Indiana Worker's Compensation Institute

Gunshots recently sounded in a workplace in Northern Indiana.  Sadly, the loss of two lives, and multiple injuries resulted from the actions on one employee.  The workplace is generally a safe place.  In fact, it is a place where people have often felt safer than they do in other environments.  Despite the enormity of the problem of workplace violence, a lack of information about the causes and predictors of workplace violence continues to exist.

The consequences of workplace violence are serious and often life changing, not just for the individuals involved, but also for the workplace itself.  There are several factors which help to identify and predict the likelihood of workplace violence.  The assessment of risk in the workplace is the focus of current scientific study.  However, even with the benefit of scientific knowledge the assessment of potential violence in the workplace is often inaccurately and inconsistently investigated.  Moreover, the accuracy of predictions based on the information gathered is erratic.  The inconsistent methods of evaluating risk assessment have not led to consistent or accurate predictions regarding workplace violence.  Risk assessment should conform to an understood strategy for evaluating the relevant factors.  This is the only way to more accurately and reliably predict workplace violence.

Predicting workplace violence requires the identification of workplace factors which form the context of the behavior and personal factors directly affecting the employee.  Understanding the specific personal factors and workplace factors, and how they interact permits the psychological evaluator to make more accurate predictions.

Workplace factors consist of factors likely to occur in the workplace.  The factors have a significant bearing on the individual’s psychological and behavioral reaction.  For example, perceived injustice, electronic monitoring and concern regarding job insecurity are examples of workplace factors affecting an individual’s attitude and psychological experience in the workplace.  Thus, an overly close and punitive style of supervision often negatively impacts the individual worker.

Personal factors such as alcohol use and abuse, a history of aggressive behavior, perceived low self-esteem, and the use of psychological aggression, exemplify the personal factors predictive of workplace violence.  The previous use of aggression has been documented to be one of the personal characteristics of aggressive employees.  It is also illustrative of a potentially aggressive employee who is likely to act out in the workplace.  Aggression appears to be an element which is stable across context and time.  As a result, an individual’s past history of aggression in general is often predictive of future violence in the workplace.

Finally, although it is possible that personal and work factors may operate independently in predicting workplace violence, a more accurate prediction of the workplace violence can actually be better understood when the interaction of both is clearly understood.  When negative workplace factors are combined with a history of alcohol use, past general aggression, low self-esteem and the use of psychological aggression, the likelihood of workplace violence significantly increases.

Assisting employers in better understanding high risk employees is obviously important so as to avoid the sad and horrifying consequences of violent actions in the workplace.   The proper assessment of a potentially violent employee involves an appropriate and thorough psychological examination of personal and workplace factors.  As noted, workplace and personal factors need to be explored and properly assessed.  The risk assessment should consist of reviewing historical items such as past incidences of violence, and the presence of a personality disorder or other major mental illness.  In addition, negative attitudes related to the workplace, a lack of psychological insight and active symptoms of mental illness, combined with impulsivity and unresponsiveness to past treatment are also to be considered.

Finally, risk management issues should also be assessed.  For example, do the plans for violence lack feasibility, and what exposure does the individual have to destabilizing factors.  In addition, it is important to understand how compliant an employee has been with past attempts to resolve conflicts in the workplace.  A limited personal support system and a high level of personal stress increase the potential for acting violently.

In summary, increasing the accuracy of predictions regarding workplace violence requires a thorough and comprehensive assessment of personal factors and workplace factors. Understanding how these factors act together enables the psychological examiner to more accurately assess the likelihood of physical violence in the workplace.  Avoiding potentially explosive situations is to ignore the reality of impending danger in the workplace. By way of example, homicide is the leading cause of death of women in the workplace.  As such, it is imperative that a zero tolerance policy related to violent behavior in the workplace be encouraged.  Moreover, physical and psychological aggression in the workplace should be documented and monitored carefully.   Aggressive behavior should be evaluated more thoroughly to protect the safety and well-being of the other employees.  In this way, the workplace remains an opportunity for everyone to be productive and pursue their vocation.

