Tag Archives: musculoskeletal disorders

What Do New Workers' Compensation Reforms Sweeping the Country Have in Common?

AOECOE – Not Just Another Acronym

California Senate Bill 863 was passed in the fall of 2012 and went into effect on January 1, 2013. Senate Bill 1062 was just signed into law by Governor Mary Fallin of Oklahoma and will take effect January 1, 2014. On April 30, 2013, Tennessee Governor, Bill Haslam, signed into effect Senate Bill 200. House Bill 154 is expected to go into effect in Georgia in July, 2013. What are these bills? The first of many sweeping Workers' Compensation reforms. A common theme in these bills and other pending reforms is to level the playing field for employers and accept only those claims that arise out of the course and scope of employment, AOECOE.

A well-known term of art in the Workers' Compensation arena, AOECOE is not just an acronym. It is transitioning from a term of art to a statement with teeth, as reforms are actually including such wording into bills. The purpose of doing this is to establish whether an employee's alleged injury is work-related and happened in the course and scope of employment, or whether the injury is non-industrial or affected by third parties.

Workers' Compensation is a no fault system and thus benefits the injured worker, as, in order to receive benefits, he or she does not need to prove that the employer was negligent. However, it is the injured party's burden to show that the injury did, in fact, occur while at work, while employed as an employee and while undertaking some activity for the benefit of the employer. The injury itself must have been caused by the accident or employment conditions, and not from some other non-industrial related factors or degenerative factors.

The determination of AOECOE has long been an OSHA policy. OSHA's Injury and Illness Recordkeeping Regulation Section 1904.5: Determination of work-relatedness contained under section (a) basic requirement states in order for an injury or illness to be work-related an event or exposure in the work environment is either caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the work environment.

California's SB 863 was signed into law by Governor Brown on September 18, 2012, for a January 1, 2013, effective date. While certainly not the first bill to consider AOECOE issues, it is one of the most significant Workers' Compensation reform bills to specify AOECOE language. SB 863 calls for an Independent Medical Review (IMR). While this process may be problematic for an employer, since an IMR can be requested only by an injured worker following a denial, modification, or delay of a treatment request through the utilization review (UR) process, the bill specifically states that this does not apply if the injury is in question for AOECOE reasons.

On May 8, 2013, Oklahoma Governor Fallin signed into law historic Workers' Compensation reform, Senate Bill 1062. The bill defines compensable injury as arising out of the course and scope of employment and does not include: any strain, degeneration damage or harm to disease or condition of the eye or musculoskeletal structure or other body part resulting from the natural result of aging, osteoarthritis, degenerative process or pre-existing, except if a treating physician clearly confirms an identifiable and significant aggravation arising out of AOECOE.

On April 29, 2013, Tennessee Governor Haslam signed a Workers' Compensation reform bill into law, SB 200. It specifies that injuries arise out of and in the course and scope of employment only if proven by a preponderance of evidence that employment contributed more than 50% to causing the injury, AOECOE.

In my experience, the majority of injuries are real, but they are not AOECOE. Injured parties may exaggerate the severity and extent of their injuries or may attempt to hide pre-existing conditions. So how do any employers determine if injuries are AOECOE? The answer is simple. They need to ascertain what the employees' statuses are pre-injury. This is effectively done with baseline testing.

Baseline testing is a bookend solution. To be effective, it should be objective, meet the criteria for evidenced-based medicine, be job related and consistent with medical necessity. It needs to be specific to the metrics being evaluated. A good example of a specific baseline test that is recognized in some jurisdictions by statute is audiometric testing. Hearing tests are routinely done in environments with high noise exposure to determine a baseline that is referenced once a claim is filed. This is commonly referred to as the lock box defense.

Audiometric testing is beneficial for documenting hearing loss but is not designed to address other conditions such as musculoskeletal disorders (MSD). MSDs are the most frequent and costly claims for an employer. In order for a baseline test to be utilized for MSD, it must not only be objective and reproducible, it must contain measurements to ascertain electromyography (EMG), range of motion (ROM) and function.

In addition, baseline testing must be legally defensible. In 1990, Congress enacted the Americans with Disabilities Act that outlines what makes a legally defensible test. To be legally defensible, the testing needs to be job-related and consistent with business necessity i.e. the employer must show that it “substantially promote[s]” the business' needs. It must be repeatable, objective and address functionality. Also, since baseline testing is considered to be a medical exam, it needs to evaluate some functions of the job.

