Tori Hudgings, OTR/L
Virtual Hand to Shoulder Fellow '23
My name is Tori Hudgings and I’ve been practicing as an occupational therapist in the hand therapy setting since I graduated from OT school in May 2020. I work for a private practice company that solely provides hand therapy services based in the Memphis, TN Metropolitan area. With the increase in hospital-based and physician-owned therapy clinics in the area, our private practice has seen a dip in private insurance referrals over the last 10 years, as patients are choosing to receive their therapy services “in-house” for convenience and connection with their doctor. In spite of this, we have become a preferred provider for many third-party payors- primarily those representing the worker’s compensation population. At our small clinic, I would estimate 85% of patients are receiving hand therapy services due to a work-related injury. These injuries range in severity, from repetitive stress injuries due to overuse to traumatic amputations, degloving, and crush injuries. Many of our patients are working manual labor and utilizing various tools continuously throughout their workday. They are often required to lift/push/pull 50# and more and operate heavy machinery. Working with the injured worker has a number of unique challenges. Particularly for those of you that may be less experienced with treating this patient population, below are some of the important factors to take into consideration to ensure you are providing this population with the best possible care.
Even before the first visit, there are things that need to be especially considered for the worker’s compensation population. Firstly, most of the patient’s care is overseen by a nurse case manager (NCM) who is responsible for organizing their care throughout the entirety of their case. Many times, the NCM will call and schedule the patient’s appointment and ensure all doctor’s appointments are attended and information is being shared with the applicable parties; they also want to be kept in the loop with the patient’s progress and attendance history. Often, visits must first be authorized and approved by a worker’s compensation adjuster, who will determine what services are allowable. Occasionally, this is a point of contention, as the experienced clinician may find the patient could benefit from services/interventions that are not deemed “medically necessary” by third-party payors in which you may need to do some advocating on your patient’s behalf. Also, important to note, there may be extra forms or documentation third-party payors require to continue reimbursing for services that you as the therapist are responsible for managing.
One of the first things to make note of in a worker’s compensation evaluation is how long it has been since the date of injury. Unfortunately, there is an abundance of documentation that is involved with worker’s compensation cases, and sometimes, things fall through the cracks during the approval process. This can cause a delay in the patient getting to see us. With hand stiffness in particular, we are racing the clock in order to address the deficits in the connective tissue before the deformities can become permanent. If a patient is delayed 5-6 weeks before getting into hand therapy, we are going to need to hit the ground running, progressing faster than a worker who was just injured a few days ago.
The primary goal of most worker’s compensation cases might be what you expect: get the patient back to work. To do this, we need information such as the patient’s job title, job demands, and current job status. I typically begin by asking the patient to describe a normal day at their job and then perform an activity analysis to determine the specific therapy goals to set. If a patient is on light or limited duty, we can assess what they are currently doing at work and how successful they are at those tasks, and we can address them accordingly. Goals are then set to get the patient back to performing their regular job tasks, if able. Additionally, it’s important to consider that someone may not be intending to return to their job for whatever reason- no longer available, permanent impairment that will not allow a return to that position, moving to another position, etc.
As with all traumatic injuries, there are likely accompanying psychosocial components that may occur. They may be dealing with fear avoidance due to fear of pain or reinjury, pain catastrophizing, emotional distress, or depression. Often, workers are anxious about not being able to return to their jobs due to their decreased ability to function in the work setting. Patients might be going through the stages of grief, dealing with the loss of a job or a digit or their normal life routine. Their injury may have been traumatic enough to cause flashbacks or a post-traumatic stress response. It’s important to build an appropriate therapeutic relationship to be able to encourage and support your patients through whatever they may be dealing with.
On the other hand, we occasionally interact with patients who are interested in secondary gain. Secondary gain has been described as benefits that can be had by being ill or injured such as disability payments, more time off work, worker’s compensation settlements, opioid prescriptions, or even just sympathy and attention. From time to time we encounter patients who are malingering for secondary gain which can be frustrating as a therapist who is truly concerned with helping a patient meet their therapy goals. We are suspicious of malingering when there are unexplainable losses in range of motion from session to session, subjective reports of pain that do not match the clinical presentation of the patient or the typical presentation of a certain diagnosis, and with guarding during passive motion and special tests. Sometimes it can be beneficial to perform certain tests or assessments while distracting the patient in order to get a more realistic measurement. There are also validity tests that can be ordered by MD if malingering for secondary gain is suspected.
Often, our worker’s compensation patients have been working in physically demanding jobs for most if not all of their lives. Some patients may even have multiple jobs that the injury is keeping them from doing, creating added stress due to the economic burden of their injury. Most workers’ compensation paychecks are around 66% of their normal pay, and for someone who is living paycheck to paycheck, this could have extreme consequences on the patient and their families. These socioeconomic factors make it imperative that we do everything in our power as hand therapists to get our patients back to their jobs.
Return to Work Training
Lastly, it’s important to begin simulated return-to-work training as soon as precautions are lifted, and protocols allow. The best way to improve your skills at a specific task is to practice it. Thus, our clinic has equipment for work simulation allowing patients to begin work-related tasks in a controlled setting. Weighted boxes, tools, carts, pallets- the more occupation-based you can be in this phase of treatment the better. If a patient has a certain lifting requirement for their job, we try to get them lifting that much and potentially more in the clinic once healing allows. Sometimes, work conditioning is ordered by the treating physician which patients usually attend multiple times a week for roughly two hours of specific return-to-work training. For extra heavy job demands, they may be referred for work hardening, which is roughly 4 hours per visit, typically 5 days a week to best prepare the worker for return to the workplace.
Treating a new or unfamiliar population can be challenging- especially when there are different or additional considerations. If worker’s compensation is something you’re not experienced with, hopefully, this provided insight into the various considerations to best manage these cases and support the injured workers in their recovery and return to work.
Barron, C., Ring, D., Vranceanu, A. Psychosocial Aspects of Arm Health. In: Skirvin, Osterman, Fedorczyk, Amadio, Feldscher, and Shin (eds). Rehabilitation of the Hand and Upper Extremity. 7th ed. Philadelphia: Elsevier, 2021, pp. 1694- 1703. Ch. 118