Rehabilitation Provider Placement

Client (pseudo name): Kyle Rudolph DOB: 22/03/1976

Medical Condition: Lower back Injury L4/5 Disc ProlapseHistory and Treatment: •Mr Rudolph sustained a back injury on 4th June 2011.

•He was diagnosed with L4/5 disc prolapse.

•He underwent disc excision and decompression procedure on 24/5/12

•He has not significantly improved his pain levels or functional capacity since his injury. He is being treated with weekly sessions of physiotherapy and hydrotherapy.

• Mr Rudolph’s referral was made by the insurer on 15/8/12 for an initial assessment and Nominated Treating Doctor case conference to assist Mr Rudolph to return to suitable employment.

• At the time of referral Mr Rudolph was certified unfit to work up until 28/9/12. He is unable to return to pre injury work as a painter and is unsure regarding his future work options.

Reason for Referral:

Explaining the scope of the Rehabilitation Provider and Role of the Occupational Therapist to the Client:

• Explained through initial contact over the phone.

• Scope of service and role of Occupational Therapist explained in commercial context.

• Collaboration between stake holders to promote efficient return to work program.

• The role of the Occupational Therapist in this service is primarily to assist the client to return to work and empower the individual to regain their capacity to return to their worker role and assist in the treatment and management of their condition.

• Provided client with informed consent and confidentiality

Brigham, C., Engelberg, A., & Richling, D. (1996). The changing role of rehab: focus on function. Patient Care, 30(3), 144.

Model of Human Occupation:

• The Model of Human Occupation (MOHO) is a conceptual model of practice for Occupational Therapist that attempts to explain an individuals motivation for occupation, their patterns of occupational behaviour into routines and lifestyles, the nature of skilled performance and the impact of environmental factors on occupational performance and behaviour.

• The Model of Human Occupation was an appropriate Model of practice to frame Mr Rudolph’s case management as it was effective in looking at the values and role of Mr Rudolph in his occupational environment and attempted to inform on motivational factors that both excited or inhibited his ability to return to work and importantly engage his worker role.

Braveman, B. (1999). The model of human occupation and prediction of return to work: a review of related empirical research. Work, 12(1), 25-35. Mentrup, C., Niehaus, A., & Kielhofner, G. (1999). Applying the model of human occupation in work-focused rehabilitation: a case illustration. Work, 12(1), 61-70.

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Understanding the Scope of the service and other factors impacting upon information gathering:

Before starting the information gathering it was important to understand the scope of the service and develop some parameters to improve my understanding of the service context. I also needed to be aware of the client’s injury and its nature to inform diagnostic reasoning and be aware of his cultural differences to inform of any considerations in assessment and treatment. It was instrumental to understand the role of the Occupational Therapist and the service provision of the Rehabilitation provider before information gathering as this informed me what kind of information I was gathering and what I needed to inform effective clinical judgement.

Model of Human Occupation:

• In applying the Model of Human Occupation in practice it was important to collect data in order to create an explanation of Mr Rudolph’s unique circumstances. This explanation emerged as I integrated data on the client with concepts from the model of human occupation. This allowed for informed clinical judgement that assisted in goal making and choice of intervention.

Braveman, B. (1999). The model of human occupation and prediction of return to work: a review of related empirical research. Work, 12(1), 25-35. Lee, J., & Kielhofner, G. (2010). Vocational intervention based on the Model of Human Occupation: a review of evidence. Scandinavian Journal Of Occupational Therapy, 17(3), 177-190. doi:10.3109/11038120903082260Mentrup, C., Niehaus, A., & Kielhofner, G. (1999). Applying the model of human occupation in work-focused rehabilitation: a case illustration. Work, 12(1), 61-70. ..

Information gathered:

• I looked over the Workcover NSW policy to inform my pragmatic reasoning and ensured I was familiar with the aetiology, treatment and pathology of lower back injuries. I contacted Mr Rudolph’s doctor to inform myself of his current status and treatment. I also looked over previous case notes and medical reports to further improve my understanding and begin to formulate the particular circumstances of Mr Rudolph.

