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Reliably Determining Occupational Causation


Reliably Determining Occupational Causation April 21, 2010 Dan Rafael Azar MD MPH QME Medical Director Alliance Occupational Medicine Santa Clara & Milpitas – PowerPoint PPT presentation

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Title: Reliably Determining Occupational Causation

Reliably Determining Occupational Causation
  • April 21, 2010
  • Dan Rafael Azar MD MPH QME
  • Medical Director
  • Alliance Occupational Medicine
  • Santa Clara Milpitas

Identifying Causation is Critical
  • Impacts claim management
  • Impacts source of medical treatment
  • Impacts employee health
  • Impacts liability for treatment
  • Impacts future costs
  • Impacts profitability
  • Impacts morale
  • Make the right decision as early as possible

Evaluation and Treatment is a Partnership
  • Employee-Patients
  • Employers
  • Carriers (adjusters)
  • Utilization Review
  • Medical Case Managers
  • Attorneys
  • WCAB judges
  • Legislature

Evaluation and Treatment is a Partnership
  • We share goals (some of us)
  • Get the EE
  • as well as possible
  • as quickly as possible
  • for the lowest cost
  • Goal MMI (maximal medical improvement)
  • Goal PS (Permanent Stationary)

Why use an Occ. Med. Clinic?
  • Measure our success by case management
  • Causation determination
  • Disability management
  • Claims management
  • Cost effectiveness
  • Responsible for quality of ancillary services
  • In-house specialists are held to higher standard
  • Personalize treatment for local employer
  • Typically best choice for initial treatment

First Visit Basics
  1. Diagnosis
  2. Causation
  3. Treatment

Treatment Philosophy
  • Attitude of provider
  • Neutral in mind
  • Positive in attitude
  • Not pro-EE
  • Not pro-ER
  • Thorough history taking
  • Fact finder
  • Active listener
  • Thorough exam
  • Thorough documentation
  • Fact organizer
  • Synthesize treatment plan
  • Lead, Communicate and Coordinate to Implement
  • It takes a team
  • Define roles
  • Problem solve
  • Educate stakeholders generously

Treatment Philosophy
  • Always strive to do the right thing Speak the
  • WC serves a specific purpose
  • WC is not a safety net
  • Treating a non-occupational illness under WC is
    not doing the EE a favor
  • Establish causation as AOE/COE
  • Arising Out of Employment
  • (occurring in the) Course Of Employment
  • Probable cause
  • Not just a possible cause
  • Significant contributor
  • Not trivial
  • No patient-physician relationship exists until
    causation is resolved and treatment is started

First Visit
  • Goal put together a unbiased narrative that
    tells a believable story
  • Fact collecting and organizing
  • Develop a relationship with patient
  • Dispel bias against company doc
  • Reflect comprehension
  • Express compassion

Thoroughness at First Visit IncludesReviewing
All Available Information
  • Authorization form from employer
  • Patient description of injury mechanism
  • Anatomic illustration of injured areas
  • Basic current and past work history
  • Clarify prior relevant medical history

History Establishing Diagnosis, Causation and
Pre-Injury Baseline
  • What happened?
  • No problems before then?
  • What makes it worse?
  • Ask for specific responses.
  • Ask questions until it makes sense
  • Check for non-occupational contributors
  • Check for consistency of causation
  • Worse at End of Day? Week?
  • How does it feel on weekends, vacation?
  • Organize a time line for current injury
  • Include treatment received since onset of sxs

History Why now?It Should Make Sense
  • What changed in this EEs life (at work or home)
    to trigger this injury?
  • Increased work volume?
  • Increased work hours (OT)?
  • Increased work pace?
  • Coworker laid off?
  • Coworker maternity/disability leave?
  • Relocating offices without correct ergonomics?
  • Is there a clear causative relationship?
  • If it doesnt make sense its non-occupational
    until proven otherwise

Identify Non-Industrial Contributors?
  • Personal Medical Illnesses (diabetes, thyroid,
  • Hobbies knitting, sewing
  • Gardening / Home Projects / Remodeling
  • Sports
  • Family / Small Children / Dependent Adults
  • School / Second Job
  • Over-committed
  • Just too much
  • Many working mothers homemakers
  • Unrealistic personal expectations
  • Poor interpersonal boundaries,

