days after surgery — I return them to some sort of work, with some restrictions.” Following hip arthroscopy, Domb hopes to return people to a desk job within about 2 weeks, to medium-level physical jobs in about 3 months to 4 months and heavy level physical jobs in about 6 months.

To determine if a patient requires a permanent duty restriction, Domb uses tools like functional capacity evaluations (FCEs). Conducted by physical therapists, FCEs assesses a patient’s physical command capabilities.

Guidelines such as the Official Disability Guidelines can be helpful. They provide the median number of physical therapy visits and days off work needed to treat a specific injury. “It tells you the most common number of days off work; it does not tell you the most effective number of days off work,” Di Paola said. “It is good use those guidelines as a ceiling, but it does not mean that you need to use that much treatment or keep people off work that long.”

The surgeon is the best equipped to make the return-to-work decision.

“Ultimately, the orthopedic surgeon is the quarterback of this team,” Levine said. “I think return to work, it is a shared decision-making to some extent but as the quarterback and the orthopedic surgeon, I ultimately have to say whether the patient is ready or not based on my medical evaluation.”

This patient population also represents challenges from a practice management perspective. “The thing you have to recognize is that there is a distinct difference between the administration of a workers’ compensation claim and the administration of other insurance claims,” Di Paola said. “That has to do with the need for the insurance company to have certain information in advance, such as the mechanism of injury and being specific about work restrictions.”

Treating workers’ compensation patients means submitting significantly more paperwork and potentially special training for practice staff.

“You need to send letters, sometimes to the insurance company, the patient’s employer, maybe their lawyer,” Andersson said. “You need to fill out forms with respect to work return, some of which are heavy and complicated. Overall, the burden on your office according to a couple of studies from a few years back is about 30% greater than it is with your patients with commercial insurance.”

Despite some additional paperwork hassles, the orthopedic surgeons who treat this patient population must maintain a focus on the end goal: returning the patient to work in some capacity, Andersson, who is also the Basic Science & Technology Section Editor for Orthopedics Today, said.

“You have to treat the patient’s injury, but at the same time you have to be aware of the fact that one of the aspects of the management of this patient is to return the patient to work, whether it is the same type of job or a different job; it all depends on the patient’s abilities,” he said. “All along, it is [the surgeon’s] responsibility to at some point say, ‘This is as far as we can go in terms of treatment.’ We refer to that stage as having reached maximum medical improvement — now it is time to close the workers’ compensation case and go back to work, in whatever capacity you are able.”– by Colleen Owens

References:

Atlas SJ. Spine (Phila Pa 1976) 2010;35:89-97.

De Moraes VY. PLoS One. 2012;doi:10.1371/journal.pone.0050251.

Holtby R. J Shoulder Elbow Surg. 2010;doi: 10.1016/j.jse.2009.06.011.

Stake CE. Am J Sports Med. 2013;doi:10.1177/0363546513496055.

For more information:

Gunnar B.J. Andersson, MD, PhD, can be reached at Midwest Orthopaedics at Rush, 1611 W. Harrison St., Chicago, IL 60612; email: gunnar_andersson@rsh.net.

Lisa K. Cannada, MD, can be reached at the Department of Orthopedic Surgery, Saint Louis University, 621 S. New Ballas Rd., St. Louis, MO 63141; email: lcannada@slu.edu.

John Di Paola, MD, can be reached at Occupational Orthopedics, 6464 SW Borland Rd, Tualatin, OR 97062; email: oji@occortho.com.

Benjamin G. Domb, MD, can be reached at Hinsdale Orthopaedics and the American Hip Institute, 1010 Executive Ct., Suite 250, Westmont, IL 60521; bendomb@gmail.com.

William N. Levine, MD, can be reached at Columbia University Medical Center - Irving Pavilion (Atchley), 171 Ft. Washington Ave., New York, NY 10032; email: wnl1@cumc.columbia.edu.

Disclosures: Di Paola is the founder of Occupational Orthopedics. Andersson, Cannada, Domb and Levine have no relevant financial disclosures.

POINTCOUNTER

Should treatment and return-to-work guidelines play a role in the management of workers’ compensation patients?

POINT 

Treatment guidelines have secured a place in the management of these patients

Kurt T. Hegmann

High-quality treatment guidelines that comply with the Institute of Medicine’s criteria are amongst the few means to distill the body of evidence on treatment of injuries and maintain clinical currency. The American College of Occupational and Environmental Medicine (ACOEM) has distilled more than 16,000 studies in guidelines. In addition, there are more than 1,000 peer-reviewed musculoskeletal studies produced annually to add to this evidence base. It clearly is impossible for a physician to read that many studies to ascertain what the current evidence is and how it has, in some cases, changed over time.