Non Standardised Initial Assessment:

• A non-standardised initial assessment was used for Mr Rudolph. The initial interview assesses the impact of the disability or injury on the client’s activities of daily living and their capacity to work. It encompasses other factors that may be contributing to a person’s incapacity to work other than just their physical limitations. The assessment determines the main barriers to work and forms the primary occupational issues that are impacting on the clients ability to return to work or find employment.

• The assessment is well embedded within Model of Human Occupation’s framework and effectively addressed Mr Rudolph’s environmental and motivational factors impacting on his ability to return to work. It was also important in addressing his skilled performance and tailoring that to areas of work he might be interested in.

Non Standardised Initial Assessment:

• I felt that the initial assessment allowed for me build rapport

with Mr Rudolph quickly and allowed for all of his issues to be raised to me because he trusted that the information he was providing would be beneficial to his particular circumstances and that I could work with him collaboratively in his recovery.

Tahan, H., & Schminkey, P. (2012). Motivational Interviewing: Building Rapport With Clients to Encourage Desirable Behavioral and Lifestyle Changes. Professional Case Management, 17(4), 164-172.

Functional Capacity Evaluation:

• A functional capacity evaluation (FCE) provides a comprehensive assessment of the client's physical tolerances for work. It is a norm referenced assessment of functional abilities based on physical examination, objective evaluation of performance and client reporting and is used to judge physical capacity to work and determine suitable duties. It contains both standardised and non-standardised components as part of its assessment.

Geisser, M., Robinson, M., Miller, Q., & Bade, S. (2003). Psychosocial factors and functional capacity evaluation among persons with chronic pain. Journal Of Occupational Rehabilitation, 13(4), 259- 276. Gross, D., & Battié, M. (2003). Construct validity of a kinesiophysical functional capacity evaluation administered within a worker's compensation environment. Journal Of Occupational Rehabilitation, 13(4), 287-295.

Örebro Musculoskeletal Pain Questionnaire (ÖMPQ):

• The Örebro Musculoskeletal Pain Questionnaire is a 21 scored questionnaire, developed to identify patients at risk of developing persistent back pain problems with related functional disability and is a predictor for failed return to work. Interpreting the results, indicative of the risks for failed return to work: ≤ 105 = low risk; 105-130 = moderate risk; ≥ 130 = high risk.

• This assessment was particularly relevant as it directly relates to Mr Rudolph’s volition to work. Pain experienced is a primary barrier to work and is evidenced as a motivational indicator of ones ability to return to work.

Hockings, R., McAuley, J., & Maher, C. (2008). A systematic review of the predictive ability of the Orebro Musculoskeletal Pain Questionnaire. Spine, 33(15), 494-500. Johnston, V. (2009). Örebro Musculoskeletal Pain Screening Questionnaire. Australian Journal Of Physiotherapy, 55(2), 141.Sattelmayer, M., Lorenz, T., Röder, C., & Hilfiker, R. (2012). Predictive value of the Acute Low Back Pain Screening Questionnaire and the Örebro Musculoskeletal Pain Screening Questionnaire for persisting problems. European Spine Journal, 21, 773-784.

Assessment Findings

• Mr Rudolph advised that he is independent in self-care except he is unable to wear lace up shoes and requires assistance with cutting his toe nails. He is able to perform light domestic duties including hanging out washing and sweeping hard floors. However, he is unable to carry washing basket out to line and is unable to sweep.

• Mr Rudolph is dealing with significant stress which has become worse with recent family break-down. He advised that he has not slept for the last 6 months due to pain and constant worries. He feels that he would benefit from pain counselling.

Assessment Findings

• He advised that he is not capable of returning to his pre injury duties as a painter and does not consider himself capable of much work at present.

• Mr Rudolph was observed to have a loci of external control. He feels that when he returns to work is “up to his doctor to decide” and things will just improve on its own.

• Mr Rudolph is in a low level within the stages of change model and cannot reason behind anyway to improve his position.

• Mr Rudolph scored 127 on the Orebro Musculoskeletal Pain Questionnaire which indicates he is at medium risk of developing persistent back pain problems with related functional disability and is a predictor for a medium risk of failed return to work.

