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Work Reconditioning and Vocational Rehabilitation

Occupational therapists play a vital role in helping people to gain the functional skills they need to return to work or to obtain employment. Work performance can suffer if there are problems in any of the following areas:

1. Physical body
2. Sensation
3. Cognition
4. Perception
5. Mental health
6. Social interactions
7. Development
The following charts will review the various aspects of occupational therapy intervention in the areas of work reconditioning and vocational rehabilitation.
The Occupational Therapy Practitioner’s Role in Enabling Clients to Work
There are many aspects that therapists must consider when providing services to clients who want to return to work or who want to start working in the first place. Both OTR®s and COTA®s are involved in this process.
Role of the OTR®:
1. Identify and analyze the problem.
a. Why is this client unable to complete their work task?
b. What are the demands of the client’s particular job?
c. What are the client’s required work tasks?
d. What are the work routines?
e. What equipment does the client normally use?
f. Are there any ergonomic problems and how accessible is the client’s workstation?

2. Choose how to evaluate the problem (are there any assessments you can use?)
3. Come up with interventions to the address the problem
4. Supervise the COTA® who may be assisting with interventions
Role of the COTA®:

1. Implement the intervention plan
2. Document how the client is responding to treatment, including his or her ability to participate and if he or she has made progress
The following factors should be considered when designing work related interventions for clients:
– Age
– Interests
– Values
– Cultural background
– Skills and abilities
– Motivation
– Mental health
– Social ability
– Role at work
– Demands of the client’s particular job
– Work environment
– Resources available to the client
Treatment for work related conditions may be provided in acute care settings, inpatient or outpatient rehabilitation units, inpatient or outpatient mental health units, at a job site, in a sheltered workshop, or at a supported employment site. Besides clients, therapists collaborate with employers, case managers, and state or local agencies to help return clients to work or transition them from school or home to employment.

Occupational therapists provide the following work related services to both individuals or groups:

1. Consultative services – education about the following topics:
o Injury prevention in the work place
o Stress management
o Safety
o Body mechanics and posture
o Pain management
o Joint protection techniques
o Health monitoring
2. Direct services
o Help to return clients to work or establish employment if clients have never worked.
o Help promote and facilitate productive work abilities
 Increase physical ability to do work
 Help to develop more efficient ways to complete work tasks
o Help to prevent work-related injuries or other problems
 Adapt work stations or work tasks
 Facilitate communication with co-workers
o Help clients to restore skills that have been lost
o Train clients how to compensate
 Identify alternative ways to complete work duties
 Explore other possible work roles

 

Work Tolerance Screening

A work tolerance screening is used to assess a client’s physical and cognitive abilities to meet general or specific demands of essential job functions. Generally completed after client has received offer of employment. Actual employment is contingent on the client passing the screening.

Physical aspects of the job that might be assessed during a work tolerance screening include:

-Flexibility

-Strength

-Balance

-Coordination

-Cardiovascular condition

-Body mechanics

Work Reconditioning

Work reconditioning occurs when a person has sustained an illness or injury that has limited his or her ability to work in a physically demanding position for a prolonged period of time. To reduce the risk of further injury, the person undergoes work conditioning and/or work hardening prior to returning to a physically demanding job.
Definitions:

Work Conditioning: A program of physical exercise and endurance training designed to help a person regain the physical capabilities necessary to return to work. Usually provided by one discipline, such as occupational or physical therapy.
Work Hardening: A comprehensive program that addresses a person’s physical and psychological needs in preparation for return to work. Work hardening includes more direction during physical activities and a more individualized approach to intervention. Usually provided by an interdisciplinary team.
Work Simulation Activities: Functional activities designed to simulate the movement and weight lifting requirements expected of a person on an actual job.
Functional Capacity Evaluation (FCE): An evaluation of work capabilities in which a person completes a series of work simulation tasks that mimic his or her actual job in order to identify functional limitations that may prevent return to work.

An FCE includes review of medical records, interview, musculoskeletal screenings, evaluation of physical performance, formation of recommendations and report generation. FCEs are the core of all return-to-work programs.

  • Identify work restrictions
  • Rule out or discover a diagnosis
  • Determining if employee can perform physical job demands
  • Determine UE functional capacity
  • Consists of:
    • Evaluation begins with most physically demanding components with gradually increasing resistance and complexity.
    • Initial interview: establishing rapport with client and explain how FE works.
    • Subjective evaluation to determine impact of pain or injury has on ADL/job performance
    • Subjective pain assessment
    • Clinician should document how client looks/appears
    • Musculoskeletal evaluation is core of FCE→ ROM, strength, volume, sensation, soft tissue status
      • Presence of Symptom Magnification is required (the most objective method of testing for this is using the Jamar dynamometer to yield maximum level of effort.  Test with all 5 settings, starting with the 1st setting, and if max level of effort is provided – it SHOULD yield a bell-shaped curve. If not, then there is likely some sort of symptom magnification from the client occurring.
    • Job Demand Analysis: determine essential job functions via interviews, questionnaires, assessments, and job descriptions via O*NET or DOT, provided employer job description, and actual physical demands of job (level of work/frequency of physical efforts) in the real workplace. Includes ERGONOMICS assessment of the workplace/workstation too to identify risk factors.

Malingering – malingering is the term used to identify patients who are faking or exaggerating their symptoms to avoid returning to work or to obtain financial benefits from insurance. FCEs are designed with tasks built in to help identify when a patient is malingering. Therapists who are experienced in work reconditioning are adept at identifying possible malingering patients.

