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WORK CONDITIONING AND WORK HARDENING

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WORK CONDITIONING AND WORK HARDENING

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WORK CONDITIONING AND WORK HARDENING

  1. 1. WORK CONDITIONING AND WORK HARDENING - NITHIN NAIR • UNDER GUIDANCE OF DR. POTHIRAJ P. (PT)
  2. 2. LEARNING OBJECTIVES • After this session students will have in-depth knowledge about Work Hardening and Work Conditioning.
  3. 3. INJURY ACUTE CARE FCA JOB ANALYSIS WORK HARDENING JOB MODIFICATION CONDITIONING WORK CONDITIONING RETURN TO WORK EXIT ASSESSMENT TERTIARY PREVENTION
  4. 4. FCA MEET JOB REQUIREMENTS RTW CAPABILTY BELOW AVERAGE CONDITIONING & RTW DOES NOT MEET JOB REQUIREMENTS VALID POOR POSTURE & BODY MECHANICS TRAINING MEETS JOB REQUIREMENTS RTW DOES NOT MEET JOB REQUIREMENTS WORK CONDITIONING RTW WORK CONDITIONING JOB MODIFICATION RTW JOB MODIFICATION RTW CONDITIONALLY VALID / INVALID WORK HARDENING RTW INVALID FCA RTW REDUCE OR TERMINATE WORKERS’ COMPENSATION BENEFITS
  5. 5. SIGNIFICANT DIFFERENCE BETWEEN A PERSON WHO IS MEDICALLY HEALED & A PERSON WHO IS PREPARED FOR RETURN TO WORK AT FULL JOB FUNCTIONS.  Physical strength to perform work – declined due to inactivity.  Individual’s physiological resources have been depleted – Energy level & Endurance.  The person’s psychosocial equilibrium unsettled – Fear of reinjury & other anxieties.  The body part “healed” in medical terms may still be vulnerable to reinjury when subjected to job demands. LITERATURE SUGGEST THAT THERE ARE A NUMBER OF MEASURES REQUIRED, BEYOND HEALING IN ORDER TO ACCOMPLISH A SAFE AND SUCCESSFUL RETURN TO FULL PRODUCTIVITY.  Physical strength – Built up & maintained.  The injury or illness – induced physiological & chemical changes that impact energy levels & endurance must be reversed.  The capability in strength and endurance depleted by inactivity must be restored..
  6. 6. STRENGTH EDURANCE FLEXIBILITY MOBILITY SYSTEMATIC APPROACH PREVENTIVE EDUCATION WORKERS’ COMPENSATION UNDERSTANDING HEALTH CARE KNOWLEDGE OF OPTIONS HONESTY & TRUST WELL DEFINED GOALS PACING MECHANISM COPING SKILLS CO – WORKER INTERACTION EMPLOYEE / EMPLOYER COMMUNICATION PAIN MANAGEMENT SKILLS WORK HABITS MOTIVATION / CONFIDENCE PHYSICAL CAPABILITIES SUPPORT STRUCTURE SELF MANAGEMENT SKILLS SPECIFIC RTW REQUIREMENTS
  7. 7. WORKRETRAINING OPERATIONS ASSESSMENT AND EVALUATION GOAL SETTING PROGRAM DAY LENGTH PROGRAM DURATION PROGRAM PLANNING PROTOCOL GUIDELINES SIMULATION GUIDELINES Provides a baseline of comparison for goal setting, planning and progress monitoring Goals are determined by rehabilitation team and should be SMART Previous → Later (8 hours → 6 hours → 4 hours) Determined using Predictive Index Determined using FCA results, return to work job demand, injury profile, validity index result, litigation status Should be consistent, standardized and flexible No need have exactly duplicate, just simulate relevant portions of it
  8. 8. FCA VALIDITY COMPLIANCE HISTORY LITIGATION STATUS TIME OUT OF WORK JOB ANALYSIS VALIDITY DETERMINATION PHYSICAL CAPABILITY PREDICTIVE INDEX α β γ CONDITIONING 2 WEEKS 6 WEEKS 4 WEEKS
  9. 9. WORKRETRAINING STRUCTURES SPACE REQUIREMENTS EQUIPMENT REQUIREMENTS EQUIPMENT SELECTION LOCATION SELECTION SPACE SELECTION PATIENT MIX STAFFING 3 primary determinants: Type of work, Population of workers types and injury types, program protocols (hours per day and days per week) Average size space is 2,500 sq. feet Functional, manufacture warranted, multi – user capable, multi – occupational flexible, durable, space efficient, client and therapist friendly, non trendy Nearby locations, easily accessible from major highways, within 30 min drive Warehouse buildings, medical buildings, should meet ADA requirements Severely impaired mixed with later stage recovery client Depends on the client caseload and the protocols
  10. 10. PT / OT (Program Director) Assumes managerial role + supervises + presides over staff meetings Add work trainer (Exs. Physiologist, Athletic training , PT / OT assistants or Kinesiologist NUMBER OF STAFF <10 clients Single therapist (4 weeks, 4 hours/day) More staff required (6 – 8 hours program) >10 clients Work trainer should be added and staff of 2 can manage up to 20 new clients Staff Increases Case load increases
  11. 11. APTA WORK CONDITIONING DEFINITION: Work Conditioning is a work related, intensive, goal-oriented treatment program specifically designed to restore an individual’s systemic, neuro, musculoskeletal (strength, endurance, movement, flexibility and motor control), and cardiopulmonary functions. The objective of the work conditioning program is to restore the client’s physical capacity and function so that the client can return to work. APTA WORK HARDENING DEFINITION: Work Hardening is a highly structured, goal-oriented, individualized treatment program designed to return the person to work. Work Hardening programs, which are interdisciplinary in nature, use real or simulated work activities designed to restore physical, behavioural and vocational functions. Work Hardening addresses the issues of productivity, safety, physical tolerance, and worker behaviours.
