1 Workers Compensation Issues in Upper Extremity Orthopaedics Bernard F. Hearon, M.D. Clinical Assistant Professor, Department of Surgery University

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1 1 Workers Compensation Issues in Upper Extremity Orthopaedics Bernard F. Hearon, M.D. Clinical Assistant Professor, Department of Surgery University of Kansas School of Medicine - Wichita March 2, An occupational disease is one in which there is a direct cause-and-effect relationship between a work hazard and the disease. 3 Hazardous Occupations in Kansas Farm workers Grain elevator operators Sheet metal mechanics Construction workers Railroad employees Laborers Oil field workers 4 Initial intent of WC was to compensate workers and their families for serious or fatal job injuries. Over time, more common upper extremity occupational problems have been covered under WC. Though good surgical results may be achieved, motivating WC patient to RTW may be a bigger challenge. 5 Modern History of Workers Compensation Legislation 6 Germany 1880 s - Otto von Bismarck began comprehensive social insurance Workers contributed to accident insurance fund First comprehensive WC system eliminating employer negligence 7 Great Britain Employer s Liability Act eliminating negligence Workman s Compensation Act brought change in workers attitudes Sir John Collie cited abuses in Malingering and Feigned Sickness 8 Federal Employees Compensation Act (1908) Private insurance, no-fault system Federal and state regulations Covered employees engaged in interstate and foreign commerce 9 Wisconsin was first state to enact binding WC law 10 Wisconsin State Workers Comp Law (1911) No-fault state insurance for workers Employees - limited medical expense payments, wage loss benefits, but could not sue employer Employers - immune from liability suits, cost of insurance passed to the consumer By 1949, all states had WC systems and none required employee contribution

2 By 1949, all states had WC systems and none required employee contribution 11 National Commission on State Workers Compensation Laws (1972) Provide fair and prompt benefits Provide unified approach to settle disputes Eliminate trials, attorneys from process Promote safety and prevention at work 12 Expanding Scope of Coverage Full coverage - no statutory limit on time from injury or cost of care Inclusion of occupational diseases Aggravation of chronic diseases Medical cost per claim doubled from Kansas Workers Compensation Reform Act (2011) Accident - traumatic event resulting in injury Aggravation pre-existing conditions excluded Repetitive trauma must be unique to work and not be present in non-work environment Accident or repetitive trauma must be prevailing or primary factor causing injury 14 Five Big WC Issues Injury Causation Cost of Care Treatment Outcome Return to Work Impairment & Disability 15 Issue #1 - Injury Causation 16 Causation is the legal determination of whether a job activity or work injury caused an impairment. Physicians are often asked to opine regarding causation. Best opinion is based on patient history, mechanism on injury. 17 Injury Causation Determined by history and exam Occupational medicine specialist knows workplace best Orthopaedist may clarify causation Legal challenges delay medical treatment 18 Injury Causation - Key Questions Did the injury occur at work? Exactly how did the injury occur? Are the symptoms aggravated by work? Was there a pre-existing injury? Was there a pre-existing medical illness? 19 Risk Factors for Carpal Tunnel Syndrome Obesity Hypothyroidism Diabetes (14-30%)

3 Obesity Hypothyroidism Diabetes (14-30%) Pregnancy (50%) Renal disease Inflammatory arthritis Gender (women > men) Advanced age (> 50 yrs) Genetic factors 20 Occupation May Be Risk Factor for CTS Increased incidence in certain occupations Positional stress - dental hygienists Mechanical stress - beef handlers / cutters Vibration stress - sheet metal mechanics Repetitive stress - production workers Keyboarding is not causative 21 The Quality and Strength of Evidence for Etiology: Example of Carpal Tunnel Syndrome. Lozano-Calderón et al, J Hand Surg 2008; 33A: Carpal tunnel syndrome & workers compensation: A cross- Canada comparison. Watts et al., Can J Plast Surg 2003; 11: Despite weak evidence that carpal tunnel syndrome is workrelated, treatment is often covered under workers compensation insurance. 24 Upper Extremity Pain Syndrome Repetitive Stress Injury Cumulative Trauma Disorder Work-Related Overuse Syndrome Repetitive Motion Disorder Myofascial Pain Syndrome 25 Australian Experience - Repetitive Stress Injury Telcom Australian w/90,000 employees In two years, rate of RSI increased x 30! UE pain syndrome w/o objective findings Most patients were keyboard operators concerned about computerized workplace Patients did not respond to any treatment 26 Cooper v the Commonwealth - Resolution of RSI Australian Supreme Court decided case Employer not guilty of negligence Plantiff had not suffered an injury All costs awarded against plantiff RSI epidemic disappeared after decision 27 US Experience - Keyboard-Related RSI Litigation

