20032003

THE UNIVERSITY OF WESTERN THE UNIVERSITY OF WESTERN ONTARIOONTARIO

Department of Department of Epidemiology and Epidemiology and

BiostatisticsBiostatistics

Francine Lortie-Monette, MD, MSc, CSPQ, MBAFrancine Lortie-Monette, MD, MSc, CSPQ, MBA

Workers’ Workers’ Compensation in Compensation in Ontario: Ontario: Workplace Safety and Workplace Safety and Insurance Board Insurance Board (WSIB) (WSIB)

Roles of Physicians: Roles of Physicians: PreventionPrevention

DiagnosisDiagnosis

Treatment/medical managementTreatment/medical management

Facilitating return to workFacilitating return to work

ReportingReporting

WSIB/MOLTC WSIB/MOLTC AgreementAgreement

Business continues to be conducted under an agreement that was reached in October 1990 between the WSIB and MOH

FILING A CLAIM WITH WSIB -FILING A CLAIM WITH WSIB -

Once a claim has been filed, a practitioner who has examined or treated the worker has a duty to promptly disclose health-related information WSIB may need for adjudication purposes.

Conversely, there is no legal obligation to release information if the patient does not wish to file a claim.

_______ Section 37 (1) of the Workplace and Insurance Act, 1997.

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FILING A CLAIM WITH WSIBFILING A CLAIM WITH WSIB

For accidents on or after January 1, 1998, workers must file a claim for compensation:

within 6 months from the date of accident

or

in the case of occupational disease, 6 months from the date at which the worker learns that s/he suffers from the disease.

Difficult!Difficult!

incomplete medical informationincomplete medical information

poor communicationpoor communication

F.D. frequently misunderstands F.D. frequently misunderstands WSIB/employer/employee roleWSIB/employer/employee role

Body PartBody Part Evidence for Causal Relationship Evidence for Causal Relationship between physical work factors and between physical work factors and musculoskeletal disordersmusculoskeletal disorders

Neck and Neck/ShoulderNeck and Neck/Shoulder Repetition, Force, PostureRepetition, Force, Posture

ElbowElbow ForceForce

Carpal Tunnel SyndromeCarpal Tunnel Syndrome Repetition, Force, VibrationRepetition, Force, Vibration

Hand/Wrist TendinitisHand/Wrist Tendinitis Repetition, Force, VibrationRepetition, Force, Vibration

BackBack Lifting/forceful movementLifting/forceful movement

Heavy physical workHeavy physical work

Awkward PostureAwkward Posture

Whole Body VibrationWhole Body Vibration

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Musculoskeletetal Disorders and Workplace Factors. US Department of Health and Human Services, Public Health Service, Centers for Disease Control and

Prevention, National Institute or Occupational Safety and Health, July 1997.

1

WSIB Statistics-2001(1)WSIB Statistics-2001(1)

Accidents registered = 375,000

Allowed = 74%

Abandoned = 16%Denied = 3%Pending = 6%Amalgamated = 1%

Need for specific, objective information:Need for specific, objective information:

objective medical findingsobjective medical findings

treatment planstreatment plans

notification re: precautions (ie?) notification re: precautions (ie?)

Active and PassiveActive and Passive

Multiple DirectionsMultiple Directions

RANGE OF MOTION TESTING

RETURN-TO-WORK ISSUESRETURN-TO-WORK ISSUES

Returning a patient to work after an absence due to sickness or Returning a patient to work after an absence due to sickness or injury is an issue that arises almost daily in any busy family injury is an issue that arises almost daily in any busy family practice.practice.

One of the main goals for treating an ill or injured individual is to One of the main goals for treating an ill or injured individual is to restore the person, as much as possible, to their pre-injury level restore the person, as much as possible, to their pre-injury level of function.of function.

Recovery is not linear. An experienced physician will have Recovery is not linear. An experienced physician will have designed a treatment plan from the earliest days of the event, designed a treatment plan from the earliest days of the event, using the patient’s job demands as one of the treatment goals.using the patient’s job demands as one of the treatment goals.

