Fitness To Work Evaluations in

Occupational Medicine:
Best Practices

Sol Sax, BAsc, MD, FRCPC, CCBOM

OEMAC Conference
Sept 28 2014
CONFLICT OF INTEREST

u Faculty/Presenter disclosure
u  Consulting for Wellpoint Health
u  Medical Director GE Canada, Occupational
Medicine Consultant – GSK, CAMH, Tonolli
u Mitigating potential bias
u  I am not being paid to do this presentation.
 Workshop Objectives

1. Understand the business reasons for doing disability

management/fitness to work evaluation so that you can
justify their services to current or potential clients
2. Understand the process of disability management/
fitness to work evaluation so that you can provide
information to the client in a way that is meaningful
3. Appreciate the various tools available to help do a
proper disability/fitness to work evaluation so that your
reports will stand up to scrutiny by your peers, courts or
arbitrators
 The Health Continuum
©

High Energy Capacity For Life

Traditional Medicine Wellness Promotion

Balanced Lifestyle
Vitality Healthy Behaviours
Healthy Attitudes
Risk Factors (smoking, diet,
The “zero” etc.)
line ABSENCE OF ILLNESS
Symptoms
Signs
Illness
Viability Impairment
Disability

R.I.P.
Copyright Dr. Sol E Sax
Death
Risk Assessment: Person

Considerations:
-health (past, present)
-social status
-understanding of risks
Risk Assessment: Task

Considerations:
-equipment
-repetitiveness
-materials
Risk Assessment: Environment

Considerations:
-physical
-organizational
Risk Assessment

Risk
Fitness to Work Evaluation
 Nomenclature

WHAT IS MEANT BY “FITNESS TO WORK”?

u “Fitness
to work” is a medical assessment done when
an employer wishes to be sure an employee is
capable of performing the duties and responsibilities
of a specific job.
u It is voluntary, requires consent
u It is a snapshot, “a moment in time”

http://www.ccohs.ca/oshanswers/psychosocial/fit_to_work.html
Objective of Health Evaluation Options
12

u  Fit for Duty - Definition:

A condition in which workers are physically,
physiologically, and psychologically/mentally
capable of performing the tasks of their assigned
jobs within the required standards of safety,
attendance, quality, efficiency and behavior.
 When do employers request
FTWE?
u  Pre-placement
u  Post Job Offer
u  Job Transfer
u  Medical Surveillance
u  Periodic FTW evaluations for high risk or safety sensitive
positions
u  Stay at work/ Return to Work after Illness or Injury
u  Concerns re work performance, absenteeism,
workplace behaviors, etc

http://www.ccohs.ca/oshanswers/psychosocial/fit_to_work.html
 Scope of FTWE
q  Assesses holistically for the spectrum of medical,
physiological, psychological, biochemical, physical or
behavioural impairments or disabilities.
q  Determines if employee meets or does not meet each
job requirement as identified in the employer’s Job
Demands (as defined in PDA, CDA, job description)
q  Usually done by a Family Physician with special
interest in Occupational Medicine
 Specific Circumstances
u  There is a significant change in the working
conditions
u  Task – lifting, bending, climbing
u  Environment – noise, heat, allergens
u  There is a change in an employee's health
u  Stay at Work/Return to work after recovery from
a serious illness or injury
u  Follow up after job modification
u  Concerns that a new medical condition that
may limit, reduce or prevent the person from
performing a new or current job effectively (e.g.,
musculoskeletal conditions that limit mobility),

Workplace Health and Public Safety Programme, Health Canada. 2003

http://www.ccohs.ca/oshanswers/psychosocial/fit_to_work.html
 Specific Circumstances

u  Safety Concerns

u a medical condition likely to make it
unsafe to do the job (self , coworkers,
public )
u  Aggravation - The medical condition
may be made worse by the job
u  Determine appropriate accommodation