Comparison of Programs

The majority of people who suffer illnesses or injuries are able to return to work with no intervention or outpatient rehabilitation. Only a few require the more intensive training that work conditioning and work hardening provide. This chart will compare the similarities and differences between outpatient rehabilitation, work conditioning, and work hardening.

Outpatient Rehabilitation Work Conditioning Work Hardening Photo/Video
Focus of program Improving range of motion, strength, and coordination of the part of the body where the injury was sustained. Improving overall functional ability to allow independent functioning during work, leisure, and self care tasks. Improving a person’s physical strength and endurance to help that person return to work. Improving a person’s physical strength, endurance, pain management, work practices, attitude toward work, and on-the-job behavior to help that person return to work. A photographer discusses his participation in an outpatient rehabilitation program.
A fire fighter demonstrates a work conditioning program.
A client demonstrates tasks that are part of a work hardening program.
Evaluation -Medical history, independent living skills interview, work history, description of job duties.
-Evaluation of range of motion, strength, coordination, visual perceptual skills, cognitive skills as appropriate for the person’s diagnosis.
-Medical history, independent living skills interview, work history, description of job duties.
-Gather baseline data regarding the physical requirements and demands of the person’s specific job, including materials handling, body mechanics, MET levels if person has a cardiac diagnosis.
-Medical history, independent living skills interview, work history, description of job duties.
-Functional Capacity Evaluation
An occupational therapy student demonstrates an outpatient rehabilitation hand evaluation.
A brief video describes the components of a Functional Capacity Evaluation (FCE).
Treatment -Therapeutic exercise, therapeutic activities, ADLs and IADLs as appropriate for the person’s diagnosis.
-May complete a work site evaluation and recommend adaptations to the person’s work station to prevent further injury or adapt for disability.
-Strengthening of muscles used during specific job tasks.
-Endurance training, including monitoring MET levels if person has a cardiac diagnosis.
-Work simulation activities, including strengthening and endurance training.

-Materials used are exactly the same as those used on the job site.

-Training may be partially completed at a job site.

A video shows examples of outpatient occupational therapy.
A man demonstrates work conditioning activities.
A firefighter completes a work hardening activity.
Patient Education Home exercise program, proper body mechanics, joint protection techniques, energy conservation techniques. Proper body mechanics, safe materials handling techniques, energy conservation techniques, joint protection techniques. Proper body mechanics, safe materials handling techniques, energy conservation techniques, joint protection techniques, pain management and relaxation techniques, stress management.
Session Frequency 1-3x per week for 4-6 weeks, depending on insurance coverage. 1-3 hours per day, 5 days per week for 1-3 months. 5 days/week:
Week 1: 4 hours per dayWeek 2: 5 hours per dayWeek 3: 6 hours per dayAn hour per day is added each week until the person reaches 8 hours per day.

 

Vocational Evaluations: A vocational evaluation provide information about a person’s capacities and interests for work in situations when they have not worked before or are looking for a new job after illness or injury

  • General vocational evaluations→ comprehensive assessment to evaluate a person’s potential to do any type of work. Used to explore aptitudes, abilities and interests for all work options.
    • Work Readiness Programs
  • Specific vocational evaluation→ assess person’s readiness to return to particular occupation
  • When to refer to a vocational rehab counselor: when a client is looking for new job(or if they have not worked before) and uncertain of what new job he or she would like to pursue; also if client is not able to complete essential job functions/tasks due to injury/illness. 

Alternative Employment Settings

Adults who have developmental disabilities or mental health conditions may require more supervision and assistance on the job than other workers. These adults usually participate in community based programs that allow them to work while still retaining disability benefits. Programs include prevocational training programs, transitional employment programs, and supported employment. The following chart will compare these programs.

Prevocational Training Transitional Employment Supported Employment
Approach -Prepares the client for placement in an employment setting.
-Often addresses independent living skills in addition to vocational skills.
-Client is placed with a community based employer on a temporary basis to learn additional work skills and/or refine skills already learned. -Client obtains employment with assistance and works with support from a community agency until able to work independently.
Who is served Adults, usually age 21 and older Adolescents and adults age 17 and older Adults age 18 and older
Types of settings -In-house jobs: jobs that are provided by day treatment programs or clubhouse model programs, where the client works within the program (cleaning the clubhouse, assisting to prepare meals, etc.) Payment for work varies from program to program.

-Training/activity programs: programs provided by specific community agencies to address prevocational skills, usually geared for severely disabled individuals. Clients are not paid for their work. Participation in a program is usually funded by a government or nonprofit source.
-Sheltered employment: employment at a worksite specifically designed for people with developmental or psychiatric disabilities. Also called sheltered workshops. Employees are supervised and jobs are tailored to their skills. Pay is below minimum wage. The employment site is usually run by a county or non-profit program and is funded by grants, government programs, and productivity of the employees.

-Community based employers who have prearranged agreements with government or non-profit agencies who sponsor transitional employment. Public schools may also arrange for transitional employment as a part of a student’s IEP. Employment is temporary. Employees are paid a wage or stipend. -Community based employers who have prearranged agreements with government or non-profit agencies who sponsor supported employment. Employment is permanent. Support is provided until the employee can manage the job duties independently.
Services Offered Training in the following areas:

-task skills
-cognitive rehabilitation
-job seeking skills
-independent living skills
-social interaction skills
-work habits
-interests and aptitudes

On-site job training directly related to the job being performed. Training lasts for 3 to 6 months, after which the employee transitions to competitive employment, supported employment, or sheltered employment. On-site job training directly related to the job being performed. (Job coaching)

 

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