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Editor-in-ChiefMohammed I. Ranavaya, MD, JD, MS, FFOM, FRCPI, CIMEAcquisition Editor Chris E. Stout, PsyD, MBA Assistant EditorsRobert B. Walker, MD, MS, CIMEGerald A. Steiman, MD, CIME

Editorial Advisory BoardRobert Rondinelli, MD, PhD, Des Moines, Iowa Alex Ambroz, MD, Martinsburg, WV

Kathryn L. Mueller, MD, Denver, CO Francois Sestier, MD, PhD, CIME, Montreal, CanadaProf. Sigurdur Thorlacius, MD, PhD, Reykjavik, Iceland Ahmad Al-Shatti, MBBS, MSc, FFOM, KuwaitDr. Shuwaimi H. Aldosari, Riyadh, Saudi ArabiaPaul S. Allen, MA, CAMAG, Diamond Springs, CAConstantino Amores, MD, CIME, Charleston, WVArmand K. Chong, DDS, CIME, Honolulu, HIMichael Condaras, DC, CICE, Charleston, WVChris Cunneen, MBBS, FFOM, CIME, Brisbane, AustraliaKaryn Doddy, MD, FAAPMR, CIME, Las Vegas, NevadaMzukisi Grootboom, MBBS, CIME, South AfricaEmily Hoff-Sullivan, MD, CIME, Jacksonville, FLProf. Haluk Ince MD, PhD., Istanbul, TurkeyRagnar Jonsson, MD, PhD, CIME, Reykjavik, IcelandDeodat Kritzinger, MBChB, CIME, Johannesburg, South AfricaMichel Lacerte MD, London, Ontario, CanadaDr. Fajah Singh Peshi, SingaporeRichard Sekel, MBBS, CIME , Sydney, Australia Christopher D. Smelser, DO, MPH, MRO, CIME, Uniformed Services, USAAshley Smith, PT, PhD, Calgary, Canada Gerald S. Steiman, MD, CIME, Whitehall, OHPaul Dean Steinman, Jr., DO, CIME, Morgantown, WV Prof. Duarte Nuno Vieira MD, PHD, PortugalDetloff Rump, MD, PhD, Hong kongProf. John B. Walden, MD, Huntington, WV Prof. Robert B. Walker, MD, CIME, Huntington, WV Sushil M. Sethi, MD, MPH, FACS, Mansfield, OHDeanna M. Ranavaya, Managing Editor

Research Articles

Workers’ Compensation in Disability Medicine and the Case for Certification of Non-physician Healthcare . . . . . . . . . . . 2

Total Hip Arthroplasty Patients in Follow-Up Post-Physical Therapy: An Examination of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Turning the Tables: Using an Employee’s Own Actions to Defeat Their Workers’ Compensation Claim . . . . . . . . . . . . . . . . 10

Current Perspective: Sleep Disturbance in Injured Workers and Their Recovery . 17

CME Questions

CME Questions . . . . . . . . . . . . . . . . . .24-26

Answers To CME Questions From Vol 9, No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . 26

Research Digest . . . . . . . . . . . . . . . 27-28

JDM Manuscript Submission Guidelines . ................. . . . . . . . . . . . . . . . . . . . . . . 29-36

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American Board of Independent Medical Examiners

Editorial Board Contents

DISABILITY MEDICINEThe Official Periodical of the

American College of Disability MedicineAND

American Board of Independent Medical Examinerswww.abime.org

Vol. 10 No. 2 April - June 2014

CELEBRATING

20 YEARS

at the forefront of

DISABILITY MEDICINE

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Vol 10 - No. 2 April - June 2014Journal of Disability Medicine

Workers’ Compensation in Disability Medicine and the Case for Certification of Non-physician Healthcare

John E. Mayer, Ph.D. ISPA-Chicago, Illinois

Abstract:

A brief overview of the development of credentials/licensure in healthcare is provided to establish the rationale for regula-tion in the field of healthcare providers that participate in the rehabilitation of injured workers. This article pays particular attention to industrial athletes that are covered under workers’ compensation. The research reviewed provides support for the need for credentialing in non-physician healthcare workers as it points to the similar developmental path that other licensed/credentialed professions have followed leading up to their regulation. The Certified Workers’ Compensation Healthcare Provider (CWcHP) certification is introduced as an answer to this need for credentialing.

History of Certification in Healthcare Practice

Medical Licensure

Medical licensure began in Europe prior to the colonization of the United States but wasn’t automatically adopted in the American colonies. The first attempt at regulation began in the 1760s through examinations for practitioners in individual American colonies. The New Jersey Medical Society, first chartered in 1766, was the first organization of medical professionals in the United States. By the 1800s the medical societies were in charge of establishing regulations, standards of practice and certification of doctors. These medical societies began to develop their own medical schools with affiliated training programs called proprietary medical colleges.

The Medical Society of the County of New York founded in 1807, was one of the first of the proprietary medical colleges. The early American government’s reluctance to become involved in the regulation of medical services provided to its citizens increased the influence of these medical societies over the regulation of medicine in the United States. The influence of the medical societies peaked in the first half of the ninetieth century and in May 1847 representatives of 40 medical societies, 28 medical colleges from 22 states and the District of Columbia met and formed the American Medical Association (AMA).1 It wasn’t until after the Civil War, which highlighted the extremes in the competencies of medical practitioners did the movement to have

government regulate the qualifications to become a doctor resume. The state of Texas established the first modern medical licensing authority in 1873 and by the turn of the century nearly all states had established licensing boards and examinations.2

By the twentieth century all states required an examination to obtain a license to practice medicine but these examinations varied widely from requiring an interview only to a rigorous multifaceted examination with written, oral, practical examination and observation of clinical skills. Because of this wide variation in state’s examinations, reciprocity by another state of a doctor’s credentials was rare. With improved transportation and the internal migration of citizens across the United States a groundswell movement rose up in the early 1900s to have a national examination. The first proposals to have a national examination appeared in 1902 and the National Board of Medical Examiners (NBME) was founded in 1915. The first national examination was conducted in 1916. The first NBME examinations were grueling weeklong testing marathons consisting of essay, laboratory, oral, practical and bedside components. The NBME was restructured over the decades, but it wasn’t until the 1980’s that all components of the NBME were in multiple-choice format. In the early 1990’s the unification of the NBME examinations and refinement led to the development of the United States Medical Licensing Examination (USMLE). Now all medical licensing jurisdictions accept USMLE scores as the certification standard for physicians.3

Specialty board certification is the process by which a physician in the United States demonstrates

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by written, practical and/or computer based testing, mastery of knowledge and skills that define a particular area of medical specialization. The American Board of Medical Specialties (ABMS) established in 1933 is a not-for-profit organization that assists 24 approved medical specialty boards in the development and use of standards in the ongoing evaluation and certification of physicians. The ABMS now certifies physicians in 150 specialties and sub-specialties. Medical specialty certification in the United States is a voluntary process. While medical licensure sets the minimum competency requirements to diagnose and treat patients, board certification demonstrates a physician’s exceptional expertise in a particular specialty and/or sub-specialty of medical practice. The need for certification in medical profession specialties developed as a natural offshoot of physician licensing as professional practice in healthcare developed. Specialty board certification allows practitioners with specialties to practice under the broad umbrella of medical practice rather than branching off and forming fractional groups with little or no unity and less influence.4

Allied Medical Licensure in Disability Cases

Professional certification or qualification is a designation earned by a person to assure competency to perform professional duties. It is important to note that not all certifications that use post-nominal letters are an acknowledgement of educational achievement, or an agency sponsorship intended to safeguard the public interest. Often, with these certifications, an individual can simply pay a fee to a business that created a certification and then call themselves “certified.” The existence of these certifications is increasing with the use of the Internet and the acceptance of the distance-learning model. These fee-only certifications do not fit into any of the theoretical models of licensure/certification that will be discussed below and are not a subject in the analysis in this article.

Most certification programs are created, sponsored, or affiliated with professional associations or trade organizations interested in raising the standards within a given field and are not created by the government. Those programs that are completely independent from professional associations and trade organizations often enjoy the support and endorsement

of these associations and organizations.

The growth of certification programs is also a reaction to the changing employment market. Certifications are portable, since they do not depend on one company's definition of a certain job. As the workplace changed from employing workers who spent their entire careers in one place to more mobility of workers, certifications became an asset to professional’s career and to the employer. Certification is generally intended to be an impartial, third-party endorsement of an individual's professional knowledge and experience; therefore, they are not specific to just one workplace.

