ODG TWC Duty

ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 1 of 71 4/2/2007 11:32 AM ODG -TWC ODG Treatment Integrated Treatment/Disability Duration Guidelines Fitness For Duty (See body-part chapters for more recent condition specific information, especially the Low Back Chapter) Back to ODG -TWC Index CONTENTS Treatment Planning.……………………………………………………………………..2 Procedure Summary ……………………………………………………………………5 References ………………………………………………………..……………………12 (Click on any reference above to go to reference summary) Reference Summaries…………………………………………………..…………….….19 (Including abstract, evaluation, and rating) (Click on summary to go to full copy if included as a separate document) Explanation of Medical Literature Ratings: Ranking by Type of Evidence: 1. Systematic Review/Meta-Analysis 2. Controlled Trial – Randomized (RCT) or Controlled 3. Cohort Study -Prospective or Retrospective 4. Case Control Series 5. Unstructured Review OTHER: 6. Nationally Recognized Treatment Guideline (from guidelines.gov) 7. State Treatment Guideline 8. Foreign Treatment Guideline 9. Textbook 10. Conference Proceedings/Presentation Slides Ranking by Quality within Type of Evidence: a. High Quality b. Medium Quality c. Low Quality ########################################## ODG Integrated Treatment/Disability Duration Guidelines Fitness For DutyODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 2 of 71 4/2/2007 11:32 AM Fitness-to-work examinations are objective assessments of the health of employees in relation to their specific jobs, in order to ensure they could do the job and would not be a hazard to themselves or others. Fitness-to-work examinations should always be conducted with reference to the specific job the worker holds or intends to hold. The circumstances that require such examinations occur at the time of application or consideration for entry into employment and assignment to a specific job (pre-placement), return to work after illness or injury (return to work). To be useful to the employee and employer and to be consistent with human-rights legislation, pre-placement examinations must be structured so that they are specific to the working conditions and job requirements medically and are timed after a job offer has been made. An employer cannot arbitrarily deny a person a job opportunity on the basis of a physical or emotional disability. However, the job offer can be made contingent upon passing a medical examination that indicates the employee would be able to perform the job and would not be a hazard to him or herself or others while working in that job. The employee may be refused the job only if the health of the employee is not compatible with the working conditions, and the job requirements cannot reasonably be altered. There are six possible judgments, the appropriateness of which may depend on the type of fitness-to-work examination being done: fit, temporarily fit, fit subject to work modifications, temporarily fit subject to work modifications, temporarily unfit, and permanently unfit. These categories are defined below: Fit: This judgment means that the employee is able to perform the job without danger to self or others, without reservation. The subcategory "temporarily" can be used for all types of medical assessments except pre-placement. "Permanently" should never be used with a judgment of "fit" since physicians cannot see into the future. Fit subject to work modifications: A judgment in this category indicates that the employee could be a hazard to self or others if employed in the job as described but would be considered fit to do the job if certain working conditions were modified (e.g., changing the way the work is performed or the working environment). The modifications required must be clearly described in the comments section. If these can be accommodated, the employee is considered fit for the modified job. If the modifications cannot be reasonably accommodated, the employee is deemed temporarily or permanently unfit. "Temporarily" means that if the person's condition improves with time, the requirement for work modifications may be lifted. "Permanently" means that the employee will never be fit for the job without the modifications. Any employee considered fit subject to work modifications must be fully informed of both the medical findings and the modifications. Unfit: This category describes the employee who is unable to perform the job without being a hazard to self or others. This judgment and the subcategories "temporarily" and "permanently" can be used with any type of fitness-to-work examination. "Temporarily" means that the medical condition may improve with time, thus allowing return to work or transfer to some other job. "Permanently" usually means that the employee will never be fit for the job and that no modification of the working conditions is reasonably possible or medically relevant; if “permanently” means that the employee is unable to do any available job, with or without work modifications, a statement to this effect should be made in the comments section. Key Elements of a Fitness-for-Duty Examination Under the Americans with Disabilities Act: 1) Determine the presence or absence of a permanent impairment that substantially limits one or more major life activities. 2) Evaluate the patient's work capacity (mental and physical) and delineate workplace restrictions. 3) Assess workplace demands (mental and physical) and essential functions of the job.ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 3 of 71 4/2/2007 11:32 AM 4) Ascertain the patient's ability to perform the essential functions of the job with, or without, accommodations. Practical Pointers on Disability Evaluations and Certifications: 1) Do not confuse the terms "impairment" and "disability." Impairment can be defined as a loss of physiologic function or anatomic structure. By contrast, disability can be defined as a reduced ability to meet occupational demands as a result of impairment and other associated factors. Therefore, disability is a broad term that encompasses not only impairment but also a multitude of other factors. 2) Obtain appropriate consents signed and dated by the patient. 3) Clearly delineate the nature and extent of all impairments (mental and physical); segregate those pertaining to the claim. 4) Document all patient limitations (mental and physical) and workplace restrictions. 5) Assess the patient's workplace demands (mental and physical) and essential functions of the job by obtaining a functional job analysis from the employer. 6) Assess fitness for duty and employability by comparing the patient's work capacity to workplace demands. Obtain a functional capacity examination if needed. (See Procedure Summary.) 7) Ascertain the type and definition of disability being applied to the claim. 8) Determine disability status and address issues of temporary versus permanent, as well as partial versus total disability. 9) List patient’s capabilities, limitations, and restrictions. 10) Do not address issues of permanency (including impairment or disability) until the patient has reached maximum medical improvement. 11) Complete disability certification forms objectively, accurately and in a timely manner. 12) Beware of hidden patient agendas and secondary gain from disability. When considering whether a worker is fit for duty, an appreciation for the workplace in general and the specific task(s) is crucial. The physician needs a detailed job description from the employer. Ideally, this information should be corroborated by the worker. The physician's role includes: (1) providing a critical assessment of the available medical information as to completeness and validity, (2) identifying impairments that can "reasonably be anticipated" to affect performance of essential functions, (3) determining if impairments are permanent, and (4) identifying impairments that may result in a sudden or gradual adverse consequence (e.g., incapacitation in a safety-sensitive job, communicable disease) or a "direct threat" (i.e., significant risk of substantial harm to the health or safety of self, co-workers, or the public that cannot be eliminated by reasonable accommodation). ########################################## Procedure/Topic Summary – Fitness for Duty Topic Summary of medical evidence Activity restrictions See Work. Americans with disabilities act (ADA) Fitness statements often are required of physicians by patients, employers, governmental agencies, and insurance providers to determine if the patient is fit for duty. Physicians making these ability statements are legally obligated to carefully justify them when placing or excluding individuals from the workplace. The Americans with Disabilities Act (ADA) mandates that medical providers use justifiable criteria and rational thought when determining the capability and risk of an individual. (Colledge, 2000) (Colledge, 1999) To be useful to the employee and employer and to be consistent with human-rights legislation, preplacement examinations must be structured so that they are specific to the working conditions and job requirements medically and are timed after a job offer has been made. An employer cannot arbitrarily deny a person a job opportunity on the basis of a physical or emotional disability. However, the job offer can be made contingent upon passing a medical examination that ensures the employee will be able toODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 4 of 71 4/2/2007 11:32 AM Procedure/Topic Summary – Fitness for Duty Topic Summary of medical evidence perform the job and will not be a hazard to him or herself or others while working in that job. The employee will be refused the job only if the health of the employee is not compatible with the working conditions and the working conditions and job requirements cannot reasonably be altered. (Guidotti, 2003) Body mass index (BMI) BMI continues to prove useful as a screening tool and may be useful in identifying individual firefighters for health and fitness intervention measures. (Clark, 2002) There is independent and combined importance of aerobic fitness and body fatness on physiological tolerance and exercise time during weight-bearing exercise. The major advantage attributed to a higher aerobic fitness was the ability to tolerate a higher core temperature at exhaustion (the difference being as great as 0.9 degrees C), whereas both body fatness and rate of heat storage affected the exercise time as independent factors. (Selkirk, 2001) Carpal tunnel release & return to work See also Carpal Tunnel Syndrome Chapter. Conservative treatment alone is not effective in returning worker's compensation patients with CTS to work. (Lyall, 2002) Surgical treatment of carpal tunnel syndrome seems to be better than splinting. (Verdugo-Cochrane, 2002) Surgical treatment decreased the rate of duty modifications and disability ratings compared with nonsurgical treatment and reduced the odds of incurring disability. Despite the generally held belief that the outcome of treatment of occupational carpal tunnel syndrome is poor, the present study shows that both surgical and nonsurgical treatment is effective. However, patients treated with surgery had decreased disability when compared with those who were treated conservatively. (Shin, 2000) Meta-analysis of studies comparing open and endoscopic carpal tunnel release show a small but statistically significant advantage to endoscopic release in global treatment outcome. In addition, the data show a trend toward faster return to work. (AHRQ, 2003) Endoscopic carpal tunnel release appears to be a cost-effective procedure. (Chung, 1998) Now carpal tunnel release is well supported, both open and endoscopic (with proper surgeon training), assuming the diagnosis of CTS is correct. In many cases it may result in quicker fitness for duty than prolonged conservative treatment. (Unfortunately, many CTR surgeries are performed on patients without a correct diagnosis of CTS, and these surgeries do not have successful outcomes.) Carpal tunnel syndrome may be treated intially with a splint and medications before injection is considered, except in the case of severe CTS (thenar muscle atrophy and constant paresthesias in the median innervated digits). Outcomes from carpal tunnel surgery justify prompt referral for surgery in moderate to severe cases. Nevertheless, surgery should not be performed until the diagnosis of CTS is made by history, physical examination and possible electrodiagnostic studies. Surgical decompression of the median nerve usually has a high rate of long-term success in relieving symptoms, with many studies showing success in over 90% of patients where the diagnosis of CTS has been confirmed by electrodiagnostic testing. (Patients with the mildest symptoms display the poorest post-surgery results, but in patients with moderate or severe CTS, the outcomes from surgery are better than splinting.) Carpal tunnel syndrome must be proved by positive findings on clinical examination and may be supported by nerve conduction tests before surgery is undertaken. Early return to work after carpal tunnel