During History Listen for
  • Anger
  • Blaming
  • Self pity
  • Passive attitude
  • Poor coping
  • High perceived stress
  • Poor boundaries (at work and home)
  • Excessive sense of responsibility
  • Inadequate rest and recovery
  • Life out of balance
  • Poor self-care
  • Lack of regular exercise
  • Smoking
  • Diet
  • (Skip to Slide 23)

Establish Impact on Function
  • Activities of Daily Living (ADLs)
  • Impact on Work Duties?
  • Clarify work functions
  • These are additional clues to causation
  • Look for association between painful activities
    and causation
  • What were you doing when you first noticed

History gt Subjective Section of DFR / Report
  • What?
  • When?
  • Where?
  • Injury-relevant medical history
  • Prior treatment history
  • What worked?
  • Rate of recovery
  • How is work impacted by injury?
  • How is injury impacted by work?
  • Contemplate
  • Differential Diagnoses
  • Causation Apportionment
  • Treatment Plan
  • Set stage for upcoming physical examination

Physical ExaminationConfirm Diagnoses
  • Define physical boundaries of injury
  • Thinking Differential Diagnoses Probable and
    Possible Dxs
  • Identify medical red flags
  • Expedite care
  • Contact ER/Adjustor, ED, PMD, Specialist)
  • Identify case management red flags
  • Exam doesnt fit history/mechanism
  • Exam suggests non-occupational pathology
  • Exam suggests supra-tentorial amplification

Objective / Examination
  • Visual Observation during history
  • Pain with movement
  • Movement to relieve pain
  • Signs of excessive anxiety
  • Active Range of Motion (AROM)
  • Visualize painful area
  • Discoloration
  • Edema
  • Asymmetry
  • Palpation
  • Tenderness
  • Bogginess (edema)
  • Fibrosis
  • Provocative Testing
  • Tinels
  • Phalens
  • Impingement test
  • Signs of malingering
  • Symptom Exaggeration (conscious vs. unconscious)

During Examination Look for
  • Lack of aerobic fitness
  • Lack of muscular development
  • Advancing age
  • likelihood of injury increases as capacity and
    rate of healing decreases
  • Poor general health

A Assessment Diagnoses
  • Identify
  • Pathology (whats wrong?)
  • Extent of problem (define anatomic areas
  • Severity (mild, moderate, severe)
  • based on exam findings impact on function
  • Chronicity (acute, cumulative, pre-existing)
  • Cause (non-occupational, degenerative)

Plan Discussion Treatment
  • Discussion
  • Describe how I arrived at diagnoses
  • Synthesis of Subjective and Objective
  • Differential Diagnosis
  • Differential Causation
  • Explain pathology and relationship to most
    reasonable mechanism of injury
  • Acknowledge all relevant diagnoses
  • Acknowledge impact of non-occupational dxs
  • What it isnt (e.g. not CTS, not

Causation Entirely Non-Occupational
  • You need to see your own doctor I cannot treat
    you under WC
  • Friendly first aid advice
  • End on positive note
  • Less conflict with me
  • Less disruption for employer at workplace
  • Document on Work Status
  • Non-Industrial
  • See Own MD

Treatment Plan Plan Ahead
  • Plan A
  • On recheck
  • If it workstypically finish Plan A
  • If it doesnt work initiate Plan B
  • Check for non-compliance with plan A
  • Consider alternative diagnoses
  • Consider Diagnostics if they will impact care
  • Discuss injection or alternative treatment
  • Where ever possible use MTUS/ACOEM Guidelines for
    treatment plan

Treatment PlanPatient-Centric Goals
  • Actively listen to patients concerns
  • Define most disruptive diagnoses
  • I get it and Im competent
  • I can help with your injury and the problems its
    causing you trust me

Treatment Plan Educate the Patient
  • Anatomic posters
  • Explain biomechanics and provocative test results
  • Demonstrate knowledge and credibility
  • Answer questions
  • Dispel common disbeliefs
  • Reinforce with printed handouts
  • Pathology
  • Basic exercises
  • Reassure you will communicate with employer
  • Work recommendations
  • To follow restrictions as written
  • Injury is real