4 RSI epidemic disappeared after decision 27 US Experience - Keyboard-Related RSI Litigation 1990 s - multiple products liability cases vs keyboard manufacturers Alleged defective design & failure to warn Nine cases consolidated vs one company Unanimous verdicts for defendant No evidence that keyboard was causative 28 Current Concepts Review: Repetitive Stress Injury - Diagnosis or Self-Fulfilling Prophecy? Szabo et al., JBJS 2000; 82A: Etiologic Factors for Cubital Tunnel Syndrome Idiopathic Intrinsic anomalies Trauma Post-traumatic deformities Elbow OA, RA Ganglia, tumors Post-operative Heterotopic ossification Elbow instability 30 Occupation May Be Risk Factor for CuTS Repetitive elbow flexion - cashiers, assembly workers, construction workers Mechanical compression - truck drivers Vibration exposure - laborers Post-traumatic ulnar nerve subluxation 31 Associations between work-related factors and specific disorders at the elbow: a systematic literature review. van Rijn et al, Rheumatology 2009; 48(5): Incidence of ulnar nerve entrapment at the elbow in repetitive work. Descatha et al, Scand J Work Environ Health 2004; 30: Osteoarthritis of the Thumb Carpometacarpal Joint in Women and Occupational Risk Factors: A Case Control Study. Fontana et al; J Hand Surg 2007; 32A: French study 61 surgical pts, 120 controls Administered questionnaires on occupations High risk occupations sewers, tailors, domestic helpers Study group greater family history of thumb OA Probable complex multi-factorial origin 33 Causation - Summary CTS - Compensable, weak evidence RSI - Not compensable CuTS - Compensable, weak evidence TMCJ OA - Possibly compensable 34 Issue #2 - Cost of Care

5 TMCJ OA - Possibly compensable 34 Issue #2 - Cost of Care 35 The Effect of Payer Type on Orthopaedic Practice Expenses. Brinker et al, JBJS 2002; 84A: Office Encounter Documentation What is the diagnosis? Based on history, is problem work-related? Can the patient work? If not, when RTW? What are work restrictions? Duration? When maximum medical improvement (MMI)? Expect permanent impairment? When rating? 37 Effect of Workers Compensation on Diagnosis and Treatment of Patients with Hand and Wrist Disorders. Day et al., JBJS 2010; 92A: The Value Added by Electrodiagnostic Testing in the Diagnosis of Carpal Tunnel Syndrome. Graham; J Bone Joint Surg Am. 2008; 90: Electrodiagnostic Testing May confirm diagnosis Quantifies disease severity Serves as a preop baseline In-office NC-Stat acceptable Important in WC patients 40 Outcomes of Carpal Tunnel Surgery With and Without Supervised Postoperative Therapy. Pomerance & Fine; J Hand Surg 2007; 32A: Magnetic Resonance Imaging in Evaluating Workers Compensation Patients. Babbel & Rayan, J Hand Surg 2012; in press. Retrospective review all W/C pts over 3 years MRI ordered by referring physician 67 MRI scans on 62 patients All MRI scans were unnecessary for diagnosis 63% clinical dx disageed with MRI dx 42 Overutilization of shoulder MRI as diagnostic screening tool in patients with chronic shoulder pain. Bradley et al; J Shoulder Elbow Surg 2005;14: Retrospective study 101 pts, 104 shoulders Atraumatic chronic shoulder pain 41% pts had MRI before shoulder evaluation 90% over-utilization rate for MRI No difference in outcome with or w/o early MRI 43 WC Shoulder Injury Evaluation H&P to assess work-relatedness, cuff