Prolonged absence from one’s normal roles, including absence Prolonged absence from one’s normal roles, including absence from the workplace, may be detrimental to a person’s mental, from the workplace, may be detrimental to a person’s mental, physical and social well-being.physical and social well-being.

A FEW 1998 STATISTICS FROM WSIB:A FEW 1998 STATISTICS FROM WSIB:

725 Claims allowed per day, 37% with time lost from work. The average duration of short-term disability benefits: 57.7

calendar days.

Of the 97,000 lost-time claims as of March 31 (1997-1998):

94% were for musculoskeletal injuries (sprain, strain, fractures). Of these:

30% were injuries of the back (including the neck)

24% were injuries of the upper extremities.

18% were injuries of the lower extremities.

Benefits paid: $2.2 billions.

CONSEQUENCES OF CONSEQUENCES OF AN ILLNESS OR INJURYAN ILLNESS OR INJURY

The The World Health Organization International Classification of World Health Organization International Classification of Impairments, Disabilities, and HandicapsImpairments, Disabilities, and Handicaps provide a framework provide a framework

for describing the consequences of an illness or injury:for describing the consequences of an illness or injury:

ImpairmentImpairment (an organ-based concept) – any loss or (an organ-based concept) – any loss or abnormality of psychological, physiological, or anatomical abnormality of psychological, physiological, or anatomical structure or function. Impairment is described according to the structure or function. Impairment is described according to the body organ or system, e.g. visual impairment (myopia, body organ or system, e.g. visual impairment (myopia, blindness), musculoskeletal impairment (knee instability, blindness), musculoskeletal impairment (knee instability, shoulder impingement) or respiratory impairment (loss of FVC shoulder impingement) or respiratory impairment (loss of FVC or FEV1).or FEV1).

DisabilityDisability (a task-based concept) – any restriction or lack of (a task-based concept) – any restriction or lack of ability to perform an activity in the manner or within the range ability to perform an activity in the manner or within the range considered for a human being. Disability is described according considered for a human being. Disability is described according to a specific task, posture, or work environment, e.g. difficulty to a specific task, posture, or work environment, e.g. difficulty with floor-to-waist lifting, prolonged sitting, or working in the with floor-to-waist lifting, prolonged sitting, or working in the cold.cold.

In the view of the CMA & In the view of the CMA & the OMA:the OMA:

It is not the treating physician's It is not the treating physician's responsibility or role to determine whether responsibility or role to determine whether the patient’s condition meets the insurer’s the patient’s condition meets the insurer’s definition of disabilitydefinition of disability

ie the justification for the patient to be off ie the justification for the patient to be off workwork

especially as the physician is not aware of all especially as the physician is not aware of all jobs available in the workplacejobs available in the workplace

““Injury/Illness & Return Injury/Illness & Return To Work/Function:To Work/Function:

A Practical Guide for Physicians”A Practical Guide for Physicians”

Prepared by the Physician Education Prepared by the Physician Education Project in Workplace Health in conjunction Project in Workplace Health in conjunction with the OMA and the WSIBwith the OMA and the WSIB

What is the Functional Abilities What is the Functional Abilities Form (FAF)?Form (FAF)?

Highlights limitationsHighlights limitations

OptionalOptional tool completed at the request of tool completed at the request of either of the workplace partieseither of the workplace parties

Who can complete the Form?Who can complete the Form?

This form can only be completed by a This form can only be completed by a health professional who is treating the health professional who is treating the worker (ie a member of the College of worker (ie a member of the College of Health Profession as defined in Health Profession as defined in The The Regulated Professions Act, 1991Regulated Professions Act, 1991))

Health professionals do not initiate this Health professionals do not initiate this form.form.