Two major organizations oversee standards for organizations that grant credentials to individual professionals. These are The American National Standards Institute (ANSI) and the Institute of Credentialing Excellence (ICE). The American National Standards Institute (ANSI) defines the requirements of meeting the ANSI standard for being a certifying organization. According to ANSI, a professional certifying organization must meet two requirements: 1-Deliver an assessment based on industry knowledge, independent from training courses or course providers. 2-Grant a time-limited credential to anyone who meets the assessment standards.5 The Institute for Credentialing Excellence (ICE) is a U.S.-based organization that sets standards for accreditation of certification programs based on the Standards for Educational and Psychological Testing (APA, AERA, and NCME).6

Theories of Licensure/Certification and Empirical Rigor

Researchers have studied the licensure/certification process for some time studying the need for certification in some professions while others do not seem to require certification or licensure. Three different theories have been studied as to the efficacy of licensure/certification of an occupational group. These are: The Capture Theory, which explains that a profession or occupation “captures” regulation to insure that they restrict others from performing the tasks and therefore increase the need and incomes of the professionals regulated. The Public Interest Theory, which explains that professional regulation is

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established for the good of society to insure quality services. And the Political Economy Theory, which explains that both public interest and professional interests are the reasons a profession establishes regulation. The majority of studies conclude that the Political Economy Theory best explains why professions establish regulations.7,8,9,10,11,12,13,14,15,16,17,18,19

Workers’ Compensation Cases and the Need for Certification

Factoring in the analysis of the past literature on the development of professional regulation in professional fields and recognizing Political Economy Theory as a viable explanation of why an occupation should regulate their practices, the non-physician caregivers who work in rehabilitation of workers’ compensation cases fit the need for a specialty certification. This is warranted because the work with these patients meets the test of insuring quality of services for the public good (Political Economy Theory) and also the capture of professionals who deliver services to patients (Capture Theory). The complexities of the clinical information needed to rehabilitate injured workers, particularly workers who fit the industrial athlete occupations (e.g. first responders, construction workers, laborers) along with the legal knowledge and knowledge of the relationship between the employer and the injured worker require the healthcare worker to have a competency that is beyond their standard training curriculum. The Certified Workers’ Compensation Healthcare Provider certification (CWcHP) was developed to fill this need for regulation in this field.20

The International Sports Professionals Association (ISPA) released this certification to the public in June 2010 after nearly two years of research, focus group testing and development. The idea for this certification started when a national physical therapy provider first approached ISPA in 2008 to create and administer this credential. ISPA was chosen to develop this certification because it is a leading international professional association with a proven record of assessment, granting of credentials, and a member of ICE. Furthermore since many of the most complex

workers’ compensation cases involve the injured industrial athletes, ISPA with their strong knowledge base in athletics was logical to approach as the developer and administrator of this new credential-CWcHP.

With the aide of one of the nation’s leading physical therapy organizations’ research department and a team of leading Ph.D. psychologists, physical therapists, occupational therapists, athletic trainers, strength and conditioning specialists and administrators, IT experts, graduate researchers and business/project development experts, ISPA was able to compile the necessary research and address the most important issues and information regarding the rehabilitation of injured workers. This allowed the ISPA to bring a wide range of viewpoints and expertise to the table for the certification’s development, which resulted in a well-rounded approach to the knowledge necessary for/in workers’ compensation rehabilitation.

The three3 main professions eligible for this certification program are: Physical Therapists (PT, DPT); Certified Athletic Trainers (ATC); and Occupational Therapists (OTR). This certification is available for any practitioner in the above professions that is practicing or plans to practice in the field of workers’ compensation rehabilitation and/or industrial athlete rehabilitation. ATCs must abide by their respective state’s practice guidelines in regard to rehabilitating workers’ compensation patients. Almost every, but not all, states allow ATCs to be directly involved in the rehabilitation of workers’ compensation patients under the supervision of a licensed physical therapist. Physical Therapy Assistants (PTAs) and Occupational Therapy Assistants (OTAs) are also eligible for this certification program, given they too are allowed to participate in the direct rehabilitation of workers’ compensation patients according to their respective state’s practice guidelines.

The credential, Certified Workers’ Compensation Healthcare Provider or CWcHP is awarded after successful completion of the National Certification Examination for Workers’ Compensation Healthcare Providers: An Evidence-Based Approach. The examination is comprised of 100 multiple-choice questions administered online through ISPA’s unique testing platform. Of these questions, 70% refer to

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clinical-based knowledge, 20% refer to legal-based knowledge and the remaining 10% refer to information regarding the relationship between practitioners and the employer of the patient, the ramifications of their recommendations and employer rights.20

The examination is accompanied by the CWcHP Subject Study Guide to aide participants in preparing for the certification examination. Participants are also granted access to the CWcHP Video Lecture Series, which is hosted and streaming online. These two preparation and study materials are designed to be used with one another during the test preparation process. Participants are encouraged to begin the CWcHP Video Lecture Series and follow along with the CWcHP Subject Study Guide. The CWcHP Subject Study Guide is a study and educational tool that covers the examination’s purpose, importance and history, as well as all specific subject matter covered on the examination.20 Participants are directed to the specific research studies and clinical databases where the information tested on the examination can be found. This study model ensures that participants must rigorously study the information necessary to sit for the certifying examination and are required to actively seek out the information thus enhancing their learning and knowledge acquisition.

Professionals that pass the certifying examination can place the initials CWcHP after their name, signifying that they are certified to provide rehabilitative services at the highest professional level. All certified Professionals are presented with a certificate to acknowledge their accomplishment.

With the establishment of the CWcHP credential for non-physician healthcare providers, the rehabilitation of the injured worker, and particularly, the injured industrial athlete, has a quality assurance standard that gives confidence to case managers, third party reimbursement, and physicians that the rehabilitation specialist has the experience and competency to treat workers’ compensation cases.

References

1. Sigerist HE. The History of Medical Licensure. JAMA. 1935; 104(13).

2. Derbyshire R. Medical licensure and discipline in the United States. Baltimore: John Hopkins University Press; 1969.

3. Hubbard JP, Levit EJ. The National Board of Medical Examiners: the first seventy years. Philadelphia: NBME; 1985.

4. NBME Annual Report. Philadelphia: NBME; 2011.

5. American National Standards Institute Overview. Washington, DC: ANSI; 2012.

6. ICE 1100 2010(E) - Standard for Assessment-Based Certificate Programs. Washington, DC: Institute for Credentialing Excellence; 2012.

7. Olsen RN. The Reform of Medical Malpractice Law: Historical Perspectives, 55. The American Journal of Economics and Sociology. 1999; 257-275.

8. Carroll SL, Gaston RJ. Occupational Restrictions and the Quality of Service Received: some evidence, 48. Southern Economic Journal. 1981; 959-975.

9. Blair RD, Rubin S. Regulating the Professions: A public Policy Symposium. Lexington, MA: Lexington Books.

10. Frech HE. Competition and Monopoly in Medical Care. Washington, DC: AEI Press; 1996.

11. Friedman M. Occupational Licensure in Capitalism and Freedom. Chicago: University of Chicago Press; 1962.

12. Graddy E. Toward a General Theory of Occupational Regulation, 72. Social Science Quarterly. 1991; 676-695.

13. Maurizi AR. Occupational Licensing and the Public Interest, 82. Journal of Political Economy. 1974; 399-413.

14. Moore TG. A Theory of Professional Licensing, 4. Journal of Law and Economics. 1961; 93-117.

15. White WD. Dynamic Elements of regulation: the case of occupational licensure, 1. Research in Law and Economics. 1979; 15-33.

16. Peltzman S. Toward a More general Theory of Regulation, 19. Journal of Law and Economics. 1976; 211-244.

17. Posner R. Theories of Economic Regulation, 5. Bell Journal of Economics. 1974; Hofstra Law Review, 335-58.

18. Posner R. A Reply to Some Recent Criticisms of the Efficiency Theory of the Common Law, 9. 1981; Hofstra Law Review, 775.

19. Kleiner MM. Licensing Occupations: Ensuring Quality or Restricting Competition. New Jersey: Princeton University Press; 2006.

20. ISPA. The Certified Workers’ Compensation Healthcare Provider Certification. Chicago, IL. The International Sports Professionals Association. 2010.

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Total Hip Arthroplasty Patients in Follow-Up Post-Physical Therapy: An Examination of Findings

Chris E. Stout, PsyD1, 2, Kurt Gengenbacher, PT, DPT, OCS, SCS1, Brent Mack, DPT1, Jeff Rogers, BA1, Gracie Wang, BA1, and Hanying Wang MS1

1ATI Physical Therapy2College of Medicine, University of Illinois at Chicago

Address Reprint to: Chris E. Stout, Department of Research, ATI Physical Therapy, 790 Remington Blvd, Bolingbrook, IL 60440, USA E-mail: [email protected]

Abstract:Total hip arthroplasties (THA) comprise 33-50% of all total joint procedures performed annually, resulting in between 250,000 and 375,000 THAs annually. As the incidence of THAs continues to rise due to the aging of the Baby Boomer generation, it is important to consider value of post-surgical rehabilitative measures. The issue is controversial as some physicians require no post-operative out-patient physical therapy while others look for intensive, hands-on therapy. The purpose of this article, then, is to determine the effectiveness of physical therapy for post-THA patients. This is a treatment follow-up study in which researchers mailed 500 surveys to discharged patients; 169 surveys were completed and returned. Of this 159 (94.08%) reported having a favorable outcome. In addition, this study found that higher BMI led to poorer outcomes and thus should be considered when setting realistic goals for rehabilitation.