Johnston, V. (2009). Örebro Musculoskeletal Pain Screening Questionnaire. Australian Journal Of Physiotherapy, 55(2), 141.Lam, C., Wiley, A., Siu, A., & Emmett, J. (2010). Assessing readiness to work from a stages of change perspective: Implications for return to work. Work, 37(3), 321-329. Oliveira, V., Ferreira, P., Ferreira, M., Tibúrcio, L., Pinto, R., Oliveira, W., & Dias, R. (2009). People with low back pain who have externalised beliefs need to see greater improvements in symptoms to consider exercises worthwhile: an observational study. Australian Journal Of Physiotherapy, 55(4), 271-275.

Functional Capacity Evaluation Findings

Mr Rudolph was assessed as having the following postural tolerances:

•Sitting - 30 minutes

•Standing – 20 minutes

•Walking – 15 minutes

Mr Rudolph reported that postural tolerances are limited by back pain and pins and needles and heavy feeling in his legs.

Activities that require bending and overreaching, particularly from floor level increase his lower back pain.

Functional Capacity Evaluation Findings

Work Suitability:

Mr Rudolph was assessed as being able to do sedentary work. This indicates he is able to

•Occasionally lift / manual handle: 4.5 kg

•Frequently lift / manual handle: Negligible

•Constantly lift / manual handle: Negligible

•Activities that require 1.5 - 2.1 METS

Suitable work may include administration, sales assistant or retailer in hardware. Mr Rudolph displayed a particular interest in a sales position in hardware; an area he is familiar with through his previous experience as a painter.

Bennett, J., Winters-Stone, K., Nail, L., & Scherer, J. (2006). Definitions of sedentary in physical-activity-intervention trials: a summary of the literature. Journal Of Aging & Physical Activity, 14(4), 456-477. Matheson, L. (2003). The functional capacity evaluation. In G. Andersson & S. Demeter & G. Smith (Eds.), Disability Evaluation. 2nd Edition. Chicago, IL: Mosby Yearbook.

Negotiating Issues that are relevant to the client and the scope of the service

• Following comprehensive assessment occupational issues were discussed in relation to Mr Rudolph’s biggest concerns which were relevant to the scope of the service.

• As a rehabilitation provider the occupational issues that were most relevant and prioritised in this setting were those that were barriers to returning to work and that were meaningful to the client.

• During the Nominated Treating Doctor case conference, the doctor, Mr Rudolph and I all discussed his primary issues.

Prioritised Occupational Issues

1. Unable to return to pre injury duties

2. Difficulty sitting and standing for prolonged periods

3. Difficulty managing pain

4. Difficulty walking over long distances

5. Difficulty managing stress and depressive symptoms

6. Difficulty playing with child

7. Unable to place shoes on independently

8. Difficulty managing finances

Barriers to return to work

• Ongoing pain and reduced postural tolerances will limit work endurance.

• Mr Rudolph demonstrates poor adjustment to his condition and considers he is incapable of any work.

• Reported depression and stress is likely to impact negatively on condition and capacity to consider options.

• English language skills will potentially impact on range of work options

• Reliance on public transport may limit employment options

SMART Goals

1. Mr Rudolph to gain his bench mark capacity of 12 hours a week of suitable employment in 12 weeks after completing a work trial.

2. Mr Rudolph to reduce his Orebro pain measurement score from 127 to below 100 in 6 weeks following pain management counselling.

3. Mr Rudolph to be able to increase his sitting and standing postural tolerance to 1 hour each in 6 weeks.

Intervention Strategies used for Mr Rudolph’s Return to Work Program

1. Work Trial – Functional Education and monitoring of performance.

2. Pain Management Counselling.

3. Physical conditioning program.

Workplace Trial

• Setting up a workplace trial for Mr Rudolph involved

organising a trial employment for suitable work to facilitate rehabilitation of his injury in the workplace and to hopefully find suitable employment out of it.

• As my placement came to a conclusion we were in the process of negotiating a workplace trial with a warehouse for a sales position in hardware. I was unable to follow through with functional education and monitoring of his job placement, which I had been confident in doing with experience with other clients, as my prac concluded.