Functional Abilities Form:Functional Abilities Form:

The legislation requires physicians and other The legislation requires physicians and other treating health professionals to complete the treating health professionals to complete the Functional Abilities form only Functional Abilities form only if if requested to do so requested to do so by the worker or employer. by the worker or employer. Some workplaces may prefer to use a form Some workplaces may prefer to use a form designed for their specific environment. These designed for their specific environment. These workplaces are welcome to use their own from to workplaces are welcome to use their own from to gather functional abilities information but the gather functional abilities information but the WSIB does not pay health professionals for WSIB does not pay health professionals for completing these variations. completing these variations. NO MEDICAL OR DIAGNOSTIC INFORMATION NO MEDICAL OR DIAGNOSTIC INFORMATION should be requested or provided in a workplace-should be requested or provided in a workplace-specific functional abilities form.specific functional abilities form.WSIB information hotline: 1-800-465-5606WSIB information hotline: 1-800-465-5606

The Functional Abilities FormThe Functional Abilities FormEmployerEmployer Requests from the worker a copy of the Form 2647A Requests from the worker a copy of the Form 2647A

and a copy of the worker’s consent allowing the and a copy of the worker’s consent allowing the health professional to release functional abilities health professional to release functional abilities information to the employer.information to the employer.May send a copy of the form and of the consent May send a copy of the form and of the consent directly to the health professional.directly to the health professional.

WorkerWorker Having signed consent, brings a copy of it along Having signed consent, brings a copy of it along with Form 2647A to the attending health professional.with Form 2647A to the attending health professional.Asks the professional to complete the form.Asks the professional to complete the form.

Health Health ProfessionalProfessional

Completes the form, gives the employer the canary Completes the form, gives the employer the canary yellow copy, gives the worker the pink copy and yellow copy, gives the worker the pink copy and sends the sends the whitewhite copy to the copy to the WSIBWSIB..The white copy also serves as the professional’s The white copy also serves as the professional’s invoice for payments.invoice for payments.The FAE form may be faxed.The FAE form may be faxed.

Physical DemandsPhysical Demands

Material HandlingMaterial Handling::

LiftingLifting

CarryingCarrying

PushingPushing

Pulling Pulling

Non-Material Non-Material HandlingHandling::

Stand/sit/walkStand/sit/walk

Stoop/kneel/crouchStoop/kneel/crouch

ReachingReaching

Fingering Fingering

HandlingHandling

Grasp / PinchGrasp / Pinch

Tool UseTool Use

Physical Demand Characteristics of WorkPhysical Demand Characteristics of Work

Physical Demand Characteristics of WorkPhysical Demand Characteristics of Work(Dictionary of Occupational Tiles, Vol. II, 4(Dictionary of Occupational Tiles, Vol. II, 4thth Edition, Revised 1991) Edition, Revised 1991)

PHYSICAL PHYSICAL DEMAND DEMAND LEVELLEVEL

OCCASIONAL OCCASIONAL

0-33% OF0-33% OF

WORKDAYWORKDAY

FREQUENTFREQUENT

34-66% OF34-66% OF

WORKDAYWORKDAY

CONSTANTCONSTANT

67-100% OF67-100% OF

WORKDAYWORKDAY

TYPICALTYPICAL

ENERGYENERGY

EXPENDITUREEXPENDITURE

SedentarySedentary 1-10 lbs.1-10 lbs. NegligibleNegligible NegligibleNegligible 1.5-2.1 METS1.5-2.1 METS

LightLight 11-20 lbs.11-20 lbs. 1-10 lbs.1-10 lbs. NegligibleNegligible 2.2-3.5 METS2.2-3.5 METS

MediumMedium 21-50 lbs.21-50 lbs. 11-25 lbs.11-25 lbs. 1-10 lbs.1-10 lbs. 3.6-6.3 METS3.6-6.3 METS

HeavyHeavy 51-100 lbs.51-100 lbs. 26-50 lbs.26-50 lbs. 11-20 lbs.11-20 lbs. 6.4-7.5 METS6.4-7.5 METS