surgery is more dependent on the willingness of the employer and employee than on the surgical technique. (Verdugo, 2002) (Shin, 2000) (AHRQ, 2003) (Lyall, 2002) (Chung, 1998) Commercial drivers In performing driver certification examinations, the physician's primary responsibility is to the public. The Federal Motor Carriers Safety Regulations and supporting documents provide guidelines for the conditions that may be disqualifying and the conditions that may allow only temporary certification until better medical control is achieved. Some medical diagnoses, such as insulin-requiring diabetes mellitus, are automatically disqualifying, no matter how well the disease is controlled. (Pommerenke, 1998) Medical practitioners need to be aware of current advice and guidelines with respect to obstructive sleep apnea and driving. (Desai, 2003) All drivers requiring insulin treatment must be able to demonstrate satisfactory diabetic control and recognition of hypoglycaemic symptoms before being allowed to drive a motor vehicle. Note: the U.S. FMCSA (Federal Motor Carrier Safety Administration) considers insulin-requiring diabetes mellitus an automatically disqualifying condition, with some limited exemptions. (Flanagan, 2000) There is a need for a generally accepted guideline in the evaluation process of patients with heart diseases applying for a driving license. (Janosi, 2002) 50% of the truck drivers who completed a health risk appraisal were found to be at risk for a back injury. Lost time records revealed that this population had 65% more lost workdays attributed to cumulative trauma injuries compared with acute trauma injuries. Implementing a medical fitness for dutyODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 5 of 71 4/2/2007 11:32 AM Procedure/Topic Summary – Fitness for Duty Topic Summary of medical evidence program consisting of three components: physical examination (physical examination mandated by the Department of Transportation and a functional capacity evaluation), education (on safe body mechanics), and physical fitness. (Kashima, 2003) According to the DOT regulation 49 CFR Part 40, all companies with safety-sensitive employees that test positive on a random, pre-employment, reasonable suspicion or post-accident test, must be given SAP referrals. If an organization fails to do so, they can be subject to severe fines by the Department of Transportation (DOT). EAP counselors deal with a spectrum of emotional issues that affect employees, such as relationships, family stress, anxiety and substance abuse. An EAP counselor utilizes different procedures and requirements concerning confidentiality. The majority of EAP counselors do not meet the qualification standards required to perform DOT mandated SAP evaluations. Only the SAP can determine if the employee is eligible to return to safety-sensitive duty. (DOT, 2004) Diabetes All drivers requiring insulin treatment must be able to demonstrate satisfactory diabetic control and recognition of hypoglycaemic symptoms before being allowed to drive a motor vehicle. Note: the U.S. FMCSA (Federal Motor Carrier Safety Administration) considers insulin-requiring diabetes mellitus an automatically disqualifying condition, with some limited exemptions. (Flanagan, 2000) Drug use Drug use is most prevalent among young adults representing the segment of our society entering the work force. The "fitness for duty" policy stipulates that all employees assume responsibility to report to work in a fit condition and perform their jobs without increasing risk to themselves or others. (Callery, 1995) Employee assistance programs are a potential resource for fitness-to-work evaluations when alcohol and drug abuse are the basis of the medical problem. (Guidotti, 2003) According to the DOT regulation 49 CFR Part 40, all companies with safety-sensitive employees that test positive on a random, pre-employment, reasonable suspicion or post-accident test, must be given SAP referrals. If an organization fails to do so, they can be subject to severe fines by the Department of Transportation (DOT). EAP counselors deal with a spectrum of emotional issues that affect employees, such as relationships, family stress, anxiety and substance abuse. An EAP counselor utilizes different procedures and requirements concerning confidentiality. The majority of EAP counselors do not meet the qualification standards required to perform DOT mandated SAP evaluations. Only the SAP can determine if the employee is eligible to return to safety-sensitive duty. (DOT, 2004) Exercise fitness programs The scientific evidence on the effectiveness of physical activity programs at worksites is still limited. This paper systematically reviews the literature on the effectiveness of physical activity programs at worksites with respect to work-related outcomes. The evidence of an effect was limited for absenteeism, inconclusive for job satisfaction, job stress and employee turnover, and nil for productivity. (Proper, 2002) Physical activity once a week at worksites may improve the perceived work ability of employees with physically demanding work only slightly. Perceived work ability and sick leaves cannot be affected very positively using single-component exercise intervention. Work ability promotion may need a more multi-professional approach. (Nurminen, 2002) 50% of the truck drivers who completed a health risk appraisal were found to be at risk for a back injury. Lost time records revealed that this population had 65% more lost workdays attributed to cumulative trauma injuries compared with acute trauma injuries. Implementing a medical fitness for duty program consisting of three components: physical examination (physical examination mandated by the Department of Transportation and a functional capacity evaluation), education (on safe body mechanics), and physical fitness. (Kashima, 2003) The implementation of an employee health and fitness program can have positive lasting effects on both the employee and employer. In addition to implementing programs that offer a variety of choices and one on one counseling, employers would benefit from targeting the at-risk population to ensure that the programs benefit the greatest number of employees possible. (Voit, 2001) Firefighters BMI continues to prove useful as a screening tool and may be useful in identifying individual firefighters for health and fitness intervention measures. (Clark, 2002) One of the functions of the fire department physician is to give candidates and firefighters clearance to work based on medical and physical performance criteria including application of the medical standards of NFPA 1582 and physical standards as measured by agility tests and the proposed NFPA 1583. (Gerkin, 1995) Increasing morbidity is associated with higher age, lower spirometric function, lower predicted VO(2) max, increasing cholesterol, greater BMI, and higher predicted 10 year CHD risk. Although the presence of a single serious or poorly controlled condition may render anODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 6 of 71 4/2/2007 11:32 AM Procedure/Topic Summary – Fitness for Duty Topic Summary of medical evidence individual unfit for safe performance as a firefighter, multiple risk factor models or overall clinical assessments are superior means of identifying firefighters with poor health status and increased CHD risk. (Kales, 1999) Studies of simulated firefighting are needed to establish minimum hearing requirements and determine whether corrective devices can be worn safely during duty. (Kales, 1998) Inactive firefighters have a 90% greater risk of myocardial infarction than those who are aerobically fit. (Peate, 2002) Functional capacity evaluation (FCE) Both job-specific and comprehensive FCEs can be valuable tools in clinical decision-making for the injured worker; however, FCE is an extremely complex and multifaceted process. Little is known about the reliability and validity of these tests and more research is needed. (Lechner, 2002) (Harten, 1998) (Malzahn, 1996) (Tramposh, 1992) (Isernhagen, 1999) (Wyman, 1999) Functional capacity evaluation (FCE), as an objective resource for disability managers, is an invaluable tool in the return to work process. (Lyth, 2001) There are controversial issues such as assessment of endurance and inconsistent or sub-maximum effort. (Schultz-Johnson, 2002) Little to moderate correlation was observed between the self-report and the Isernhagen Work Systems Functional Capacity Evaluation (FCE) measures. (Reneman, 2002) Inconsistencies in subjects' performance across sessions were the greatest source of FCE measurement variability. Overall, however, test-retest reliability was good and interrater reliability was excellent. (Gross, 2002) FCE subtests of lifting were related to RTW and RTW level for people with work-related chronic symptoms. Grip force was not related to RTW. (Matheson, 2002) Scientific evidence on validity and reliability is limited so far. An FCE is time-consuming and cannot be recommended as a routine evaluation. (Rivier, 2001) Isernhagen's Functional Capacity Evaluation (FCE) system has increasingly come into use over the last few years. (Kaiser, 2000) Ten well-known FCE systems are analyzed --All FCE suppliers need to validate and refine their systems. (King, 1998) Compared with patients who gave maximal effort during the FCE, patients who did not exert maximal effort reported significantly more anxiety and self-reported disability, and reported lower expectations for both their FCE performance and for returning to work. There was also a trend for these patients to report more depressive symptomatology. (Kaplan, 1996) Safety reliability was high, indicating that therapists can accurately judge safe lifting methods during FCE. (Smith, 1994) Guidelines for performing an FCE: If a worker is actively participating in determining the suitability of a particular job, the FCE is more likely to be successful. A FCE is not as effective when the referral is less collaborative and more directive. It is important to provide as much detail as possible about the potential job to the assessor. Job specific FCEs are more helpful than general assessments. The report should be accessible to all the return to work participants. Consider an FCE if 1. Case management is hampered by complex issues such as: • Prior unsuccessful RTW attempts. • Conflicting medical reporting on precautions and/or fitness for modified job. • Injuries that require detailed exploration of a worker’s abilities. 2. Timing is appropriate: • Close or at MMI/all key medical reports secured. • Additional/secondary conditions clarified. Do not proceed with an FCE if • The sole purpose is to determine a worker’s effort or compliance. • The worker has returned to work and an ergonomic assessment has not been arranged. (WSIB, 2003) Heart disease & fitness to drive There is a need for a generally accepted guideline in the evaluation process of patients with heart diseases applying for a driving license. (Janosi, 2002) Hernia & return to work See also Hernia Chapter. Patients can return to normal activity soon after inguinal herniorrhaphy without increasing the recurrence rate at one year and three years and with considerable monetary benefit to one-third of workers. (Bourke, 1981) Human immunodeficiency virus (HIV) testing The U.S. District Court ruled that the Department of State's mandatory human immunodeficiency virus (HIV) testing in the medical fitness program for foreign service employees appeared rationally and closely related to fitness for duty. (U.S. District Court, 1987)ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 7 of 71 4/2/2007 11:32 AM Procedure/Topic Summary – Fitness for Duty Topic Summary of medical evidence Implantable defibrillator/pacemaker Patients with an ICD can safely resume work in industrial facilities following simple screening for electromagnetic interference. (Gurevitz, 2003) Low back pain & return to work See also Low Back Chapter. The strongest medical evidence regarding potential therapies for low back pain indicates that having the patient return to normal activities has the best long term outcome. There are many therapies, both invasive and noninvasive, whose purpose is to cure the pain, but there is no strong evidence that they accomplish this as successfully as therapies that focus on restoring functional ability, without focusing on the pain. (Elders, 2000) (Scheer, 1995) (Scheer, 1996) (Allen, 1999) (Hagen, 2000) (Hilde, 2002) (Malmivaara, 1995) (Waddell, 1997) (Indahll, 1995) (Indahl, 1998) However, modified duty may be necessary, since there is evidence for a dose-response relation between physical workload and LBP of longer duration. (Hartvigsen, 2003) Military The armed forces have devised useful systems that grade physical capability and fitness to serve under various weather conditions and in certain geographical locations. Such systems, however, have little practical use in the civilian work force. (Guidotti, 2003) Women have over twice the injury rate of men. For men and women, fewer push-ups, slower 3.2-km run times, lower peak VO2, and cigarette