13 OT Occup Rehab AOTA Exam Prep

AOTA’s NBCOT® Exam Prep
Occupational Rehabilitation and Return-to-Work

Programming
I. General Considerations
(See AOTA, 2017; Cheng & Cheng, 2011; Gateley & Borcherding, 2017, pp. 59–60, 192–194, 199–202;
Haruko Ha et al., 2013, pp. 337–379; Kaskutas & Snodgrass, 2009, pp. 18–19; Kinney & Oliveira,
2012; Larson, 2014, pp. 234–236; Lieber et al., 2000; Ratzon et al., 2012; Rice, 2014, pp. 870–876;
Smith, 2013, pp. 126–129; Snodgrass, 2011.)
A. Industrial work rehabilitation and return-to-work programming involve the client, the
employer, the employer’s human resources department, safety personnel, and case
managers.
B. Transition services involve preparing adolescents and young adults with special needs
for work.
C. These services may be provided in a variety of settings, such as a workplace,
community, school, shelter, or psychiatric center, and with a variety of populations.
D. Professional roles within work rehabilitation settings may involve both occupational
therapists and occupational therapy assistants. The occupational therapy assistant may
assist in providing verbal and written reports to the occupational therapist in the
evaluation process. The occupational therapist is responsible for completing the initial
evaluation report and developing an intervention plan. The occupational therapy
assistant’s main function is to implement interventions according to the occupational
therapist’s established plan. Both the occupational therapist and the occupational
therapy assistant should be engaged in a collaborative process to meet the client’s
needs and carry out the occupational therapy process.
E. Evaluation in the context of work activity should be done with the support of reliable
and valid assessments.
1. Social and communication skills of worker
2. Physical abilities of worker
3. Cognitive and perceptual skills of worker
4. Job analysis to define the actual demands of the job
5. Work organizational culture
6. Vocational aptitudes and interests of worker
7. Injury prevention, including ergonomics evaluations
8. Assessments of and modifications to the workplace
F. Occupational therapists promote health and wellness through educational activities.
1. Occupational therapists have a role as educators.
a. Identify affected people and populations within the work environment (e.g., by age, gender,
skill level, general health)
b. Facilitate learning for clients
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c. Implement strategies that take into consideration clients’ learning styles

2. Injury prevention programs aim to decrease employers’ costs related to work injuries, improve
worker fitness and safety, and unite employers and workers in a collaborative plan to improve
workplace safety.
G. Documentation is geared, as appropriate, toward individual clients or toward the
employer and workplace context. Documentation may be written in SOAP (subjective,
objective, assessment, and plan) note format, memos outlining recommendations and
education provided, or standardized evaluation forms. Goals in the medical system may
be written in a variety of formats, including Relevant, Understandable, Measurable,
Behavioral, Achievable (RUMBA); Client, Occupation, Assist level, Specific conditions,
Timeline (COAST), and Specific, Measurable, Achievable, Relevant, Time-limited
(SMART).
H. Work-related policies and reimbursement are regulated by federal and state law (AOTA,
2017; Haruko Ha et al., 2013, pp. 341, 344, 346, 352; Kaskutas, 2012, pp. 373–401; Rice,
2014, p. 883; Shamberg, 2012).
1. Reimbursement may be provided through a variety of sources, depending on the type of service
provided. Sources may include vocational rehabilitation, private medical insurance, employer
or organization direct payment, or government funding.
2. Several federal resources are available to assist in complying with regulations.
a. The Americans With Disabilities Act of 1990 (ADA) is legislation governing employment
practices and public accommodations for people with disabilities.
b. The Occupational Safety and Health Administration (OSHA), part of the U.S. Department
of Labor, was created to ensure “safe and healthful working conditions . . . by setting and
enforcing standards and by providing training, outreach, education, and assistance”
(OSHA, 2013). The agency provides information about general workplace safety and health,
including ergonomics guidelines for lifting and to reduce workplace injuries. See
https://www.osha.gov/dts/osta/oshasoft/ (OSHA ergonomics e-tools).
c. The National Institute for Occupational Safety and Health (NIOSH), part of the Centers for
Disease Control and Prevention, is “the federal agency responsible for conducting research
and making recommendations for the prevention of work-related injury and illness”
(NIOSH, 2013). The agency provides information about workplace safety and health topics
including injury, hazards, prevention, and ergonomics for various types of industries. See
http://www.cdc.gov/niosh/topics/ergonomics/ (NIOSH ergonomics resources).
d. The U.S. Department of Labor, Employment and Training Administration, has developed
the Occupational Information Network (O*NET), a database of job requirements, worker
attributes, and other information about thousands of occupations that can be helpful when
documenting job demands (U.S. Department of Labor, 2010). It has replaced the agency’s
Dictionary of Occupational Titles. However, both resources are used in practice.
e. Uniform Guidelines on Employee Selection Procedures from the Equal Employment
Opportunity Commission (EEOC) are in place to ensure that fair employee selection
processes are in place (EEOC, 1978). These guidelines apply to new employees, workers
returning to work after an injury or illness, and workers with disabilities.
II. Industrial Work Rehabilitation