In teaching about this evidence base, we have asked simple questions about what the body of evidence shows. In doing so, we have queried more than 2,000 providers, roughly one-third of whom were orthopedists. Without fail, physicians guessed correct answers at a rate worse than randomized responses. This is because we have largely been taught apprenticeship medicine, not evidence-based medicine (EBM), combined with being unable to keep up with the deluge of knowledge.

In my practice, I have worked for more than 8 years to revise to EBM protocols, and I have seen marked improvements in outcomes. For example, individuals supposedly ready for surgery for epicondylalgia who no longer needed surgery after an EBM protocol was instituted. Using EBM protocols, we have been able to change the focus to function for chronic back pain patients, and as a result, they are now functional and coping with their incurable pain. It has been by far the most rewarding aspect of clinical practice in the past 20 years. The challenge is it takes a long time to revise the treatment approaches we were taught over the years.

There is no longer a question about whether there is a place for high-quality guidelines in treatment. There is unanimity of opinion among evidence-based medical scholars and the only alternative is to perform individual searches of Cochrane and other high-quality systematic reviews and meta-analyses. Rather, the question is how to best implement quality guidelines.

Kurt T. Hegmann, MD, MPH, is chief of the Division of Occupational Health at the University of Utah.

Disclosure: Hegmann is editor of the ACOEM Practice Guidelines and runs one of the 18 CDC/NIOSH-sponsored OSH educational and research centers.

COUNTER

Guidelines are a starting point

David B. Cohen

Guidelines are useful for creating an overview of expectations regarding return-to-work following an injury or surgery, but it is important that all involved parties understand that guidelines require a lot of flexibility and individualization.

Individualization is necessary because the pathology varies. Rotator cuff repair plays a big part in my practice. There is a broad spectrum of pathology in the rotator cuff, and the treatments and recovery times vary. For example, in the case of surgery for partial rotator cuff tears, the surgeon frequently debrides the rotator cuff, removes bone spurs and excises the bursa. This patient’s recovery is different from that in someone who needs surgery for a full-thickness rotator cuff tear. That situation is different from the person who tore two or three of the rotator cuff tendons off the bone, or someone who tore both the rotator cuff and some of the labrum in the shoulder. It is rarely so simple as one problem, one solution and a defined period of recovery.

Guidelines are a starting point. They put expectations into the ballpark, but the specifics of the individual patient and that patient’s pathology must be better evaluated and expectations have to be altered accordingly.

Knowing what job the patient will return to postoperatively plays a critical role in shaping expectations, as well. Return to full duty is different for different patients. It means one thing for a school teacher who tore her rotator cuff in a parking lot fall, who after surgery, is able to write on a blackboard and teach in a classroom. It means something else for the telephone company employee who has to climb poles to repair wires, or the school custodian who has to regularly lift heavy bags of trash.

According to the guidelines, a surgically repaired full-thickness rotator cuff should be firmly healed to the bone by 6-months postoperatively. However, if you are sending that person back to heavy manual labor, you might give it a couple of extra months, send the patient through a work-hardening program, make sure that all of the other muscles in that person’s body, core and lower body are ready to get back to that job so that the patient does not incur another injury; whereas, you might send a person returning to a desk job back to full duty 3 months to 4 months after rotator cuff repair. Guidelines cannot be generalized to all jobs; again, specifics are crucial.

Patient age also matters. Older surgical patients with poor tissue quality might require more time to safely return to work.

I think that guidelines have a general role in the management of workers’ compensation patients. Individualization is extremely important for both the person and the job to which that person will return.

The surgeon is the only person who truly understands what is going on with that particular patient, and he or she must have the flexibility to make decisions that are maximally beneficial to the patient.

David B. Cohen, MD, is a sports medicine specialist at Connecticut Orthopaedic Specialists and an attending surgeon at Yale-New Haven Hospital.

Disclosure: Cohen has no relevant financial disclosures.

Orthopedic surgeons are often called upon to care for injured workers; however, these cases can present with many unique challenges.

“[Workers’ compensation patients] are in a unique environment,” John D. Di Paola, MD, an orthopedic surgeon with Occupational Orthopedics in Tualatin, Oregon, told Orthopedics Today. “They are affected by multiple factors that are the result of that environment, which is created by the workers’ compensation system.”