In the medical profession, life-altering decisions are made every day. For the physician, case manager and therapist, one of the most important decisions is the evaluation and treatment of the Worker’s Compensation patient. Consideration of employability, disability and residual functional capacity are all crucial decisions that have enormous implications for the worker and the employer. Of these decisions, the role of the rehabilitation team in determining the functional ability of a client is by far one of the most important decisions that will be made during the course of treatment.

A functional capacity evaluation is a comprehensive, objective measurement of the patient’s/client’s abilities and disabilities. It is a test that provides valuable information that will save time and provide critical objective data in the decision-making process. Without an FCE, the rehabilitation team and the employer must rely on the patient’s self-report and/or make impairment decisions based on imaging studies or general impressions.  With an FCE, the rehabilitation team will have the most objective data available to assist them in making quality decisions.

An accurate FCE should be comprehensive in scope by covering the physical demands as defined by the D.O.T. The FCE should be standardized and provide objective data for the physician, case manager and employer. Likewise, a quality FCE should be safe to administer so as not to put the patient at risk, as well as being practical to complete in a timely manner.   Most importantly, the FCE should be research-based due to the importance of the data contained in the report and the need to have supporting data should a case be litigated.

A quality FCE will also cover 4 main sections: Dynamic Strength (lifting, carrying, pushing and pulling), Position Tolerance (sitting, standing, crouching, stooping, kneeling and reaching), Mobility (walking, climbing, crawling, and repetitive movement) and Endurance (ability to tolerate an 8 hour day, % change in heart rate, and % change in performance).  When all 4 sections are combined, the rehabilitation team will have the most comprehensive and objective “picture” of their client and should be confident in making return to work decisions.

In summary, the FCE should answer the following questions:

What is the client’s overall level of work?

What is the client’s tolerance to an 8-hour day?

What was the client’s level of cooperation?

What are the client’s specific limitations?

Do the client’s abilities match the job demands?

What specific interventions need consideration for the client?

An FCE is without question the most comprehensive examination performed in the therapy setting.  It provides objective data for the rehabilitation team, establishes client abilities and disabilities and determines if the client will be able to successfully return to work and meet the demands of the job.

In today’s market, it is worth the time and effort to seek functional, objective data that will help you make decisions for your patients.  It is worth the time to objectively determine if your client will have a safe and productive return to work.  It is worth the time to seek a provider who administers quality, standardized and validated FCE’s that will support your decisions and underscore an accurate picture of your client’s abilities.

If you would like to learn more about the Functional Capacity Evaluation and how it can assist you in making return to work decisions, please contact Kevin J. Cassidy PT, COD @ (317) 846-3531.

The Indiana Court of Appeals has clarified a 22 year old decision that significantly limits the statute of limitations for reopening a worker’s compensation claim for additional medical benefits in situations where a permanent partial impairment (PPI) settlement has been made.

In Halteman Swim Club v. Duguid, No. 93A2-0106-EX-381 (Ind. Ct. App. 2001), the Court of Appeals reversed a decision of the Full Worker’s Compensation Board by holding that claims for post-PPI medical treatments must be filed within one year from the last date for which compensation is paid.

The Court cited to its decision in Gregg v. Sun Oil Co., 180 Ind. App. 379, 388 N.E.2d 588 (Ind. Ct. App. 1979) that “[a]pplications for the modification of an award of medical expenses must be filed within the latter one year statute of limitations, for that is the period of review incorporated by reference into the provisions of I.C. §22-3-3-4.”  Gregg at 590.  The Court in Duguid reiterated that the Board has continuing jurisdiction to award medical expenses beyond the statutory periods set out in I.C. §22-3-3-27, “so long as an application for such benefits ‘is filed within one year from the last day on which compensation was paid, whether under the original award or a previous modification.’”  Halteman Swim Club quoting Gregg at 590.