Baseline testing is not a post-offer, pre-placement test, as it can not identify disability because the data is not read and no hiring decisions are made with baseline evaluations. When a work-related injury occurs, a post loss test is conducted, at which time the baseline test is read and compared to the post loss results, hence the bookends.

When compared, the results can determine if an injury exists and if it has arisen out of the course and scope of employment, thus determining an employer's true responsibility. Good baseline testing is non-discriminatory and prevents “false” claims. The sweeping Workers' Compensation reforms allow for a new definition of “false” claim: one that is not AOECOE. A false claim no longer means fraud! A proven example of an effective baseline test is the EFA-STM.

Workers' Compensation statutes are helping employers by allowing them to accept the claims that are only AOECOE. Employers need to see that they comply with legislation, and baseline testing now gives them an objective assessment to do just that.

The Healthcare Industry Is Ripe For Baseline Testing

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Workers in the healthcare industry face many risks, and one that consistently arises as a major cost driver is musculoskeletal disorders (MSDs), better known as soft tissue injuries. Because of the difficulty in objectively identifying and subsequently treating these conditions, employers must now consider new options when it comes to risk control.

Patient handling tasks are recognized as the primary cause of musculoskeletal disorders among the nursing workforce. A variety of patient handling tasks exist within the context of nursing care, such as lifting and transferring patients. Nursing personnel have been on the top-10 list of workers with the highest risk for musculoskeletal disorders since 1999, and although the numbers of injured health care workers has decreased, nurses, nurse’s aides, orderlies, and attendants have remained at the top of this list since then.

According to OSHA, in 2010 there were 27,020 cases, which equates to an incidence rate (IR) of 249 per 10,000 workers, more than seven times the average for all industries. In 2010 the average incidence rate for musculoskeletal disorder cases with days away from work increased 4 percent, while the musculoskeletal disorder incidence rate for nursing aides, orderlies, and attendants increased 10 percent. For musculoskeletal disorder cases involving patient handling, virtually all were the result of overexertion, sprain, strain, or tear.

Additionally, according to an American Nurses Association 2012 study, 52 percent of nurses complain of chronic back pain with a lifetime prevalence up to 80% and 38% report having occupational-related back pain severe enough to require leave from work. The same study revealed that 12% of nurses leaving the profession report back pain as a main contributory factor and 20% have reported changing to a different unit, position, or employment because of back pain. In fact, nursing personnel have the highest incidence rate of workers compensation claims for back injuries of any occupation.

Nursing aides, orderlies and attendants incurred occupational injuries or illnesses in 48% of the musculoskeletal disorder cases involving health care patients. Other occupations with musculoskeletal disorder cases involving health care patients included licensed practical and licensed vocational nurses, emergency medical technicians and paramedics, personal and home care aides, health care support workers, radiologic technologists and technicians, and medical and health services managers.

A significant challenge in the healthcare industry is nursing home workers. Providing care to residents is physically demanding work. While the cost of musculoskeletal disorders to the health care industry is staggering, it has an even greater impact in nursing homes. Caregivers often suffer physical pain from their injuries and subsequently lose time from work. Nursing home facilities lose stability from caregivers’ absences, and residents suffer the loss of caregivers who understand their individual needs.

According to the CDC, the financial burden of back injuries in the healthcare industry is estimated to add up to $20 billion annually. These costs include higher employer costs due to medical expenses, disability compensation, and litigation. Nurse injuries also are costly in terms of chronic pain and functional disability, absenteeism, and turnover. Furthermore, this is an aging workforce (average age is 46.8 years), and there is an expected 20% shortage of personnel by 2015 and 30% by 2020. The indirect consequence is that back claims will likely increase as the workforce ages and new, inexperienced workers are hired to fill the shortage.

This is such a problem that as of April 2012 the following states — California, Illinois, Hawaii, Maryland, Minnesota, New Jersey, New York, Ohio, Rhode Island, Texas, and Washington — have enacted safe patient handling legislation. However, prevention may not always work for this industry. The teaching of manual lifting techniques has not been successful in affecting injury rates for nurses. This is largely due to the fact that patient characteristics and workplace environment may make it difficult to employ correct techniques. In addition, even if proper techniques are used, patient weight may exceed National Institute for Occupational Safety and Health lifting guidelines.