6 43 WC Shoulder Injury Evaluation H&P to assess work-relatedness, cuff XR to r/o fracture or dislocation Supportive treatment, NSAIDs, PT Observation & serial examination Soft tissue injury may resolve 4-6 wks MRI may be unnecessary so defer 44 Cost of Care - Summary WC administrative costs are higher Early MRI evaluation should be deferred Conservative management first Use discretion for postop PT & OT 45 Issue #3 - Treatment Outcome 46 Setting Treatment Expectations is Key Discuss all treatment options Establish outcome expectations Engage patient in decision process Physical therapy, work conditioning Return to work is not guaranteed Alternative work, vocational training 47 Carpal Tunnel Release Techniques Open CTR Mini-open CTR Endoscopic CTR 48 Evidence-Based Medicine: Endoscopic Versus Open Carpal Tunnel Release. Abrams; J Hand Surg 2009; 34A: Open Compared With 2-Portal Endoscopic Carpal Tunnel Release: A 5-Year Follow-Up of a Randomized Controlled Trial. Atroshi et al.; J Hand Surg 2009; 43A: Mini-Open Technique is my preferred surgical technique for carpal tunnel release. 51 Carpal Tunnel Surgery Outcomes in Workers: Effect of Workers' Compensation Status. Higgs et al; J Hand Surg 1995; 20A: Retrospective study WC vs NWC groups Telephone survey - RTW, job change, litigation RTW - WC group 12 weeks, NWC 3 weeks Changed jobs - WC 35%, NWC 4% CTS litigation - WC 77%, NWC 2% 52 Effect of Legal Representation on Functional Recovery of the Hand in Injured Workers Following Carpal Tunnel Release. Braun et al; J Hand Surg 1999; 24A: Retrospective study with or w/o attorney Assessed RTW, grip and pinch strength

7 Retrospective study with or w/o attorney Assessed RTW, grip and pinch strength RTW - Rep group 24 wks, non-rep 20 wks No difference in functional recovery rates No difference in final functional values 53 Ulnar Nerve Entrapment or Subluxation at the Elbow 54 Ulnar Nerve Operative Techniques Simple in situ decompression Arthroscopic-assisted decompression Medial epicondylectomy (King & Morgan) Subcutaneous transposition (Curtis) Submuscular transposition (Learmonth) Intramuscular transposition (Adson) Transmuscular transposition (Dellon) 55 Outcomes Measures Used to Assess Results After Surgery for Cubital Tunnel Syndrome: A Systematic Review of the Literature. Macadam et al, J Hand Surg 2009; 34A: Evidence-Based Medicine: Treatment of Ulnar Nerve Compression at the Elbow. Chung; J Hand Surg 2008; 33A: Three randomized, controlled clinical trials Nabhan (2005): No difference SD vs SQT Gervasio (2005): No difference SD vs SMT Biggs (2006): No difference SD vs SMT Simple decompression procedure of choice due to simplicity, potential faster recovery 57 Anterior Transmuscular Transposition is my preferred surgical technique for ulnar nerve entrapment or subluxation at the elbow. 58 Endoscopic Cubital Tunnel Release is touted as surgical technique permitting earlier return to work. 59 Patient-Rated Outcome of Ulnar Nerve Decompression: A Comparison of Endoscopic and Open In Situ Decompression Watts et al; J Hand Surg 2009, 34A: Shoulder Outcomes Shoulder self-assessment Subacromial impingement Rotator cuff tears 61 Do shoulder patients insured by workers compensation present with worse self-assessed function and health status? Viola et al; J Shoulder Elbow Surg 2000; 9: Answer is Yes for all 12 diagnoses studied 1063 consecutive shoulder pts Two questionnaires on general health