• Once a workplace trial had been organised my position would have been to provide Mr Rudolph with functional education on correct techniques in squatting, lifting and other functional tasks to minimise injury and strain on his back. It also would have involved monitoring his progress and being in regular contact with himself, his employer and Insurer.

Evidence Base for Workplace Trial

• Workers that undergo support and job placement are

gradually able to make behavioural and attitudinal changes resulting from their increase in work readiness

• Injured workers that have a work trial before finding employment have a higher percentage of employability.

• When an individual’s needs, abilities, values and job preferences are matched to be closer to the demands of different occupations, the individual is more likely to obtain and maintain employment.

• Work trials assist injured workers to reduce their anxiety and stress levels and to improve their self efficacy and perception of their own health status and capabilities.

Kluesner, B., Taylor, D., & Bordieri, J. (2005). An investigation of the job tasks and functions of providers of job placement activities. Journal Of Rehabilitation, 71(3), 26-35. Kong, W., Tang, D., Luo, X., Yu, I., Liang, Y., & He, Y. (2012). Prediction of Return to Work Outcomes Under an Injured Worker Case Management Program. Journal Of Occupational Rehabilitation, 22(2), 230-240. doi:10.1007/s10926-011-9343-zLi-Tsang, C., Li, E., Lam, C., Hui, K., & Chan, C. (2008). The effect of a job placement and support program for workers with musculoskeletal injuries: a randomized control trial (RCT) study. Journal Of Occupational Rehabilitation, 18(3), 299-306. .

Pain counselling

Mr Rudolph was referred to a psychologist that he previously advised he favoured for counselling and pain management.

It was deemed important for Mr Rudolph to gain pain counselling in order to improve his state of mind and to increase his functional capacity to be able to work and perform other duties.

Pain Counselling involves educating the injured worker to better manage their pain in readiness for work.

•learn new, evidence-based strategies for managing pain incorporating both physical and psychological components

•reduce dysfunctional pain behaviours and beliefs and perceived inflexibility of work

•demonstrate improved attitudes, self perception, confidence and coping skills to work with chronic pain.

Shaw, W. S., Tveito, T. H., Geehern-Lavoie, M., Huang, Y., Nicholas, M. K., Reme, S. E., . . . Wagner, G. (2012). Adapting principles of chronic pain self-management to the workplace. Disability & Rehabilitation, 34(8), 694–703. doi:10.3109/09638288.2011.615372.

Physical Conditioning

A Physical Conditioning program was installed for Mr Rudolph to improve his core strength and increase his capacity to work.

•Mr Rudolph was referred to an exercise physiologist to develop a program to increase core strength

•As Mr Rudolph was involved in this program externally from our service, my role included monitoring his program and compliance (up until my placement concluded). The purpose of this was to ensure Mr Rudolph was exercising safely and utilising correct techniques and to maintain his motivation throughout.

Physical Conditioning

• Physical conditioning was highly important as a part of Mr Rudolph’s return to work plan as it increased his core strength, energy levels and was a streamline to increasing his postural tolerances.

• Evidence highlights that a sustained physical conditioning program reduces the number of sick leave days or days of total incapacity by an average of 45 days when compared to general practitioner usual care or advice.

• Physical conditioning improves mindfulness and relieves stress levels

Schaafsma, F., Schonstein, E., Whelan, K., Ulvestad, E., Kenny, D., & Verbeek, J. (2010). Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Of Systematic Reviews, (1), doi:10.1002/14651858.CD001822Schonstein, E., Kenny, D., Keating, J., Koes, B., & Herbert, R. (2003). Physical conditioning programs for workers with back and neck pain: a Cochrane Systematic Review. Spine, 28(19), 391-5. .

Evaluation

The outcome of Mr Rudolph’s therapy would be evaluated on

1.The success/failure of his goals that he set out to achieve

2.His success to find and maintain suitable employment

3.Reassessment of his pain levels using the Orebro pain Scale questionnaire.