Why Baseline Testing Is The Solution For Employers
Employers are only responsible for work-related injuries that arise out of the course and scope of employment. The employer needs only to return the injured worker to pre-injury status, but it is virtually impossible for employers to objectively document an employee’s pre-injury status. The only way the Healthcare industry can manage their musculoskeletal disorder cases is by adopting the the EFA-STM baseline test, which is an objective, evidence-based tool designed to measure the functional status of an injured worker and to identify return-to-work opportunities.

The EFA-STM Program is specifically customized for an employer’s current workforce as well as new hires and complies with all ADAAA and EEOC regulations.

It begins by providing baseline soft-tissue injury testing for existing employees, as well as new hires. The data is maintained off-site and only interpreted when and if there is a soft tissue claim. After a claim, the injured worker is required to undergo the post-loss testing, thereby granting control of claim when this is often not the case. The subsequent comparison objectively demonstrates whether or not an acute injury exists. If so, the claim is accepted for the exact injury, or aggravation delta between the post-loss and baseline tests, thereby limiting liability to only what the employer owes and eliminating the issue of paying for existing or degenerative issues. If no acute pathology is found, then the claim is never accepted. The utilization of this book end strategy allows for unprecedented access to information and allows for better treatment.

Good Ergonomics Is Good Economics: Computer Workstations Need Not Be Hazardous to Your Health

Introduction
Two thirds of employees in industrialized countries use a computer on a daily basis. One in five interact with a computer at least 3/4 of the total work-time1. This usage of the technology ushered in an epidemic of work related ailments known as musculoskeletal disorders (MSDs). They are also known as repetitive motion disorder (RMD), repetitive motion injury (RMI), repetitive strain injury (RSI), ergonomic related disorder (ERD) and cumulative trauma disorder (CTD).

Though these disorders may as yet not be household terms, the patent effects of substantial computer use reveal themselves in terms of increased morbidity and declining productivity. In short, in the absence of ergonomic practices, employee efficiency in the American workplace takes a substantial hit.

Chart 1

Chart 1

In fact, according to the United States Bureau of Labor and Statistics (Chart 1), the prevalence rates for these types of disorders increased 1200% from 1982 to 1994 for all standard industry codes; however, those who employed good ergonomic safety management strategies enjoyed a 27% decline through 2000. Even though the rate reached a plateau for office or knowledge workers (computer workers) the wane may have occurred as a result of skewed interventions (e.g., training, workspace design and layout, equipment and accessories, work organization, etc.)2.

In addition, according to the Liberty Mutual Workplace Safety Index, injuries due to repetitive motion disorders from using computers were the #4 cause of work injuries in 2001 and 2002. The bottom line? A $2.8 billion price tag in 2002 for haphazard ergonomics3.

The Good News
According to OSHA, work related musculoskeletal disorders are the most prevalent, most expensive, and most preventable injuries in the American workplace today 4. The Center for Disease Control and Prevention's Injury Control Division reveals that injuries follow the same principles as infectious diseases and are just as predictable and therefore, just as preventable5.

Historical Sketch Of Computer Usage
Twenty years ago, computer workstations typically adjusted easily; however, they were relatively uncomfortable. Over time, they have morphed into rather complex devices with myriad levers and buttons that allow an uneducated user too many options for damage. Position (user may sit or stand), chair interfaces that move in multiple directions, numerous viewing angles of the monitor and fancy keyboard constructions that are split in half and look like accordions supply bells and whistles that may end up delivering harm unless organizations provide training. For those in the know, today's desktop computer were not necessarily designed to cooperate with the body; the user's natural alignment and paths of motion need not become contorted or required to engage in movements that never were designed to become repetitive nor prolonged. Modern fixed computer workstations beg accommodation to the body's motion flow.

Unfortunately, just when we are getting accustomed to our cubicles and other workstation environments, and are making gains in users' ergonomic awareness, some large computer companies have stopped making these computers and amazingly, are forecasting the death of the personal computer. Over the last 10 years, advances in technology have brought us a smorgasbord of new miniaturized devices or gadgets that provide us with faster communication — in essence what amounts to a handheld mobile computer workstation. Ironically, with this enhanced portability comes additional risk exposure for injury, particularly for the hands and neck.