INTRODUCTION

As the Baby Boom Generation, numbering nearly 77 million, continues to age, the healthcare industry is seeing an increase in demand. These people are looking for ways to decrease their pain and improve their function. Pain can be caused by multiple factors; among these are arthritis and traumatic injury. This can lead to impaired ability to perform activities of daily living (ADLs). There is increased interest in total hip arthroplasty (THA) as an effective treatment option for these impairments.

One primary indication for THA is osteoarthritis (OA). Almost 50% of adults are at risk for OA, with a large portion of those affected being elderly. 1 There is also speculation that the rate of arthritis, of which OA is the most common type, 2 will only increase. By 2020, as many as 59.4 million Americans will suffer from arthritis, up from 40 million in 1995. 3

Those cases that do not respond to conservative management (i.e. physical therapy, analgesics, cortisone injections) are good candidates for THA4. Although obesity is known to lead to increased risk of co-morbidities such as pulmonary and cardiac conditions, in this paper obesity is only considered a relative contraindication for THA5. When patients discuss THA, it is more likely their motivation to have less pain while going about their daily routine is often a more important consideration than their obesity.

It was estimated by the American Academy of Orthopedic Surgeons in 2007 that 750,000 total joint procedures are performed annually.6 Total hip arthroplasties comprise 33-50% of this total. The quick math shows that between 250,000 and 375,000 THA’s are performed annually. As noted in an article by Kelly and Bozic, in a 10 year span from 1995-2005 there was a 61% increase in incidence of THA’s.7 It has been speculated that by 2030 there will be almost 450,000 THA’s/year, and an increase in revisions from 41,000 to 98,000. 7 The failure rate in 1987 was 23% at an average of 5 years after THA,8 but 10 years later in 1997 the expected failure rate was 1% per year for a 15 year span. 5 Surgical techniques have continually been improved to decrease risk of need for revision, with the most obvious being the advent of the anterior and minimally invasive approaches.4

Typical age for a THA is 66,9 and the majority of procedures in the United States are done for individuals >60 years old.10 As of 2007, Medicare paid for 60% of these procedures.6 In 2005 the annual cost associate with THA in the United States was $9.35 billion, with each case costing roughly $39,348, an increase of 146% when compared to ten years prior.7 It is unclear if these numbers include outpatient rehabilitation following THA.

It has been the anecdotal clinical experience of the physical therapist authors (KG and BM) that post-operative rehabilitation has been somewhat controversial with some physicians requiring no out-patient therapy, others requiring minimal therapy

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to focus on exercise instruction, and yet others looking for intensive hands-on therapy services centered on optimizing patient function with minimal compensations. The American Academy of Orthopaedic Surgeons (AAOS) has yet to release their evidence-based guidelines on management of OA of the hip.11 However, the American Physical Therapy Association (APTA) released in 2010 an independent study course on THA.4 Their summary of the available evidence indicates in the rehabilitation setting, conservative management should focus on strengthening the hip musculature and manual therapy. These interventions have shown promising results, but further research is needed.

Heilslein also reviewed the different surgical interventions which are available.4 As alluded to previously, there are multiple approaches utilized for THA (i.e. anterior, anterolateral, lateral, posterior, and transtrochanteric). Not only can the approach vary, but there are other options that may be utilized in the management of OA and traumatic hip injury. For those patients that have a fracture of the femoral head and/or neck, a hemiarthroplasty may be performed. In this procedure the acetabulum is not replaced, but rather the femoral head and neck. In recent years hip resurfacing has gained traction in the United States. This is done usually in younger patients that are more likely to require a revision at some point in their lifetime. The goal is to preserve as much of the skeletal anatomy while allowing the implant to take the high load required with an active lifestyle.

Method These findings represent a treatment follow-

up study of total hip arthroplasty patients from a national outpatient physical therapy practice’s clinics in the Midwest. Researchers mailed a survey form and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) 12,13,14 to 500 consecutively discharged patients from Illinois and Wisconsin from February 2010 through calendar 2011, along with a cover letter explaining the study and a self-addressed, stamped return envelope. The response rate of completed and returned surveys was 34.4% (n=169). Good outcomes were based on patient self-report as being able to function at a level consonant with their pre-injury level of functioning or better. In scoring

the WOMAC, a lower percentage indicates better scores, therefore it is known as a disability measure. For example, pain subscale of 0% indicates the patient is not limited by pain, and physical functioning subscale of 10% specifies the patient is 10% disabled with functional tasks.

Subjects A total of 169 former patients responded with

completed datasets. Of this 159, or 94.08%, reported having a good outcome as defined by functioning at a level similar to their pre-injury level of functioning, or better. The mean average age of this group was 66.50 years with a SD=+10.35. The mean average age of all respondents was 66.76 years (SD=+10.31). Within the 169 patients, 95.92% (94 out of 98) female respondents reported a good outcome, 91.55% (65 out of 71) male respondents reported a good outcome. The Body Mass Index (BMI) was calculated for all respondents, and was found to yield a mean average of 28.45 (SD=+5.60).

Results Findings indicate that 94.08% (n=159) of

respondents had favorable outcomes. The mean number of physical therapy visits this group had was 18.23 (SD=+6.07), compared to a mean of 18.21 (SD=+6.06) for the entire sample, and a mean of 18.00 (SD=+6.13) sessions for the poor outcome group. Using an independent-samples equal variance t-test, the result indicated there was no significant difference of average number of PT visits between the good and poor outcome groups (t-value=0.11, P=0.9091). As for BMI, the good outcome group’s mean average was lower than those in the poor outcome group (28.22, SD=+5.49 versus 32.18, SD= +6.27, respectively). The result from an independent-samples equal variance t-test indicated there was a significant difference of average BMI between two outcome groups (t-value=2.20, P=0.0294).

Mean average age of the good outcome group was 66.50 years (SD=+10.35) versus the poor outcome cohort’s average of 70.80 (SD=+9.20). By using an independent-samples equal variance t-test there was no significant differences of average age between two outcome groups (t-value=1.28,

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P=0.2021). When looking for any significant differences between outcomes for men and women using a Pearson Chi-square test, χ2=1.41, P=0.235 suggests that sex did not influence outcomes; however, since there were only 6 males and 4 females having a poor outcome, this finding may be not reliable.

Those with good outcomes report low levels of hip pain, stiffness, swelling, buckling, weakness or limping. This is in contrast with poor outcome individuals’ experience, and is significant. Those with good outcomes also report few limitations in walking, going up or down stairs, kneeling, squatting, sitting with a bent knee, or rising from a chair. Again, these findings are superior to those with poor outcomes, and when conducting an independent-samples equal variance t-test, with an α level of 0.05 on the Total Score of the WOMAC, the t-value=5.05 was significant with P<0.0001. A tabular summary of findings appears in Table 1.

Differences between two outcome groups on the WOMAC Total Scores were significant (t-value=5.05, P<0.0001), by using an independent-samples equal variance t-test. Similarly, when analyzing the subscales of the WOMAC, it was found that the good outcome

group’s scores were all statistically significantly better: Pain Scores (t-value=4.56, P<0.0001), Stiffness Scores (t-value=2.72, P=0.0071), Physical Functioning (t-value=5.27, P<0.0001), Social Functioning (t-value=2.80, P=0.02), and Emotional Functioning (t-value=1.92, P=0.0569).

Discussion The data from this study shows some interesting

trends that may help to explain a patient’s likelihood of success/failure following THA. Further studies would need to be performed to fully explore the likelihood ratios of these factors. However, we can draw rudimentary conclusions based on the data present. For example, we see that clearly BMI should be considered when determining if a patient will likely have a successful outcome. Our findings are supported further by Riddle and Stratford, as they noted that patients with decreased body weight tend to have less pain and greater function. 15 Although not significantly different, it is apparent that there was a difference in age between groups. The group reporting success is younger and should be taken into consideration when developing a plan of care for patients post THA.