•Outcome-based

•Evidence-based

Presented By Occupational Therapist Student

Bennett, J., Winters-Stone, K., Nail, L., & Scherer, J. (2006). Definitions of sedentary in physical-activity-intervention trials: a summary of the literature. Journal Of Aging & Physical Activity, 14(4), 456-477. Brigham, C., Engelberg, A., & Richling, D. (1996). The changing role of rehab: focus on function. Patient Care, 30(3), 144.Braveman, B. (1999). The model of human occupation and prediction of return to work: a review of related empirical research. Work, 12(1), 25-35. Geisser, M., Robinson, M., Miller, Q., & Bade, S. (2003). Psychosocial factors and functional capacity evaluation among persons with chronic pain. Journal Of Occupational Rehabilitation, 13(4), 259- 276. Gross, D., & Battié, M. (2003). Construct validity of a kinesiophysical functional capacity evaluation administered within a worker's compensation environment. Journal Of Occupational Rehabilitation, 13(4), 287-295. Hockings, R., McAuley, J., & Maher, C. (2008). A systematic review of the predictive ability of the Orebro Musculoskeletal Pain Questionnaire. Spine, 33(15), 494-500. Johnston, V. (2009). Örebro Musculoskeletal Pain Screening Questionnaire. Australian Journal Of Physiotherapy, 55(2), 141.Kluesner, B., Taylor, D., & Bordieri, J. (2005). An investigation of the job tasks and functions of providers of job placement activities. Journal Of Rehabilitation, 71(3), 26-35. Kong, W., Tang, D., Luo, X., Yu, I., Liang, Y., & He, Y. (2012). Prediction of Return to Work Outcomes Under an Injured Worker Case Management Program. Journal Of Occupational Rehabilitation, 22(2), 230-240. doi:10.1007/s10926-011-9343-zLam, C., Wiley, A., Siu, A., & Emmett, J. (2010). Assessing readiness to work from a stages of change perspective: Implications for return to work. Work, 37(3), 321-329. Lee, J., & Kielhofner, G. (2010). Vocational intervention based on the Model of Human Occupation: a review of evidence. Scandinavian Journal Of Occupational Therapy, 17(3), 177-190. doi:10.3109/11038120903082260Li-Tsang, C., Li, E., Lam, C., Hui, K., & Chan, C. (2008). The effect of a job placement and support program for workers with musculoskeletal injuries: a randomized control trial (RCT) study. Journal Of Occupational Rehabilitation, 18(3), 299-306.

Matheson, L. (2003). The functional capacity evaluation. In G. Andersson & S. Demeter & G. Smith (Eds.), Disability Evaluation. 2nd Edition. Chicago, IL: Mosby Yearbook. Mentrup, C., Niehaus, A., & Kielhofner, G. (1999). Applying the model of human occupation in work-focused rehabilitation: a case illustration. Work, 12(1), 61-70. Oliveira, V., Ferreira, P., Ferreira, M., Tibúrcio, L., Pinto, R., Oliveira, W., & Dias, R. (2009). People with low back pain who have externalised beliefs need to see greater improvements in symptoms to consider exercises worthwhile: an observational study. Australian Journal Of Physiotherapy, 55(4), 271-275. Sattelmayer, M., Lorenz, T., Röder, C., & Hilfiker, R. (2012). Predictive value of the Acute Low Back Pain Screening Questionnaire and the Örebro Musculoskeletal Pain Screening Questionnaire for persisting problems. European Spine Journal, 21, 773-784. .Schaafsma, F., Schonstein, E., Whelan, K., Ulvestad, E., Kenny, D., & Verbeek, J. (2010). Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Of Systematic Reviews, (1), doi:10.1002/14651858.CD001822Shaw, W. S., Tveito, T. H., Geehern-Lavoie, M., Huang, Y., Nicholas, M. K., Reme, S. E., . . . Wagner, G. (2012). Adapting principles of chronic pain self-management to the workplace. Disability & Rehabilitation, 34(8), 694–703. doi:10.3109/09638288.2011.615372Schonstein, E., Kenny, D., Keating, J., Koes, B., & Herbert, R. (2003). Physical conditioning programs for workers with back and neck pain: a Cochrane Systematic Review. Spine, 28(19), 391-5. Tahan, H., & Schminkey, P. (2012). Motivational Interviewing: Building Rapport With Clients to Encourage Desirable Behavioral and Lifestyle Changes. Professional Case Management, 17(4), 164-172.