smoking were risk factors for time-loss injury. Among the men only, lower levels of physical activity before U.S. Army Basic Combat Training and both high and low levels of flexibility were also time-loss injury risk factors. Multivariate analysis revealed that lower peak VO2 and cigarette smoking were independent risk factors for time-loss injury. (Knapik, 2001) Decreased fitness level (identified as increased body mass index) among males and increased age were related to increased Line-of-duty injuries or illnesses (LODs). (Lorich, 2002) Overweight/obesity was the behavioral factor with the largest effect among men, with aerobic exercise frequency ranked second; among women, the order of these two factors was reversed. Cigarette smoking only had an adverse effect among men. For a hypothetical active-duty Air Force (ADAF) man who was sedentary, obese, and smoked, the results suggested that aggressive behavioral risk factor modification would produce a 77% relative decrease in risk of low fitness. (Robbins, 2001) Modified duty & return to work A program that incorporates employee and supervisory training and job accommodation, and an industrial hygienist trained in ergonomics to facilitate the placement of individuals with restrictions, may result in a significant decrease (55%) in the rate of lost workday cases. (Bernacki, 2000) For each level of job provided in ODG's Best Practice guidelines, specific modifications and restrictions are provided to be used to modify duty and/or the workstation to allow for early return-to-work while taking actions to prevent re-injury. These modifications work directly with the pathways and durations in the Best Practice guidelines, and can be used by providers when preparing an employers RTW form. (Denniston, 2002) Neck pain & return to work See also Neck Chapter. Patients diagnosed with WAD (whiplash associated disorders), and other related acute neck disorders may commence normal, pre-injury activities to facilitate recovery. Rest and immobilization using collars are less effective, and not recommended for treating whiplash patients. (Verhagen, 2002) (Borchgrevink, 1998) (Gennis, 1996) (Rosenfeld, 2000) Physical demands Metabolic demands in working life today remain high. This is reflected in a mismatch between individual physical capacity and the physical demands of work for 25% of the population. (Karlqvist, 2003) Physical workload increases the risk of retirement on a disability pension especially due to musculoskeletal disorders. In heavy physical work, the risk is increased especially among men with musculoskeletal or cardiovascular disease and poor cardio-respiratory fitness. (Karpansalo, 2002) Pilots & airline staff Employers have a legal duty to manage safety in airline staff and to meet this duty it is necessary to control risks arising from pre-existing medical conditions. (McGregor, 2003) Psychiatric aspects of fitness for duty See also Stress & Mental Chapter. The incidence of reported workplace violence is on the rise and can be devastating beyond the immediate injury. Forensically oriented mental health professionals can assist companies by providing pre-employment screenings, fitness-for-duty evaluations and threat assessment by using the results of current research on potentially violent individuals. (Fletcher, 2000) Workplace needs set the tolerance limits within which the worker must operate. They are different for a police officer, for a correctional officer, for a schoolteacher, and for a school custodian. (Brodsky, 1996) Employee assistance programs are a potential resource for fitness-to-work evaluations when alcohol and drug abuse are the basis ofODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 8 of 71 4/2/2007 11:32 AM Procedure/Topic Summary – Fitness for Duty Topic Summary of medical evidence the medical problem. (Guidotti, 3003) Behavioral/Mental/Psychological Fitness For Duty (FFD) of workers, another important element of individual-to-work fitness, is now beginning to receive more attention. (Rigaud, 2001) Pulmonary testing Spirometric testing in the workplace is recommended, where spirometry is employed in the primary, secondary, and tertiary prevention of occupational lung disease. Primary prevention includes pre-placement and fitness-for-duty examinations. Test performance and interpretation need to follow current recommendations/standards in the pulmonary and regulatory fields. (Townsend, 2000) Serial Pulmonary function tests (PFTs) are useful in following patients and screening exposed populations of workers for respiratory conditions. (Sood, 2001) Screening chest radiographs Studies have shown low efficacy of screening chest radiographs in various populations. Routine screening of flight duty applicants does not appear to be justified. (Cox, 2000) Seizures or syncope Loss of consciousness is usually due to either seizures or syncope. There are no evidence-based historical diagnostic criteria that distinguish them. (Sheldon, 2002) Syncope is defined as a self-limited loss of consciousness, usually combined with falling due to the inability to maintain postural tone. The most important step is to differentiate patients with heart disease from others. In contrast to the increased mortality risk for patients with cardiac syncope, patients with vasovagal syncope have a benign prognosis. (Wohrle, 2003) Vasovagal syncope (VVS) is an exaggerated tendency to the common faint that affects any age group. Conventional treatment is non-specific and involves strategies to increase blood pressure. Patients with VVS are often unable to work or complete education due to actual, or fear of, syncopal symptoms. Patients with VVS whose symptoms had proved resistant to conventional treatments where intervention with cognitive behavioural therapy (CBT) led to significant reductions in reported syncopal episodes. All subjects post-intervention were able to return to work or schooling. CBT is an effective treatment in those with difficult to manage VVS. (Newton, 2003) Skin disorders and job fitness assessment Several dermatoses can be aggravated or caused by occupational factors (e.g. atopic dermatitis, allergic contact dermatitis, irritant contact dermatitis, keratinization disorders, lichen planus, physical urticaria). (Crippa, 2002) Sleep disorders Medical practitioners need to be aware of current advice and guidelines with respect to obstructive sleep apnea and driving. (Desai, 2003) Work See individual body-part chapters for more recent condition specific information. ########################################## REFERENCES Agency for Healthcare Research and Quality (AHRQ), Evidence Report/Technology Assessment: Number 62, Diagnosis and Treatment of Worker-Related Musculoskeletal Disorders of the Upper Extremity, 2003 Allen C, Glasziou P, Del Mar C, Bed rest: a potentially harmful treatment needing more careful evaluation, Lancet 1999 Oct 9;354(9186):1229-33 Barron BA, Disability certifications in adult workers: a practical approach, Am Fam Physician. 2001 Nov 1;64(9):1579-86. Bernacki EJ, Guidera JA, Schaefer JA, Tsai S, A facilitated early return to work program at a large urban medical center, J Occup Environ Med 2000 Dec;42(12):1172-7 Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I. Acute Treatment of Whiplash Neck Sprain Injuries. Spine 1998;23:25-31. 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October 2003 Wyman DO, Evaluating patients for return to work, Am Fam Physician. 1999 Feb 15;59(4):844-8. ########################################## REFERENCE SUMMARIES Agency for Healthcare Research and Quality (AHRQ), Evidence Report/Technology Assessment: Number 62, Diagnosis and Treatment of Worker-Related Musculoskeletal Disorders of the Upper Extremity, 2003 Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities. This report is a systematic evaluation of the evidence pertaining to a broad range of issues related to the diagnosis and treatment of worker-related upper extremity disorders (WRUEDs). For the purposes of this report, "worker-related" is defined as a disorder that affects workers, not as a disorder necessarily caused by work. Four disorders are the focus of this report; carpal tunnel syndrome, cubital tunnel syndrome, epicondylitis, and de Quervain's disease. To identify information for this evidence report, the EPC searched 31 electronic databases, the World Wide Web, and four U.S. Government databases. In addition to these searches, researchers also reviewed the bibliographies and reference lists of all studies included in this evidence report, searched Current Contents®/Clinical Medicine on a weekly basis, and routinely reviewed over 1,600 journals and supplements maintained in ECRI's collections. The EPC's meta-analyses of distal motor latency studies found the sensitivity of the test to be 57% to 66% and the specificity to be 98%. Meta-analysis of palmar sensory latency studies found a sensitivity of 76% and a specificity of 98%. The sensitivity of Phalen's maneuver was lower than its specificity, and two trials reported sensitivity of 80% to 90%. All of the studies of Tinel's sign found that its sensitivity was lower than its specificity, and none found a sensitivity of 75 percent or greater. There was too much heterogeneity in the results for them to conclude that one test was superior to the other, or to compare these tests to nerve conduction testing. Meta-analysis of studies comparing open and endoscopic carpal tunnel release show a small but statistically significant advantage to endoscopic release in global treatment outcome. In addition, the data show a trend toward faster return to work and to activities of daily living among patients receivingODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 15 of 71 4/2/2007 11:32 AM endoscopic release. Endoscopic release has a higher complication rate and a higher rate of reoperation. Meta-analysis of global outcomes demonstrates a potential benefit from not performing neurolysis. Results of four studies suggest that injection of steroid into the carpal tunnel yields superior global outcomes compared to no treatment, placebo, or oral steroids. However, relief from steroid treatments is not complete. Results of a single study suggest that manual therapy may have some use in the treatment of carpal tunnel syndrome. The only clinical finding variable shown by more than one study to significantly predict treatment outcomes was electrodiagnostic testing. Patients with mildly impaired or normal results of electrodiagnostic tests had longer sick leaves and were less likely to be satisfied with the results of treatment. This finding was statistically significant in three of the four studies examining this relationship. The available evidence suggests that patients who are not receiving workers' compensation tend to return to work faster than those receiving such compensation. Three prospective cohort trials have indicated that the SF-36 is not a useful instrument for assessing functional limitations in individuals with carpal tunnel syndrome. The SF-36 was reported to be unresponsive to treatment and unable to predict ability to work. Four prospective cohort trials have indicated that the Levine CTS-I may be a useful instrument. ########################################## Allen C, Glasziou P, Del Mar C, Bed rest: a potentially harmful treatment needing more careful evaluation, Lancet 1999 Oct 9;354(9186):1229-33 Centre for General Practice, Graduate School of Medicine, University of Queensland, Australia. See Low Back chapter. Publication Types: · Review · Review, Tutorial PMID: 10520630 Rating: 1b ########################################## Barron BA, Disability certifications in adult workers: a practical approach, Am Fam Physician. 