  12. 12. CONDITIONING WORK CONDITIONING WORK HARDENING FLEXIBILITY / MOBILITY    STRENGTHENING    CONDITIONING    OUTCOMES    ASSESSMENTS   JOB SIMULATION   FUNCTIONAL CIRCUIT   EDUCATION   VOCATIONAL REHABILITATION  PSYCHOSOCIAL REHABILITATION  COMPARISON OF THE TERMS WORK HARDENING, WORK CONDITIONING, AND CONDITIONING.
  13. 13. WORK CONDITIONING / WORK HARDENING  Frequency – 4–8 weeks, 5 days/week, 4 hours/day  Movements required in work place – used as treatment plan  Initiated and supervised by professional therapists  Work simulation included  Structured body mechanics  Preceded by FCA  Uses job requirements as objectives  Incremental task achieved – progress measure  Capability level based on safe performance of job tasks & job site ergonomics CONDITIONING  Frequency – 2-4 weeks, 3-5 days/week, 2-4 hours/day  Movements required in work place – used as treatment plan  Initiated and supervised by professional therapists  Work simulation not included  Structured body mechanics  Preceded by traditional clinical evaluation  Uses fitness level as objectives  Fitness goal attained – progress measure  Capability level based on physical fitness
  14. 14.  Both are work – oriented with specific work goals.  Both are initiated with an appropriate evaluation (entry assessment) and concluded with a return to work discharge evaluation (exit assessment)  Both have limited duration  Both interface with other team members (physicians, employers, insurance representatives, rehab. Consultants) WORK CONDITIONING  Addresses physical and functional needs; may be provided by one discipline (single discipline model)  Requires work conditioning examination and evaluation  Moderate space allocation  Utilizes more of physical conditioning and functional activities related to work  Provided in multi – hour sessions upto 4 hours / day → 5 days / week → 8 weeks WORK HARDENING  Addresses physical, functional, behavioural, vocational needs; with a multi disciplinary model)  Requires work hardening examination and evaluation  Large space allocation  Utilizes more of real or simulated work activities.  Provided in multi – hour sessions upto 8 hours / day → 5 days / week → 8 weeks
  15. 15. Previous models largely ignored the role of the work place preparedness in return to work so the newer multidimensional definition seeks to add constructs of work place preparedness including early return to work and a focus on decreasing lost time with a gap analysis principle that also includes consideration of the role of work place (barriers and facilitators) in return to work planning and goal setting. PREVIOUS MODELS – WORK CONDITIONING / HARDENING CURRENT MODEL – WORK REHABILITATION  Addresses physical, functional, behavioural, vocational needs within a multidisciplinary model that includes medical and workplace stakeholders.  Requires examination and evaluation with functional testing. Also requires communication and co-ordination with other stakeholders.  Utilizes various therapeutic interventions with a functional emphasis, emphasizing the role of the worker / work activities.  Treatment session determined by situational analysis, may extend from hour / multi – hour sessions depending on evaluation plan of care and options / availability for work reintegration.