(See Haruko Ha et al., 2013, pp. 341, 352, 356, 359–360, 364; Innes, 2012, p. 330; Lieber et al., 2000,
p. 167; Maher, 2014, pp. 1120–1122; Snodgrass, 2011, pp. 40–41.)
A. Work-related musculoskeletal disorders (WMSDs)
1. WMSDs are defined as a class of soft tissue injuries affecting the muscles, tendons, and nerves.
They are typically characterized by a slow and insidious onset and are thought to be the result
of microtrauma. WMSDs account for one-third of all occupational injuries and illnesses in the
United States.
2. Common types and examples of WMSDs include some back injuries, carpal tunnel syndrome,
de Quervain’s tenosynovitis, and lateral epicondylitis.
3. Factors that increase risk for developing WMSDs include heavier levels of material handling,
poor workstation design, and poor work process design.
4. An injury sustained in a fall is not considered a musculoskeletal disorder per the U.S.
Department of Labor (Sanders, 2004, p. 302).
B. Back and neck rehabilitation
1. Back and neck rehabilitation training provides strategies focused on improving fitness, job
comfort, and workplace safety for individuals or groups of workers either to prevent injury or to
retrain clients after injury.
2. Several factors influence a client’s capacity to use new strategies:
a. Physical and cognitive abilities
b. Intellectual abilities
c. Emotional status
d. Work skills and work tolerances
e. Work habits and values in a given occupational situation
3. The occupational therapist actively engages the client in actual or simulated job tasks to assess
dynamic activity sustained over time. Checklists are one form of rating scale that may be used
to assess a client’s body mechanics, but they are not useful in determining the client’s actual
body movements. Moreover, most body mechanics instruments do not have established
reliability and validity and are not sensitive to changes in task performance.
4. The occupational therapist assesses the client for ergonomic risk factors involving forceful
exertions, repetition, awkward or static posturing, contact stress, excessive vibration, and cold
temperatures.
5. The occupational therapist provides strategies to help clients maintain ergonomic principles:
a. Body mechanics and postural alignment strategies:
i. Keep the spine in alignment.
ii. Hold objects close to the center of gravity.
iii. Avoid twisting through the spine by facing the object straight on.
iv. Use both sides of the body equally, and maintain a wide base of support.
b. Environmental fit can be improved by changes to the work environment, such as
workstation modification, proper tool access and fit, proper materials handling, and
adjustments to environmental factors such as temperature and lighting.
c. A holistic and client-centered approach considers the psychosocial needs of clients in
addition to the clients’ physical deficits. Cognitive–behavioral strategies (e.g., positive
reinforcement, progressive relaxation, biofeedback) are appropriate.

C. Symptom magnification (Schultz-Johnson, 2011a, p. 1829–1830).

1. Symptom magnification is defined by Matheson (as cited in Schultz-Johnson, 2011a, p. 1829)
as “a nonadaptive, static approach to manipulating society with display of symptoms.” Other
terms used are consistency of effort, sincerity of effort, or maximum voluntary effort.
2. Symptom magnification encompasses unconscious and conscious behavior. Malingering is the
deliberate or conscious faking of symptoms and disability in order to achieve personal gain
through avoiding work or responsibility.
3. Four types of symptom magnification are commonly seen: refugee, symptom misinterpreter,
game player, and identified patient.
a. The refugee uses symptoms to escape an unresolvable conflict.
b. The symptom misinterpreter responds to physical changes in the body in an extreme manner
because of difficulty processing sensory and kinesthetic input or unrealistic belief systems
about the manner in which the body works.
c. The game player consciously attempts to convince those working with him or her of the
reality of symptoms for positive gain.
d. The identified patient assumes the patient role as a lifestyle.
4. The symptom minimizer is a client who keeps symptoms hidden so that he or she can return to
normal activity or avoid appearing weak.
5. Identification of symptom magnification is a required part of a functional capacity evaluation
(FCE). Clients should present with predictable levels of function and dysfunction. The clinician
should screen for behaviors, symptoms, and signs that are inconsistent with the client’s
medical history.
6. According to Miller (as cited in Schultz-Johnson, 2011a, p. 1830), pain associated with a true
pathological condition appears in the anatomical areas associated with the pathological
condition; appears in response to stress related to force, repetition, or position; increases with
increased stress; and is accompanied by observable physical responses.
7. A common assessment used to assist the clinician in determining maximum effort is the five-
level grip test. Using the Jamar dynamometer, the client is instructed to grasp the
dynamometer at each setting handle on the dynamometer. The strongest grip is expected on
the second and third settings. When graphed, results are expected to fall in a bell-shaped curve
(Kasch & Walsh, 2013, pp. 1046–1047; Klein, 2014, p. 81).
D. Injury prevention program (EEOC, 1978; Haruko Ha et al., 2013, pp. 344–373).
1. Four characteristics for implementation of a successful work injury prevention program include
ongoing management support, supervisory support, employee participation, and ongoing
support and reinforcement of the program. Steps to implement such a program include
developing a corporate plan; establishing an injury prevention team; training for risk factor
identification, conducting ergonomic evaluations; developing risk factor controls; and
implementing medical management strategies such as early intervention and transitional
work/modified duty programs.
a. Primary prevention goal: to identify and reduce risk factors early, before injuries occur, and
to promote healthy work habits and lifestyle
b. Secondary prevention goal: early identification of symptom-related risk factors, ultimately
to minimize or reduce the duration, severity, and cost of work-related injuries