Very Very HeavyHeavy

Over 100 lbs.Over 100 lbs. Over 50 lbs.Over 50 lbs. Over 20 lbs.Over 20 lbs. Over 7.5 METSOver 7.5 METS

Material Handling Material Handling Characteristics of WorkCharacteristics of Work

(U.S. Dept. of Labor D.O.T. 1996)(U.S. Dept. of Labor D.O.T. 1996)

OccasionalOccasional (0 to 33% of the workday) (0 to 33% of the workday)1 lift/carry every 15 min1 lift/carry every 15 min

FrequentFrequent (34 to 66% of the workday) (34 to 66% of the workday)1 rep every 5 min1 rep every 5 min

ConstantConstant (67 to 100% of the workday) (67 to 100% of the workday)>1 rep every 5 min>1 rep every 5 min

Non-Material Handling Non-Material Handling Characteristics of WorkCharacteristics of Work

Occasional Occasional (0 to 33% of the workshift)(0 to 33% of the workshift)1-100 reps over 8hr 1-100 reps over 8hr

Frequent Frequent (34 to 66% of the workshift)(34 to 66% of the workshift)100-500 reps over 8hr 100-500 reps over 8hr

Constant Constant (67 to 100% of the workshift)(67 to 100% of the workshift)>500 reps over 8hr >500 reps over 8hr

A combination of tests / no “one indicator”A combination of tests / no “one indicator”Kinesio-physical ApproachKinesio-physical Approach

Normal expectations ie Push > pull, shoulder height values Normal expectations ie Push > pull, shoulder height values < bench height abilities< bench height abilities

Consistency in testing of same variable with different testsConsistency in testing of same variable with different tests

Objective physiological responses to activityObjective physiological responses to activityHR & BP monitoring ++Clinical observationsHR & BP monitoring ++Clinical observations

*Static Coefficients of Variation*Static Coefficients of Variation (>50% CV > 15%)(>50% CV > 15%)

*Jamar Grip (Expected Bell Curve* / CV*)*Jamar Grip (Expected Bell Curve* / CV*)Controversial if solely usedControversial if solely used

*Caution-Ref. Shechtman, Journal Hand Therapy, July 2001*Caution-Ref. Shechtman, Journal Hand Therapy, July 2001

Consistency of Effort TestingConsistency of Effort Testing

Canadian Classification and Dictionary of Canadian Classification and Dictionary of Occupations DefinitionsOccupations Definitions

SedentarySedentaryLifting Lifting 10 lbs10 lbs maximum. maximum.

Occasional lifting and/or Occasional lifting and/or carrying.carrying.

Primarily sitting, with occasional Primarily sitting, with occasional walking or standing.walking or standing.

LightLightLifting Lifting 20 lbs20 lbs maximum. maximum.

Frequent lifting and/or carrying Frequent lifting and/or carrying up to 10 lbs.up to 10 lbs.

May require significant standing May require significant standing or walking.or walking.

May involve sitting with pushing May involve sitting with pushing and pulling of the arms and/or and pulling of the arms and/or leg controls.leg controls.

MediumMediumLifting Lifting 50 lbs50 lbs maximum. maximum.Frequent lifting and/or carrying Frequent lifting and/or carrying up to 20 lbs.up to 20 lbs.May involve sitting with pushing May involve sitting with pushing and pulling of the arms and/or and pulling of the arms and/or leg controls.leg controls.

HeavyHeavyLifting Lifting 100 lbs100 lbs maximum. maximum.Frequent lifting and/or carrying Frequent lifting and/or carrying up to 50 lbs.up to 50 lbs.

Very HeavyVery HeavyOccasional lifting in Occasional lifting in excess of excess of 100 lbs100 lbs..Frequent lifting and/or carrying Frequent lifting and/or carrying in excess of 50 lbs.in excess of 50 lbs.

