Back at Work, Serving and ProtectingSep 1
Officer Kayhla Hendren of the Bel Air (Md.) Police Department was directing traffic away from a fire in November 2013 when a vehicle ran over her.
The impact was so hard, The Aegis newspaper noted, that it broke her firearm. It broke her body, too.
She suffered a severe concussion, with nearly complete vision loss and multiple cognitive deficits; a right ankle fracture; a torn ligament in her right knee; a torn flexor tendon in her right elbow.
Her path to recovery, including four surgeries and what she described as “lots and lots and lots” of physical therapy, was arduous but ultimately successful. After more than two years under the watchful eye of Drayer Physical Therapy Institute, the mother of two young children was released to full duty by her attending physician.
In August 2016, she returned to the police department and a hero’s welcome from her fellow officers.
“I have always wanted to do this job,” Hendren said, “since I was a kid, and I wasn’t going to let one incident change my life, let one person’s mistake alter my life.”
EFFICIENT, SAFE RETURN
At the heart of Hendren’s recovery was Drayer’s approach to workers’ compensation, known as WoRx Work & Industry Services. Under WoRx, Drayer treats work-related injuries and provides industrial consulting and injury-prevention services to corporate and industrial clients.
For injured workers, treatment is designed to return them to work efficiently and safely, with open lines of communication among physicians, insurance companies, nurse care managers and employers. Care is customized to meet the unique needs of worker and employer by first gathering the information needed to plot a return to work.
“We plan for discharge at the time of the initial evaluation,” said Jeff Clinger, Drayer’s national director of industrial rehab.
WoRx care management is based on the reality that a physical therapist will spend more time with the injured worker than anyone else involved in the case. Therapists know the physical and emotional struggles associated with being away from and returning to work.
While Hendren’s accident was traumatic, many WoRx patients suffer over-use injuries and require an examination of job demands to identify any aspects that could continue to irritate and cause pain.
Therapy focuses on improving performance deficits by advancing the injured worker safely through functional programs or advocating for reasonable accommodations. Therapy mirrors job duties but at a lower demand. If a job requires the repeated lifting of 25 pounds, for instance, in therapy it might be reduced to five pounds and increase in weight over time.
Extensive injuries such as Hendren’s often suggest a slower return to work. She arrived at Drayer’s Hickory center in Bel Air in June 2014 after completing intensive rehabilitation while in the hospital. Her body was still broken but her spirit was not as her infectious can-do spirit revealed itself to the center’s staff.
She was committed to once again serving and protecting her community.
Hendren and her physical therapist communicated frequently with her physician and case manager concerning her challenges and progress in acute (initial) physical therapy and eventually in a work conditioning program.
Because the duration of Hendren’s care was long, it was crucial to document her improvement on a regular basis. The coordinated health care team – comprising PT, case manager, doctor and employer – advanced Hendren’s care by demonstrating that she was not at Maximum Medical Improvement by documenting objective functional gains (showing improvement from one point in time to the next).
Hendren’s concussion symptoms, including vision loss, had resolved. Although she arrived asymptomatic for a concussion, her brain was actively healing. The treating clinician was mindful of how hard to push her so as not to bring on symptoms, such as dizziness, vision changes, fatigue.
Unique to Hendren’s case was the severity of her traumatic brain injury and the tremendous variability associated with a police officer’s daily duties. Some of these unique physical demands include physical pursuit over a variety of surfaces and barriers (while wearing a full uniform, including utility belt), administering physical restraints, and self-defense and weapons qualifications.
Pain manifests in many ways across all patients, but a return to work component adds an additional layer of complexity. Research suggests that pain is significantly greater when financial and return to work stresses are added to an injury.
Like athletes recovering from injuries, not all injured workers are able to return to their regular positions, at least not right away. Tests such as a Functional Capacity Evaluation (FCE) allow a clinician to compare a patient’s work capabilities with his or her job demands.
These services are considered vital to providing comprehensive workers’ compensation care. The parties to a case – injured worker, physician, employer, adjuster, case manager – want to maximize a patient’s capacity and tolerance while minimizing the risk of re-injury to patient or injury to co-workers.
One of the most important factors in successful recovery and return to work is the support of family members, physician, employer, case manager.
For two months, Hendren participated in work conditioning, the objective of which is to restore physical capacity and function to enable a patient to return to work.
As with all work conditioning clients, Hendren progressed through advanced, physically demanding exercises to restore cardiovascular conditioning. She performed real work tasks (work simulation) while advancing to wearing everything required of a police officer.
She started in static positions (standing, elevated work, kneeling and squatting), steadily increasing her tolerance; next came lifting, progressing from 10 pounds to 100 pounds; finally came mobility and dynamic activities: stair climbing, running, balancing, jumping and repetitive trunk rotation.