c. Tertiary prevention: occurs after an injury or illness has been diagnosed; interventions focus
on medically treating the work-related injury and restoring the work role
2. Job demands analysis: A job demands analysis looks to define the actual demands of a job. It
involves the use of questionnaires, interviews, observations, and formal assessments completed
in the real work environment. Use of employer-provided job descriptions assists clinicians in
identifying essential job functions. Many FCEs include a job demands analysis. During the
course of a job demands analysis, it is important to distinguish between tasks that are
essential and those that are not.
a. Collect data to guide the assessment.
i. Interview supervisors, workers, or both to gather information on the number of job
tasks for the job.
ii. Obtain a job description to confirm the nature and requirements of the job tasks
(optional).
iii. Determine essential versus marginal functions of the job tasks.
iv. Observe workers performing each of the job tasks.
v. Measure the physical environment in which the job is carried out (e.g., height of work
table), the physical requirements of the job (e.g., weight to be lifted or carried, whether
work is performed while sitting or while standing), and the frequency of the job’s physical
demands.
b. Determine level of work.
i. The DOT (Dictionary of Occupational Titles), developed by the U.S. Department of
Labor (n.d.-a), defines the physical demands of work, using a standardized classification
system, and defines occupations in the United States. It also defines overall levels of
work and the strength demands for and frequencies of the physical components of work.
It was last revised in 1991.
ii. The O*Net 98 database developed by the U.S. Department of Labor (n.d.-b; 2010) is a
newer system for classifying occupations.
iii. Clinicians are recommended to refer to both systems when obtaining occupational
information.
c. DOT specifications of physical demands of work are as follows:
i. Lifting
ii. Standing
iii. Walking
iv. Sitting
v. Carrying
vi. Pushing
vii. Pulling
viii. Climbing
ix. Balancing
x. Stooping
xi. Kneeling
xii. Crouching
xiii. Crawling
xiv. Reaching
xv. Handling
xvi. Fingering

xvii. Feeling
xviii. Talking
xix. Hearing
xx. Seeing
d. DOT definitions for overall levels of work are as follows:
i. Sedentary work: Exerting as much as 10 lb of force occasionally or a negligible amount
of force frequently to lift, carry, push, pull, or otherwise move objects, including the
human body. Involves sitting most of the time, but may involve walking or standing for
brief periods of time. Jobs are sedentary if walking or standing are only required
occasionally and all other sedentary criteria are met.
ii. Light work: Exerting as much as 20 lb of force occasionally, as much as 10 lb of force
frequently, or a negligible amount of force constantly to move objects. Physical demands
are in excess of those for sedentary work. Even though the weight lifted may only be a
negligible amount, a job should be rated as light work when
• It requires walking or standing to a significant degree.
• It requires sitting most of the time but entails pushing or pulling of arm or leg controls.
• It requires working at a production rate or pace entailing constant pushing or pulling of
materials, even though the weight of those materials is negligible.
• Note: The constant stress and strain of maintaining a production rate or pace, especially in
an industrial setting, can be physically demanding for a worker, even if the amount of force
exerted is negligible.
iii. Medium work: Requires exerting 20–50 lb of force occasionally, 10–25 lb of force
frequently, or more than negligible to 10 lb of force constantly to move objects. Physical
demand requirements are in excess of those for light work.
iv. Heavy work: Requires exerting 50–100 lb of force occasionally, 25–50 lb of force
frequently, or 10–20 lb of force constantly to move objects. Physical demand
requirements are in excess of those for medium work.
v. Very heavy work: Requires exerting force in excess of 100 lb occasionally, in excess of 50
lb frequently, or in excess of 20 lb constantly to move objects. Physical demand
requirements are in excess of those for heavy work.
e. DOT definitions for physical demand frequencies are as follows:
i. Never: Activity or condition does not exist.
ii. Occasionally: Activity or condition occurs as much as one-third of the day.
iii. Frequently: Activity or condition occurs one-third to two-thirds of the day.
iv. Constantly: Activity or condition occurs two-thirds of the day to a full day.
3. Work tolerance screening is used to assess a client’s physical and cognitive abilities to meet the
general or specific demands of the essential functions of a job. A useful screening is based on an
accurate job description.
a. In assessing physical demands, the occupational therapist focuses on client factors and
functional abilities and on the activity demands of the job. Client factors include flexibility,
strength, balance, coordination, cardiovascular condition, and body mechanics. Functional
abilities include sitting, standing, walking, lifting, carrying, bending, squatting, crawling,
climbing, reaching, stooping, and kneeling. Activity demands include forces, angles,
weights, distances, repetitions, work area layout, and tools and equipment (Larson, 2014, p.
235; Rice, 2014, p. 880).