These smaller devices foster awkward postures such as hands twisted into claws, and unnatural neck and shoulder angles — in short, resulting in increased discomfort and less than-efficient performance6. The root cause appears to be poor design — keyboarding areas, pointing devices (mouse) and a monitor-to eye interface that work together to produce a non-accommodating interactive work station. In particular, laptops (notebooks), tablets, I-phones and various PDAs unwittingly draw an unaware user into muscular and skeletal distortions.

Are the gadgets themselves to blame? Arguably, what is most important is the method by which we interact with them: the duration of exposure (how much is too much?), work organization and flow-process stress that occurs at less-than-optimal locations for usage. For example, many users must often conduct business in places such as coffee shops, airport waiting areas, planes, trains, and automobiles — places not designed for anyone to remain effectively postured.

Several primary physical risk and causation factors come into play between the computer user and all computer workstation environments, whether large or small. Three interfaces must be negotiated: the support interface (chair and floor), the manual interface (keyboard and mouse) and the monitor interface (distance from user, luminance, height). In addition to physical risk factors, behavioral variables commonly emerge: individual keyboarding and mousing techniques and style, excessive work pace without a break, prolonged sitting, and awkward forward head and wrist postures complicate the risk. What should be done about this trend?

The Spectrum Of Prevention
Fortunately, there are several easy-to-use methods to implement an effective ergonomics program. Once incorporated, they have prevention potential. A good ergonomics program can minimize computer-related musculoskeletal disorders by utilizing a more proactive and comprehensive approach to the potentially disabling conditions computer users in various workplace settings encounter. The answer lies in numbers.

It has been well documented that an integrated model of ergonomics safety management is critical for developing a healthy, effective workforce provided the company emphasizes a grassroots participatory approach in order to maximize collaboration and communication. The first step is to dedicate an ergonomic team. A successful group should comprise: an ergonomist, risk manager or loss control specialist, health service provider, company management representative (e.g., human resources, CFO, general manager, etc.), and a pre-designated employee ergonomics team trainer (leader)7.

This model efficiently capitalizes company resources and makes the best use of opportunities for surveillance and behavior change. It has been particularly effective in various organizations where the majority of employees consist of office and biotechnical workers typically tethered to their desktops 4-16 hours; all the while engaging in forceful/repetitive/awkward keyboarding and mousing whether interacting with desktop computers or hand-held devices. This extended risk exposure without appropriate rest cycles invites subsequent unwieldy neck and constrained back postures. The inevitable result? Discomfort at best or an actual recordable MSD at worst.

Nevertheless, these disorders have been shown to respond significantly to surveillance and behavioral change interventions such as job-task-specific ergonomics team training that provides information about strategies to maintain neutral work postures and movements when interacting with computers (Table 1).