“Running in shorts and a T-shirt on a treadmill is vastly different from performing the same task while wearing a fully loaded utility belt and running in boots over uneven surfaces,” Clinger said.
These requirements were simulated in the clinic – the amount of resistance, duration and frequency increased over time as Hendren tolerated them – to replicate worst-case scenarios.
By demonstrating her capabilities, Hendren instilled confidence in her physician, her case manager, her fellow officers (who drove her to and from her rehabilitation appointments) and herself that she could safely return to work and be an asset to the police force.
Not only has she achieved a comeback, but she has been back on the job for more than one year. Her story is a shining example of what can be accomplished with a collaborative approach to clinic-based work-injury management.
Vuadens, P., Arnold, P., Bellman, A. “Return to work after a traumatic brain injury: a difficult challenge.” Vocational Rehabilitation. 2000: 143-163.
Zumer, Bryna. “Bel Air police officer back on the street after being hit by car in 2013.” The Aegis, Aug. 31, 2016.
With work-related injuries, it is critical to create a safe return to work strategy and include functional goal setting as part of the plan of care.
Return to work goals are best derived from the employers’ documented minimal essential job demands to meet Americans with Disabilities Act (ADA) and U.S. Equal Employment Opportunity Commission (EEOC) guidelines.
Participation in a work conditioning program can be critical for employees who are away from work for an extended time or are returning to a U.S. Department of Labor job classification of “Medium, Heavy to Very Heavy.”
While participating in a work conditioning program, Drayer patients typically advance from three to five days per week and from two to four hours per day, depending on their tolerances and abilities.
The reason for this graded approach is to monitor safe progression in overall physical capacity and tolerance while avoiding neurological and physiological regression.
RESEARCH ABSTRACT: SELF-MANAGEMENT IN TREATING WORKERS’ COMP CASES
By Misty Seidenburg
Musculoskeletal disorders are the most common cause of work limitations and unemployment: They account for more than 40 percent of workers’ compensation claims.
Self-management already is an effective tool in the management of chronic disorders. This review looks at the use of self-management in treating workers’ compensation cases.
Specifically, it defines self-management for return to work; outlines the role of the clinician in promoting self-management; details skills for effective self-management to remain at work; and determines readiness for work.
Workers have reported multiple barriers to returning to or remaining at work, prompting researchers to develop self-management strategies to improve work-related outcomes. The goal of self-management is enhanced self-confidence, which is associated with improved clinical outcomes and positive health behaviors.
Clinicians can involve a patient in self-management strategies at each stage of injury rehabilitation. Self-management involves activity modification, medication and pain-relief strategies as well as engaging the patient in treatment decisions to regain function for work.
Dual decision-making – clinician and patient working together – in designing an appropriate exercise program can enhance patient ownership during the rehabilitation process.
For self-management to succeed, patients must:
• Have knowledge of their conditions;
• Follow care plans developed with healthcare professionals;
• Have confidence in their healthcare providers;
• Participate in decision-making;
• Manage signs and symptoms of their conditions in all areas of life;
• Adopt healthy behaviors;
• Have access to and use of support services.
A clinician is in a good position to help the patient acquire these self-management skills:
The clinician can identify limitations to full participation in work and brainstorm strategies with the patient to solve these issues. Research has shown that adding problem-solving skills to graded activity for chronic low back pain resulted in a reported 50 percent fewer sick days and better work retention in the year after intervention.
Encouraging the use of available resources can foster a sense of patient control.
A positive bond between patient and clinician is associated with treatment satisfaction and improved function.
Evidence suggests that providing a patient with a specific and achievable action plan is associated with faster and better return to work outcomes.
To maximize the success of self-management for the patient, the clinician must establish the patient’s readiness for return to work, how important work is for the patient, and how confident the patient is in returning to full-duty work.
Various self-report tools are available and can be used to compare with the job description to accurately determine physical job demands. The importance of a job to a patient and the barriers to performing that job (pain, fear of re-injury, fatigue, depression) affect the patient’s ability and motivation to recover.
Ensuring a patient’s confidence in return to work is strongly linked to a return to usual activities.
A trend toward promoting self-management for chronic conditions is evidenced by a shift away from relying on healthcare providers to one in which patients take an active role in disability management.
Physical therapists are ideally situated to influence the patient to take an active role in the rehabilitation process and should facilitate positive self-management behaviors to empower individuals to remain at or return to work.
Johnston, V., Jull, G., Sheppard, D., Ellis, N. “Applying principles of self-management to facilitate workers to return to or remain at work with a chronic musculoskeletal condition.” Man Ther. 2013;18:274-280.