b. General strength testing is not an accurate predictor of potential for injury; more important
is whether the client can perform the tasks required to do the job.
c. A work tolerance screening is generally done after the client has received an offer of
employment conditional on the client passing the screening. If the client does not pass, he
or she is evaluated for a disability, and the employer then determines whether reasonable
accommodations will allow the client to carry out the duties of the job. The employer may
allow the client to take a job in another area while regaining skills or strengths identified
through the screening as needing attention. The employer may also release the client from
the job offer if the client is unable to pass the screening. The EEOC provides guidelines to
ensure that fair employee selection processes are upheld when conducting work tolerance
screenings.
d. Documentation of a work tolerance screening should specify weight limits, activity
tolerance in time, restrictions within the environment, the client’s report of pain, and the
occupational therapist’s observations of the client. Documentation should be directed to the
identified payer (e.g., a vocational rehabilitation program, workers’ compensation insurer,
or long-term disability insurer).
4. Ergonomics
a. General information
i. The goal of ergonomics is to improve the health, safety, and efficiency of both the worker
and the workplace.
ii. The target client can be an individual worker, a group of employees, or the employer.
iii. Ergonomics is about fitting the workplace to the human body.
iv. The workplace is composed of specific job-task demands, equipment, and setup.
b. Evaluation process: Schedule the evaluation during normal work hours to observe activities
in a typical work shift. Gather information by interviewing the worker and the supervisor.
Obtain an overview of all job-task requirements. Observe how the worker performs the job
in his or her normal fashion. Observe work habits inherent to the worker. Observe task
demands inherent to the environment and setup.
i. Identify common ergonomic risk factors (OSHA, n.d.-f).
• Repetitive movement (such as high-risk repetition rates for the upper extremity)
• Forceful or prolonged exertion of the hands
• Frequent or heavy lifting; pushing, pulling, or carrying of heavy objects
• Awkward or static postures, especially for a prolonged period of time
• Excessive vibration
• Extreme temperatures, especially cold temperatures
• Prolonged contact stress
• Material handling with faulty body mechanics, especially if lifting or twisting movement is
required
ii. Identify work habit–related risk factors (e.g., not taking breaks or delaying breaks,
cradling telephone between shoulder and ear, holding hand actively over the keyboard
during a pause, using improper body mechanics in lifting) and the worker’s perspective
on ergonomic risk factors.
iii. Identify workstation and environment setup.
• Workstation height
• Seat height
• Monitor height
• Keyboard and mouse height

• Positions of commonly used items in the workstation

• Tools
c. Interventions
i. Engineering controls: modification of the environment, the workstation, or the setup
with or without the use of assistive devices
• Workstation checklist (OSHA, n.d.-a)
• Workstation components, such as keyboard and mouse (OSHA, n.d.-d)
• Workstation environment (OSHA, n.d.-e)
• Good working positions (OSHA, n.d.-b)
• Recommended dimensions of workstations for seated and standing work
• Recommended chair characteristics at workstations
ii. Work practice controls
• Modification of work habits through use of assistive devices or adaptive strategies
• Body mechanics training
• Tool maintenance
• Selection and use of personal protective equipment
• Provision of conditioning or stretching exercises
• Practice and incorporation of new work habits and exercises into work routine
• Modification of work processes (OSHA, n.d.-c)
iii. Administrative controls
• Changes in line speed, staffing, or physical demands of jobs, such as decreasing production
rates or limiting overtime work
• Job rotation through different workstations that require different task demands
• Allowing and enforcing regular periodic rest breaks throughout the day
• Provision of personal protective equipment
• Provision of equipment to prevent heavy lifting
• Worker education on work safety, identification of ergonomic risk factors, and injury
prevention; employer education regarding reasonable accommodations
iv. Checklists for combating ergonomic risk factors
• State of Wisconsin, Department of Administration (2013)
• Haruko Ha et al. (2013, p. 363, Table 14-5)
v. Empowering corporate clients
• Understand the organization’s culture.
• Obtain management commitment.
• Establish an incentive system: monetary vs. groupthink and positive praise.
• Create and nurture a teamwork environment and a sense of team accomplishment.
E. Injury and Return-to-Work Management
1. Interruptions in ability to work may be related to physical (work-related musculoskeletal
disorders; cumulative trauma disorders; repetitive motion injuries; traumatic injuries; aging;
progressive disability), cognitive, psychological/behavioral, or sociocultural factors.
2. Medical management and acute rehabilitation: Work therapy involves work tasks to improve
function. Work therapy can occur at any point in the healing of injured tissues, and it is
typically part of the acute phase of the rehabilitation program (Schultz-Johnson, 2011b, pp.
1840–1845).
3. Work readiness programs provide individuals with a process to help them identify goals for
work and a plan to return to work. These programs prepare a person to return to work.