8 61 Do shoulder patients insured by workers compensation present with worse self-assessed function and health status? Viola et al; J Shoulder Elbow Surg 2000; 9: Answer is Yes for all 12 diagnoses studied 1063 consecutive shoulder pts Two questionnaires on general health W/C group reported significantly lower function Study controlled for patient age and gender 62 Measurement of baseline shoulder function in subjects receiving workers compensation versus noncompensated subjects. Sallay et al; J Elbow Shoulder Surg 2005, 14: Post-Traumatic Impingement Common after shoulder injuries Fall is usual injury mechanism Anatomy may predispose some patients Subacromial injection may be effective Subacromial decompression if no better 64 Anterior acromioplasty: Effect of litigation and workers compensation. Frieman & Fenlin; J Sh El Surg 1995;4: pts rx w/acromioplasty for impingement 49% had filed work comp claims 97% good or excellent result and 91% RTW W/C group took 14.2 weeks RTW Non W/C group took less than 5 weeks RTW 65 Arthroscopic Acromioplasty: A Comparison Between Workers Compensation and Non-Workers Compensation Populations. Nicholson; J Bone Joint Surg 2003, 85A: Consecutive series 106 pts (40 W/C, 66 not) No difference in mean outcome scores Significant difference in RTW (13.7 vs 9.1 wks) Higher work demand > delayed RTW in both 66 Rotator Cuff Tears Most common in middle-aged men Traumatic vs degenerative dilemma Partial-thickness vs complete Full-thickness are small, moderate or massive Nonoperative treatment temporizes Arthroscopic repair is standard of care 67 Repair of the rotator cuff: A comparison of results in two populations of patients. Misamore et al; J Bone Joint Surg 1995; 77-A: consecutive rotator cuff repairs W/C 24 patients, non W/C 79 patients 42% W/C pts returned to full activity 94% non W/C pts returned to full activity

9 42% W/C pts returned to full activity 94% non W/C pts returned to full activity Time to RTW not significantly different (6 mo) 68 Patients with Workers Compensation Claims Have Worse Outcomes After Rotator Cuff Repair. Henn et al; J Bone Joint Surg 2008, 90A: patients (39 W/C pts, claim pending) Evaluated w/outcome measures 1 yr postop W/C status associated w/worse outcome Analysis controlled for confounding factors 69 Impact of work-related compensation claims on surgical outcome of patients with rotator cuff related pathologies: A matched case-control study. Holtby et al; J Elbow Shoulder Surg 2010, 19: patients, 110 W/C, 110 non-w/c 41% RCR, 59% decompression +/- DCE W/C status associated w/worse outcome Both groups improved at 1 year postop 70 Meta-Analysis: Association Between Compensation Status and Outcome After Surgery. Harris et al., JAMA 2005; 293: Issue #4 - Return to Work 72 Determinants of Return to Work After Carpal Tunnel Release. Cowan, et al; J Hand Surg 2012; 37A: Risk Factors for Delayed RTW Pre-existing arm disability Government employment Repetitive motion Heavy labor / forceful hand use Long commutes Long works days Poor physical health Depression Low self-confidence 74 Risk Factors for Delayed RTW (cont) Pain severity Poor coping skills Low job satisfaction Fear of re-injury, increased pain No autonomy at work Non-supportive work policies Non-supportive co-workers Workers compensation claim Active litigation 75 Evidence-Based Medicine: Return to Work in Setting of Upper