2001 Nov 1;64(9):1579-86. University of Rochester School of Medicine and Dentistry, New York, USA. barron@urmc.rochester.edu Family physicians are frequently asked to complete disability certification forms for workers. The certification process can be contentious because of the number of stakeholders, the varying definitions of disability and the nature of the administrative systems. Insufficient training on disability during medical school and residency complicates this process. Disability systems discussed include workers' compensation, private disability insurance, the Americans with Disabilities Act and the Family and Medical Leave Act. Strategies that help the physician complete disability certification forms effectively include identification of disability type, ascertainment of the definition of disability being applied, evaluation of workplace demands and essential job functions, assessment of worker capacity, and accurate and timely completion of the forms in their entirety. PMID: 11730313 ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 16 of 71 4/2/2007 11:32 AM TABLE 4 --Key Elements of a Fitness-for-Duty Examination Under the Americans with Disabilities Act Determine the presence or absence of a permanent impairment that substantially limits one or more major life activities. Assess the patient's work capacity (mental and physical) and delineate workplace restrictions. Assess workplace demands (mental and physical) and essential functions of the job. Ascertain the patient's ability to perform the essential functions of the job with or without accommodations. TABLE 5 --Practical Pointers on Disability Evaluations and Certifications Do not confuse the terms “impairment” and “disability.” Obtain appropriate consents signed and dated by the patient. Clearly delineate the nature and extent of all impairments (mental and physical) pertaining to the claim. Document all patient limitations (mental and physical) and workplace restrictions. Assess the patient's workplace demands (mental and physical) and essential functions of the job by obtaining a functional job analysis from the employer. Assess fitness for duty and employability by comparing the patient's work capacity to workplace demands; obtain a functional capacity examination as indicated and consider other factors outlined in Table 1. Ascertain the type and definition of disability being applied to the claim. Determine disability status and address issues of temporary versus permanent and partial versus total disability. Do not address issues of permanency (impairment or disability) until the patient has reached maximum medical improvement. Complete disability certification forms objectively, accurately and in a timely manner. Beware of hidden patient agendas and secondary gain from disability, such as a miraculous recovery just before disability benefits end or employment is terminated. Rating: 5b ########################################## Bernacki EJ, Guidera JA, Schaefer JA, Tsai S, A facilitated early return to work program at a large urban medical center, J Occup Environ Med 2000 Dec;42(12):1172-7 Division of Occupational and Environmental Medicine, Johns Hopkins University, School of Medicine, 600 N. Wolfe Street, Billings Administration 129, Baltimore, MD 21287-1629, USA. This study found that an Early Return to Work Program that included an industrial hygienist trained in ergonomics to facilitate the placement of individuals with restrictions resulted in a significant decrease (55%) in the rate of lost workday cases before versus after the return to work program. Publication Types: · Evaluation Studies ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 17 of 71 4/2/2007 11:32 AM Rating: 5a ########################################## Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I. Acute Treatment of Whiplash Neck Sprain Injuries. Spine 1998;23:25-31. (1) Emergency Clinic, University Hospital, Trondheim, Norway. STUDY DESIGN: A single-blinded, randomized treatment study with a follow-up period of 6 months. OBJECTIVE: To study the long-term consequences of whiplash neck sprain injuries in patients treated with two different regimes during the first 14 days after the car accident. Patients in the first group were encouraged to act as usual, i.e., continue to engage in their normal, pre-injury activities; that group was compared with another group of patients who were given time off from work and who were immobilized using a soft neck collar. The end point of the comparison was the evaluation of subjective symptoms 6 months after the accident. SUMMARY OF BACKGROUND DATA: Few randomized treatment studies have been performed to evaluate the clinical outcome for patients with neck sprain. METHOD: Patients who participated in the study were recruited from the Emergency Clinic at the University Hospital in Trondheim, Norway. The study group included 201 patients (47% of the study group) with neck sprain that resulted from a car accident. Neck and shoulder movements and subjective symptoms, which were assessed using several different measurements, were assessed during the follow-up period. RESULTS: There was a significant reduction of symptoms from the time of intake to 24 weeks after the treatment period in both groups. There was a significantly better outcome for the act-as-usual group in terms of subjective symptoms, including pain localization, pain during daily activities, neck stiffness, memory, and concentration, and in terms of visual analog scale measurements of neck pain and headache. CONCLUSIONS: The outcome was better for patients who were encouraged to continue engaging in their normal, pre-injury activities as usual than for patients who took sick leave from work and who were immobilized during the first 14 days after the neck sprain injury. Publication Types: · Clinical Trial · Randomized Controlled Trial PMID: 9460148 [PubMed -indexed for MEDLINE] Comments by Dr. Whitney of the Colorado Division of Workers' Compensation: Design. Randomized Trial. Population/sample size: -201 patients (81 men, 120 women) age 18-70 recruited at first ER visit for neck sprain following car accident in Norwegian University Hospital setting -Only private car crashed enrolled, no bus or large vehicle crash -Randomized to usual activity (n=96) or 14 days sick leave with soft collar immobilization 2 hours on and 2 hours off and at night (n=105); all received 5 day prescription for NSAIDS Main outcome measures: -Assessment of symptoms (VAS for headache & neck pain, neck stiffness, hatch marks for area affected by pain, and pain with 17 daily activities, memory, concentration, tinnitus) at 2 weeks, 6 weeks, and 6 months -Neurologic exam at 2 weeks and 6 months by physician blinded to assignmentODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 18 of 71 4/2/2007 11:32 AM -Symptom scores resolved by factor analysis into 3 factors: pain, attention, and tinnitus -Groups compared by repeated measures ANOVA and repeated measures ANCOVA adjusting for baseline symptoms -Both groups improved equally on pain factor at 6 months, but usual activity group had better scores on some components of pain factor: pain distribution and pain during daily activities, neck stiffness, headache; also for attention -Use of sick leave between 2 weeks and 6 months not different between groups -Range of motion in neck and shoulder & tinnitus not different between groups Authors’ conclusions: -The outcome was better for patients who were encouraged to continue engaging in their normal, pre-injury activities as usual than for patients who took sick leave from work and who were immobilized during the first 14 days after the neck sprain injury. -Usual activity group did better than soft collar immobilization, even though 10% of usual activity group still severely symptomatic at 6 months -Patients with long-lasting symptoms may continue engaging in normal life activity; instruction to act as usual at first consultation may encourage this Comments: -Patients recruited on first consultation, but not stated how much time had elapsed between car crash and first consult Rating: 2a, 201 cases ########################################## Bourke JB, Lear PA, Taylor M, Effect of early return to work after elective repair of inguinal hernia: Clinical and financial consequences at one year and three years, Lancet 1981 Sep 19;2(8247):623-5 Since January, 1976, male patients undergoing elective unilateral inguinal herniorrhaphy have been included in a trial to see whether early return to normal activity is associated with an increased recurrence rate and to investigate economic consequences. By June, 1981, 500 patients had been reviewed at one year. 2 patients had defaulted. The first 200 patients had been examined at one year and three years. Recurrence was assessed independently, and recurrences were found of which the patient was unaware. The acceptable definition of recurrence was need for reoperation or a truss. The overall recurrence rate at one year was 3.9%. At three years no further recurrences were detected in the first 200 patients. There was no difference in the recurrence rate for those in the "early" group with 8 recurrences in a total of 246 patients and 10 recurrences in 245 patients in the control group. the median inactivity period in the "early" group was 48 days, compared with 65 days in the control. This differences of 17 days is significant (p=0.001). The self-employed "early" group returned to work in a median of 31 days. One-third of workers were losing a median of pounds 31 per week (range pounds 3-pounds 200). Patients can return to normal activity sooner after inguinal herniorrhaphy than has been advised without increasing the recurrence rate at one year and three years and with considerable monetary benefit to one-third of workers. Publication Types: · Clinical Trial · Randomized Controlled Trial PMID: 6116097 ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 19 of 71 4/2/2007 11:32 AM ########################################## Brodsky CM, Psychiatric aspects of fitness for duty, Occup Med. 1996 Oct-Dec;11(4):719-26. Department of Psychiatry, University of California at San Francisco, USA. The above examples illustrate the complex of biologic, psychological, and social factors that result in a fitness for duty referral. Workplace needs set the tolerance limits within which the worker must operate. They are different for a police officer, for a correctional officer, for a schoolteacher, and for a school custodian. Tolerance limits are affected by factors out of the employer's control, e.g., civil service rules, union contracts, and by the culture of the workplace, the latter being a set of unwritten rules. Ideally, the psychiatrist who performs the fitness for duty examination would have all of the information described above, but in most cases does not. The psychiatrist who has this information can begin to put in place one part of the mosaic that is the ethnography of work. PMID: 8976512 Rating: 5c ########################################## Callery YC, Schepis-Mallon N, Fitness for duty policy: implementation in the workplace, AAOHN J. 1995 Oct;43(10):522-6. 1. Drug use is most prevalent among young adults representing the segment of our society entering the work force. 2. The "fitness for duty" policy stipulates that all employees assume responsibility to report to work in a fit condition and perform their jobs without increasing risk to themselves or others. 3. The supervisor focuses on observable behavior; the employee health practitioner completes a confidential medical evaluation; the EAP professional performs an in-depth evaluation; and the human resources representative/manager evaluates the employee's continued employment. 4. After treatment and rehabilitation, the employer gains a productive, healthy, and substance free employee, and the employee gains by entering a program of sobriety supported by the organization. PMID: 7575786 Rating: 5c ########################################## Chung KC, Walters MR, Greenfield ML, Chernew ME, Endoscopic versus open carpal tunnel release: a cost-effectiveness analysis, Plast Reconstr Surg 1998 Sep;102(4):1089-99 Section of Plastic and Reconstructive Surgery, University of Michigan Medical Center, Ann Arbor 48109-0340, USA. Endoscopic carpal tunnel release is a controversial procedure used in the treatment of carpal tunnel syndrome. Although endoscopic carpal tunnel release is associated with less incisional pain and faster recovery time than the open carpal tunnel release, opponents of endoscopic carpal tunnel release suggest that its benefits are outweighed by its higher complication rates from median nerve transection and transient numbness of the fingers. Because of the huge economic and social impact of carpal tunnel syndrome in this country, weODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 20 of 71 4/2/2007 11:32 AM performed a cost-effectiveness analysis comparing endoscopic carpal tunnel release and open carpal tunnel release using guidelines established by the Panel on Cost-Effectiveness in Health and Medicine of the U.S. Public Health Service. A decision analytic model was used to measure differences in cost and effectiveness--expressed as quality-adjusted life-years (QALYs)--between endoscopic carpal tunnel release and open carpal tunnel release. The societal perspective was chosen, and probabilities for various outcomes for the two procedures were obtained from published randomized-controlled trials. Cost data were derived from the Medicare Resource-Based Relative Value Units published in the Federal Register. QALYs were obtained from two groups of health care providers using a utility-assessment questionnaire. Using probabilities for various outcomes from the two published randomized-controlled trials comparing endoscopic carpal tunnel release and open carpal tunnel release, we constructed a decision tree to derive both the cost and the QALYs for the two procedures. The incremental cost difference between endoscopic carpal tunnel release and open carpal tunnel release was $46, using Medicare cost and probabilities of various outcomes derived from a study by Brown et al. in 1993. We calculated QALYs for five age groups--25, 35, 45, 55, 65--assuming a life expectancy of 75 years. The marginal effectiveness (QALY of endoscopic carpal tunnel release minus QALY of open carpal tunnel release) ranged from 0.235 QALY for the 25-year-old age group to 0.066 QALY for the 65-year-old age group, giving a cost-effectiveness ratio of $195/QALY and $693/QALY, respectively. When compared with other accepted medical interventions such as breast cancer screening ($4836/QALY) and exercise to prevent coronary heart disease ($13,508/QALY), endoscopic carpal tunnel release seems to be cost-effective. However, our sensitivity analysis indicated that the cost-effectiveness ratio was very sensitive to a major complication such as median nerve injury. For endoscopic carpal tunnel release to be a cost-effective procedure, the incidence of median nerve injury must be one percentage point less for endoscopic carpal tunnel release than for open carpal tunnel release. Based on the data from the randomized-controlled trials, endoscopic carpal tunnel release seems to be a cost-effective procedure; however, before it can be recommended, greater emphasis must be given to the training of surgeons in this new technique, so that major complications such as median nerve injuries can be avoided. In addition, future studies must better define the actual incidence of nerve injuries for both endoscopic carpal tunnel release and open carpal tunnel release in the community setting. ########################################## From the Cochrane Library: Hypothesis/study question To compare the cost-utility of endoscopic carpal tunnel release with open carpal tunnel release in the treatment of carpal tunnel syndrome. Carpal tunnel syndrome is a common disease in the USA, accounting for more than 200,000 surgical procedures per year. Economic study type Cost-utility analysis. Study population Patients with a history of hand numbness and tingling sensations along the median nerve distribution, and persistent hand pain. Setting Hospital setting. The study was carried out at the University of Michigan, Ann Arbor, Michigan, USA. Dates to which data relate Effectiveness data were collected from studies previously published between 1992 and 1993. Resource use data were collected between 1996 and 1997. The price year was 1997. Source of effectiveness data Effectiveness data were derived from a review of previously published studies and estimates of effectiveness. Modelling A decision analytic tree was constructed to model QALYs and costs associated with the two treatmentODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 21 of 71 4/2/2007 11:32 AM strategies. Outcomes assessed in the review The review assessed probabilities of various outcomes and complications of the two treatment strategies. Study designs and other criteria for inclusion in the review Randomised controlled trials with at least 50 subjects in each group were included in the review. Sources searched to identify primary studies MEDLINE was searched. Number of primary studies included Two trials were included (Brown trial, Agee trial). Method of combination of primary studies Results were not combined. Results of the review For endoscopic carpal tunnel release, the following probabilities of outcomes were found (Brown trial, Agee trial): no complication (0.939,0.942); persistent symptoms (0.012,0.024); finger numbness (0.026,0.024); wound infection (0.013,0.000); scar tenderness (0.010,0.010); transection of median nerve (0.000,0.010). For open carpal tunnel release, the following probabilities of outcomes were found (Brown trial, Agee trial): no complication (0.824,0.924); persistent symptoms (0.026,0.000); finger numbness (0.000,0.000); wound infection (0.000,0.031); scar tenderness (0.150,0.030); transection of median nerve (0.000,0.015). Methods used to derive estimates of effectiveness Effectiveness data were also derived from authors' assumptions. Estimates of effectiveness and key assumptions After six months, it was assumed that patients would revert to a perfectly healthy state with a utility of 1.0. For chronic states that would last for a lifetime, it was assumed that subjects would discount the utilities for future years. Measure of benefits used in the economic analysis The benefit measure was quality adjusted life years (QALYs). QALYs were converted from utilities obtained from resident therapists, hand therapists and nurse researchers by means of an anonymous utility assessment questionnaire. The rating method was used to derive utilities. Direct costs Costs were not discounted given the short time period of treatment (less than 1 year). Quantities and costs were not reported separately. The direct costs were calculated as the costs of endoscopic and open carpal tunnel release and costs of treating complications. Direct costs included surgeon's fees, anaesthesia fees, and hospital costs. The quantity/cost boundary adopted was that of the health service. The estimation of quantities and costs was based on actual data. Cost data were derived from the Medicare Resource-Based Relative Value Units published in the Federal Register and from a private, nonprofit, community hospital in south-eastern Michigan. The price year was 1997. Indirect costs Indirect costs related to lost productivity and lost leisure time were included in the benefit measure. Currency US dollars ($). ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 22 of 71 4/2/2007 11:32 AM Sensitivity analysis A one-way sensitivity analysis was conducted on costs. A two-way sensitivity analysis was conducted on costs and QALYs. Estimated benefits used in the economic analysis No statistical difference (p <0.14) was found in the utility scales between the two groups for all outcomes. Based on the effectiveness results reported in the Brown trial, the marginal utility of endoscopic release over open release varied between 0.235 QALYs (age 25) and 0.066 QALYs (age 65). Based on the effectiveness results reported in the Agee trial, the marginal utility of endoscopic release over open release varied between 0.025 QALYs (age 25) and 0.021 QALYs (age 65). Cost results Based on the effectiveness results reported in the Brown trial, the marginal costs of endoscopic release over open release were $46 (Medicare costs) and $769 (private sector costs). Based on the effectiveness results reported in the Agee trial, marginal costs of endoscopic release over open release were $23 (Medicare costs) and $744 (private sector costs). Synthesis of costs and benefits When using Medicare costs, endoscopic release exhibited cost-utility ratios that ranged from $195 to $1,074 per QALY. When using private sector costs, endoscopic release exhibited cost-utility ratios that ranged from $3,271 to $35,427 per QALY. This cost-utility ratio was highly dependent on the effectiveness data, and in particular, the incidence of median nerve injury. Author's conclusions Endoscopic carpal tunnel release appears to be a cost-effective procedure. The marginal effectiveness, however, is very sensitive to a major complication such as median nerve injury in the endoscopic carpal tunnel release branch. CRD commentary Selection of comparators:The rationale for the selection of the comparator was clear. Open procedures are the more traditional in carpal tunnel syndrome and the intervention is considered by many practitioners to be somewhat controversial. Validity of estimate of measure of benefit:The relevant measure of benefit was examined. The results are highly dependent on the nature of techniques performed and experience levels. Assumptions were made regarding the duration of disability secondary to complications, because this duration has not been well established in the literature. Both the former and the latter imply that results may differ across settings and countries. Two different samples were used to derive utilities. Further studies could elicit values from the general population and the population of patients with carpal tunnel syndrome. Validity of estimate of costs:Direct costs were included in the cost measure and indirect costs in the QALY measure. To assess the variability in costs and their impact on cost-utility ratios, costs derived from two sources were used. No statistical analysis was reported. Other issues: Future studies must better define the actual incidence of nerve injuries for both endoscopic and open carpal tunnel release in the community setting. The generalisability of the results is variable due to the skill factor of the surgeons performing this intervention. Implications of the study The cost-effectiveness of endoscopic carpal tunnel release, as noted by the authors, can be improved by placing more emphasis on the training of surgeons in this technique so that major complications can be avoided. Future studies need to define the incidence of nerve injuries for both procedures. ########################################## Clark S, Rene A, Theurer WM, Marshall M, Association of body mass index and health status in firefighters, J Occup Environ Med. 2002 Oct;44(10):940-6. Department of Environmental and Occupational Health, School of Public Health, University of North Texas Health Science Center, Bedford, TX, USA. seclarkdomph@earthlink.netODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 23 of 71 4/2/2007 11:32 AM This study concluded, “BMI continues to prove useful as a screening tool and may be useful in identifying individual firefighters for health and fitness intervention measures.” PMID: 12391773 Rating: 4b ########################################## Colledge AL, Johns RE Jr, Unified fitness report for the workplace, Occup Med. 2000 Oct-Dec;15(4):723-37, iv. Labor Commission, State of Utah, Salt Lake City, 84114-6610, USA. Fitness statements often are required of physicians by patients, employers, governmental agencies, and insurance providers to determine if the patient is fit for duty. Physicians making these ability statements are legally obligated to carefully justify them when placing or excluding individuals from the workplace. The Americans with Disabilities Act (ADA) mandates that medical providers use justifiable criteria and rational thought when determining the capability and risk of an individual. This chapter reviews the legal requirements of the ADA for employers and physicians and presents a uniform methodology that both can use to determine the performance capability of an individual with a temporary or permanent impairment or disability. Publication Types: · Review · Review, Tutorial PMID: 11013053 Rating: 5a ########################################## Colledge AL, Johns RE Jr, Thomas MH, Functional ability assessment: guidelines for the workplace, J Occup Environ Med. 1999 Mar;41(3):172-80. Labor Commission, State of Utah, Salt Lake City 84114-6610, USA. See Form Publication Types: · Review · Review, Tutorial PMID: 10091140 Rating: 5a ##########################################ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 24 of 71 4/2/2007 11:32 AM Cox JE, Keesling CA, Johnson CE, Grayson DE, Morrison WB, The utility of screening chest radiographs for flight physicals, Mil Med. 2000 Sep;165(9):667-9. Wilford Hall Medical Center, Lackland Air Force Base, TX 78236-5300, USA. Previous studies have shown low efficacy of screening chest radiographs in various populations. Findings of approximately 3,500 screening chest radiographs performed for flight duty were reviewed to determine the rate of detection of significant abnormalities. There were abnormal findings in 107 chest radiographs (3%). Fifty-five of these (1.6% of total), after additional evaluation, were found to be false positive. Only two medically significant conditions were found in the screening population. Based on our data, routine screening of flight duty applicants does not appear to be justified. PMID: 11011537 Rating: 4a ########################################## Crippa M, Belleri L, Gelmi M, Sala E, Alessio L, [Skin disorders and job fitness assessment] [Article in Italian], Med Lav. 2002 Jan-Feb;93(1):1-10. Scuola di Specializzazione in Medicina del Lavoro, Universita degli Studi di Brescia, Servizio di Medicina del Lavoro, Azienda Spedali Civili di Brescia. BACKGROUND: Assessment of fitness for employment represents the final phase of the risk evaluation and health surveillance carried out during pre-employment and periodical medical examination. Dermatoses are frequent diseases both in the general population and workers, therefore job fitness assessment for workers with skin problems will frequently fall within the occupational health area. The physician must verify whether or not the dermatosis is an occupational disease and must adopt preventive measures to avoid any worsening or relapse of the clinical situation due to occupational factors. OBJECTIVES: This article gives suggestions for correct management of occupational and non-occupational skin diseases in the workplace, with practical examples of job fitness assessment. METHODS: We first examined the role of the occupational physician in the evaluation of occupational risk factors that can induce work-related dermatoses or aggravate other dermatoses. We then discussed the factors that must be considered during assessment of fitness for employment when dermatoses are present. Finally, we examined practical examples of occupational or non-occupational dermatoses that can cause functional limitations, factors that can influence job fitness evaluation, and the possible