You Can’t Have Good Work Conditioning Without Good Job Descriptions

Recently**, a physical therapist who I’ve known for years reached out to me for some advice. She had two patients that were being sent for “work conditioning” to her. The problem was that job descriptions weren’t provided for either of the two patients. She knew that the “I only have to do this…..I never have to do that” wasn’t the whole story. She also knew that I had been involved in writing job descriptions for those positions for some of our clients. Having performed Functional Capacity Evaluations with us in the past, she also knew that having a solid job description is key in matching up demonstrated performance to essential physical and postural demands.

Work conditioning is defined by the American Physical Therapy Association as “work related, intensive, goal-oriented treatment program specifically designed to restore an individual’s systemic, neuromusculoskeletal and cardiopulmonary functions. The objective is to restore the injured employee’s physical capacity and function for return to work.”

Without understanding what the functional demand is for a specific position, it is difficult to define the goals of a work conditioning program. One of the patients that she had inquired about was a school bus driver. He had told my friend that he “really didn’t have to do much beyond sit in the driver’s seat and drive. Maybe, open the door every so often to let the kids on in the morning or off in the afternoon.” He was returning to work from a lower extremity injury that resulted in a joint replacement. Having performed FCEs for school bus personnel before, she knew that the demands were more but was unsure of the other tasks.

School bus drivers are tasked with performing pre- and post- inspections of their vehicles. This involves checking in and around the vehicle, checking storage compartments (if the bus has one), ensuring that all emergency exits (including the roof exits) are operational, and being able to check under the seats for both children and their belongings. Also, in some districts, bus drivers may be switched to different routes based on employer needs. Switching routes may require drivers to pick up students who may be in wheelchairs. When the wheelchair lift malfunctions, drivers use a manual, hydraulic pump to elevate and lower the lift as needed. This task requires the driver to be able to squat or kneel to a level to operate the manual pump. Drivers, if an aide is not present, may have to secure wheelchairs to floor mounted devices, which requires the ability to kneel while reaching. With demands such as those listed, she needed to work with this patient on being able to step up/down to get into and out of the bus, to be able to kneel to perform tasks, and make sure that the driver demonstrated the ability to perform the overhead tasks of checking the emergency exits. The ability to perform these demands are even more important as a result of the NTSB school bus driver recommendations that I mentioned in a January blog post.

Based on the APTA definition, work conditioning covers a larger swath than when the patient was being treated solely for the injury that brought them to physical therapy. During that initial portion of the treatment, therapy focused on the needs of healing for the specific body part along with improving range of motion and strength as appropriate based on the healing process. Work conditioning helps to pick up to make sure that the other aspects of the injured worker such as their cardiovascular endurance, strength, power, and muscular endurance are not impaired when they are returned back to work. As a result, work conditioning includes activities to improve physical capacity in all of these areas. When an individual begins a work conditioning program, their initial status in these components should be documented – both as a baseline as well as for comparison to the essential postural and physical demands. This will help the therapist communicate to the patient, the case manager, the physician, and the employer as to where the patient is in regard to return to duty.

When quarantine/shelter in place orders begin to be lifted, work conditioning is going to play an important role in returning workers that had been out on workers comp prior to the pandemic to their previous roles. For many of these patients, they may have been shifted over to telerehab as clinics closed for safety issues. Telerehab and “virtual physical therapy” are great for keeping in contact with the worker and moving them along in their rehab journey as best as can be done in these circumstances. However, they may not have access to the resources or guidance to recondition themselves for work prior to returning to their job. Correcting this deconditioning is going to be vital to their success upon return to work as well as for reducing their risks for suffering another injury after return to work.

Yellow school bus. Vector illustration
Yellow school bus. Vector illustration

** – I had started writing this several weeks before all of the “shelter in place” orders started to come down from the different states and it sat in a draft folder for a while. As I revisited the draft after a little over 3 weeks in quarantine, it made me think about the fact that some injured workers currently in PT may be deconditioned if not by now, but definitely by the time the shelter in place orders are lifted. Getting these workers into a work conditioning program at the soonest appropriate time point may be the best chance for a successful return to work process.

Taking A Deeper Dive Into Your Injury Data

Recently, WorkersCompensation.com and Safety+Health Magazine ran two articles that provided interesting injury information that came from taking a deeper dive into reported injury data.

WorkersCompensation.com reported that injury rates in construction workers in Tennessee were higher for those on the job under two years. In both Tennessee and Ohio, injury rates for workers with less than 1 year of experience accounted for 47.5% and 45.6% of the total injuries, respectively. Workers with less than 6 months of experiences accounted for 37.1% and 33.6%, respectively.   The article notes two important thoughts:

  • Fingers and hand injuries were among the top 10 injured body parts – an issue that can be reduced with appropriate PPE
  • Teaming up new, inexperienced workers with mentors to learn to recognize work hazards

Safety+Health took an interesting look at the effects of shift length and inexperience on the risk of injury to those working in the mining industry. They reported on data from a study by researchers at University of Illinois at Chicago that found that miners working shifts longer than 9 hours “were 32% more likely to suffer work-related fatalities and 73% more likely to be part of an incident that caused injuries to multiple miners.” Risk factors for injury for those working more than 9 hours included workers that had less than 2 years experience in the job as well as irregular work schedules. Among the suggestions to reduce the risks were fixed schedules and a recommendation into looking deeper into the effects of longer shifts on “fatigue and nutrition”.