In this Cover Story, Orthopedics Today explores the biggest clinical and practice management obstacles presented by this patient population and how surgeons can best manage these patients.

One challenge for the surgeon is to navigate the nature of the workers’ compensation environment. Workers’ compensation insurance covers only those injuries that occur in the workplace or as a direct result of the patient’s work, Di Paola said. When a worker is injured, the employer begins an investigation, which can be intrusive, he said.

“Sometimes that will make some workers feel as though they are not trusted or that they are not being honest,” Di Paola said. “That can sometimes immediately set up a negative environment of suspicion or fear or anxiety about the whole process.”

John D. Di Paola, MD, noted that although some published studies point to workers’ compensation patients having more negative outcomes after treatment compared with non workers’ compensation patients, this finding has not always manifested in real-life practice.

Image: Lori Di Paola

Throughout the process, workers’ compensation patients receive many legal notifications from their insurance carriers, which are typically written in legal jargon.

“When patients get these notifications, they do not know what [they] mean and that can also make them feel as if they are in a hostile environment,” Di Paola said.

“There are several publications that show that the treatment response is not as good in workers’ compensation patients as in patients with commercial insurance,” said Gunnar B.J. Andersson, MD, PhD, who is professor and chairman emeritus in the department of orthopedic surgery at Rush University Medical Center in Chicago. “And the reason why that is the case is not always entirely clear.”

Poorer outcomes

From the trauma literature, findings from the Lower Extremity Assessment Project (LEAP) indicate that patients who filed workers’ compensation claims had poorer outcomes, according to Lisa K. Cannada, MD, an associate professor of orthopedic surgery at Saint Louis University, in St. Louis.

Results from the Spine Patient Outcomes Research Trial (SPORT) also demonstrated that workers’ compensation patients did have not results equal to non-workers’ compensation patients, she said.

Lisa K. Cannada

Furthermore, a recent meta-analysis by de Moraes and colleagues showed that patients receiving workers’ compensation who underwent orthopedic procedures had a two-fold greater risk of negative outcomes. These findings do not always transfer to real-life practice, however.

“Although this has been put forth in the literature, I do not believe it is true because that has not been my experience after doing this for 30 years,” Di Paola said. “Most of the workers want to get better and get back to work, and they will cooperate.

“Nonetheless, that bias appears in the medical literature, and so it affects the way the patient is treated by the health care providers,” Di Paola continued.

PAGE BREAK

New research, different findings

Newer research may help dispel that notion. Benjamin G. Domb, MD, who is the medical director of the American Hip Institute and clinical assistant professor at Loyola University in Chicago, and colleagues compared the 2-year outcomes of workers’ and non-workers’ compensation patients undergoing hip arthroscopy following labral tears. The investigators matched the patients in each group (21 hips each) for age, surgical procedures, degree of arthritis, gender and various radiographic findings.

The researchers assessed patients preoperatively and 2-years postoperatively with the modified Harris Hip Score (mHHS), the Non-arthritic Hip Score (NHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL) and the Hip Outcome Score-Sport-Specific (HOS-SS) Subscales. Preoperatively, workers’ compensation patients had significantly lower scores for all measures.

The results showed that both groups had significant improvement in all patient-reported outcome measures, according to Domb. In the workers’ compensation group, scores improved from preoperatively to 2 years postoperatively as follows: mHHS, 46 to 67.7; NHS, 39.3 to 66; HOS-ADL, 39.7 to 69.5; and HOS-SS, 15.3 to 49.8.

For the non-workers’ compensation group, scores increased 67.9 to 85.8 for mHHS, 62.6 to 84.4 for NHS, 69.8 to 86.9 for HOS-ADL and 41.9 to 73.8 for HOS-SS subscales.

“They were dramatic improvements; both groups benefited greatly,” Domb, who is also an attending surgeon at Hinsdale Orthopedics, told Orthopedics Today.

It is important to note the functional level of the workers’ compensation group started out lower and it ended lower; however, their improvement was equal to the non-work comp group, according to Domb.

This showed that “work comp patients can benefit equally to a non-workman’s compensation group, but given their lower starting and ending points using patient-reported outcome functional measures, their expectations the expectations of the surgeon should be adjusted accordingly,” Domb said.

Although this study focused on hip arthroscopy, “I think the findings extend beyond hip arthroscopy because this is one of the few level 2 studies that have been done on work comp patients for any kind of surgery,” Domb said.