4. Work conditioning/work hardening: Work hardening is an outcomes-focused, individualized,

interdisciplinary program that addresses the medical, physical, psychological, behavioral,
functional, and vocational components of employability and return to work. Work hardening
relies heavily on actual task replication. A person may participate in a work hardening
program only once high levels of stress will no longer pose a threat to tissue hemostasis
(Schultz-Johnson, 2011b, p. 1840).
a. A work hardening interdisciplinary team often includes occupational and physical
therapists and assistants, psychologists, vocational evaluators and counselors, addiction
counselors, licensed professional counselors, exercise physiologists, or dietitians.
b. Once the worker’s needs have been identified and a baseline level of performance
established, the occupational therapist develops a treatment plan to address problem areas
through work-oriented activities that will challenge the worker to attain the next level of
functioning. The activities must be within the worker’s capabilities and must challenge the
worker without causing undue stress, fatigue, or increased risk for reinjury.
c. The length and duration of a work hardening program depends on the needs of the worker.
As the worker improves, involvement gradually increases to as much as 5–8 hr/day. There
is no prescribed number of days per week or hours per day in which a worker should
participate in a work hardening program. The design of the program establishes the type,
duration, and intensity of services according to predicted outcomes. Professionals in work-
oriented services agree that attendance and workplace tolerance are relevant to the
competitive marketplace and that programs should be available 5 days per week. This level
of participation is recommended in the final stages of the program. For a person whose
general physical status has deteriorated, total body reconditioning requires a minimum of 1
month and a maximum of 3 months.
d. Work hardening may include warm-up and cool-down exercises, conditioning exercises,
practice of body mechanics, and use of job modifications (Schultz-Johnson, 2011b, p. 1841).
e. A key concept of the work hardening process is the gradation of activities to progressively
increase task demands. The hierarchy of functional return is a gradation from gross to fine
motor, from less to more resistive, from skill- to speed-focused, and from simple to complex
(Pitts et al., as cited in Schultz-Johnson, 2011b, p. 1844).
f. Work conditioning is specifically designed to restore the client’s systematic neuromuscular–
skeletal function, and it typically involves only one discipline. The focus of work
conditioning is on limited work tasks; it places more emphasis on exercise, aerobic
conditioning, and education (Schultz-Johnson, 2011b, p. 1841).
g. The clinician should monitor the client’s performance for signs and symptoms of
overexertion, muscle fatigue, or both, including slowed performance, distraction,
perspiration, increased respiratory rate, performance of exercise patterns with decreased
ROM (range of motion), and inability to complete the prescribed number of repetitions. Any
of these signs and symptoms may indicate an adjustment to the program (Breines, 2013, p.
741).
5. Worksite evaluations are on-the-job assessments to determine whether an individual can return
to work after onset of disability or whether a person can benefit from reasonable
accommodations to maintain employment. These evaluations are typically conducted after a job
site analysis is completed. The following areas are assessed: the essential functions of the job,
the functional assets and limitations of the worker, and the physical environment of the
workplace. The objective of a worksite evaluation is to determine whether the person can safely