One of the key things that we ask on our FCE intake paperwork is the amount of time that a claimant has been working in their current position. More often than not, many of those who have been sent to us for the functional capacity evaluation have less than 1 year in the position in which they were injured. Length of employment at time of injury is a data point that all employers should be monitoring. When trends appear such as in the two studies noted, employers need to take a look at hiring practices and new hire training practices. They may find that their hiring process should include a post-offer pre-employment test of physical abilities to ensure that new hire candidates meet the essential physical and postural demands of the position.

Looking at injury data (OSHA logs, loss run data, etc.) should be a part of the process of setting up a post-offer pre-employment process in conjunction with performing on-site measurements to create a customized job description of the essential postural and physical demands. The injury data may help to pinpoint job tasks that require a deeper look to determine why employees are getting injured. Is it an ergonomic issue? Is it an issue of strength? Is it an issue of better standard operating procedures?

One of our clients asked for our assistance in reviewing the injury data after initiating a post-offer pre-employment testing process for an ambulance transport service to determine the effectiveness of the program. We looked at data from 3 years prior to initiation of the process as well as 3 years after (we encourage employers to look at this more frequently).   The initial review of the data indicated a minor drop in injuries after initiating the program (an overall drop of 6 injuries after initiating testing).

With only a small reduction in injuries, a deeper dive into the data was required. Several interesting variables were found during this deeper dive:

  • The number of neck, shoulder, and lower back injuries decreased but injuries involving the hands and exposure injuries increased
  • The number of employees decreased by 20% between the two periods
  • The number of transports increased after testing when there were less employees increasing the amount of exposure opportunities to be injured

Taking into account the reduction in the number of employees and the increase in patients transported, there is a 26.8% reduction in injuries.

Taking the deeper dive into the data allows for a greater understanding of the mechanisms that may be driving the injuries that your employees are experiencing. Make the time to look at your OSHA logs to see if there are injury trends, look at the amount of time employed at time of injury to see if there are trends with your new employees, or take a look at your loss runs to see if certain departments have either a greater number of injuries or a greater amount of lost time compared to other departments. All of these become a starting point in reducing future injuries.minied

 

 

 

The most important Super Bowl viewers

Over the last decade, the issue of concussions in professional football has been addressed in books, movies, lawsuits, and significant coverage in the news media.

While nobody is fully sure of the best way to completely address the issue and minimize the risk of concussions during play and practice, the NFL instituted an important program in 2012 to become more proactive in addressing potential concussion situations during games.  The NFL began placing certified athletic trainers (ATCs) in the stadiums to view games with the purpose of looking at both the in-game contact as well as player behavior after plays and along the sidelines.

The inclusion of these healthcare professionals was a result of a hit to Browns quarterback Colton McCoy during a late season game in  December 2011 after the institution of a video review system for injuries.  The hit that McCoy took was not noticed during the game but after the game.  The NFL realized that a set of eyes were needed to review potential issues in real time.  The ATC spotters observe both the game and video feed from the broadcast coverage in real time to identify plays that may result in concussion or injury whether it is from player to player contact or contact with the ground.  The ATCs then contact either the team medical staff or the unaffiliated neurotruama consultant to advise them of what was observed.  These calls can not be handled by bench staff from the team.  The ATCs also instruct technicians to send the video of the specific incident to the sidelines for medical staff to include in their evaluation of the athlete.  According to the NFL, approximately 10 plays per game initiate this process.  ATC spotters can also initiate a medical timeout.  These timeouts are not charged to either team.

While there are several criteria for ATCs who wish to apply to this program, I think the most interesting are:

  • At least 10 years experience – enough experience to really have an idea of what they are observing
  • Can not have been the Head Trainer for any NFL team previously
  • Can not have been employed by an NFL team in the last 20 years

I think the last two criteria that I mentioned are probably the best at showing a positive intent for this program by the NFL.  These two criteria help to minimize the impact that past relationships with teams and/or players may have on an ATC Spotters observations.

While this is a great program and the NFL appears to have done a great job in keeping the program impartial and they have empowered the ATCs with the authority to stop game play, this only addresses observational, subjective game day issues.  It still does not provide an objective and measured value to the cumulative impacts that occur during the game – or more importantly, the significant hours of practice and seasons of games that comprise a player’s career.

Helmet impact sensors like those from Shockbox may help to provide a more objective dataset to determine the amount of cumulative impacts that a player goes through during the course of games and practices.  The US military has been studying head trauma through the use of helmet sensors since 2007 and began collaborating with the NFL in 2012 to better advance the science and address the issues.

The US Army had been using helmet based sensors in Afghanistan to measure blast pressures during IED events during combat patrols.  The sensors are triggered with forces greater than 150 newtons, which is the equivalent of just under 34 pounds of force.  Not a whole lot of force when compared to the forces of between 447 pounds and 1,066 pounds in boxers when punching.  However, a drawback to the Army/DARPA program was that it was only run in combat zones and did not take into account proximity and cumulative exposure to blast pressures when firing heavy weapons. The program was ended in late 2016.

There is one five year study that was done at University of North Carolina that looked at not just game day impacts but also the hits sustained during practice sessions.  The data that they collected shows some interesting data points.  They found that some impacts that were of significant force did not cause concussions while some lesser impacts that were below “threshold” did cause concussions.  Within these below threshold concussions, they found that the area of the point of impact on the head is just as important as the amount of force.

We still have a lot to learn about the causes and effects of concussions as well as treatment post concussion (as we’ve pointed out in a Friday Five post).  But, we can take notes from the positive aspects of what the NFL has done so far with their ATC Spotter program in being more proactive in dealing with health related “workplace” issues.