Table 1. Summary of FindingsMean Average +/- Standard Deviation and Significance

Variable All Subjects Good Outcomes Poor Outcomes P ValueN 169 159 (94.08%) 10

Age 66.76 +/- 10.31 66.5 +/- 10.35 70.8 +/- 9.2 n.s.BMI 28.45 +/- 5.60 28.22 +/- 5.49 32.18 +/- 6.27 0.0294

# of PT visits 18.21 +/- 6.06 18.23 +/- 6.07 18 +/- 6.13 n.s.Total Scores * 13.92 +/- 14.53 37.9 +/- 14.96 <0.0001

Pain Scores 12.45 +/- 15.01 35 +/- 17.64 <0.0001Stiffness Scores 17.70 +/- 17.94 33.9 +/- 22.89 0.0071

Physical Functioning 13.73 +/- 14.96 39.6 +/- 16.61 <0.0001

Social Functioning 6.68 +/- 12.98 (N=151) 26.1 +/- 21.72 0.02

Emotional Functioning

8.13 +/- 13.18 (N=151)

16.4 +/- 13.55 0.0569

All (N=169) Males (n=71) Females (n=98)# of PT visits 18.21+/- 6.06 18.14+/- 5.78 18.27+/- 6.28

Good Outcome 159 (94.08%) 91.55% (n=65) 95.92% (n=94)Poor Outcome 10 (5.92%) 8.45% (n=6) 4.08% (n=4)

*Scores from the WOMAC, lower score = better outcome

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Taking into consideration the age factor, there is a study that shows a higher failure rate in those under 50.8 They showed a 35% failure rate for this population versus a 19% rate for those over 50. Are these failures due to natural history or are the patients more active, leading to more injury/stress on the prosthesis? Also, would formal rehabilitation have helped to decrease these failure rates? At this time there has not been a study done to look at failure rates in relation to the amount of therapy services provided.

This study does have limitations that should be noted. The authors had no knowledge concerning the prosthesis type, if the surgery was a revision, or what surgical approach was used for the subjects. Similarly, the surgeon’s restrictions were not known and may have factored into the rehabilitation process and overall function of the individual.

Another variable that was not known and may have affected the outcome is the mechanism of injury that led to the surgery (e.g., traumatic or atraumatic). Studies8 have shown a higher risk of failure in traumatic causes. Other concomitant injuries, psychosocial issues, and history of injury on the contralateral limb were not obtained from the past medical history and may also contribute to the individual’s success/failure.

This study has a large N which is a primary strength. Along with this, there were a number of positive outcomes. This supports the role rehabilitation can play in the recovery of such patients. Another positive aspect of this study’s approach is the use of the WOMAC survey instrument. Multiple studies have shown the WOMAC to be valid and reliable with this population. 13,14, 15 The significant difference in scores between the success group and failure group helps to confirm our findings beyond the subject’s subjective report of return to prior level of function.

Future Research In order to better understand the beneficial impact

of outpatient physical rehabilitation, further research should be conducted. Such studies could include a control group with no outpatient therapy provided, and more detailed documentation of procedures/interventions performed in treatment would help to confirm or refute the need for physical therapy in patients’ status post THA. Another recommendation for future studies would be to collect data pre- and post-treatment, in addition to post-discharge.

ConclusionsFor patients undergoing THA it is important

to maximize their function, and it is known that the cost of these procedures is significant. When this is coupled with the growing number of procedures performed each year, it is critical to find the best course of treatment for this large population. These researchers found that higher BMI led to poorer outcomes and thus should be considered when setting realistic goals for rehabilitation. Another variable that could factor into the decision-making process for expectations is the patient’s age at time of surgery.

There are many provocative questions that now should be asked based on this investigation. The most obvious are: is outpatient rehabilitation necessary? Without such services would the successful outcomes still be accomplished? Conversely without such intervention would the failed outcomes subjects have scored themselves worse on the WOMAC and report less functional ability? Finally, it is important to investigate what the optimal numbers of visits could be in order to maximize the efficiency and function of such patients.

REFERENCES1. Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008; 59(9): 1207-1213.

2. Murphy L, Helmick CG. The impact of osteoarthritis in the United States: A population-health perspective. Am J Nurs. 2012; 112(3): S13-S19.

3. Iorio R, Robb WJ, Healy WL, et al. Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: Preparing for an epidemic. J Bone Joint Surg Am. 2008; 90(7): 1598-1605.

4. Heislein DM. Hip Arthroplasty. Joint Arthroplasty: Advances in Surgical Management and Rehabilitation. La Crosse, WI: Orthopaedic Section, APTA, Inc.; 2010:1-23.

5. Crawford RW, Murray DW. Total hip replacement: Indications for surgery and risk factors for failure. Ann Rheum Dis. 1997; 56: 455-457.

6. Lavernia CJ, Hernadez VH, Rossi MD. Payment analysis of total hip replacement. Curr Opin Orthop. 2007; 18: 23-27.

7. Kelly MP, Bozic KJ. Cost drivers in total hip Arthroplasty: Effects of procedure volume and implant selling price. Am J Orthop. 2009; 38(1): E1-E4.

8. Sandborn PM, Cook SD, Harding AF, Kester MA, Haddad RJ. Clinical performance of endoprosthetic and total hip replacement systems. J Rehabil Res Dev. 1987; 24(3): 49-56.

9. Passias PG, Bono JV. Total hip arthroplasty in the older population. Geriatrics and Aging. 2006; 9(8):535-543.

CONTINUED TO PAGE 16

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Turning the Tables: Using an Employee’s Own Actions to Defeat Their Workers’ Compensation Claim

INTRODUCTION Given the “no-fault” nature of workers’

compensation programs, defense counsel often face an uphill battle in defending employees’ claims against employers for accidental injuries allegedly sustained at work. With the abrogation of the “traditional” affirmative defenses, what options are left to defend these claims? Often, one only has to look at the nature of the employee’s own actions to find a viable defense to compensability of their workers’ compensation claim.

The “No-Fault” ProblemWorkers’ compensation programs in the United

States are state regulated with laws determined by each state legislative body and implemented by a state agency. Programs were adopted in the early 1900’s to provide benefits to workers suffering from occupational injury or disease. Ultimately, the programs adopted had a few common principles and similar categories of benefits. Although the details concerning the level of benefits provided and the administrative mechanisms used to deliver the benefits aried dramatically from state to state, and still do.

The basic principle underlying establishment of workers’ compensation programs was that injured workers would receive benefits without regard to fault and employers in return would receive limited liability. Essentially, employees are entitled to benefits if the injury was caused by their employment, regardless of who caused the injury and employers would be responsible for specific benefits in exchange for the elimination of lawsuits for negligence. Elimination of lawsuits against employers for negligence was certainly welcomed, but what did the employers have to give up in exchange for this limited liability?

One important “trade off ” for employer’s limited liability was the abrogation of traditional negligence defenses. Many workers’ compensation systems insure employees against the operation of the doctrines of contributory negligence, assumption of the risk, and the fellow servant rule. Roberts v. Consolidation Coal Co., 208 W.Va. 218, 539 S.E. 2d 478 (2000). As such, the misconduct of an employee, whether simply negligence or even willful disregard of the employer’s rules, often has no bearing upon whether an employee’s injury is compensable. Barry v. Aetna Life & Cas. Co., 133 Ga.App. 527, 211 S.E.2d 595 (1974); and Merchant v. Pinkerton’s Inc., 50 N.Y.2d 492, 407 N.E.2d 443, 429 N.Y.S.2d 598 (1980).

On the other hand, some statutes provide benefits only if the employee did not intentionally cause the event that results in the injury and some preclude compensation for employees injured because of the deliberate or willful misconduct. Delware Tire Center v. Fox, 401 A.2d 97 (Del. Super., 1979), judgment aff ’d, 411 A.2d 606 (Del., 1980); Ex Parte Bowater, Inc., 772 So.2d 1181 (Ala. 2000); Lumbermans Mut. Cas. Co., Inc. v. Amerine, 139 Ga.App. 702, 229 S.E.2d 516 (1976); Cavender v. Bodliy, Inc., 550 N.W.2d 85 (S.D., 1996). But, before any type of misconduct will be held to bar recovery of compensation, it must be the proximate cause of the harm for which compensation is sought. DeMichaeli & Associates v. Sanders, 167 Ind.App. 669, 340 N.E.2d 796 (2nd Dist. 1976).

The “Traditional Negligence Defenses”The key loss to employers with the enactment

of “no-fault” workers’ compensation systems was the loss of traditional negligence affirmative defenses like contributory negligence, comparative fault, and assumption of the risk. Workers’ compensation statutes that abrogated these common law defenses have survived

Justin T. Nestor and Brian J. Hindman

Biography Info: Justin T. Nestor is a Partner at Bryce Downey & Lenkov LLC, and focuses his practice on workers’ compensation and gen-eral liability defense. Brian J. Hindman is an Associate at Bryce Downey & Lenkov, LLC who also focuses on workers’ compensation and general liability defense. Both Mr. Nestor and Mr. Hindman are licensed in Illinois and Indiana.