10 Active litigation 75 Evidence-Based Medicine: Return to Work in Setting of Upper Extremity Illness. Pomerance; J Hand Surg 2009; 34A: Factors Associated with Earlier RTW Proactive RTW planning by all parties Patient understanding of injury and prognosis Optimistic patient expectations for recovery Physician recommendation for patient RTW Employer accommodation of injured worker 77 Practical RTW Guidelines Preoperative discussion setting RTW goal Earlier RTW is better, but too soon is bad Provide work restrictions every office visit Goal should be RTW without restrictions FCE may be helpful w/permanent restrictions RTW after each operative treatment 78 Failed RTW Secondary gain issues may prevail Wage benefits during recovery period Compensation if permanently unable to work FCE may be helpful to assess outcome, effort Litigation may lead to chronic pain syndrome Physician must recognize early and disengage 79 Psychometric Assessment of Patients with Chronic Upper Extremity Pain Attributed to Workplace. Dzwierzynski et al., J Hand Surg 1999; 24A: Psychosocial Aspects of Disabling Musculoskeletal Pain. Vranceanu et al., JBJS 2009; 91A: Issue #5 - Impairment & Disability 82 Impairment is a medical term for loss of use or derangement of body part, function or system. 83 Disability is a legal term for the difference between the patient s physical capability and that required by a specific job. Disability is also defined as the reduction of a patient s capacity to meet personal, social or occupational demands or statutory or regulatory requirements due to an impairment. 84 Final questions from the work comp insurance carrier Has the patient reached MMI? Are there permanent work restrictions? Is there any permanent partial impairment or disability? 85 Current Concepts Review: Upper Extremity-Specific Measures of Disability and Outcomes in Orthopaedic Surgery. Smith et al., JBJS 2012; 94A: Biomedical and Psychosocial Factors Associated with Disability

11 85 Current Concepts Review: Upper Extremity-Specific Measures of Disability and Outcomes in Orthopaedic Surgery. Smith et al., JBJS 2012; 94A: Biomedical and Psychosocial Factors Associated with Disability After Peripheral Nerve Injury. Novak et al., JBJS 2011; 93A: AMA Guides to Evaluation of Permanent Impairment Standard framework for evaluation All organ systems may be rated Applies to permanent impairments Impairments ratings are estimates Physician judgment important Difficult to avoid rater bias 88 Permanent Partial Disability is the percentage reduction in the patient s ability to earn comparable wages in the open labor market. 89 Temporary Total Disability occurs when patient is unable to return to gainful employment for a time-limited period. 90 Temporary Partial Disability occurs when patient returns to restricted work at less than full pay. Compensation payment makes up the salary difference. 91 Permanent Total Disability occurs when the patient is completely and permanently unable to engage in gainful employment. 92 Apportionment is the degree to which an impairment is due to an occupational disorder as opposed to a pre-existing condition. Often an issue in successive work injuries. 93 Upper Extremity Impairment in AMA Guides Amputation, any level Loss of motion, any joint Sensory loss, any nerve Motor loss, any muscle Nerve entrapment, any nerve Peripheral vascular disease Joint crepitus 94 Upper Extremity Impairment in AMA Guides (cont) Snovial hypertrophy Joint subluxation, any joint Carpal instability Arthroplasty, any joint Intrinsic tightness Constrictive tenosynovitis Loss of grip strength

12 Constrictive tenosynovitis Loss of grip strength 95 Guide to the Guides: Evaluator s Resource Algorithm to the AMA Guides to the Evaluation of Permanent Impairment, Fifth Ed.- Musculoskeletal, Nervous System and Pain 96 Rating Methodology Determine which tables apply Finger impairment > hand Hand impairment > upper extremity Lower extremity? Spine? Combine body parts > whole body 97 Months to years later, expect attorney call requesting deposition to justify your impairment rating. 98 Impairment & Work Restrictions AMA s Guides should be used as a guide Impairment may not correlate w/restrictions Work restriction may avoid re-injury Patient w/o impairment may need restriction Pt w/impairment may not need restriction 99 Common WC Misconceptions Injury causation may be determined arthroscopically Every work comp patient must have MRI evaluation Every work comp problem has a surgical solution Every work comp story has a happy return-to-work ending Permanent work restrictions imply permanent impairment education > residents file outline & references

Shoulder Injuries and Workers' Compensation: the Role of the Orthopaedic Surgeon

Shoulder Injuries and Workers' Compensation: the Role of the Orthopaedic Surgeon Erich Gauger, MD Major, USAF Staff Orthopaedic Surgeon USAF Academy, 10th MDG Disclosures No benefits in any form have been