and adequately carry out the essential functions of the job with or without any reasonable
accommodations.
6. Light- or modified-duty programming allows a worker to temporarily perform job duties
involving less physical demand. The worker’s regular duties are gradually added as he or she
improves in skill and strength. An employer who wants the worker to return to work only when
he or she has full capabilities may challenge the need for a modified duty program; the
occupational therapist should help the employer understand that early return to work
improves a worker’s long-term success. The occupational therapist should always consider the
employer’s capacity to provide modifications, particularly in small organizations (Cheng &
Cheng, 2011, p. 450).
7. Functional capacity evaluation is an objective assessment of a person’s ability to perform work-
related tasks. It is the core of all return-to-work programs. Such evaluations can be performed
by a multitude of disciplines, and a wide variety of FCEs are currently used in practice. A
typical FCE includes a review of medical records, an interview, a musculoskeletal screening, an
evaluation of physical performance, the formation of recommendations, and the generation of a
report. A comprehensive FCE includes all of the physical demands of work as defined by the
DOT (AOTA, 2017; Haruko Ha et al., 2013, p. 342; Schultz-Johnson, 2011a, pp. 1813–1822,
1825–1826, 1828, 1831; Schultz-Johnson, 2011b, p. 1842).
a. Clinical indications for conducting a comprehensive FCE:
i. To identify work restrictions
ii. As a provocative means to confirm, rule out, or discover a diagnosis
iii. As a postoffer or preinjury screening to determine whether an employee can perform the
physical demands of a job
iv. To objectify physicians’ recommendations
v. To limit physicians’ liability
vi. To determine whether a worker is a candidate for remedial programs
vii. To determine whether a worker is a candidate for vocational rehabilitation
viii. To determine general upper-extremity functional capacity
ix. To determine the probability that a worker has performed consistently
x. To learn whether a worker has been abused by the system
xi. To determine the level of reasonable accommodations necessary to reinstate an injured
worker
b. Indications for FCE:
i. A postoffer screening is performed after a worker receives a job offer to determine
whether the job’s demands match the person’s work capacity.
ii. Fit-for-duty tests are performed by occupational medicine physicians to determine
whether a worker can return to work after an injury.
iii. An FCE should not be used with the intent to prove worker fraud.
iv. FCE can assist a physician in generating impairment or disability ratings.
• Impairment rating is a worker’s percentage of whole-body function. It often determines a
final monetary settlement for an injured worker. It focuses on the permanent quantifiable
physical loss related to an injury when the worker is at the maximum medical endpoint.
• Disability rating combines the worker’s impairment and the impact of that impairment on
the worker’s ability to perform the preinjury job or any job.
c. Who performs FCEs?

i. Clinicians are recommended to have several years of experience in the field before
performing an FCE.
ii. Performing an FCE is not recommended for novice clinicians.
iii. Clinicians new to return-to-work programs are recommended to attend conferences and
trainings, access resources, and network with colleagues to become familiar with
terminology and regulations and to enhance their skills and knowledge.
d. Formats of FCEs
i. The format of an FCE varies on the basis of the purpose of the referral, the type of
worker’s compensation system involved, and the amount of time authorized for the
evaluation.
ii. The typical kinesiophysical approach to FCE includes an intake or initial interview that
assesses subjective pain, the effect of the injury or illness on ADLs and functional
abilities, and the effect of cosmesis. Physical (neuromusculoskeletal) evaluation includes
ROM, strength, sensation, volume, soft tissue status, and special tests. Physical demand
testing includes standardized tests, work simulation, situational assessment, evaluation
of specific functional capacity, computerized variable resistance testing, and manual
material handling evaluation. Reevaluation assesses inflammatory response to activity,
sensation, or pain and includes a follow-up questionnaire.
iii. An FCE typically begins with the most physically demanding components of the
evaluation. Physical demand components of an evaluation should gradually increase in
resistance and complexity.
iv. The initial interview is an opportunity to establish rapport with the client, explain the
procedure and purpose of the evaluation, confirm the consistency of preevaluation
records, and determine the feasibility of the client’s proceeding with the evaluation on
the basis of the client’s cognitive, psychological, and medical issues and vocational goals.
v. A subjective evaluation focuses on the client’s subjective experience of the injury or
illness, with a primary focus on pain, impact on ADLs, and cosmesis.
vi. Pain assessments include the use of pain diagrams and pain scales and record the
location of pain, changes in pain levels over the course of a day or activity, and factors
that increase or decrease pain and affect sleep and rest. Pain assessments may be
repeated periodically throughout the course of an evaluation. Care must be given to
avoid increasing the client’s focus on pain.
vii. On the basis of the client’s subjective reports, the clinician may include classic
components of ADL assessment in the FCE.
viii. The clinician should document the appearance of the client and of the relevant
extremity or extremities. Disease process and trauma may affect appearance and may
have an impact on function.
ix. Musculoskeletal evaluation is the core of an FCE. It evaluates ROM, strength,
sensation, volume, and soft tissue status.
x. A comprehensive FCE should be well designed; use standardized, practical, objective,
reliable, and valid assessments; and include all the physical demands of work as defined
by DOT. Clients should not be pushed beyond their maximum level of performance.
xi. Physical demand testing includes standardized assessments with associated norms and
nonstandardized components. A standardized test should be chosen by the clinician on
the basis of the client’s age, gender, culture, education, and occupation. Clinicians
selecting a standardized test should consider its validity, reliability, and test specificity.