11


constitutional claims that they deprive employers of their property without due process of law. Boston & M.R.R. v. Armburg, 285 U.S. 234, 52 S. Ct. 336, 76 L.Ed. 729 (1932).

The common law doctrine of contributory negligence bars recovery when the plaintiff ’s own negligence contributed to the injury. The latter half of the 20th century saw the gradual decline of this harsh doctrine as states either judicially or legislatively replaced contributory negligence with the concept of comparative fault.

Comparative fault concepts range from pure comparative fault, which allocates liability to each party on a percentage basis unless the plaintiff is 100% negligent, to systems of modified comparative fault which permit courts to bar recovery when the plaintiff ’s percentage of fault is at or above 50% or 51%.

Assumption of the risk is the legal doctrine that a plaintiff is not entitled to compensation, if knowing of a dangerous condition, voluntarily exposed himself or herself to the risk that caused the injury. In the workers’ compensation context, the theory was that the employee implicitly assumed all of the ordinary and usual risks of a job. This common law defense was commonly used to defend employee injury cases prior to the enactment of workers’ compensation laws.

An employee’s conduct will be subject to three basic types of workers’ compensation statutes. The most common kind of statute contains no “affirmative defenses” based on the employee’s misconduct, except perhaps self-injury and intoxication. A second type of statute makes the employee’s willful misconduct a defense. A third type makes certain types of misconduct, such as failure to use safety devices or violation of law, either a complete defense or grounds for a reduction in the award.

Some states’ workers’ compensation laws specifically address the traditional negligence defenses. For example, Indiana’s statute provides as follows:

“No such injured employee shall be held to have been guilty of negligence or contributory negligence where the injury complained of resulted from such employee’s obedience or conformity to any order or direction of the employer or of any employee to whose orders or directions he was under obligation to conform or obey, although such order or direction

was a deviation from other rules, orders, or directions previously made by such employer.

I.C. 22-3-9-2. Despite the differences between each state’s

treatment of the traditional common law defenses, there is one common theme…the claimed injury must causally relate to the employment. Workers’ compensation acts will look at injuries to determine whether they “arise out of ” and are “in the course of ” the injured party’s employment. The distinction between compensable and non-compensable injuries is generally distinguished by prohibited activities that do not constitute a departure from the course of employment and those that do. Specifically, this distinction draws a line between prohibited methods of doing the employee’s regular job, and prohibited activities outside of or incidental to the main job duties. This can include acts for personal benefit and personal comfort activities among others.

Thus, the importance of early investigation into the facts and circumstances surrounding a claimed work-related injury can make a world of difference when defending these claims. Defense counsel should look away from traditional methods of defending cases, i.e., the traditional negligence defenses, and look to investigating whether the injured employee’s own actions can provide a viable defense to their workers’ compensation claim. Two general categories of defenses based on an employee’s own action which have evolved include an employee’s personal risks unrelated to the employment and an employee’s deviation from the course and scope of employment.

Personal Risks Unrelated to EmploymentSome of the most difficult claims are those

which the employee sustained injuries in the course of the employment (i.e., was on the job and was during working hours), but a question exists as to whether the accident and resulting injury arose out of the employment because the risk was purely personal to the employee or entirely unrelated to the work. The following are some examples of defense strategies available where an employee is injured by activities involving risk personal to them and unrelated to their employment.

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A. IntoxicationGenerally, intoxication is not a per se bar to a

workers’ compensation claim, unless the employee was so intoxicated as to be no longer able to follow the employment and thus the injury did not arise out of the employment. In some jurisdictions, a claimant’s entitlement to workers’ compensation benefits is barred if the injury or death was caused by the employee’s intoxication. Smith v. Workers’ Comp. Appeals Bd., 123 Cal.App.3d 763, 176 Cal.Rptr. 843 (5th Dist., 1981); Delaware Tire Center v. Fox, 401 A.2d 97 (Del. Super., 1979), judgment aff ’d, 411 A.2d 606 (Del. 1980); Parro v. Industrial Com’n, 167 Ill.2d 385, 657 N.E.2d 882 (1995); and DeMichaeli & Assoc. v. Sanders, 167 Ind.App. 669, 340 N.E.2d 796 (2nd Dist. 1976). Generally, however, intoxication alone at the time of the accident is not a sufficient basis for denying workers’ compensation benefits because intoxication alone does not necessarily constitute a departure from employment sufficient to preclude recovery. Republic Indemnity Co. v. Workers’ Comp. Appeals Bd., 138 Cal.App.3d 42, 187 Cal.Rptr. 843 (2nd Dist. 1982); Dale v. Trade Street, Inc., 258 Mont. 349, 854 P.2d 828 (1993); and Phelps v. Positive Action Tool Co., 26 Ohio St.3d 142, 497 N.E.2d 969 (1986).

For an employee’s intoxication to constitute a defense to a workers’ compensation claim, there must be proof by the employer that the worker’s intoxication was a substantial factor in causing the injury. Republic Indemnity Co. v. Workers’ Comp. Appeals Bd., 138 Cal. App. 3d 42, 187 Cal.Rptr. 843 (2nd Dist. 1982); Kindel v. Ferco Rental, Inc., 258 Kan. 272, 899 P.2d 1058 (1995). Thus, while an employer raising the employee’s intoxication as a defense has the burden of proving the intoxication was a proximate cause or substantial factor in bringing about the accident, death or injury, the employer is not required to prove the intoxication was the sole proximate cause of the accident and resulting injury or death. Smith v. Workers’ Comp. Appeals Bd., 123 Cal. App. 763, 176 Cal.Rptr. 843 (5th Dist. 1981); Sidney for Sidney v. Raleigh Paving & Patching, Inc., 109 N.C.App. 254, 426 S.E.2d 424 (1993). If the worker’s intoxication has been proven, some states statutorily presume the worker’s injury was caused primarily by the intoxication. R. P. Hewitt & Associates of Florida, Inc, v. Murnighan, 382 So.2d 353 (Fla.App. 1st Dist., 1980). However, this presumption ordinarily may be rebutted by sufficient evidence of other cause because if the

presumption was irrebutable, it would violate the worker’s constitutional right to due process. Recchi America v. Hall, 692 So.2d 153 (Fla. 1997).

Some states’ workers’ compensation acts provide a statutory defense based on the employee’s intoxication. A word of caution, even though the workers’ compensation act may provide a statutory defense for intoxication of the employee, the causation requirement will still likely need to be satisfied.

For example, Louisiana’s Workers’ Compensation Act provides “no compensation shall be allowed for an injury caused, by the injured employee’s intoxication at the time of the injury.” LSA-R.S. 23-1081(1)(b). Similarly, Indiana’s Workers’ Compensation Act provides as follows:

“No compensation is allowed for an injury or death due to the employee’s knowingly self-inflicted injury, his intoxication...or his knowing failure to perform any statutory duty. The burden of proof is on the defendant.”

I.C. 22-3-2-8.Thus, if an employee’s intoxication is suspected

as a cause of the claimed work-related injury, defense counsel should make sure a thorough investigation is undertaken to determine whether it was a substantial factor is causing the accident and resulting injury or death. This defense will require scientific proof of intoxication and will likely require expert testimony to refute the employee’s argument that the intoxication was not a substantial factor in causing the accident. Counsel should also remember the burden of asserting this defense, whether statutory or not, is on the employer. In states where proof of the employee’s intoxication creates a presumption the injury was occasioned by the intoxication, counsel should be prepared for the employee’s attempts to rebut the presumption with sufficient evidence of other causes.

Although a difficult defense from a proof perspective, the employee’s intoxication at the time of the injury can be an effective defense strategy under the proper circumstances and factual situation. Another viable defense strategy based on an employee’s personal risk involves employees injured in fights where they are the aggressor.

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B. Assaults and Fights Where Employee is the Aggressor

Generally, an injury to an employee as a result of an assault by a co-employee committed in the course of employment and arising out of some incident or condition of employment, and not done for solely for personal reasons, is compensable as arising out of the employment. State Compensation Ins. Fund v. Industrial Acc. Comm’n of Cal., 38 Cal. 2d 659, 242 P.2d 311 (1952); and Doe v. Purity Supreme, Inc., 422 Mass. 563, 664 N.E.2d 815 (1996). On the other hand, an injury arising from an assault on an employee committed for purely personal reasons does not arise out of the employment and is not compensable. Tampa Maid Seafood Products v. Porter, 415 So.2d 883 (Fla.App. 1st Dist., 1982); and McCurry v. Container Corp. of America, 982 S.W.2d 841 (Tenn., 1998).