role of allergological tests. RESULTS AND CONCLUSIONS: Several dermatoses can be aggravated or caused by occupational factors (e.g. atopic dermatitis, allergic contact dermatitis, irritant contact dermatitis, keratinization disorders, lichen planus, physical urticaria). Close cooperation between the dermatologist and the occupational physician is very important in order to make an etiological diagnosis that is necessary for the job fitness assessment. It is difficult to define definitive criteria for the assessment of fitness for employment; in this article only some suggestions are made and they can vary according to the different situations. Publication Types: · Review · Review, Tutorial PMID: 11987496 ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 25 of 71 4/2/2007 11:32 AM Rating: 5c ########################################## Denniston, et al., Official Disability Guidelines (ODG), 8th edition, "Return-To-Work Best Practice Guidelines", December 2002. Return-To-Work "Best Practice" Guidelines. ODG's Best Practice guidelines are unique in identifying the key variables that determine disability duration for each diagnosis. Use them whenever possible to identify specific target durations for individual cases within a given condition by matching them up to a return-to-work pathway as provided. These pathways may include type of therapy or procedure, type of job, and key indicators of severity. Modified duty durations are provided and will interface with the "Activity Modifications" explained below, wherever possible. Without these pathways it is not always meaningful to provide a target number of days for disability duration. These Best Practice and Summary guidelines are based on over 3 million cases from CDC & OSHA (presented graphically below), combined with review by over eighty members of the ODG Editorial Advisory Board. Activity Modifications. For each level of job provided in the Best Practice guidelines, specific modifications and restrictions are provided to be used to modify duty and/or the workstation to allow for early return-to-work while taking actions to prevent re-injury. These modifications work directly with the pathways and durations in the Best Practice guidelines, and can be used by providers when preparing an employers RTW form. Example below: 724.2 Lumbago Return-To-Work Summary Guidelines Midrange: 20 days At-Risk: 79 days Return-To-Work "Best Practice" Guidelines Vague, descriptive diagnosis with multiple causes --Mild, clerical/modified work: 0 days Mild, manual work: 7-10 days Severe, clerical/modified work: 0-3 days Severe, manual work: 14-17 days Severe, heavy manual work: 35 days Severe, heavy manual work, chemical dependence comorbidity: 49 days With radicular signs, see 722 (disc disorders) With radiating pain, no radicular signs, see 847 (sprains & strains) Obesity comorbidity (BMI >= 30), multiply by: 1.31 Capabilities & Activity Modifications for Restricted Work: Clerical/modified work: Lifting with knees (with a straight back, no stooping) not more than 5 lbs up to 3 times/hr; squatting up to 4 times/hr; standing or walking with a 5-minute break at least every 20 minutes; sitting with a 5-minute break every 30 minutes; no extremes of extension or flexion; no extremes of twisting; no climbing ladders; driving car only up to 2 hrs/day. Manual work: Lifting with knees (with a straight back) not more than 25 lbs up to 15 times/hr; squatting up to 16 times/hr; standing or walking with a 10-minute break at least every 1-2 hours; sitting with a 10-minute break every 1-2 hours; extremes of flexion or extension allowed up to 12 times/hr; extremes of twisting allowed up to 16 times/hr; climbing ladders allowed up to 25 rungs 6 times/hr; driving car or light truck up to a full work day; driving heavy truck up to 4 hrs/day. Description: Pain, discomfort, stiffness, and weakness of the lower back which may or may not extend to the legs, hips, and buttocks. This is a symptom of many diagnoses but it is not a disease in itself. Lumbago andODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 26 of 71 4/2/2007 11:32 AM other back problems are second only to upper respiratory infections as a reason for lost work. Low back pain Low back syndrome Lumbalgia ########################################## Desai AV, Ellis E, Wheatley JR, Grunstein RR, Fatal distraction: a case series of fatal fall-asleep road accidents and their medicolegal outcomes, Med J Aust. 2003 Apr 21;178(8):396-9. Sleep Research Group, Woolcock Institute of Medical Research, Sydney, NSW, Australia. Obstructive sleep apnoea is associated with an increased risk of sleep-related motor vehicle accidents. Seven recent legal cases of fatal motor vehicle accidents on NSW roads are presented, where the driver who caused the accident was suffering from an unrecognised or under-treated sleep disorder. The legal outcomes in these cases were variable: some of the drivers have been acquitted and others have been jailed. All remained licensed to drive immediately after their accidents. In some of the cases, the driver was cleared of any culpable driving offence because of a defence of sleepiness or a sleep attack without warning ("Jiminez defence"). This appears at odds with current medical research and legal opinion in other countries. More research is needed to understand the relation between sleep disorders and awareness of sleepiness. Medical practitioners need to be aware of current advice and guidelines with respect to obstructive sleep apnoea and driving. Publication Types: · Review · Review, Tutorial PMID: 12697012 Rating: 5c ########################################## DOT, U.S. Department of Transportation, Federal Motor Carrier Safety Regulations, Rules and Notices 2004 http://www.fmcsa.dot.gov/rulesregs/fmcsr/regs/40.285.htm The Federal Motor Carrier Safety Administration (FMCSA) was established as a separate administration within the U.S. Department of Transportation on January 1, 2000, pursuant to the Motor Carrier Safety Improvement Act of 1999. According to the DOT regulation 49 CFR Part 40, all companies with safety-sensitive employees that test positive on a random, pre-employment, reasonable suspicion or post-accident test, must be given SAP referrals. If an organization fails to do so, they can be subject to severe fines by the Department of Transportation (DOT). EAP counselors deal with a spectrum of emotional issues that affect employees, such as relationships, family stress, anxiety and substance abuse. An EAP counselor utilizes different procedures and requirements concerning confidentiality. The majority of EAP counselors do not meet the qualification standards requiredODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 27 of 71 4/2/2007 11:32 AM to perform DOT mandated SAP evaluations. Only the SAP can determine if the employee is eligible to return to safety-sensitive duty. ########################################## Elders LA, van der Beek AJ, Burdorf A, Return to work after sickness absence due to back disorders--a systematic review on intervention strategies, Int Arch Occup Environ Health 2000 Jul;73(5):339-48 Department of Public Health, Erasmus University Rotterdam, The Netherlands. elders@mgz.fgg.eur.nl OBJECTIVES: The aim was to review the literature with regard to the effectiveness of intervention programmes for the prevention of aggravation of back disorders or prolonged duration of sickness absence. METHODS: A systematic search of the literature was performed using three groups of key words and inclusion/exclusion criteria. Effectiveness was evaluated using two measures: the difference between intervention and referent groups in return to work, and the fraction of sickness absence among referent groups that could be prevented if these referents had undergone the same intervention (preventable fraction). RESULTS: Twelve articles with quantitative information on the effect of ergonomic interventions on return to work were included. In eight studies, introduction of a back-school programme was the preferred intervention, combining exercise and functional conditioning, and training in working methods and lifting techniques. In seven out of eight back-school studies, return to work was significantly better in the intervention group. Intervention after 60 days, in the subacute phase of back pain, showed the most promising results. In these studies the preventable fraction varied between -11% and 80%, largely depending on the stage and phase of back disorders and the time of follow-up. The success of intervention also depended on the profile of the referents when left untampered. In all studies compliance during the intervention was fairly good, but there was a lack of information on sustainability of the intervention during the follow-up and on recurrence of back complaints and consequent sickness absence. CONCLUSIONS: Few studies were performed to assess the outcome return to work after ergonomic intervention. However, there is evidence that intervention in the subacute phase of back pain is preferable. Future intervention studies should address intervention sustainability and recurrence of sickness absence due to back pain over at least a 1-year follow-up period. Publication Types: · Review · Review, Tutorial PMID: 10963418 From the Cochrane Library: Secondary types of non-medical prevention were compared to a reference treatment. Individual case management was excluded. Included interventions appear to be classified into two groups: back-school type interventions (a combination of exercise and functional conditioning, education, training in work methods and lifting techniques) and non back school type interventions (including McKenzie method exercise, functional conditioning and education, physician notification of treatment guidelines, combination of pain relief, and graded medical exercise). Reference treatments included: physical therapy/manipulation; placebo therapy; other care by physician; usual care; education only; conventional physiotherapy; self-exercise; and usual care and operative treatment. Organisational and administrative interventions were also searched for but none were found. The studies differed in design and population studied. Participants were heterogeneous and differed inODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 28 of 71 4/2/2007 11:32 AM duration and stage of low back pain at the start of the study. There were large differences among referent groups in inclusion and exclusion criteria and outcomes. Compliance with the intervention was good in eight studies, reasonable in two studies, poor in one and unknown in another. Compliance sustainability was rated good in three studies, poor in one study and unknown in the others. Effect sustainability was rated good in three studies, reasonable in three studies, and unknown in four. Absolute reduction of sickness absence and time lost from work ranged from 22% to 42%. The preventable fraction ranged from 50% to 70%. Back-school type interventions (8 studies). Studies differed in the period of follow-up (range 21 days to 1800 days). Seven of the eight studies showed a significant overall difference between RTW of the participants and the control group. One study showed no statistically significant difference between groups. Outcome < 60 days (4 studies): rate difference ranged from -7% to 29%. Preventable fraction ranged from -11% to 47%. Outcome from 60 days to 1 year (8 studies): significant effect found in 4 studies, with rate difference 22% to 42%. Outcome at 360 days (4 studies): rate difference ranged from -1% to 42%. Preventable fraction ranged from -100% to 76%. Non back-school type interventions (4 studies). Results were inconsistent, with only one study reporting a significant effect of the intervention. In three studies, the RD was better among referents than in the intervention group. Problems with studies included: poor compliance of the physician with the intervention (applying treatment guidelines) with few patients receiving the intervention; and intervention was not work related, was started too soon after sick leave due to back pain, and meant the end of receiving benefits. Few studies were performed to assess the outcomes return to work after ergonomic intervention. However, there is evidence that intervention in the subacute phase of back pain is preferable. Future intervention studies should address intervention sustainability and recurrence of sickness absence due to back pain over at least 1-year follow-up period. The aims were stated and inclusion criteria defined in terms of intervention, participants and outcome. A number of relevant databases were searched, although by restricting the search to articles published in the English language, other relevant studies may have been omitted. No attempts were made to locate unpublished material and methods used to select studies were not described. Study design was not specified in the inclusion criteria and validity was not assessed. Some relevant details of the primary studies were presented in tabular format but methods used to extract data were not described. Given the clinical heterogeneity among