Treatment Plan Talk to the Patient
  • Explain multi-pronged treatment approach
  • Expectation
  • Its your job to get better
  • Outcome depends on patient effort
  • No change no gain
  • Outcome depends on severity of illness
  • Outcome depends on delay in seeking care
  • Reassure
  • think positive
  • take action
  • be realistic
  • Make yourself available to patient

Specific Treatment Plan for an Acute Injury
  • Mild / Minimal Injury
  • First Aid Only (OSHA not labor code)
  • Non-Rx meds if sufficient
  • No Physical Therapy
  • Or option of instruction only by therapist
  • No modalities or procedures
  • Full Duty (if safe)
  • Depends on severity

Treatment Plan for anModerate to Severe Acute
  • Start Physical Therapy ASAP
  • Recheck 2 7 days
  • Restrictions if medically necessary
  • Only if necessary
  • Specific to injury
  • Specific to job duties
  • Safety driven
  • Prescription meds if medically necessary
  • Avoid narcotics or muscle relaxants where
  • Use OTCs or topicals
  • Limits pain or sedation as an excuse for not

Goals of Physical Therapy
  • Recover full function
  • Establish healthy habits
  • Minimize risk of recurrence

Physical Therapy
  • During early phase of treatment
  • Decrease pain inflammation
  • TENS
  • Ultrasound
  • Phonophoresis/Iontophoresis
  • Myofascial release
  • Teach proper use of ice and heat
  • Improve active range of motion (AROM)
  • Reduce injury-related anxiety
  • Educate about pathology
  • Encourage movement
  • Teach proper technique

Physical Therapy
  • Late Phase of Treatment
  • Focus on increased flexibility, strength
  • Teach self-care and personal responsibility
  • Provide home exercise equipment (if needed) and
  • Theraputty
  • Theraband
  • Home exercise ball
  • Foam Roll
  • Limit TENS unit to specific cases for pain
  • Limit home traction unit to radicular cases
  • Prescribe one month trial
  • Re-evaluate for demonstrated use and benefit
    before refill

Cumulative Trauma Injury
  • Defined by mechanism not anatomy.
  • Work Related Musculo Skeletal Disorders (WRMSDs)
    Includes many different tendinopathies,
    myofascial pain syndrome and sometimes peripheral
    nerve entrapment (CTS)
  • Identify specific diagnosis
  • Extensor tendinitis bilateral wrist (RgtL)
  • Lateral epicondylitis R elbow mild, chronic

4 Major Causes of Cumulative Trauma Injury
  • Excessive force
  • Awkward positions
  • Static muscular tension
  • Insufficient conditioning for job requirement

Cumulative Trauma Injury Challenges
  • Gradual onset
  • Delay in seeking care
  • Multifactorial cause
  • Prone to Injury Creep
  • Typical treatment guidelines geared to single,
    acute conditions under ideal conditions
  • High risk of recurrence

Cumulative Trauma Injury Challenges
  • Milder cases an absence of objective symptoms
  • Subjective symptoms such as pain influenced by
    mood, attitude and job/life satisfaction
  • Response to treatment impacted by personality
  • The mis-educated and over-educated
  • Fear, anxiety and frustration

CTI Treatment Plan
  • Ergonomics - evaluate adjust
  • Self-care
  • Microbreaks hourly?
  • HEP flexibility, strength, endurance and reduce
  • Technique at work and home
  • Splints?
  • Work Habits (hours, pace, days, location)

Call Designated Employer Representative (DER)
  • Diagnoses
  • Why I consider it occupational
  • Treatment plan
  • Establish Communication
  • Early intervention if there are discrepancies in
  • Insider information
  • back story
  • pre-claim conflict
  • workplace issues
  • Re-examination of causation

Case Management at MD Recheck
  • Before you walk in
  • Always check previous note and if needed DFR
  • Always check PTx flow sheet for of visits and
    exercise compliance
  • Stay on track with treatment plan
  • Check for new reports, diagnostics, consults,
    correspondence and status of certification
  • Reinforce patient-physician relationship

Case Management at MD Recheck
  • How is it going?
  • Get specific about injury
  • Patients wants to talk about pain
  • I want to talk about function
  • Get specific about functional capacity
  • Check compliance
  • Home Exercises / Microbreaks
  • Meds
  • Splints