The fact that an assault was provoked by the injured employee (i.e., the aggressor) does not necessarily render the injury non-compensable although it may do so if the aggression amounts to willful misconduct. State Compensation Ins. Fund v. Industrial Acc. Comm’n of Cal., 38 Cal. 2d 659, 242 P.2d 311 (1952). However, in some states, the aggressor who brings on self injury will barred from recovery. Armour & Co. v. Industrial Comm’n, 397 Ill. 433, 74 N.E.2d 704 (1947). Of note, in cases involving the issue of who was the initial aggressor, courts have found that there can only be one initial aggressor. Franklin v. Industrial Comm’n, 341 Ill.App.3d 128, 791 N.E.2d 1171 (1st Dist., 2003).

Consequently, early investigation to determine who the initial aggressor in assault cases is important in determining compensability. Likewise, investigation into the cause and circumstances of the assault is critical to determining whether the employee’s injuries are compensable. If the circumstances warrant, an employee’s involvement in a fight where they are the initial aggressor is an effective defense strategy which may bar their workers’ compensation recovery.

C. Acts for Purely Personal BenefitAnother area where an employee’s own actions

may bar their workers’ compensation recovery is when they are performing acts purely for their own personal benefit.

Generally, injuries sustained on company premises are found to be compensable, but this is not an absolute rule of law. The key determination is whether the employee was injured by the nature of the work they are supposed to be performing or whether the injuries resulted from risks personal to the employee.

Generally, the rule for denying workers’ compensation benefits for acts performed by employees solely for their own benefit does not apply to acts of personal convenience or comfort. Price v. Workers’ Comp. Appeals Bd., 37 Cal.3d 559, 693 P.2d 254 (1984); and Marmolejo v. Dept. of Industry, Labor and Human Relations, 92 Wis.2d 674, 285 N.W.2d 650 (1979). The “personal comfort doctrine,” sometimes called the “personal convenience exception,” was developed to cover situations where an employee is injured while taking a brief pause to tend to the necessities of life. Thus, acts that are reasonably necessary to the health and comfort of an employee while at work (i.e., satisfaction of thirst, hunger, other physical demands, or protection from excessive cold) are incidental to the employment. Injuries sustained during the performance of these acts of personal comfort are generally compensable as arising out of and in the course of the employment. Mazzone v. Connecticut Transit Co., 240 Conn. 788, 694 A.2d 1230 (1997); and Meredith v. Jefferson County Property Valuation Administrator, 19 S.W.3d 106 (Ky. 2000).

Nonetheless, even if the personal activity of the employee is involved, the requirement that the accidental injury arose out of the employment is not eliminated by application of the personal comfort doctrine. The activity must be reasonably foreseeable and incidental to the employment to entitle the employee to compensation. Likewise, if an employee voluntarily exposes themselves to a risk outside any reasonable exercise of their duties, the resulting injury will not be considered to have occurred during the course of the employment. O’Donnell v. City of Chicago, 126 Ill.App.3d 548, 467 N.E.2d 971 (1st Dist., 1984); and Weiss v. City of Milwaukee, 208 Wis.2d 95, 559 N.W.2d 588 (1997).

Also, an employee’s injury arising from a violation of an employer’s rule relating to acts done for personal benefit is not compensable because it does not arise out of the employment or because it constitutes willful misconduct. Saunders v. Industrial Comm’n, 189 Ill.2d

14


623, 727 N.E.2d 247 (2000); and Boatright v. Dothan Aviation Corp., 278 Ala. 142, 176 So.2d 500 (1965).

Again, a thorough investigation by defense counsel is key to determining whether an employee’s injuries sustained while performing purely personal activities is compensable. Careful consideration should be made with regard to whether the employee’s actions arose out of or in the course of their employment, and whether the employee violated the employer’s rule regarding acts for personal benefit or comfort.

Deviation from EmploymentHaving examined some of the ways an employee’s

workers’ compensation recovery may be barred due personal risks unrelated to their employment, another category of defenses which will preclude recovery is when the employee’s actions deviate from the course and scope of their employment. But, when do an employee’s own actions completely remove them from the course and scope of their employment? What exceptions have state legislatures and courts created to determine when an employee’s own actions have taken them outside the course of their employment so that an injury sustained is not compensable under workers’ compensation?

A. HorseplayGenerally, injuries sustained by workers engaging

in practical jokes or horseplay are not compensable under workers’ compensation because the injuries do not arise out of the employment. McKnight v. Consolidated Concrete Co., 279 Ala. 430, 186 So.2d 144 (1966); and Lincoln v. Whirlpool Corp., 151 Ind.App.190, 279 N.E.2d 596 (3rd Dist. 1972). However, this rule has been limited in some jurisdictions to cases in which the injured employee participates in the act. Pacific Employers Ins. Co. v. Industrial Acc. Comm’n, 26 Cal.2d 286, 158 P.2d 9 (1945); and Ford v. Barcus, 261 Iowa 616, 155 N.W.2d 507 (1968). This has sometimes been referred to as the “non-participant exception.”

Different jurisdictions hold that not all conduct like this is to be considered as a departure from the employment. For example, some cases have allowed compensation where although the injured employee engaged in horseplay, they had abandoned it at the time of the injury, thus breaking the causal relationship between the horseplay and the injury. Baird v. Travelers Ins. Co., 98 Ga.App. 882, 107 S.E.2d 579 (1959); and

Rex-Pyramid Oil Co. v. Magan, 287 Ky. 459, 153 S.W.2d 895 (Ky.App., 1941).

Some states via their workers’ compensation act have allowed employers to protect themselves from liability for certain hazards, such as horseplay among employees, by adopting and publishing rules prohibiting such activities. I.C. 22-3-2-8 (Indiana); and Western Union Tel. Co. v. Owens, 82 Ind.App. 474, 146 N.E. 427 (Ind. App., 1925).

Generally, injuries sustained by employees engaging in horseplay will not be compensable as the activities do not arise out of or in the course of the employment. In states where the establishment of rules prohibiting such activities will bar recovery for injuries sustained during these activities, employers should adopt and publish rules to protect against liability for this type of workers’ compensation claim.

B. Violation of Company RulesIt would seem that an employee injured engaging

in horseplay should not be able to claim workers’ compensation benefits, but what about when the employee violates a company rule?

Generally, violation of a safety rule or company policy may take the employee entirely out of the scope of their employment and any resulting injury that occurs during the violation is not compensable. Saunders v. Industrial Comm’n, 189 Ill.2d 623, 727 N.E.2d 247 (2000). Likewise, an employee’s violation of work safety rules will bar recovery where the violation constitutes willful misconduct. Adams on Behalf of Boysaw v. Hercules, Inc., 21 Va.App. 458, 465 S.E.2d 135 (1995). But, violation of an employer’s rule is not a per se bar to recovery and an employee’s negligence in violating an employer’s rule is not necessarily a bar to receiving workers’ compensation benefits. Brown v. Hertz Corp., 246 So.2d 32 (La.App., 1971), writ denied, 258 La. 576, 247 So.2d 394 (1971); Lukesh v. Ortega, 85 N.M. 444, 623 P.2d 564 (1980); and Durrah v. Washington Metropolitan Area Transit Authority, 760 F.2d 322 (Ct. App. D.C., 1985).

However, if an employer’s rule sets the boundaries of employment, when violated, the accident does not arise out of and in the course of employment and is not compensable. Scheller v. Industrial Comm’n of Arizona, 134 Ariz. 418, 656 P.2d 1279 (Ariz.App., 1982); Arkansas State Police v. Davis, 45 Ark.App. 40, 870 S.W.2d 408 (1994). Even under this view, if

15


an employment rule pertains only to the means or manner of performing a job, a violation will not bar the employee’s recovery because the employee is still within the scope of employment when the rule is violated. Schroeder v. Industrial Comm’n of Arizona, 132 Ariz. 455, 646 P.2d 886 (Ariz.App., 1982); and Mitchell v. State, Dept. of Educ., 85 Haw. 250, 942 P.2d 514 (1997).

Of note, denying compensability for a violation of a safety rule is subject to proof of a causal relationship between the violation and injury. Swillum v. Empire Gas Transport, Inc., 698 S.W.2d 921 (Mo.App. S.D., 1985). Generally, to bar or reduce a claim for workers’ compensation based on a violation of a safety rule, the employer must prove the following:

(1) At the time of the injury, the employer had in effect a rule or policy requiring the employee’s use of the safety appliance;

(2) The rule or policy was regularly enforced by the employer;

(3) The injured worker had actual knowledge of the rule or policy; and

(4) The employee willfully and intentionally failed or refused to follow the rule or policy.

Thus, although violation of a company rule or policy is not a per se bar to an employee’s recovery, careful consideration and investigation should be undertaken to determine whether violation of the rule will prohibit the employee’s recovery under workers’ compensation. Likewise, employers should determine whether violation of a safety rule consistent with the previously mentioned requirements will protect them from liability for an employee’s violation of a safety rule.