Plaintiff Duguid injured her left knee on June 29, 1996.  Temporary total disability (TTD) benefits were last paid for the period ending January 1, 1998.  Duguid settled her claim on April 23, 1998 on the basis of a 17% PPI of the leg in an amount totaling $3,825.00.  On October 18, 1999 she filed an Application for Adjustment of Claim alleging the need for additional medical treatment related to her June 1996 leg injury.  Under the two-year statute of limitations, her deadline for filing the Application would have been January 1, 2000.

The decision does not state how the one-year statute of limitations was determined.  Not included in the decision is that the PPI award divided by Duguid’s TTD rate calculates to just under 35 weeks.  If the 35 weeks were counted from the date of injury, the last date for which compensation was paid under the PPI settlement was March 2, 1997.  However, TTD benefits were paid beyond that date.  If the 35 weeks were added to the last date of TTD payments (January 1, 1998), the last date for which compensation was paid under the PPI settlement would be September 3, 1998.  Apparently, one of these two methods was used to determine the one-year statute of limitations because counting the 35 weeks from the actual date of the PPI settlement would make the last date of compensation December 24, 1998.  Calculating a one-year statute of imitations from the date of settlement would have made Plaintiff’s filing timely, but would have been contrary to the accepted method of calculating the period for which compensation is paid under a PPI award from the end of the TTD period or from the date of injury.  Accordingly, Duguid’s last date to file her Application under the one-year statute of limitations was September 3, 1999.

The Worker’s Compensation Board has long allowed claims for additional medical services to be filed under the two-year statute of limitations applying to claims for any additional disability benefits.  The general perception is that a need for additional medical services implies an associated disability and vice versa.  However, the Court rejected Plaintiff Duguid’s argument that her Application was not for PPI,
but for medical expenses.  The Court held that “[t]his is a distinction without a
difference, . . . as Gregg specifically applied its holding to medical expenses as well as to PPI.”  The decision also notes the Court’s reaffirmation of Gregg in Berry v. Anaconda Corp., 534 N.E.2d 250 (Ind. Ct. App. 1989).

Interestingly, the Court reinforced its opinion by references to the doctrines of stare decisis and legislative acquiescence.  The Court cited Lincoln Utilities, Inc. v. Office of Utility Consumer Counselor, 661 N.E.2d 562 (Ind. Ct. App. 1996) for the proposition that previous decisions of the Court must be followed when construing a statute unless it is provided with a strong reason justifying departure.  The Court found no such reason to deviate from the Gregg interpretation.

Under the concept of legislative acquiescence, the Court noted that the General Assembly has modified I.C. §22-3-3-4 and 27 on several occasions since Gregg was decided and has not taken action to correct the Court’s interpretation.  The decision refers to the Court’s holding in Department of Revenue v. U.S. Steel Corp., 425 N.E.2d 659 (Ind. Ct. App. 1981) that “[w]hen the court interprets a statute and the legislature fails to take action to change that interpretation, the legislature is presumed to have acquiesced in the court’s interpretation.”

The Court’s citation to these two doctrines of jurisprudence may be understood as a statement by the Court that, simply put, “we assume this interpretation is correct unless you tell us otherwise.”  This action deflects any criticism of the holding to the General Assembly and properly asks that body to make any desired change to the law.

There has long been discussion of enacting a uniform statute of limitations applicable to all claims.  This decision is likely to renew such debate because many claims for additional medical services will now be foreclosed under the one-year statute of limitations.  In the short term, this will be beneficial to employers.  However, the backlash is likely to be an increased practice of filing Applications for Adjustment of Claim before the ink is dry on PPI settlements.  Claimants will do so to beat the statute of limitations and thus greatly add to the Board’s docket.  As the Court of Appeals apparently recognized, this will eventually become a legislative question.

Think of EMG’s as an extension of the physical examination. When someone has the clinical symptoms and physical findings for carpal tunnel, you may use it to tell you how severe the carpal tunnel is, as well as, how the disorder progresses over time, and, if the diagnosis is in doubt, prove or disprove it.

EMG’s are actually composed of two parts: the nerve conduction studies (NCS) as well as the electromyogram (EMG).

The NCS part involves studying the nerves themselves. Electricity is sent from one part of the nerve to a different part of the nerve. The time it takes to travel from point A to point B is divided over the measured distance between the two points (mm/msec) and a conduction velocity calculated.