Case Management at MD Recheck
  • Reinforce
  • To change outcome we need a change in behavior
  • Monitor for passivity, blaming non-compliance,
    sabotage, inconsistencies
  • The Lecture Ultimately this is going to be
    your problem if
  • Restrictions become permanent
  • Fact Impairment / Disability ratings have
  • Chronic pain is chronic and can ruin your life

Case Management (cont.)
  • If responding to PTx/HEP consider 2nd Rx if
  • Not ready for independent self care
  • Not ready for trial of full duty
  • If not responding consider
  • Certified Hand Therapy (CHT)
  • Chiropractic
  • Acupuncture
  • Myofascial release
  • Discuss treatment options with patient
  • Placebo effect
  • Sense of control
  • Not appropriate for all patients

Especially Challenging Cases
  • Low Back Pain from prolonged sitting
  • Depression/Anxiety from work (Stress claim)
  • Depression from chronic pain, etc.
  • Sick Building Syndrome / Chemical Sensitivity
  • Noncompliance with treatment plan

Low Back PainFrom Prolonged Sitting
  • History
  • Look for prior injury or alternate causation
  • Check Ergonomics
  • Check Work Volume
  • Thorough examination
  • The talk
  • The human body and prolonged static posture
  • Microbreaks
  • Overall fitness / balance
  • Poor Job Fit this is your problem

Stress Claim / Psych. Claim
  • So how did you get hurt?
  • Basic history about circumstances
  • Relationships
  • Work volume
  • Doesnt meet gt50 occupational causation
  • See your own MD
  • Call employer and advise
  • Strong case for legitimate claim
  • Make referral for psych. referral
  • Continue care through personal health plan until
    claim accepted (we are not mental health

  • Pre-existing?
  • Identify early because this will impact coping
    and recovery.
  • Refer to personal MD for treatment because not
    occupational causation.

Depression due to injury
  • Chronic Pain
  • Disability
  • Financial Impact
  • Impairment
  • Reassure
  • Normal response to consequences of any illness
    or disability
  • Depression is situational and will resolve with
    physical recovery or emotional adjustment

Depression due to injury
  • Recommend patient see PMD
  • WC not designed to manage depression
  • Patient probably predisposed to
    depression/anxiety check history
  • Do not automatically accept as secondary to
    original injury
  • If denies prior hx of depression consider psych.
  • PTP cannot ignore patient psych complaints
    associated with injury
  • While consult being certified (?) refer back to

Sick Building SyndromeChemical Sensitivity
  • History, history, history
  • Investigate thoroughly before accepting claim
  • Review MSDS (if applicable)
  • Discuss with DER or Safety Manager
  • Review Industrial Hygiene report
  • Toxic response must make sense
  • Causation is EEs duty to establish
  • Toxicology consult if highly plausible/probable
  • Chemical Sensitivity is ultimately a job fit

Problematic Patients
  • Passive / Depressive / Anxious personality
  • Borderline personality
  • Type A personality
  • Never feel ready for trial of full duty
  • Proceed with trial of full duty
  • Call employer
  • If fails trial of full duty
  • Mis-diagnosis?
  • Consult?
  • Diagnostics?
  • Work Capacity Evaluation (WCE)?

Other Problematic Patients
  • I dont ever want my case closed
  • It might come back
  • What if I need to find another job
  • I wont continue to treat you if
  • you are not responding to care, or
  • stable and dont need regular medical care.
  • Reassure and describe Future Medical
  • I got laid off
  • Often a secondary gain issue
  • If on full duty see above
  • If on modified duty request WCE
  • Figure out what is blocking MMI

Closing Cases as PS
  • Depends on outcome
  • Cured?
  • Residual symptoms?
  • Residual impairment?
  • Residual disability?
  • Permanent work restrictions?

Other Issues to be Resolved at PS
  • AMA Guides Whole Person Impairment Rating
  • Causation Is residual WPI Occupational?
  • Apportionment Is the WPI of mixed causation?
  • Future Medical What? How much? How specific
    about type? Indefinite?
  • Permanent Work Restrictions?

Common WCE Results
  • Most IWs are full duty capable despite pain
    and behaviors
  • Many identified as having inadequate Chronic
    Pain Coping Skills
  • Very sore after testing strongly suggests
    non-compliance with HEP

Thank You
  • Alliance Occupational Medicine
  • 315 South Abbott Ave., Milpitas
  • 2737 Walsh Ave., Santa Clara
  • Please visit us at