Nonstandardized assessments or structured activities allow the evaluator to grade and

tailor the FCE to the individual worker.
xii. Work simulation requires the client to perform tasks similar to the actual job. This is a
treatment approach and not an evaluation.
xiii. Situational assessment requires an exact duplication of all the physical demands of the
target occupation.
xiv. Computerized variable resistance tests assess function in both dynamic and static
modes. They are not a necessary component of an FCE.
xv. Manual material handling evaluation quantifies the client’s lifting capacity for
comparison with future performance or with general job requirements. The clinician
should consider instructing clients in the use of proper body mechanics so as to avoid
injury.
xvi. Onsite evaluation involves the evaluation of the client in the workplace and occurs with
the consent and authorization of the employer and the insurance carrier.
xvii. Reevaluation and postevaluation are the final components of the FCE, and they are
completed a day or more after the evaluation. They are used to determine activity
performance and to monitor edema, discoloration, and pain levels postassessment.
xviii. The FCE report should include an overview of referral and background information;
intake information; a summary of intake subjective findings; physical examination
findings; observations from the physical demand findings, including results from
standardized and nonstandardized tests; observations from work- or task-specific
evaluations; comments on the apparent presence or absence of symptom magnification;
and a summary with conclusions and recommendations.
8. Job accommodations: The process of identifying reasonable job accommodations requires
cooperation between the worker, the employer, and the occupational therapist.
a. The Job Accommodation Network (https://askjan.org) is the best resource to assist
employers and disabled workers with reasonable accommodations.
b. Most job accommodations cost nothing. They may involve altering the job duties or work
schedule, modifying the facility, purchasing adaptive equipment or assistive technology, or
modifying or designing a new product.
c. A productive modified-duty program should focus on maintaining the employee in a
productive capacity while facilitating progressive recovery, designate staff to monitor a
worker’s adjustment to and tolerance of work tasks, and ensure that the demands of the
assignment are within the stated restrictions of the employee’s abilities (Sanders, 2004, pp.
306–307).
d. The impact of the ADA on work-oriented programs (Kornblau, 2013, pp. 383–388; Schultz-
Johnson, 2011a, p. 1814) is as follows:
i. The ADA prohibits discrimination against individuals with disabilities in employment
by private, nongovernment employers who have 15 or more employees.
ii. Postoffer, preplacement, or fitness-for-duty screenings of a job applicant’s ability to
perform essential job functions are permissible.
iii. An individual with disabilities is defined as “one who has a physical or mental
impairment that substantially limits one or more major life activities.”
iv. Essential job functions are defined as job duties fundamental to the position the
individual holds or desires to hold, as opposed to marginal functions of the position.

Essential functions are those functions that an individual must be able to perform with
or without reasonable accommodations.
v. As defined by the ADA, a reasonable accommodation is any change in the work
environment or in the way work is customarily performed that enables an individual
with a disability to enjoy equal employment opportunity. Employers need only make
reasonable accommodations for employees who are qualified individuals with
disabilities.
vi. A qualified individual with a disability is defined by the ADA as “an individual with a
disability who satisfies the requisite skills, experience, education, and other job related
requirements of the employment position” he or she holds or desires and who, “with or
without reasonable accommodation, can perform the essential functions of the
employment position.”
vii. According to the ADA, reasonable accommodations include physical changes to the
environment; job restructuring; part-time or modified-duty schedules; job reassignment
to a vacant position; acquisition of or modification to equipment; adjustment or
modification of examinations, training manuals, and policies and procedures; provision
of qualified readers or interpreters; and any other similar accommodations for
individuals with disabilities.
viii. Undue hardship is an exception to the requirement of employers to provide reasonable
accommodations per the ADA. Undue hardship refers to any accommodation that would
be unduly costly, extensive, substantial, or disruptive or that would alter the nature of
the operation of the business.
9. Vocational evaluation provides information about a person’s capacities and interests for work
in situations when he or she has not worked before or is looking for a new job after injury or
illness. Vocational evaluation may also generally examine individual interests and abilities in
order to explore work opportunities.
a. Vocational evaluations or work evaluations are processes that use actual or simulated work
for vocational assessment and to help clients in their vocational development (Haruko Ha et
al., 2013, pp. 343–344). These assessments can last 3 to 10 consecutive days, depending on
the goals of assessment. Vocational counselors typically conduct these assessments in
private agencies; however, occupational therapists may conduct these assessments in public
and private medical and nonmedical settings. The two types of vocational evaluation are
general vocational evaluation and specific vocational evaluation.
b. General vocational evaluation is a comprehensive assessment of a person’s potential to do
any type of work. It is used to determine the person’s aptitudes, abilities, and interests and
to explore all reasonable options for work.
c. Specific vocational evaluation assesses a person’s readiness to return to a particular
occupation.
III. Transition Services From School to Work
(See AOTA, n.d., 2017; Haruko Ha et al., 2013, pp. 373–374; Ratzon et al., 2012, pp. 158–160; Rice,
2014, p. 874; Whetzel, 2013.)
A. Transitional programs are offered during a transition period when the client is able to
complete some but not all job tasks. Such programs may encompass job coaching,
education, instruction, and monitoring of the company’s return-to-work programs.