Navigating the rules as to whether an employee’s violation of a company rule will bar recovery under workers’ compensation can be difficult given the difficult task of determining the nature of the rule which was violated. But, when will unreasonable risk undertaken by an employee which results in their injury or death bar recovery under workers’ compensation?

C.Unreasonable RiskGenerally, an employee’s misconduct, whether

simple negligence or willful disobedience of

workplace rules, has no bearing on whether an injury is compensable. Barry v. Aetna Life & Cas. Co., 133 Ga.App 527, 211 S.E.2d 595 (1974); and Merchant v. Pinkerton’s Inc., 50 N.Y.2d 492, 407 N.E.2d 443, 429 N.Y.S.2d 298 (1980). But, some statutes provide for benefits only if the employee did not intentionally cause the event that results in the injury. In fact, some statutes preclude recovery for employees injured because of their deliberate and reckless indifference to danger, or because they have engaged in willful misconduct. Delware Tire Center v. Fox, 401 A.2d 97 (Del. Super., 1979), judgment aff ’d, 411 A.2d 606 (Del. 1980); and Lumbermans Mut. Cas. Co., Inc. v. Amerine, 139 Ga.App. 702, 229 S.E.2d 516 (1976).

Again, before any type of misconduct will be sufficient to bar recovery, it must be the proximate cause of the harm for which recovery is sought. DeMichaeli & Assoc. v. Sanders, 167 Ind.App. 669, 340 N.E.2d 796 (Ind.App., 1976). Likewise, an employer defending on the grounds that the employee’s injury resulted from the employee’s willful misconduct has the burden of proof to establish this defense. Wright v. Gunther Nash Min. Const. Co., 614 S.W.2d 796 (Tenn., 1981).

There are several critical inquiries to determine whether an employee’s own actions constitute unreasonable risk so as to preclude recovery under workers’ compensation for any resulting injuries. First, a careful investigation should be conducted to determine whether the employee’s actions constitute a deliberate and reckless indifference to danger, or because they have engaged in willful misconduct. If so, the employee’s recovery under workers’ compensation may be barred. Likewise, employers should have clearly established safety rules and determine whether the employee’s actions will preclude recovery even though they do not rise to the level of willful misconduct or reckless indifference.

ConclusionThe by-product of the “no-fault” nature of state

workers’ compensation systems makes it more difficult for employers to defend against claims where the employee’s own actions should be taken into account in determining compensability. Without the use of traditional affirmative defenses, defense counsel is faced with finding ways to defend claims for accidental

16


injuries where the employee’s own actions caused or contributed to the accident and resulting injuries. Generally, the defenses based on an employee’s own actions will require proof of causation, i.e., that the conduct caused the claimed injury.

Employers should carefully review their existing safety rules and make sure that employees have actual knowledge of the rules. Further, a thorough investigation for all claims where the employee’s own actions possibly caused or contributed to the accidental injuries should be undertaken to determine whether a viable defense exists without reliance on traditional negligence defenses. Through the use of alternative defense theories and thorough investigation, defense counsel can find ways to mitigate abrogation of the traditional common law defenses to defeat workers’ compensation cases.

CONTINUTED FROM PAGE 910. Anterior hip replacement. Encyclopedia of Surgery Website. http://www.surgeryencyclopedia.com/Fi-La/Hip-Replacement.html Updated 2014. Last Accessed January 21, 2014.

11. Clinical practice guidelines. American Academy of Orthopaedic Surgeons Website. http://www.aaos.org/Research/guidelines/guide.asp Updated 2013. Last Accessed January 21, 2014.

12. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988; 15: 1833-1840.

13. Dunbar MJ, Robertsson O, Ryd L, Lindgren L. Appropriate questionnaires for knee arthroplasty: results of a survey of 360 patients from the Swedish knee arthroplasty registry. J Bone Joint Surg Am. 2001; 83: 339-344.

14. McConnell S, Kolopack P, Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum. 2001; 45(5): 453-461.

15. Riddle DL, Stratford PW. Body weight changes and corresponding changes in pain and function in persons with symptomatic knee osteoarthritis: A cohort study. Arthritis Care & Research. 2013; 65(1): 15-22.

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Current Perspective: Sleep Disturbance in Injured Workers and Their Recovery

Kathy Sexton-Radek, PhD., C.BSMElmhurst College / Suburban Pulmonary & Sleep Associates

Background: Examination of the sleep and rehabilitation literature reflects little attention to sleep quality in injured and recovering workers. A search for studies that address sleep quality for workers was conducted.

Study Design: Systematic review examining the topic of sleep in injured and recovering workers

Methods: An examination of the General/Clinical/Rehabilitation Psychology, Medline and PubMed literature was reviewed in terms of their focus on sleep disturbance in the injured/recovering worker.

Results: A large proportion of scientific literature provided evidence for the need for sleep to maintain good health and the impact of sleep schedule on functioning. Few empirical studies addressing sleep quality in the injured/recovering worker exist.

Conclusions: Sleep quality impacts daytime functioning; poor sleep quality in the injured worker jeopardizes their recovery/ability to obtain health.

Clinical Relevance: Recommendations for the Occupational Professional are given. The importance of attending to sleep issues as they impact daytime functioning in injured/recovering workers is addressed.

Key Terms: Sleep Quality, Injured Workers, Recovery from Injury, Sleep

What is known about the subject: Very little is known about this topic, this manuscript provides emphasis to the need to address sleep issues in injured and recovering workers.

What this study adds to existing knowledge: This systematic review is a novel examination of two rich research topics (Sleep Medicine, Occupational Disorders & Disease) with a focus to the injured/recovering worker.

Current Perspectives: Sleep Disturbance in Injured Workers and their Recovery

With good quality sleep defined as an average of fifteen minutes to sleep onset, 6.5 to 8 hours sleep with a minimal number of wake ups (6 or less) and time awake (30 minutes or less each wake up)1, there are considerable individual differences in defined sleep quality. Some individuals report good sleep quality with six and a half hours of sleep with the first four to four and a half hours uninterrupted and others report seven and a half hours with “few wake ups.”2

An overnight sleep study followed by a nap study with results analyzed by a Sleep Specialist is the definitive gauge of sleep quality. However, the individuals’ self-report provides salient information about their sleep quality. Telecommunications workers that reported sleep problems were less likely to rate their health as excellent, experienced a higher prevalence of pain-related conditions or GI problems. These workers reported use of more healthcare, higher medical expenditures, higher absenteeism and lower job satisfaction than those workers not reporting sleep problems.3

More consistently, sleep disturbances are

reported with the narrow margin of subsequent daytime impairment. In recent years, problems with sleep and daytime fatigue and/or sleepiness are receiving greater attention.4 Sleep disturbance is associated with substantial decreases in quality of life. Thus, the heterogeneity of sleep quality reports usually results from the homogeneity of poor sleep quality responses: daytime sleepiness/impaired functioning and inability to initiate/maintain sleep at night. A specific diagnosis by a Sleep Specialist following an all-night Polynosomnographic (PSG) sleep study is essential. Periodic limb movement, Sleep Apnea and Parasomnias are serious sleep disturbances, less commonly complained about and necessitating an assessment by a professional Sleep Specialist.Sleep Issues

Sleep disturbances in terms of poor sleep quality affect daytime functioning. Both cognitive and motor performance is impaired in sleep deprived subjects.5 Deficits in memory performance, creativity, initiation of tasks, concentration are common findings in study participants with poor sleep quality.6 In America, the Department of Motor Vehicles reports increases in car accidents where reports of sleepiness are reported.5

In medical studies, the restorative feature of

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sufficient deep sleep (i.e., Stage 3 sleep) at the first half of the night of sleep results from poor sleep quality. People with poor sleep quality such as Insomnia, use medical services more than do those without insomnia.7, 8 Insomnia has been associated with the development of depression, a condition related to health problems and increased utilization of medical services.9 Chronic poor sleep quality, left untreated, results in primary sleep disorders, that similarity with pain and medical conditions, are associated with respiratory stability, neurodegenerative disorders, medication effects, depression and cardiopulmonary disorders.10, 11

Natural sleep patterns are determined by the level of sleep demand and timing (i.e., bedtime) of sleep. Corresponding physiological and behavioral changes occur in the body as one feels sleep – such as slow eye rolling and closing movement, lower temperature and neutral cognition.11 In fifteen to thirty minutes time, an individual will fall asleep and move to non-rapid eye movement Stage 1 sleep followed by Stage 2 non-REM sleep then Stage 3 non-REM sleep. After this interval, usually about ninety minutes, a physiological stage of Rapid Eye Movement sleep characterized by saccadic eye movement, a distinct physiological brain wave pattern and tonic muscle relaxation throughout the body. This sequence is repeated in three to four cycles of sleep throughout the night. A disruption in this cycling with an awakening not only reduces the overall amount of sleep but also physiologically recalls the sleeper back to the beginning of a cycle. In these events, the amount and ordering of sleep impacts overall sleep quality.