studies, a narrative review was appropriate. However, attention was not drawn to the better sources of evidence and statistical heterogeneity was not assessed. In view of the lack of assessment of validity, the authors conclusions must be interpreted with caution. Clinical implications: the authors state back school interventions regardless of their programmes and heterogeneity showed more effect after 60 days of sickness absence than other non back-school interventions and that interventions in the subacute phase seemed preferable unless a strong intervention effect could be exercised upon the already strong recovery among patients in the early stages of low back pain. Research implications: the authors state that future research should be aimed at RCTs concerning an organisational and technical intervention sustained over a follow-up period of at least one year, with special attention to the occurrence of low back pain sick leave. Rating: 1b ##########################################ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 29 of 71 4/2/2007 11:32 AM Fernhall B, Unnithan VB, Physical activity, metabolic issues, and assessment, Phys Med Rehabil Clin N Am. 2002 Nov;13(4):925-47. Exercise Science Department, Syracuse University, 820 Comstock Avenue, Room 201, Syracuse, NY 13244, USA. Bfernhal@syr.edu Considering the important health consequences of physical activity and aerobic capacity, current guidelines recommend that all individuals should be physically active all or most days of the week. Relatively little is known about physical activity patterns or aerobic capacity of individuals who have disabilities, but existing data clearly show a disturbing pattern of low levels of physical activity and aerobic capacity in most, if not all, populations who have disabilities. More research is needed on all populations who have disabilities, not only documenting current levels of physical activity and aerobic capacity but also investigating potential strategies for improvement. Unfortunately, the techniques available for measuring physical activity have significant shortcomings. DLW shows considerable promise, but it is expensive and not appropriate for population studies. All other techniques have significant shortcomings in regard to tracking individual physical activity patterns, but they might provide valuable insight regarding group behavior. Although maximal exercise testing is the gold standard for measuring aerobic capacity, this technique is difficult to use in many populations that have disabilities. Few protocols have been validated for use with individuals who have disabilities, and indiscriminant use of protocols developed for nondisabled populations is inappropriate when testing individuals who have disabilities. Submaximal testing could be of considerable utility, but few protocols have been validated. For most populations that have disabilities, submaximal tests designed to predict VO2peak are not valid, given the altered disability-specific physiological responses, which usually result in gross overpredictions. Submaximal tests designed to compare (either intra or inter individual comparisons) physiological responses at predetermined submaximal work rates show considerable promise. Both populations of children who have disabilities that are discussed herein exhibit low levels of physical activity and aerobic capacity, which is consistent with most of the literature for any group that has disabilities. Although the mechanisms for producing lower levels of activity and aerobic capacity differ among children who have mental retardation and children who have CP, the outcome is similar in both populations. Appropriate testing methodology differs between these populations, and the different mechanisms involved demonstrate the disability-specific nature of research in children who have disabilities, which also illustrates the difficulty of producing general guidelines for exercise and physical activity interventions. Current data clearly show the need for improving both physical activity patterns and aerobic capacity in most children who have disabilities. Failure to accomplish this goal will ultimately have considerable negative health outcomes for individuals who have disabilities. Publication Types: · Review · Review, Tutorial PMID: 12465568 Rating: 5b ########################################## Flanagan DE, Watson J, Everett J, Cavan D, Kerr D, Driving and insulin--consensus, conflict or confusion? Diabet Med. 2000 Apr;17(4):316-20 Bournemouth Diabetes and Endocrine Centre, UK.ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 30 of 71 4/2/2007 11:32 AM AIMS: All drivers requiring insulin treatment must be able to demonstrate satisfactory diabetic control and recognition of hypoglycaemic symptoms before being allowed to drive a motor vehicle. Clinicians have a duty to discuss fitness to drive with their patients. However, is the advice given consistent and in line with the regulations published by the Driver and Vehicle Licensing Authority (DVLA)? METHODS: Six 'real-life' case scenarios were posted to clinicians (consultant diabetologists, specialist registrars and diabetes specialist nurses) within Wessex, UK. The identical cases were also sent to the DVLA for their comments. RESULTS: Sixty-six doctors (36 consultants) and 70 diabetes specialist nurses were contacted by postal questionnaire of which replies were received from 17 consultants (47%), 17 specialist registrars (57%) and 39 diabetes specialist nurses (56%). Although there was general agreement in cases of hypoglycaemia unawareness, there was disagreement where patients had or were at risk of unstable control albeit for a short time. CONCLUSIONS: Patients treated with insulin may receive conflicting information concerning their ability to drive. PMID: 10821299 Rating: 5b ########################################## Fletcher TA, Brakel SJ, Cavanaugh JL, Violence in the workplace: new perspectives in forensic mental health services in the USA, Br J Psychiatry. 2000 Apr;176:339-44. Section of Psychiatry and Law, Rush-Presbyterian-St. Luke's Medical Center, Isaac Ray Center, Inc., Chicago, IL, USA. BACKGROUND: This paper reviews current research on workplace violence in the USA and offers suggestions concerning the roles that mental health professionals with forensic expertise can play in this expanding field. AIMS: To clarify the role of the mental health professional in evaluating issues related to workplace violence. METHOD: Manual and computer literature searches were performed. RESULTS: The incidence of reported workplace violence is on the rise and can be devastating beyond the immediate injury. Forensically oriented mental health professionals can assist companies by providing pre-employment screenings, fitness-for-duty evaluations and threat assessment by using the results of current research on potentially violent individuals. CONCLUSIONS: With the growing interest in workplace violence come many opportunities for mental health professionals to assist companies in assessment, intervention and prevention. Publication Types: · Review · Review Literature PMID: 10827881 Rating: 5b ########################################## Gennis P, Miller L, Gallagher J, Giglio J, Carter W, Nathanson N. The Effect of Soft Cervical Collars on Persistent Neck Pain in Patients with Whiplash Injury. Acad Emerg Med 1996;568-73. ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 31 of 71 4/2/2007 11:32 AM (1) Bronx Municipal Hospital Center, Department of Emergency Medicine, NY 10461, USA. pskm34a@prodigy.com OBJECTIVE: To assess the efficacy of soft cervical collars in the early management of whiplash-injury-related pain. METHODS: A controlled, clinical trial was conducted in an urban ED. Adults with neck pain following automobile crashes indicated their initial degrees of pain on a visual analog scale. Patients with cervical spine fractures or subluxation, focal neurologic deficits, or other major distracting injuries were excluded. Patients were assigned to receive a soft cervical collar or no collar based on their medical record numbers. Pain at > or = 6 weeks postinjury was coded as none, better, same, or worse, and analyzed as 3 dichotomous outcomes: recovered (pain = none); improved (pain = none or better); and deteriorated (pain = worse). RESULTS: Of 250 patients enrolled, 196 (78%) were available for follow-up. Of these patients, 104 (53%) were assigned to the soft cervical collar group, and 92 (47%) to the control group. These groups were similar in age, gender, seat position in the car, seat belt use, and initial pain score. Pain persisted at > or = 6 weeks in 122 (62%) patients. The groups showed no difference in follow-up pain category (p = 0.59). There was no significant difference between the 2 groups in complete recovery (p = 0.34), improvement (p = 0.34), or deterioration (p = 0.60). The study had a power of 80% to detect an absolute difference of at least 20% in recovery, 17% in improvement, and 7% in deterioration (2-tailed, alpha = 0.05). CONCLUSIONS: Most patients with whiplash injuries have persistent pain for at least 6 weeks. Soft cervical collars do not influence the duration or degree of persistent pain. Publication Types: · Clinical Trial · Randomized Controlled Trial PMID: 8727627 [PubMed -indexed for MEDLINE] Comments by Dr. Whitney of the Colorado Division of Workers' Compensation: Design: Pseudo-randomized trial Population/sample size: -250 patients enrolled from adult ER of urban level I trauma center seen within 24 hours of car crash resulting in neck pain; 196 followed at 6 weeks -Exclusion for fracture/dislocation, focal neurologic findings, hospitalized cases, or diminished cognitive function -Odd numbered medical records assigned to soft cervical collar to be worn as much as tolerated (n=104); even numbered assigned no collar (n=92); both groups advised to rest and given NSAIDS at discretion of treating physician -Power of 80% to detect 20% difference in proportion with full recovery Main outcome measures: -Telephone follow-up 6 weeks after ER consultation to determine degree of pain (none, better, same, or worse), whether further care was sought, hours of collar use, whether soft collar produced symptomatic relief -54/250 patients were lost to follow-up; no difference in age, gender, presenting pain, or group assignment between those lost to follow-up and those remaining in study -Higher initial pain score in women and in patients reporting seat belt use at time of crash -Collars worn for median of 14 days with median daily use of 6 hours; 68 of 86 collar users who expressed a preference indicated that collar provided some relief from collar use -Complete pain relief at 6 weeks in 74/196 patients, improvement in 88, no change in 12, andODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 32 of 71 4/2/2007 11:32 AM worsening in 12 -No difference in pain categories between collar/no collar groups Authors’ conclusions: -No evidence that soft collar promotes recovery from cervical sprain due to car crash injuries -Analgesic use was not well documented, and may have biased the outcome Comments: -Telephone follow-up gives a crude estimate of clinical status Wearing collar as much as tolerated may yield different result from use prn Rating: 2b, 250 cases ########################################## Gerkin D, Firefighters: fitness for duty, Occup Med. 1995 Oct-Dec;10(4):871-6. Phoenix Fire Department, Arizona, USA. One of the functions of the fire department physician is to give candidates and firefighters clearance to work based on medical and physical performance criteria. In this chapter the author discusses the practical application of the medical standards of NFPA 1582 and physical standards as measured by agility tests and the proposed NFPA 1583, presenting guidelines for hiring, return to work, and administration of periodic exams. Publication Types: · Review · Review, Tutorial PMID: 8903755 Rating: 5c ########################################## Grenier SG, Russell C, McGill SM, Relationships between lumbar flexibility, sit-and-reach test, and a previous history of low back discomfort in industrial workers, Can J Appl Physiol. 