Another matched case-control study, this time in the shoulder, showed similar results. Holtby and colleagues reported on 220 patients who had undergone rotator cuff surgery. Their findings show that workers’ compensation patients had significant improvement 1 year after decompression or repair of their rotator cuff.

William N. Levine

Di Paola performed a literature search on medial menisectomy, the most common operative procedure performed on injured workers in the United States. He found a 50% failure rate with medial menisectomy. In contrast in his study, “We found that 98% of those patients got well, returned to work at full duty with no impairment or disability in 4 [months] to 6 months after surgery,” he said.

More and better training in the care of workers’ compensation patients may overcome the bias that exists. Currently, orthopedic surgeons receive little to no training when it comes to treating this specific patient population.

“We could probably do a better job as educators in helping our young residents understand the different challenges,” said William N. Levine, MD, who is chair of the department of orthopedic surgery at Columbia University’s College of Physicians and Surgeons, in New York City.

Pediatric, sports medicine and gerontologists all receive specialized training about the specific patient population they cover, Di Paola said.

“We do not have that same kind of training program to help doctors understand how to successfully treat injured workers,” he said.

Training in this area should be introduced early in medical education and it should be reinforced throughout residency, especially in orthopedics, Di Paola said. “I went through 6 years of residency training and I did not get 1 minute of training on how to deal with the workers’ compensation system and what to expect. The only thing I was taught was not to expect the patients to get better.”

PAGE BREAK

Cannada agrees that educating residents is important.

“Workers’ compensation education should be a part of all residency programs, so that they learn from the beginning how to deal with certain issues, such as malingering, functional capacity evaluations, case managers, etc.,” she said.

There are several important factors to consider in the treatment of workers’ compensation patients. At the outset, the physician must define the mechanism of injury, which means carefully documenting the patient’s description of how the injury occurred. This will identify the positions and forces that were active during the injury.

“That will help throughout the claim to determine what was caused and not caused by the work incident,” Di Paola said. “Understanding the mechanism of injury also helps you also understand what possible and probable injuries could take place under those circumstances.”

Domb agreed. “Generally, one needs to record whether the injury caused the pathology, contributed to the pathology or was not the cause of the pathology,” he said. “It is important to note that the laws for what constitutes causation differ by state, so you have to have some awareness of what the specific laws are in your state.”

Educate the patient

Di Paola likes to take some time at the beginning of the process to educate the patient about the workers’ compensation system, its purpose and explaining the physician’s role.

“We put a lot of emphasis on reassuring patients that they are going to get better,” Di Paola said. “We see patients who have been elsewhere who say ‘Well, my doctor told me to start looking for a new job because I was never going back to the job that I had,’ which most of the time, is not accurate.”

Managing expectations in this patient population is important. “One of the dilemmas that we have is that many of these workers are heavy, heavy laborers,” Levine told Orthopedics Today. “Managing their expectations of what it means to return to the previous level of activity may be entirely different than managing the 60-year-old sedentary person whose only needs are being able to reach the top shelf, do their daily activities and may be [to] play some doubles tennis.

“I [counsel] the patients right from the start, especially if they have a significant heavy labor type position, that vocational rehabilitation is something they are going to have to consider if they are undergoing workers’ compensation surgery,” Levine, who is also the Shoulder & Elbow Section Editor for Orthopedics Today, said.

It is important to discuss medication use early on as well, Di Paola said.

“The first time that we prescribe a narcotic or sedative medication to a patient, we tell them that we are going to get them off that medicine, that this is not a permanent form of dealing with their injury,” he said. “Oftentimes, we will set a time limit.”

For the orthopedic surgeon another key factor is to remain alert for patients with secondary gain issues, Cannada said. “[The surgeon should] have some objective evaluation of [the patient’s] subjective complaints if you feel they are lagging behind,” she said.

If there are concerns about secondary gains, observe the patient’s effort in physical therapy (i.e., how many visits), examine their requests for pain medicine and carefully assess subjective complaints that are difficult to quantify, Cannada, who is also an Orthopedics Today Editorial Board member, said.

Other red flags include a history of multiple surgeries, multiple periods of being out of work due to injury and pain out of proportion to the physical presentation of the injury, Levine said.

In hip arthroscopy, objective testing such as diagnostic injections, can help identify these patients, Domb said.

Return-to-work readiness

Once patients have undergone successful treatment, the next step is to get them back to work as quickly as possible. To start, it is important to have a thorough job description, Cannada said. That description must address job requirements in terms of strenuousness (light, medium or heavy duty), the amount of lifting involved, etc. These factors influence the timing of the return to work as well as any duty restrictions, if needed, she said.