  16. 16. POST INJURY CARE PHASE  TAKE THE REFERRAL  SET UP THE FILE  SCHEDULE THE CLIENT  INTAKE INTERVIEW  ORIENTATION / SIGNING – FACILITY POLICIES  AUTHORIZATION – RELEASE OF INFORMATION  CLIENTS RIGHTS LIST  JOB ANALYSIS OR WORK INFORMATION REVIEW  ASSESSMENTS  FLEXIBILITY / MOBILITY  STRENGTHENING  CONDITIONING  JOB SIMULATION  FUNCTIONAL CIRCUIT  EDUCATION  VOCATIONAL REHAB  PSYCHOSOCIAL  OUTCOMES  ADMINISTER FCA  REVIEW MEDICAL HISTORY  COMPARE FCA RESULTS WITH JOB REQUIREMENTS  DEVELOP EXIT GOAL  IDENTIFY PROGRAM LENGTH  CONFIRM PROBABILITY OF REACHING JOB REQUIREMENTS LEVEL  IF LOW PROBABILITY – JOB MODIFICATION  IDENTIFY STARTING POINT  IDENTIFY WEEKLY PROGESSION CHECK  IDENTIFY BODY MECHANICS ADAPTATIONS NEEDED  IDENTIFY EDUCATIONAL NEEDS  IDENTIFY EXERCISE NEEDS  PLAN JOB SIMULATION ACTIVITIES  IDENTIFY NEED FOR OUTSIDE SERVICES. SCHEDULE IMPLEMENTESTABLISHINTAKE
  17. 17. ASSESSMENT ENTRY ASSESSMENT INTERIM ASSESSMENT EXIT ASSESSMENT
  18. 18.  Purpose: Improve client’s postural adaptability for performance of work related tasks  Exercises are carried out as a part of the warm-up and cool-down periods  Clients home programs which occurs during the work retraining program and continues after the completion of the program can be selected from these exercises  Each stretch is held for 5 seconds and repeated 5 times  Benefits  Improve circulation`  Reduce neuromuscular inhibition  Provide carry over to functional activities  Improve confidence to safely move into posture
  19. 19.  The selection of the exercises is based on the results of the FCA, the job requirements, and the specific body part that is injured  Strengthening exercises should be a part of each day of treatment (20-30 minutes). They should be mixed in with work conditioning and work hardening components. (Part – Whole Concept)  Some strengthening exercises will be taxing so it is important to space them out, allowing ample rest and recovery between exercises.  Equipment & Exercise Selection – Isometric & active exs, free weights, dumbbells, and weight cuffs, Resisted exercise machine, hydraulic resistance, isokinetic equipment, thera band, gymnastic ball, WH & WC equipment  Objectives of the strengthening components  Develop strength in selected areas of the body  Work through specific areas of deficits  Support general improvement  Improve client’s ability to perform job simulation  Strengthen body parts to accommodate mechanical stresses  Increased localized strength for maintaining static posture
  20. 20.  It involves overloading the aerobic system, stressing it beyond its current limits to gain improvement in aerobic capability  Benefits  Improves Endurance  Improves Cardiovascular efficiency  Facilitates weight loss  Reduces pain and enhances well being  Guidelines  Intensity – Determined by Karvonen formula , 60 -80% of HRmax is taken  Frequency – 3 – 5 times / week, minimum 15 – 30 minutes of continuous activity  Type of Exercise – Must involve large muscle group, be repetitive in nature, and maintained over a period of time. It can be walking, running, biking, rowing, cross country skiing (simulated), stepping or swimming. Upper body ergometers can also be used.
  21. 21.  Job simulation can be defined as putting a worker in a similar or mock situation that closely resembles the task or tasks that the worker performs on the job  Work stations that simulate dynamic job functions should match individual’s job classification, postural treatment needs, body part injured  Break tasks into smaller independent component → Learn them in safe manner → Combine them again to resemble actual job  Approaches : General Simulation → Specific Simulation  Benefits of Job Simulation  Case resolution and return to work  Reduces fear of injury  Improves confidence in performing tasks  Determines client’s job task capabilities  Provides a safe and controlled environment General Simulation Specific Simulation Work on a part of the body / task Involves whole body / task Uses simulated physical demands Uses actual job task Works primarily on one physical demand at a time Involves multiple physical demands simultaneously Precedes specific simulation Succeeds general simulation
  22. 22.  Activities included are meant to be a distraction from pain while the individual is carrying out increased level of postural complexities.  Activities need to be short in duration (3 mins each), rapid paced and enjoyable to bring about a positive attitude  Total time devoted – 30 mins / day  Functional circuit activities should be based on “SAID” principle and should target postures and movements that are in need of rehabilitation and strengthening.  Monitoring Functional Activities: Direct observation and Indirect observation  Direct observation includes: Activities in standard FCA (kneeling, crawling, stooping, bending, squatting, reaching and grasping), Eye-hand co-ordination, Mobility, Reports and behaviours, Hearing and seeing.  Indirect observation includes: Pacing, Sequencing, Ability to follow multiple instructions, Partner and group responsiveness, Consistency, Motivation and Co-operation.  It can be considered as a good opportunity to develop client’s adaptations to immediate demands.