OCCUPATIONALOCCUPATIONAL Health Stressors:Health Stressors:

Work monotony

low job control

mental stress

perception about work

lack of flexibility

UE Specific UE Specific RecommendationsRecommendations

Ability / force level for Ability / force level for sustained grip/pinch sustained grip/pinch or torquing or torquing Job & task rotationsJob & task rotationsComment on Comment on frequency of frequency of repetitionsrepetitionsComment on high Comment on high reps with recovery reps with recovery times neededtimes needed

Avoid vibrationAvoid vibrationLimit exposure to cold Limit exposure to cold / intolerance/ intoleranceUse of glovesUse of glovesComments on use of Comments on use of tools tools (built-up handles)(built-up handles)

Awkward or sustained Awkward or sustained posturesposturesGraduated RTW Graduated RTW schedulesschedules

The provision of the right health care at The provision of the right health care at the right time.the right time.

Return to best possible healthReturn to best possible health

The prevention of recurrences & of worker The prevention of recurrences & of worker impairmentimpairment

ADDITIONAL RESOURCES AVAILABLE IN THE ADDITIONAL RESOURCES AVAILABLE IN THE MANAGEMENT OF OCCUPATIONAL INJURIES / MANAGEMENT OF OCCUPATIONAL INJURIES /

DISEASES -DISEASES - continuedcontinued

Regional Evaluation Center (RECs):

Regional Evaluation Centers focus on musculoskeletal injuries. They do help clarify the diagnosis, prognosis and therapeutic options as necessary. There are RECs in the following areas:

Ottawa, Kingston, Peterborough, Oshawa, Toronto, Hamilton, St. Catharines, Kitchener, London, Windsor, Sudbury, Timmins, Kenora, Sault Ste.Marie, and Thunder Bay.

RECs are obligated to schedule appointments within 10 days of receiving the referrals, and must provide a report within 10 days of the examination.

ADDITIONAL RESOURCES AVAILABLE IN THE ADDITIONAL RESOURCES AVAILABLE IN THE MANAGEMENT OF OCCUPATIONAL INJURIES / MANAGEMENT OF OCCUPATIONAL INJURIES /

DISEASESDISEASES -- continuedcontinued

Specialty Clinics:

Injured workers may be referred to Specialty Clinics through The Workplace Safety and Insurance Board (WSIB). These Specialty clinics provide expert assessments in the following areas:

Amputations and Burns, Upper Extremities, Neurology (Head Injury or severe neck injury), Prosthetics, Psychotraumatic Disorders,

Chronic Pain/Functional Restoration.

These clinics were initially centralized in the Toronto-Mississauga hospitals but further decentralization is taking place.

Specialized opinions may also be obtained from individual experts in specific disciplines.

ADDITIONAL RESOURCES AVAILABLE IN THE ADDITIONAL RESOURCES AVAILABLE IN THE MANAGEMENT OF OCCUPATIONAL INJURIES / MANAGEMENT OF OCCUPATIONAL INJURIES / DISEASESDISEASES

The Occupational Health Clinics for Ontario Workers (Hamilton, Toronto, Windsor and Sudbury):

Do specialized assessments,

Review the literature as needed,

Comment on possible work-relatedness of condition, etc.

Contacts (1)Contacts (1)Health Professional Access LineHealth Professional Access Line

416-344-4526 orToll Free 1-800-569-7919

Provider Registration SectionProvider Registration Section200 Front St West, 4th Floor

Toronto ON M5V 3J1Toll Free 1-800-387-0750

Fax 416-344-2955

Contacts (3)Contacts (3)

Website www.wsib.on.ca

For health care professionalshttp://www.wsib.on.ca/wsib/wsibsite.nfs/Public/HealthProfessionalshttp://www.wsib.on.ca/wsib/wsibsite.nfs/Public/HealthProfessionals

To download formsTo download formshttp://www.wsib.on.ca/wsib/wsibsite.nfs/public/Formshttp://www.wsib.on.ca/wsib/wsibsite.nfs/public/Forms