Also, the amount of nerve fibers transmitting can be measured by the size (amplitude), of the electrical pulse received. Thus, the health of the nerve can be measured objectively.

The EMG part involves studying the muscles. A pin is inserted into different muscles and the electrical activity in the muscles is picked up.

When there is muscle damage, as from a muscle disorder (myopathy), the electrical signals are altered. The normal triphasic wave (similar in appearance to the QRS wave of an EKG), becomes shorter and more narrow.

Also, when there is damage to the nerves innervating the muscle (ie. radiculopathies), the normal triphasic wave is again altered. Depending on how long the damage has occurred, different changes can be seen.

These include increased wave complexity, wave size, and number of waves.

Moreover, when either nerve or muscle are damaged, there will be spontaneous electrical activity (fibrillations), not normally seen.

Common reasons that physicians order EMG’s include numbness, paresthesias (pins/needles or other strange sensations), weakness, and pain that are otherwise unexplained and/or need further evaluation.

Examples include: carpal tunnel syndrome (median neuropathy at the wrist), cubital tunnel syndrome (ulnar neuropathy at the elbow), cervical, thoracic, or lumbar radiculopathies, peripheral neuropathy, myopathies, cranial nerve palsies, brachial plexopathies, neuromuscular disorders (ALS, myotonic conditions, etc.)

Please feel free to contact me if you have any question I can help with. 317-888-1051

As we move rapidly into the 21st century, I hold desperately to the fact that people are still being treated by people and as people. How can a health practitioner provide quality interventions if we do not place our hands on our clients. Manual therapy is a unique form of physical therapy that takes these principals in mind.  It is a type of care that makes our patients feel like they are being heard and validated in their complaints. We do use modalities and prescribe exercise as other therapists, but what makes us stand out is we spend a full hour assessing with our hands the biomechanical insufficiencies and other impairments causing the pain and discomfort.

What is a manual therapist  
As mentioned previously, a manual therapist is a physical therapist that has specialized in examining soft tissue and joint impairments such as myofascial restrictions, scar adhesions, and capsular tightening that often go undiagnosed. It is an art of assessing faulty mechanics of the spine and other joints. We have successful techniques that treat chronic headaches, rib pain, and herniated discs, to name a few. We are uniquely trained physical therapists who listen with our hands as well as our ears. We have received several years of training at an osteopathic university or other manual accredited institution.

Why manual therapy 
Quite simply, people want to be touched. Your patients want to know that you can find their pain. It builds great rapport with our clients when we can put our hands on them and reproduce the exact signs and symptoms that brought them to our office. They need to know that you care and are knowledgeable. There is something unique, if even a placebo effect, of making an assessment with our hands.

Second of all, manual therapy is a holistic type of therapy.  We examine and assess all parts of the body including physical, social, and emotional. A person’s pain can become so chronic in nature that it is as much of a routine as brushing their teeth. It can effect their social life by sheltering them inside because it hurts too much or they do not want to bother others. It can have adverse effects on their psyche, either through mind altering drugs or an irritation that consumes their thoughts. Manual therapists will address these issues and work in corroboration with the physicians on other interventions and referrals that may be helpful.

What kind of interventions can I expect from a manual therapist? 
Nothing quite as powerful as the human touch. Several treatments will be used depending on the nature of the impairment. Myofascial release is just as it sounds a release of the myofascial tissue. Our bodies are lined and held together by a touch connective tissue called fascia. This fascia weaves between our muscles, bones, and circulatory system. After surgery or a traumatic accident this fascia can become injured and, as with other injuries, it can form a scar.  Since fascia is woven throughout our body, a scar in our low back can lead to shoulder or neck problems. A manual therapist is trained to stretch this tissue out, thus “releasing” its binding properties and returning a person to normal function.