  23. 23. Main Objective: Educate clients on the proper use of their body to perform job comfortably, and to prevent re-injury.  Educational information should be consistent and on-going throughout the program  Educational sessions can be either individual sessions or group sessions.  Primary topics : Presented during group sessions (For a 6 week WH program – select 3 topics and rotate every week  Secondary Topics: Interspersed with primary topics. And can be covered as group sessions or individual sessions Topics Primary The injury (back, neck, upper extremities) Prevention Pain management Stress management Secondary Dependencies Nutrition Fitness Getting and Keeping a job Pain and Interpersonal relationships Others
  24. 24. The role of vocational rehabilitation consultant (VRC) organised into 5 major categories 1. As a referral source: Recommends providers for assessments and programs of treatment. Options available for referring clients. 2. As a communication and information facilitator: handles - sensitive issues, workers compensation benefits complications, transportation issues, job modifications, current information on job availability, accessing needed records / results. 3. As a source for speciality testing and needs: can recommend medical, standard capability test, psychological tests. 4. As a provider of guidance and advisory: assist with consultation, provide assistance in compliance issues, can advise if psychological intervention is needed, safe guard legal rights. 5. As a paperwork and payment facilitator: can intervene on behalf of client for expediting paperwork or processing bill. Why VRC referrals important ?  Prompt admission (FCA, RTW program)  Prompt , clear and responsive reporting  Clear recommendations  Congruent goal setting  Clear delineation of time frames  Solution –oriented approach  Defensible assessment and treatment  Standardized and consistent approach and outcomes  Flexibility
  25. 25. o Psychological component is one of the primary defining differences between Work Hardening and Work Conditioning o Program Director should select appropriate professionals (Psychologist / Psychosocial specialist) Identify triggers that indicate a potential need for psychosocial intervention  Conditionally valid or invalid determination  Little or no communication with co-workers / employer  Compliance issues  Being disruptive  Negative thoughts (Suicide, Violence)  Old pain/problems reappear shortly before discharge  Inability to work with equipment which had caused injury Psychosocial specialist should be prepared to address following topics  Pain management  Dependencies  Fear of return-to-work  Employee / employer relationship issues  Managing family and work issues,  Co-worker issues  Anxiety and stress management techniques  “Injured” self image syndrome
  26. 26. Ultimate Goal : Increase Productivity and Reduce Costs Hence, there is a growing demand of outcome studies – with it they can provide better tailored treatment, improve assessment procedures, support treatment and reimbursement, market industrial therapy services to new prospects 3 categories of outcomes should be measured to fully evaluate work retraining program  Clinical solutions: Return to work and reinjury percentages  Satisfaction survey: Client and Referral source  Follow-up client reports: 6 and 12 months post RTW Specific measures worth including  Length of time between injury – start of work retraining – return to work  Program components administered  Return to work status  Same employer – same job  Same employer – modified job  Same employer – modified job  Different employer – same job  Different employer – modified job  Different employer – different job  Not re-employed  Reinjury rates
  27. 27. PAIN ISSUES CLINICAL AND PHYSICAL ISSUES MOTIVATIONAL & MENTAL ISSUES COMBINATION CLINICAL & MOTIVATIONAL ISSUES
  28. 28. Pain  First determine whether the pain is simply discomfort from exertion or actual damage to the muscle tissues.  Remedies may include individual educational sessions, pain coping strategies, buddy activities, psychologist intervention. Clinical and Physical issues  Client pacing too fast – use reference points such as heart rate  Inexperience with equipment / exercises – provide accurate instructions, provide encouragement and observe and address incorrect techniques  Pain while performing exercise – differentiate between tissue damage pain and conditioning discomfort and then address each separately
  29. 29. Motivational and Mental Issues  Exhibits Depression – Document observations, report to the physician and other team members → professional consultation  Prior experience with exercise has been ineffective – Explain the work related reasons and science behind exercise, use outcome studies (evidences) for support  Blames trainer for consequences they anticipate – help them realize that he or she is the beneficiary of the program, not the victim Combination of Clinical and Motivational Issues  Evidences fear of reinjury - document the observation and discuss issues with the client, educating the client so that knowledge can overcome fear of the unknown.  Reports minor injury from the previous day – Injury however minor should be documented when they occur.  Doesn’t take some of the activities seriously – Certain activities are interim steps in the part to whole progression toward dynamic work function.
  30. 30. 1. INDUSTRIAL THERAPY – GLENDA KEY (1ST EDITION) 2. TEXTBOOK OF PREVENTION PRACTICE AND COMMUNITY PHYSIOTHERAPY (VOLUME: 1) – Dr. BHARATI BELLARE (1ST EDITION) 3. PHYSIOTHERAPY IN COMMUNITY HEALTH AND REHABILITATION – WAQAR NAQVI (1ST EDITION)

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