Workplace Health and Public Safety Programme, Health Canada. 2003

http://www.ccohs.ca/oshanswers/psychosocial/fit_to_work.html
Outcome of FTWE
q  Fit
q  Unfit
q  Fit with restrictions / limitations?
q Duration of restrictions / limitations
(temporary or Permanent)
q If Temporary, suggested
reassessment date, if required
 How to conduct a FTW
Evaluation
1.  Ascertain tasks and duties that the person has
to perform at work.
2.  Explain the content of the FTWE to the
employee and get consent
3.  Collect information on the health status of the
person. History and focussed examination to
identify current functional abilities.
4.  Consider potential effects of medication and
other treatments, including side effects.
How to conduct a FTW
Evaluation
5.  Create a problem list of issues that may affect the
ability to perform the tasks and duties of the specific
work. This should include immediate problems (e.g.
current functional limitations, side effects of current
medication, and uncontrolled health conditions) as
well more long term issues that may affect work or be
affected by work exposures.
6.  Decide whether the patient is physically and mentally
able to do the specific task – if not, this is indicated as
a limitation.
7.  Decide whether there is a risk of significant harm to the
patient or others with the work activity – if yes, indicate
this is a restriction.
 How to conduct a FTW
Evaluation
7.  If the patient can perform the requirements of the
role without restriction or limitations, they can be
certified as medically able to work.
8.  If there are limitations and/or restrictions, these
should be outlined as specifically as possible in a
report to the employer/manager so that
accommodations can be considered and
implemented.

Ref- Foundations Course in Occupational Medicine Syllabus – U of A

Essential Duties
Bona Fide Occupational Requirements

q  Whodecides what these are and if

the employee requires
accommodation ?
Essential Duties
q  It
is the Employer's duty to accommodate. This
means that the employer has a responsibility to
ensure that all reasonable attempts have been
made to modify the job, the job requirements, or
the working conditions so that employment can
continue in a way that is safe for the employee
and coworkers
Fitness to Work Evaluation-
Disability Management
Situations
Why Pay Attention?
u  The Burden of Disability
q  Absenteeism
q  Presenteeism
u  If an employee is off work for 6 months, the
likelihood of EVER returning to work is 50%, after 12
months, 10%
The Disability Iceberg

u  Visible costs:

q  Income replacement
q  Overtime
u  Invisible costs:
q  Supervisor’s time
q  Payroll Admin costs
q  HR time
q  Retraining
q  Co-worker morale
q  Presenteeism
 Definitions (WHO)
¨  Impairment = loss of structure or function
Anatomic/pathological definition
¨  Disability = inability to perform a certain role or
task -- Functional definition
¨  Handicap = a disadvantage for a given
individual, resulting from an impairment or a
disability, that prevents the fulfillment of a role
that is considered normal (depending on age,
sex and social and cultural factors) for that
individual‘ -- Social definition
¨  Maximal Medical Recovery (MMR) = a plateau
in the process of recovery where it is unlikely
that there will be any further significant
improvement even with treatment
 Models of Disability

¨  Medical model – Impairment predicts disability

¨  Psychological model – mental pathology is seen as
the main cause of disability
¨  Social model – social groups and social evolution
are driving forces which shape individual and
organizational behaviour. These theories centre on
identifying the social and economic conditions
which contribute to dysfunctional social systems,
which in turn produce the disabled individual.
¨  BioPsychoSocial model – disability as a
continuously evolving process subject to many
influences. This model incorporates findings and
information from the medical, psychological and
social theories to determine which causal factors
are most important to a disabled individual at any
given point in the evolution of his or her disability.
 Models of Disability

¨  The medical model does not explain why two

employees with the same diagnosis and level of
impairment could have different levels of
disability, or perhaps no disability at all.
¨  It is best used when the medical conditions
(illness or injury) are straightforward.
¨  But it can lead to an adversarial approach to
disability management that results in an
atmosphere of mutual distrust.
 Definitions – Insurers

¨  Operationally insurers use a traditional medical,

legal or social definition of disability as a
determinant of benefit entitlement.
¨  Key Question – What is the effect of the
impairment on the employee's ability to work ?
¨  This assumes that there is a direct correlation
between impairment and disability, as
determined by average length-of-disability
tables.
¨  It is based on the medical model of disability.
Other Key Concepts 30

u  Risk
u  Capacity
u  Tolerance
 Risk 31

u  “Risk” refers to the chance of harm to the patient,

or to the general public, if the patient engages in
specific work activities. Risk, in this regard, means
the person should not do something, even
though he/she may actually be capable of doing
the activity. Significant risk would justify ‘work
restrictions’. For example, individuals with
uncontrolled seizure disorders are not permitted
to work as commercial airline pilots or bus drivers
based on risk.
 Capacity 32

u  “Capacity” refers to concepts such as strength, flexibility and

endurance which can be objectively measured. A patient is
physically able to perform the task in question while ignoring
symptoms. Current ability may increase with exercise or decrease
with deconditioning. For example, after a wound into the biceps
muscle mass of the arm, an individual may not yet have the
strength to permit lifting a certain amount of weight; or after a
fracture of the shoulder, an individual may not yet have enough
shoulder motion for his/her hand to reach the overhead control
on a factory press.
 Tolerance 33