PAGE BREAK

Medication use must be addressed before the worker can return to the job. “Generally, they have to be off narcotics,” Domb said. “Usually, by their first postoperative visit — 10 days to 14 days after surgery — I return them to some sort of work, with some restrictions.” Following hip arthroscopy, Domb hopes to return people to a desk job within about 2 weeks, to medium-level physical jobs in about 3 months to 4 months and heavy level physical jobs in about 6 months.

To determine if a patient requires a permanent duty restriction, Domb uses tools like functional capacity evaluations (FCEs). Conducted by physical therapists, FCEs assesses a patient’s physical command capabilities.

Guidelines such as the Official Disability Guidelines can be helpful. They provide the median number of physical therapy visits and days off work needed to treat a specific injury. “It tells you the most common number of days off work; it does not tell you the most effective number of days off work,” Di Paola said. “It is good use those guidelines as a ceiling, but it does not mean that you need to use that much treatment or keep people off work that long.”

The surgeon is the best equipped to make the return-to-work decision.

“Ultimately, the orthopedic surgeon is the quarterback of this team,” Levine said. “I think return to work, it is a shared decision-making to some extent but as the quarterback and the orthopedic surgeon, I ultimately have to say whether the patient is ready or not based on my medical evaluation.”

This patient population also represents challenges from a practice management perspective. “The thing you have to recognize is that there is a distinct difference between the administration of a workers’ compensation claim and the administration of other insurance claims,” Di Paola said. “That has to do with the need for the insurance company to have certain information in advance, such as the mechanism of injury and being specific about work restrictions.”

Treating workers’ compensation patients means submitting significantly more paperwork and potentially special training for practice staff.

“You need to send letters, sometimes to the insurance company, the patient’s employer, maybe their lawyer,” Andersson said. “You need to fill out forms with respect to work return, some of which are heavy and complicated. Overall, the burden on your office according to a couple of studies from a few years back is about 30% greater than it is with your patients with commercial insurance.”

Despite some additional paperwork hassles, the orthopedic surgeons who treat this patient population must maintain a focus on the end goal: returning the patient to work in some capacity, Andersson, who is also the Basic Science & Technology Section Editor for Orthopedics Today, said.

“You have to treat the patient’s injury, but at the same time you have to be aware of the fact that one of the aspects of the management of this patient is to return the patient to work, whether it is the same type of job or a different job; it all depends on the patient’s abilities,” he said. “All along, it is [the surgeon’s] responsibility to at some point say, ‘This is as far as we can go in terms of treatment.’ We refer to that stage as having reached maximum medical improvement — now it is time to close the workers’ compensation case and go back to work, in whatever capacity you are able.”– by Colleen Owens

References:

Atlas SJ. Spine (Phila Pa 1976) 2010;35:89-97.

De Moraes VY. PLoS One. 2012;doi:10.1371/journal.pone.0050251.

Holtby R. J Shoulder Elbow Surg. 2010;doi: 10.1016/j.jse.2009.06.011.

Stake CE. Am J Sports Med. 2013;doi:10.1177/0363546513496055.

For more information:

Gunnar B.J. Andersson, MD, PhD, can be reached at Midwest Orthopaedics at Rush, 1611 W. Harrison St., Chicago, IL 60612; email: gunnar_andersson@rsh.net.

Lisa K. Cannada, MD, can be reached at the Department of Orthopedic Surgery, Saint Louis University, 621 S. New Ballas Rd., St. Louis, MO 63141; email: lcannada@slu.edu.

John Di Paola, MD, can be reached at Occupational Orthopedics, 6464 SW Borland Rd, Tualatin, OR 97062; email: oji@occortho.com.

Benjamin G. Domb, MD, can be reached at Hinsdale Orthopaedics and the American Hip Institute, 1010 Executive Ct., Suite 250, Westmont, IL 60521; bendomb@gmail.com.

William N. Levine, MD, can be reached at Columbia University Medical Center - Irving Pavilion (Atchley), 171 Ft. Washington Ave., New York, NY 10032; email: wnl1@cumc.columbia.edu.

Disclosures: Di Paola is the founder of Occupational Orthopedics. Andersson, Cannada, Domb and Levine have no relevant financial disclosures.

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POINTCOUNTER

Should treatment and return-to-work guidelines play a role in the management of workers’ compensation patients?