Table 1: Team Intervention Recommendations

Have A Seat
  1. While adjusting your chair, make sure that you are sitting on the seatpan.
  2. Maneuver the backrest so it supports the low back curve and the shoulder blades at a 90 -105 degree angle (upright and lever should be located at very back of chair on the right or ratcheting it up and down for the Office Masters).
  3. When keyboarding, recline to 120 degrees for surfing the net or telephoning and decline at 60 – 90 degrees for writing.
  4. Use sit-to-stand options (available now for alternating 30 minutes standing and 30 minutes for sitting).
Watch Your Hands
  1. While keyboarding/mousing, keep your arms, wrists and hands in a neutral work posture, as if playing a piano.
  2. Avoid flexing wrists downward, sideways or extending upwards.
  3. Place hands on lap or armrest when paused or resting.
  4. Wrist rests are to be used when resting only!
Feast Your Eyes
  1. Rest your eyes by placing hands in your lap for 30 seconds while looking away from your screen at another object 20 feet away. Repeat every ten minutes, as you really do deserve a break today … a small one now will give your body a big one later!
Ring A Bell
  1. Consider installing software that reminds you to take short breaks every 10 -15 minutes. While seated, stretch hands, neck and shoulders using helps such as the ForgetMeNot Online Reminders that can be found at the following link www.remedyinteractive.com> (microbreaks).
Stretch Your Day
  1. Get up from your desk or table and walk to the water cooler or perform some simple stretches near your workstation at least once every 50 minutes or so (macrobreaks) that can be found at the following link www.netergonomics.net (wallet-sized stretching cards).
Heads Up
  1. Pay close attention to head posture. Draw an imaginary line so that it begins at the top of your head, extends over your ear to the shoulder, ending at the hip.
  2. Head posture should be maintained suspended, like a puppet, with an imaginary line drawn from the top of head, over the ear, aligned directly over the shoulder and hip as viewed from the side. This avoids forward head posture or craning (for every inch the head moves over the shoulder, the neck bears 30 additional pounds of pressure per square inch … yikes!
No Foot Faults
  1. Plant feet firmly on the floor at a 90-degree angle to the knees.
  2. Avoid resting feet on the pedestals of the chair.
  3. Order a footrest if you are less than 5'2″ or have a medical condition that elicits edema (swelling) in the legs/feet. See www.ergoanywhere.com.
Arms Distance
  1. Place your computer monitor/monitors directly in front of you at an arm's length away or 18 – 28 inches with the top of the screen or tool bar at your eye level.
  2. Tilt the screen back 15 degrees, much like you would hold a book you are reading (unless you use bifocals/trifocals-then lower it slightly).
  3. Make sure you have had an eye exam within the last year.
  4. There are specialized accommodation products for mobile computer laptops, tablets, e-readers and smart phones found at www.ergovue.com that will make life a little easier while on the go!
Make It Happen
  1. Communicate with clients in easy-to-understand messages.
  2. Underscore the benefit to both the worker and the company that employs these practices.
  3. Emphasize the long term effects of increased production, increased efficiency, and improved personal health.
  4. Utilize specific and customized approaches such as the OccuCom Ergonomic Team Training Program package that is available at www.netergonomics.net, which also provides Cal-OSHA and Fed-OSHA compliance.

If your employees are experiencing any discomfort, have them contact their supervisor or designated ergonomics-team leader for a possible ergonomic evaluation of their workstations. Also, these same principles and practices will apply to employees with material-handling tasks of transferring mail, printed materials, folders, bins, etc. in the office area. Any employee whose tasks include lifting should be trained to use correct lifting postures, personal protective equipment, and employ stretching and strengthening recommendations for maintaining neutral work postures, especially in the wrists, shoulders, and low back.

Moreover, as ergonomists, health and safety professionals, human resources personnel, loss control and risk managers, and managers of various workplace settings, we must provide a solution to the question of how much exposure for those workers interacting with various computer devices is too much. Employees who must use a workstation are ever exposed to potential harm through extra strain or forces from the repetitive motions and awkward postures while keyboarding mousing, or staring at a monitor screen for hours on end. Further, we must be on the lookout for the important question in terms of what is good ergonomics vs. voodoo ergonomics. We must be adept at identifying the potential smokescreens of unsuccessful products and advice given to companies with real problems in their workplace. White collar environments are especially at risk for unqualified vendors … be careful out there when selecting an intervention program8.

References

1 Brandt, LP. Neck and shoulder symptoms and disorders among Danish computer workers. Scand J Work Environ Health 2004, 30:399-409.

2 Sherrod, C. Johnson, D. The modulation of upper extremity musculoskeletal disorders in a knowledge worker population with chiropractic care and ergonomics. ACC-RAC Washington, DC. Journal of Chiropractic Education, 58;2007.

3 Liberty Mutual Safety Index of 2002. Liberty Mutual Insurance Company Seminar. 2003.

4 Sherrod, C. The relationship between an ergonomics team training program and the compression of repetitive motion injuries in a bus operator population. ErgoCon Conference Proceedings, 4; 2000.

5 Cotton, P. Preventive medicine extends to injuries, too. Journal of American Medical Association 1990, 263:19-2097.

6 Korkki, P. So many gadgets, so many aches. New York Times. 2011; 12.

7 Sherrod, C. The relationship between an ergonomics team training program and the compression of repetitive motion injuries in a bus operator population. ErgoCon Conference Proceedings, 4; 2000.

8 Chong, I. Prioritize office workstation goals and watch out for voodoo ergonomics. Occupational Health and Safety. 1993, pg. 55-57.