“Tolerance” is a psychophysiologic concept. It is the ability to

tolerate sustained work or activity at a given level. Symptoms
such as pain and or fatigue are what limit the ability to do the
task(s) in question. The patient may have the ability to do a
certain task (no work limitation), but not the ability to do it
comfortably.
Tolerance is the ability to put up with the symptoms (like pain or
fatigue) that accompany doing work tasks in order to gain the
rewards of work (income, self-esteem, health benefits of work,
etc.).
 Types of Disability

¨  Sick leave

¨  Short term
¨  Long term
¨  Worker's Compensation
Disability Management
Who?

Employer Employee

Human Resources
Occupational Health
Health and Safety Professional
Disability Case Manager
Insurer
Union
Legal
Disability Management-Tools
?

q  StatsCan reports

q  Presley Reed
q  Official Disability Guidelines
q  CPG’s
q  IME’s
q  FAE/FCE/FCA
Disability Management
Medical Disability Advisor
(http://www.mdguidelines.com/)

Low Back Pain – ICD 724.2, 724.4, 724.5

Disability Management
Official Disability Guidelines
Low back Pain (ICD 724)
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

(http://www.disabilitydurations.com)
Disability Management
Officail Disabilty Guidleines
ODG

u  RTW Claims Data (Calendar-days away from work by

decile)10%20%30%40%50%60%70%80%90%100%Mean10121415203135427936537.41
u  CDC NCHS LOD (Length Of Disability, in days)* Median (mid-point) 5.0 Mean (average) 15.19 Mode
(most frequent) 2 Calculated rec. 7 Percent of Cases (12719 cases) 15.7 10.6 7.5 7.0 6.0 4.2 1.9 2.5
1.2 0.7 1.4 0.8 1.2 0.6 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 1 2 3 4 5 6 7 8 9 10 11 12 13
14+ Days *CDC NHIS cases with no lost workdays: 4922 (38.7%)

u  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
Disability Management
Clinical Practice Guidelines
CMA Infobase

https://www.cma.ca/En/Pages/clinical-practice-
guidelines.aspx
Agency for Healthcare Research and Quality
(US)- National Guideline Clearinghouse
http://www.guideline.gov/
American College of Occupational and
Environmental Medicine
http://www.acoem.org/
Other Factors That Can Determine
Duration of Disability

u  Worker Factors—Sex, Age, Hours of work, job

satisfaction, commuting distance, family
commitments, personality, health status
u  Task Factors – strenuous, repetitive, boring, breaks
u  Work Environment factors—
u  Physical -Temperature, noise, dust, humidity, light,
odours, office design
u  Organizational - and Respect, sick pay, supervision, HR
Policies (such as performance management), nature
and size of the organization, Health and safety policies
and practices, access to OHS
u  Socio cultural – Region, Economy, Pension age, Health
services access, epidemics, social security benefits
Yellow Flags
(AKA psychosocial barriers to recovery)
u  Belief that pain and activity are harmful
u  ‘Sickness behaviours’ (like extended rest)
u  Low or negative moods, social withdrawal
u  Treatment that does not fit best practice
u  Problems with claim and compensation
u  History of back pain, time-off, other claims
u  Problems at work, poor job satisfaction
u  Heavy work, unsociable hours
u  Overprotective family or lack of support
IME?

q  From an employer’s perspective, an IME is “an

independent evaluation to establish clinical
observations and conclusions that document the
worker’s current condition.”
q  Especially useful as it applies to fitness to do
one’s role, with or without accommodation, or
to do any role
q  Allows the company to make fair decisions
about an employees ability to work, or their
entitlement to benefits (STD, LTD)

(Ref: Liz Scott, OOHNA Journal, Spring 2008)

Why do an IME?
q  Confirm presence or absence of a particular
diagnosis
q  Determine causality
q  Evaluate whether further testing is required
q  Evaluate whether additional treatment or
rehabilitation is needed
q  Determine functional limitations of Activities of
Daily Living (ADL’s)
q  Determine job limitations and precautions
q  Evaluate degree of an impairment
q  Determine whether MMR has been achieved
(Ref John Kraus Occ Med STARS 1997)
Why is an IME unique?
¨  Objective and unbiased
¨  Comprehensive – all previous reports reviewed
¨  HCP professional has not treated and will not be
treating the “client”, therefore no “doctor–
patient relationship” established
¨  Results are provided to the referral source and
not to the individual
¨  IME is paid for by the referring agent
¨  IME often disputed and will be the subject of a
legal review
¨  IME is performed ONCE (snapshot)
When to do an IME?