POINT 

Treatment guidelines have secured a place in the management of these patients

Kurt T. Hegmann

High-quality treatment guidelines that comply with the Institute of Medicine’s criteria are amongst the few means to distill the body of evidence on treatment of injuries and maintain clinical currency. The American College of Occupational and Environmental Medicine (ACOEM) has distilled more than 16,000 studies in guidelines. In addition, there are more than 1,000 peer-reviewed musculoskeletal studies produced annually to add to this evidence base. It clearly is impossible for a physician to read that many studies to ascertain what the current evidence is and how it has, in some cases, changed over time.

In teaching about this evidence base, we have asked simple questions about what the body of evidence shows. In doing so, we have queried more than 2,000 providers, roughly one-third of whom were orthopedists. Without fail, physicians guessed correct answers at a rate worse than randomized responses. This is because we have largely been taught apprenticeship medicine, not evidence-based medicine (EBM), combined with being unable to keep up with the deluge of knowledge.

In my practice, I have worked for more than 8 years to revise to EBM protocols, and I have seen marked improvements in outcomes. For example, individuals supposedly ready for surgery for epicondylalgia who no longer needed surgery after an EBM protocol was instituted. Using EBM protocols, we have been able to change the focus to function for chronic back pain patients, and as a result, they are now functional and coping with their incurable pain. It has been by far the most rewarding aspect of clinical practice in the past 20 years. The challenge is it takes a long time to revise the treatment approaches we were taught over the years.

There is no longer a question about whether there is a place for high-quality guidelines in treatment. There is unanimity of opinion among evidence-based medical scholars and the only alternative is to perform individual searches of Cochrane and other high-quality systematic reviews and meta-analyses. Rather, the question is how to best implement quality guidelines.

Kurt T. Hegmann, MD, MPH, is chief of the Division of Occupational Health at the University of Utah.

Disclosure: Hegmann is editor of the ACOEM Practice Guidelines and runs one of the 18 CDC/NIOSH-sponsored OSH educational and research centers.

COUNTER

Guidelines are a starting point

David B. Cohen

Guidelines are useful for creating an overview of expectations regarding return-to-work following an injury or surgery, but it is important that all involved parties understand that guidelines require a lot of flexibility and individualization.

Individualization is necessary because the pathology varies. Rotator cuff repair plays a big part in my practice. There is a broad spectrum of pathology in the rotator cuff, and the treatments and recovery times vary. For example, in the case of surgery for partial rotator cuff tears, the surgeon frequently debrides the rotator cuff, removes bone spurs and excises the bursa. This patient’s recovery is different from that in someone who needs surgery for a full-thickness rotator cuff tear. That situation is different from the person who tore two or three of the rotator cuff tendons off the bone, or someone who tore both the rotator cuff and some of the labrum in the shoulder. It is rarely so simple as one problem, one solution and a defined period of recovery.

Guidelines are a starting point. They put expectations into the ballpark, but the specifics of the individual patient and that patient’s pathology must be better evaluated and expectations have to be altered accordingly.

Knowing what job the patient will return to postoperatively plays a critical role in shaping expectations, as well. Return to full duty is different for different patients. It means one thing for a school teacher who tore her rotator cuff in a parking lot fall, who after surgery, is able to write on a blackboard and teach in a classroom. It means something else for the telephone company employee who has to climb poles to repair wires, or the school custodian who has to regularly lift heavy bags of trash.

According to the guidelines, a surgically repaired full-thickness rotator cuff should be firmly healed to the bone by 6-months postoperatively. However, if you are sending that person back to heavy manual labor, you might give it a couple of extra months, send the patient through a work-hardening program, make sure that all of the other muscles in that person’s body, core and lower body are ready to get back to that job so that the patient does not incur another injury; whereas, you might send a person returning to a desk job back to full duty 3 months to 4 months after rotator cuff repair. Guidelines cannot be generalized to all jobs; again, specifics are crucial.

Patient age also matters. Older surgical patients with poor tissue quality might require more time to safely return to work.

I think that guidelines have a general role in the management of workers’ compensation patients. Individualization is extremely important for both the person and the job to which that person will return.

The surgeon is the only person who truly understands what is going on with that particular patient, and he or she must have the flexibility to make decisions that are maximally beneficial to the patient.

David B. Cohen, MD, is a sports medicine specialist at Connecticut Orthopaedic Specialists and an attending surgeon at Yale-New Haven Hospital.

Disclosure: Cohen has no relevant financial disclosures.