2003 Apr;28(2):165-77. Faculty of Applied Health Sciences, Dept. of Kinesiology, University of Waterloo, Waterloo, ON, N2L 3G1. The sit-and-reach (S&R) test is often included in standard fitness tests (e.g., Canadian Physical Activity, Fitness and Lifestyle Appraisal [CPAFLA]), justified on the assumption that it is an indicator of low back health. Two issues were examined here: Is low back flexibility linked to having a history of low back disorders? And is the S&R test an indicator of low back flexibility? The relationship between S&R test scores, lumbar range of motion, and having a history of low back discomfort was examined in 72 asymptomatic (at test time) industrial workers (70 M, 2 F; mean age 35 ys; height 1.79 m; mass 84.7 kg). The S&R test, among many collected, was performed according to the CPAFLA guidelines. History of low back discomfort (LBD) was categorized based on whether or not time was lost from work. The S&R test was unable to distinguish between those with a history of LBD and those without. Specific lumbar sagittal range ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 33 of 71 4/2/2007 11:32 AM of motion could make this distinction. A moderate correlation (r = 0.42) surfaced between S&R and lumbar flexibility. This study suggests that the value of S&R as an indicator of previous back discomfort is questionable and there may be better indicators for inclusion in the CPAFLA. PMID: 12825327 Rating: 4b ########################################## Gross DP, Battie MC, Reliability of safe maximum lifting determinations of a functional capacity evaluation, Phys Ther. 2002 Apr;82(4):364-71. Faculty of Rehabilitation Medicine, University of Alberta, 3-48 Corbett Hall, Edmonton, Alberta, Canada T6G 2G4. dgross@ualberta.ca BACKGROUND AND PURPOSE: Functional capacity evaluations (FCEs) are measurement tools used in predicting readiness to return to work following injury. The interrater and test-retest reliability of determinations of maximal safe lifting during kinesiophysical FCEs were examined in a sample of people who were off work and receiving workers' compensation. SUBJECTS: Twenty-eight subjects with low back pain who had plateaued with treatment were enrolled. Five occupational therapists, trained and experienced in kinesiophysical methods, conducted testing. METHODS: A repeated-measures design was used, with raters testing subjects simultaneously, yet independently. Subjects were rated on 2 occasions, separated by 2 to 4 days. Analyses included intraclass correlation coefficients (ICCs) and 95% confidence intervals. RESULTS: The ICC values for interrater reliability ranged from.95 to.98. Test-retest values ranged from.78 to.94. DISCUSSION AND CONCLUSION: Inconsistencies in subjects' performance across sessions were the greatest source of FCE measurement variability. Overall, however, test-retest reliability was good and interrater reliability was excellent. PMID: 11922852 Rating: 3b ########################################## Guidotti TL, Cowell JWF, Jamieson GG, Occupational Health Services: A Practical Approach -Full Text, http://www.ualberta.ca/~gjhangri/ohp/contents.htm, 2003 Chater 18 --Fitness-to-Work Fitness-to-work examinations are objective assessments of the health of employees in relation to their specific jobs, in order to ensure they can do the job and will not be a hazard to themselves or others. They should always be conducted with reference to the specific job the worker holds or intends to hold. The circumstances that require such examinations occur the time of application or consideration for entry into employment and assignment to a specific job (preplacement), return to work after illness or injury (return to work). Typically the terms used are fit, unfit, and fit subject to work modifications, with the latter two further qualified as temporary or permanent. The armed forces have devised useful systems that grade physical capability and fitness to serve under various weather conditions and in certain geographical locations. Such systems, however, have little practical use in the civilian work force. To be useful to the employee and employer and to be consistent with human-rights legislation, preplacement ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 34 of 71 4/2/2007 11:32 AM examinations must be structured so that they are specific to the working conditions and job requirements medically and are timed after a job offer has been made. An employer cannot arbitrarily deny a person a job opportunity on the basis of a physical or emotional disability. However, the job offer can be made contingent upon passing a medical examination that ensures the employee will be able to perform the job and will not be a hazard to him or herself or others while working in that job. The employee will be refused the job only if the health of the employee is not compatible with the working conditions and the working conditions and job requirements cannot reasonably be altered. Table 18.1. Reasons for Performing a Fitness-To-Work Evaluation Preplacement: When an employee has been offered a full-or part-time job subject to passing a relevant medical examination. Return to work: When an employee is returning to work after a serious illness or injury and that person's ability to perform the original job is not known, or When an employee has returned to work at a modified job and is still undergoing therapy, rehabilitation or both. Continuing Disability: When an employee remains away from work and must be assessed for continuing short-term or long-term disability payment or workers' compensation. Performance-Initiated Review: When health reasons are identified as the cause of failing job performance and a medical review has been suggested (job not yet at risk) or required (job at risk) by the employer. Job Transfer: When an employee transfers to a position whose working conditions are significantly different. Change in working conditions in existing job: When the existing working conditions have been significantly altered. Change in health status in existing job: When health problems have developed that may be aggravated by existing working conditions. Rating: 5b ########################################## Gurevitz O, Fogel RI, Herner ME, Sample R, Strickberger AS, Daoud EG, Morady F, Prystowsky EN, Patients with an ICD can safely resume work in industrial facilities following simple screening for electromagnetic interference, Pacing Clin Electrophysiol. 2003 Aug;26(8):1675-8. Indiana Heart Institute, Indianapolis, Indiana, USA. ossigur@hotmail.com Patients with ICDs are commonly advised to quit industrial jobs because of concerns that strong electromagnetic fields operating in the industrial environment might interfere with ICD functions. This study was done to assess interactions between industrial equipment and ICDs, and to devise a simple low risk screening protocol. We studied 18 patients carrying nine different ICD models who were met at their workplace by a clinical technician and were asked to walk through their workplace and perform typical duties while sensing status was monitored by listening to the ICD's beeper. All devices were interrogated at the completion of testing. At follow-up, patients were contacted by phone and were asked about employment status and history of ICD discharges or syncope. One hundred eighty-four contacts with 114 types of industrial equipment in 13 different industrial facilities (including 31 contacts with arc welding machines) were monitored. Interference with ICD's function occurred in only one contact (0.5%), when ICD therapy was temporarily suspended while a worker was attaching a huge electromagnet to a crane. At follow-up 46.0 +/-6.0 months after testing, 7 patients (41%) are still holding the same job, 7 have retired because of reasons unrelated to their ICD, and 3 patients were transferred to a nonindustrial job. None of the patients had either an ICD shock or syncope during work. The use of a simple screening procedure can safely identify sources of electromagnetic interference that may affect ICD operation, and can predict long-term safety of working in an industrial workplace for ICD patients.ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 35 of 71 4/2/2007 11:32 AM PMID: 12877699 Rating: 3c ########################################## Hagen KB, Hilde G, Jamtvedt G, Winnem M, Bed rest for acute low back pain and sciatica, Cochrane Database Syst Rev 2000;(2):CD001254 Health Services Research Unit, National Institute of Public Health, P.O. Box 4404 Torshov, N-0403 Oslo, Norway. k.b.hagen@labmed.uio.no BACKGROUND: Low back pain is a common reason for consulting a general practitioner, and advice on daily activities constitutes an important part in the primary care management of low back pain. OBJECTIVES: To assess the effects of bed rest for patients with acute low back pain or sciatica. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group trial register, Cochrane Controlled Trials Register, MEDLINE, Embase, Sport, Scisearch, and reference lists of relevant articles. We also contacted authors of relevant articles. Date of the most recent searches: December 1998. SELECTION CRITERIA: We included all randomised studies or quasi randomised studies where at least one comparison group of adult patients with acute low back pain with or without radiation of pain below the knee was advised to rest in bed for at least two days and one group was not, or where comparison groups were advised to stay in bed for different lengths of time. The main outcomes of interest were pain, functional status, recovery and return to work. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed the validity of included trials and extracted data. Investigators were contacted to obtain missing information. MAIN RESULTS: Nine trials with a total of 1435 patients were included. Five trials met all four validity criteria and were assessed to have low risk of bias, while four trials were assessed to have moderate to high risk of bias. Four trials compared bed rest with advice to stay active, and overall the results were heterogeneous. Overall results from two high quality studies indicate no difference in pain intensity at three weeks follow-up [Standardized Mean Difference 0.0 (95%CI: -0.3, 0.2)], and a small difference in functional status in favour of staying active [Weighted Mean Difference 3.2 (on a 0-100 scale) (95%CI 0.6, 5.8)]. Two high quality trials reported no differences in pain intensity between two to three days of bed rest and seven days of bed rest. Another two high-quality trials found no differences between bed rest and exercises in pain intensity or functional status. REVIEWER'S CONCLUSIONS: Bed rest compared to advice to stay active will at best have small effects, and at worst might have small harmful effects on acute LBP. Differences in effects of advice to stay in bed compared with advice to stay active are small for patients with low back pain with or without sciatica. There is not an important difference in the effects of bed rest compared with exercises in the treatment of acute low back pain, or seven days compared with two to three days of bed rest in patients with low back pain of different duration with and without radiating pain. Publication Types: · Review · Review, Academic PMID: 10796429 Rating: 1b ########################################## Hainer BL, Preplacement evaluations, Prim Care. 1994 Jun;21(2):237-47.ODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 36 of 71 4/2/2007 11:32 AM Department of Family Medicine, Medical University of South Carolina, Charleston. A subcategory of fitness-for-duty evaluation, preplacement evaluations have a primary purpose of helping patients function as employees in occupations suited to their abilities, safely and with minimal risk to themselves, fellow workers, and the public. This article discusses the components of preplacement evaluations, ethical issues, and the effectiveness of these evaluations. Publication Types: · Review · Review, Tutorial PMID: 8084915 Rating: 5c ########################################## Harten JA, Functional capacity evaluation, Occup Med. 1998 Jan-Mar;13(1):209-12. Kessler Institute for Rehabilitation, East Orange, NJ 07018, USA. The functional capacity evaluation (FCE) is a tool for assessing the extent of a patient's disability. Several factors help to determine whether an FCE should be conducted. Once underway, the evaluation includes an intake interview, musculoskeletal and functional assessments, validation of effort, and interpretation and recommendation. Publication Types: · Review · Review, Tutorial PMID: 9477419 Rating: 5c ########################################## Hartvigsen J, Kyvik KO, Leboeuf-Yde C, Lings S, Bakketeig L, Ambiguous relation between physical workload and low back pain: a twin control study, Occup Environ Med 2003 Feb;60(2):109-14 Nordic Institute of Chiropractic and Clinical Biomechanics, Klosterbakken 20, DK-5000 Odense C, Denmark. j.hartvigsen@nikkb.dk AIMS: To examine the association between self reported physical workload and low back pain (LBP) in younger twins. To investigate whether genetic factors interact with physical workload in relation to LBP. METHODS: A twin control study was performed within a population based twin register using 1910 complete monozygotic (MZ) and same sexed dizygotic (DZ) twin pairs aged 25-42 and discordant for LBP. LBP in the affected twins was divided into two groups: "LBP for 30 days during the past year". Physical workload was divided into four categories: "sitting", "sitting/walking", "light physical", and "heavy physical". Data were analysed in a matched design using conditional logistic regression. MZ and DZ twins were analysed separately and together in order to determineODG TWC Fitness For Duty http://www.odg-twc.com/odgtwc/Fitness_For_Duty.htm 37 of 71 4/2/2007 11:32 AM possible genetic influences in relation to physical workload and LBP. RESULTS: Statistically significant graded relations were found for increasing workload and LBP of longer duration but not for LBP of shorter duration (