Muscle energy and joint mobilizations are processes of using your muscle’s energy, or strength, to mobilize poorly functioning joints.  Muscle energy is the non-manipulative way to correct poor joint movement. Joint mobilizations are characterized into five groups ranging from a gentle oscillation to a high velocity manipulation. They are used for pain relief and increasing a persons mobility. Both techniques are good for alleviating headaches, low back pain, rib or painful breathing problems, or other joints in the arms and legs that have lost motion.

Position release is a form of manual therapy that works our knots in muscles and helps a person relax. Once a tender point is found, the muscle is moved to maximal relaxation and this position is maintained for 90 seconds. After several points are “released” the affected body part is taken through the new motion. This technique works very well to break the chronic chain of pain often seen in people with long standing discomfort.

A technique similar to that of positional release is a trigger point therapy/release. Our bodies are full of trigger points that are located usually in the belly of the muscle. When they become active, you will notice discomfort on palpation and possible painful movement.  These can hinder fluid movement and cause soreness.  To release these tender spots simply apply pressure for 30-180 seconds and it should resolve during that time period.

How can I benefit from manual therapy
Manual therapy literally means therapy with our hands. “Everything in moderation” is a phrase by mother would use often. This goes for exercise as well. A manual therapist will prescribe specific key exercises that are targeted specifically at increasing the healing process and preventing the problem from returning. Instead of coming to an exercise class for an hour, we will work with you to provide manual resistance for strengthening using the principals of PNF, Feldenkrais, and NDT.  We spend the majority of our time touching, evaluating, and healing with our hands. Your are an active participant in interventions.

We will show you ways to release your own trigger points and other self-help tools that can be very helpful.

Heel fractures are a fairly common workplace injury in heavy laborers or those working at heights. It is estimated that approximately 70 percent of these injuries occur on the job.  The vast majority are caused by a fall over six feet. Most heel fractures extend into the surrounding joints and are displaced.  The patient will have immediate pain, swelling, and will not be able to bear weight. Compartment syndrome of the foot is possible. Routine x-rays include AP, lateral, axial and an oblique view.  CT scanning is mandatory if surgical fixation is planned. Associated injuries are common and lumbar compression fractures may occur in up to 10 percent.

Treatment for these complex injuries remains difficult. However, for displaced fractures in the hands of an experienced surgeon, open reduction and internal fixation results in the opportunity for a superior outcome over non-operative treatment.  Surgery is often delayed 10 to 21 days to allow swelling to subside and the soft tissues to stabilize. After surgery a patient is immobilized for approximately three weeks to allow the wound to heal.  Range of motion is then started but weight bearing is delayed for eight to ten weeks following surgery. Return to work varies greatly among patients but may be several months for return to full duty with no standing or walking restrictions. Post-operative problems can still occur even in experienced hands. The most common is wound healing problems and flap necrosis. Heavy smokers are at an increased risk for this problem. Neuroma formation and stiffness may also occur. Even in good to excellent result, patients may lose subtalar (side-to-side) motion. The major late development is post-traumatic arthritis of the subtalar joint.  Surgical fixation decreases this risk but certainly doesn’t eliminate it.  Loss of subtalar motion affects the ability of an individual to work on uneven surfaces or ground.  If arthritis pain cannot be controlled with anti-inflammatory medications or orthotics, a subtalar fusion is required.

Worker’s compensation patients don’t do as well as those not injured on the job. Only 25 percent had a good to excellent result versus 88 percent of non-worker’s compensation patients. Functional outcome scores also are insignificantly lower in the worker’s compensation individuals. Long-term data suggests that up to 70 percent will have difficulty on uneven surfaces, 30 percent have difficulty walking greater than one mile.  Pain is found in94 percent of patients (mild-57 percent, moderate-37 percent, and severe-6 percent).  Overall, 74 to 90 percent of patients return to work with some restrictions.  Impairment ratings are based on the loss of motion at the subtalar joint, post-traumatic arthritis, possible arthrodesis and the possible need for brace use.

Calcaneus fractures that are displaced and intra-articular (approximately 75 percent) are significant injuries that may result in major alterations of an individual’s previous function. The best opportunity for maximal improvement rests in the hands of those orthopadeic surgeons who are experienced in dealing with those complex fractures.