¨  You doubt that the medical information supports a

certain decision (more treatment, prolonged
disability)
¨  You are uncertain if a person can return to work
with or without accommodation
¨  You are uncertain if a person is eligible for a
benefit (medical, pension, insurance benefit such
as LTD, other income)
¨  You need confirmation of diagnosis or causality
(work-related vs non-occupational)
Pitfalls of an IME?

¨  Client may not be cooperative, angry, cynical,

negative
¨  Sometimes ask for an advocate (relative, friend,
union rep, paralegal) to be present
¨  Client may be having a bad (or good) day in
terms of function
¨  Client may refuse to perform some of the
maneuvers due to pain, fear of aggravation of
pain, or simply to thwart the assessor
 What is an FAE?
¨  A Functional Abilities Evaluation is a specific
assessment performed by a Registered
Physiotherapist, Occupational therapist, or
Kinesiologist to help identify a client’s or employee’s
physical work tolerances. Following thorough
assessments and measurements, the assessor
determines physical impairments and abilities that
exist.

http://meridianhealthassessments.com/assessments/FAEs.php
 What is an FAE?
•  An instrument that can reliably measure the functional physical
ability of a person to perform a work-related series of tasks.
•  There is no “gold standard,”
•  Over the past twenty years, many researchers have tried to
develop FAE instruments.
•  Matheson 1984.
•  Isernhagen 1988 - multidisciplinary team should assist in
determining a person's functional capacity.
•  Hart 1994 - a physician and physical therapist working in
conjunction to assess a patient's resulting impairment.
•  About 10 different types of commonly used FAE’s
•  Blankenship, Ergos Work Simulator and Ergo-Kit
variation, the Isernhagen Work System, Hanoun Medical,
Physical Work Performance Evaluation (Ergoscience),
WEST-EPIC, Key, Ergos, ARCON, and AssessAbility.
•  Only Isernhagen has good evidence to support reliability
Iowa Orthop J. 2007; 27: 121–127
Questions?

Work – Health – Productivity

Back Up Slides
 Disability Management
Best Practice

1.  Document the Principles of your program

2.  Create a DM policy, strategy and process by
engaging key stakeholders
3.  Figure out how you are doing – track key metrics
4.  Set goals or objectives
5.  Clarify who is accountable for what and hold them
accountable
6.  Communicate broadly
7.  Use the tools and resources – disability guidelines,
occupational health, clinical guidelines, FTWE, IME
8.  Track your progress
9.  Audit and revise regularly
Disability Management
What?

¨  Disability management is a proactive, employer-

centred process that coordinates the activities
of labour, management, insurance carriers,
healthcare providers and vocational
rehabilitation professionals for the purpose of
minimizing the impact of injury, disability or
disease on a worker's capacity to successfully
perform his or her job.

Ref – Anna Blake, Benefits Canada, March 2000

 Disability Management
Why?

¨  A well designed, progressive, DM program can

shorten or even prevent employee absences,
reduce costs and maintain productivity.
¨  Integrated DM programs apply consistent principles
and complementary processes to all disability-
related benefits (short- or long-term disability
programs, workers’ compensation and other third
party insurers).
¨  The most effective approach combines integrated
DM with prevention. The best DM programs begin
BEFORE the disability starts.
¨  Research shows that the best results come from a
combination of a strong organizational commitment
centered on line supervisors, overseen by expert
internal resources and supported by clinical case
management.
Disability Management
How?
Guiding principles are that:
¨  Team efforts are focused on a safe, timely and
sustainable return to work
¨  The disability case management model is
biopsychosocial, not primarily medically based
¨  The Disability Case Management Specialist,
Occupational Health Nurse and Occupational
Health Physician are health advocates not
employee or employer advocates
¨  Successful outcomes are predicated on early
intervention to establish the proper course of
action, and,
¨  Supervisors/managers and employees are key
team members whose relationship is critical to
successful interventions.
Disability Management
How?

¨  Tracking – what are your Metrics?

q  Number of claims per employee ( frequency)
q  Average duration per claim (severity)
q  Days lost per employee
q  % payroll
q  Etc.