Transitional programs provide clients the opportunity to use environmentally focused

interventions to facilitate return to work.
1. As defined by the 1997 amendments to the Individuals With Disabilities Education Act,
transition planning is to be part of the individualized education program. Transition planning
promotes movement from school to postschool activities.
Accommodations for Workers With Autism Spectrum Disorder

• Provide advance notice of topics to be discussed at meetings.
• Provide the person with work requests in writing rather than through verbal interaction.
• Split assignments into smaller tasks with specific deadlines for each step.
• Encourage the use of a timer or handheld organizer or calendar (paper, computer, or phone
based).
• Provide a written checklist of assignments.
• Permit structured breaks to provide an opportunity for physical activity.
• Allow work from home if appropriate to the job description.
• Provide a private workspace with adequate room to move around and with reduced distractions
(e.g., white noise machine, desk rather than overhead lighting).
• Establish employer policies that specify no perfume or use of products with excessive odor (e.g.,
air freshener plug-ins).
2. Transitional evaluation is typically completed by an occupational therapist.

3. Completion of job site analysis is clinically indicated and is a component of transition services
evaluation.
B. Job coaching provides an appropriate level of support on the basis of individual needs
in the work environment; it may include job training or assistance for job task
completion (AOTA, 2017; Haruko Ha et al., 2013, pp. 348, 373–374; Larson, 2014, p. 235;
Rice, 2014, pp. 876–880).
1. Job coaching is necessary when a client is unable to return to work because an injury or illness
(e.g., work-related musculoskeletal disease, brain injury, spinal cord injury) prevents him or
her from fulfilling job requirements. Clients with developmental delays or other childhood
conditions may need job coaching during the transition from school to work.
2. Job coaching involves evaluation, intervention, and reevaluation using nonstandardized
interviews, observation of task performance or simulation, and activity analysis. It typically
occurs in the workplace setting while the individual is performing assigned work duties.
a. Evaluation includes a job analysis to identify the activity demands of a work task if the
work setting is known. A job analysis identifies the physical, social, cognitive, and
psychological demands of a specific position.
b. Optimal psychosocial and sociocultural functioning is critical to successful work entry or
return to work. Psychological factors affecting the client’s ability to work may include
family pressures, financial issues, or work stresses (e.g., challenges in using the workers’
compensation system). Sociocultural issues may include age discrimination or productivity
requirements.

c. The value a client perceives in their work is an important motivating factor. The
occupational therapist helps clients identify work-related goals and priorities. Interventions
may involve training the client to visualize what he or she wants to be, ensuring small
successes along the way, and facilitating identification of work that has intrinsic value to
the client.
d. When providing transition-related services, the occupational therapist considers what the
client wants or needs to do after leaving school and identifies the client’s occupational
performance strengths and challenges, using academic performance and functional skills as
indicators.
e. The occupational therapist’s role in supported employment settings is to identify the
amount and type of support to be provided and to develop clients’ work skills to enable
them to complete job tasks. Natural supports are a primary component of supported
employment. Modifications to job tasks may include task adaptation, job-specific training
for the individual, or coworker support in specific task completion.
IV. Documentation
(See Schultz-Johnson, 2011b, p. 1845; Smith, 2013, pp. 118–124.)
1. Work programs require more documentation than acute therapy. The use of progress notes,
daily schedule and circuit sheets, and progress summaries is recommended to complement
initial and discharge evaluations.
2. Documentation should include information regarding whether the patient completed the
program; pain reports; behaviors; psychosocial complaints; progress; modalities received,
including any meetings attended, by whom, and why; derogatory remarks; classes or job
analyses completed; cancellations and reasons for them; plans for the next session; and
descriptions of adaptations and modifications trialed.
3. The use of daily schedule sheets is recommended in order to provide the client with a list of
activities and promote the client’s responsibility for his or her own rehabilitation program.
4. Progress summaries are used to communicate with the interdisciplinary team and with
insurance carriers about the client’s response to the program.
5. Documentation is a permanent record of what occurred with a client, and it should justify the
need for occupational therapy services. It is a legal document used to communicate the
occupational therapy process and to promote reimbursement for services.
a. Best practice is to complete documentation as soon as possible after therapy services are
provided to enhance accuracy of information.
b. Altering, substituting, or removing documentation should never occur. If corrections need to
be made, the only acceptable methods are to enter data into the record as a late entry or to
draw a single line through words and initial, date, and sign the entry.
6. Goals should be client centered, objective, and measurable and should include a time frame.
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Occupational Rehabilitation and Return-to-Work

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c. Implement strategies that take into consideration clients’ learning styles

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C. Symptom magnification (Schultz-Johnson, 2011a, p. 1829–1830).

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• Positions of commonly used items in the workstation

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4. Work conditioning/work hardening: Work hardening is an outcomes-focused, individualized,

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Nonstandardized assessments or structured activities allow the evaluator to grade and

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Transitional programs provide clients the opportunity to use environmentally focused

Accommodations for Workers With Autism Spectrum Disorder

2. Transitional evaluation is typically completed by an occupational therapist.

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