The pattern of sleep at birth, infancy, toddlerhood and childhood is comparatively different. With the focus on the worker in this paper, the description of adulthood sleep has been given. For the typical worker’s age range, 19 to 65 years, adult sleep pattern change with ensuing years. Three primary differences between young worker sleep (age 18 years) and aged workers (age 65 years), are: 5-10% reduction in total sleep time, reduction in the amount of deep sleep, and the reduction in the amount of REM.12,

13 Studies have indicated the changes in sleep in the aged worker results in discontinuity, duration and depth of sleep.8 Sleep-disordered breathing (i.e., Obstructive Sleep Apnea, Central Sleep Apnea, Sleep-related Hypoventilation) and Restless Legs Syndrome

increase with age.13 Taken together, disorders of sleep substantially reduce sleep quality, decreases in total sleep time and impairment in daytime functioning.14, 15

Insomnia is a primary sleep disorder that is characterized by difficulty falling asleep and/or staying asleep consecutively for thirty days. In the United States, studies identified prevalence rates of 10% to 23% of Insomnia.16, 17 Obstructive Sleep Apnea is the cessation of airflow resulting from the collapse of the upper airway during sleep. With this, respiratory effort continues with an eventual breath after seconds and at reporting minutes of ceased airflow. This gas of air after this airflow cessation is accompanied by several sounds (i.e., loud snore, cackle) or the forced inspiration that causes a vibration in the throat tissue that is heard as a loud snore.

Clinically, the loss of airflow corresponds to a marked blockage in availability of oxygen.16 Central Apnea and Sleep-related hypoventilation are measured in an all-night PSG and are thought to be associated with neurological dysfunction. Periodic limb movements are characterized by periodic and repetitive foot flexion resulting in disturbances in sleep. In older adults, the prevalence of periodic limb movement has been reported to be some 45% and includes symptoms of uremia and peripheral neuropathy.12, 17

With aging, sleep patterns are also characterized by a larger proportion of circadian rhythm sleep disorders (Advance Type) in the older adult population. Older adults are at risk for advance type circadian rhythm sleep disorder where one’s biological clock is programmed to initiate sleep at an earlier time than desired.10

Additionally, advanced phase circadian rhythm sleep disorder places the sleeper more at risk of awakenings during sleep and sleepiness during the day. 12

Thus, these alterations in functioning that are generated by poor sleep quality/sleep disorder correspond to increased vulnerability for them, and medical conditions in those of advancing age is a matter of significant clinical importance. Professionals caring for workers that are injured or recovering from an injury need an understanding of sleep issues that impact a proportionally greater risk for sleep disturbance.

A worldwide study of individuals’ sleep revealed that 21% felt they don’t have good sleep quality with 32% of that sample meeting criteria for clinical insomnia.18 Standard scales used in sleep medicine such

19


as the Epworth Sleepiness Scale were used in this ten-country, 35,327 participant study.18

Sleep Issues Related to Workers’ Injury and RecoveryThe United States Department of Labor Statistics

reports the number of fatal occupational injuries in Agriculture/Forestry/Fishing, Mining, Transportation, Construction, Police and Sheriff ’s Patrol officers as some of the occupations at the top of the tabulations. Common occupational diseases include lung disease, skin disease and diseases of concern such as carpal tunnel syndrome, computer vision syndrome and lead poisoning. It is estimated that 4 million workers in the United States suffered from non-fatal work related injuries or illnesses in 2007.19,20,21 The spine, hands, head, lungs, eyes, skeleton and skin are the organs most commonly effected in occupational injuries.

Effective recovery from work-related injuries often involves litigation. While

Workers’ Compensation claims specify the amount of time allowed for recovery, healthcare professions assess and determine the readiness for return to work. Healthcare/Medical teams focused on putting injured workers back to work as soon as possible, to return to their job with lighter duty and frequent evaluations of the worker’s ability to perform tasks and activities at work are considered successful.22,23

There appears to be a need for more specific attention to an injured and recovering worker’s sleep quality. Sleep becomes disturbed due to pain, discomfort, and altered schedules. Few studies have examined sleep disturbance in the injured and/or recovering worker. In an evaluation of the sleep literature on this topic, it was found that many studies have substantiated the negative state of sleep disturbance to recovery from injury.

In twenty-four analyses of sleep in sleep deprived and non-sleep deprived participants, Jung and colleagues measured more energy expenditure when sleep deprived.24 Sleep conserves energy. With complete loss of a night of sleep, considered to be acute sleep deprivation, and likely to be an episode to workers with injury or in recovery cannot be counter measured by rest and exercise. Cognitive effects (i.e., errors on vigilance tasks) and subjective reports of sleepiness were documented in an investigation of performance and sleep debt.24 The prevalence of short sleep hours (i.e., less or equal to 6 hours/night) and impairments in sleep were found to decrease in a dose response relationship

with overtime work hours in an investigation by Natashima and colleagues.25 Female white-collar workers that were on long term sick leave served as participants in a study by Sandmark that focused on health and sleep in long term sick list participants.26

Results reported that those women that returned to work rated less negative consequences of the long term sick leave and experienced better sleep quality.26 In careful follow-up analysis of recovery from sleep deprivation, the recovery pattern related to physiological sleep and subjective ratings of sleepiness were not related but rather, the sleep habits prior to the experiment.27 Specifically, the variability in bedtimes and waketimes results in erratic, fragmented sleep. These individual differences in sleep patterns reflect the changing patterns of erratic sleep (e.g., late bedtime-late waketime followed by next night of early bedtime-typical waketime) that may occur in an injured/recovering worker. Sleep is regulated by amount of sleep needed and timing of the sleep interval. Individual sleep typically follows a 24 hour rhythm in sleep propensity,28 with light and social timing providing modification of this interval. That is, the internal stability of sleep is perturbed by internal behavior factors, such as bedtime and waketime choices.

Day describes the use of education via a blog to instruct patients, particularly workers with injuries and/or in recovery, of the need to monitor their sleep position.29 Sleeping in a neutral position, rather than with one’s head or arms or back twisted or awkwardly positioned, results in less stiffness and possible soreness.29 The torsion in the neck created by prone position sleeping taken together with prolonged positions (as in pain conditions where the sleeper restricts their movements), during sleep results in reduced blood flow and stiffness. Dr. Day suggested the side and back positions for sleep as ideal with pillows between and under the knees, respectively. (Back sleeping is contraindicated when an individual is diagnosed with Sleep Apnea.)

Shift work and rotating shift work schedules present a complicated circumstance to the injured worker. The average amount of minutes for shift 1 (421.3 plus or minus 61.0 minutes) and shift 2 (410.8 plus or minus 73.6 minutes) are longer than what is typically reported for shift 3 (364.0 plus or minus 91.0 minutes).30 In general, night shift workers sleep

20


less than day shift workers – some studies, reportings of a two-hour difference between the groups has been indicated. Work productivity is degraded and more accidents occur when individuals are sleep deprived.31 Healthy work scheduling to accommodate the need for recovery from work fatigue due to the work and/or the schedule are essential to reducing poor sleep quality. Hoefelman and colleagues examined the responses of Brazilian workers in their epidemiological study.32 Poor sleep quality was reported to be present in 21% of the workers (n = 47,477), and was associated with poor vegetable intake, physical inactivity, negative perception of health/well-being/stress and diabetes (in females) and hypertension (in males). Workers with insomnia were found to have as high frequency for injury according to Nakata and colleagues’ cross-sectional study of daily sleep habits to occupational injuries.33 Dozing off in passive situations characterized by routinized, familiar tasks is prominent in workers with insomnia. The sleep debt incurred from insomnia results in slow information processing, increased period of non-responding or delayed responding during attention based tasks, reductions in short term memory accuracy, and errors on vigilance tasks.36

Sleep Quality and Worker FunctioningThe National Sleep Foundation conducts a

national annual “Sleep in America Poll” and the 2012 poll focused on Transportation workers sleep.5 The sample for the 2012 Sleep in America Poll included: airline pilots, truck drivers, train operators, bus drivers (55% school bus drivers, 20% public transit bus drivers), and taxi/limo drivers. Train operators started a shift between 10 p.m. and 3:30 a.m. significantly more times

than all other workers (2.7 times). The transportation workers’ sleep times varied across work week and time off. Nine percent of the sample scored in the clinical categorization as “sleepy.” Twenty percent of the train operator participants reported driving drowsy at least once in the past month while not on the job.

Negative health outcomes such as inadequate/reductions in healing time result from poor sleep quality, specifically short sleep duration. Farant and colleagues measured differences in immune system biochemical leukocytes after sleep restriction. Further stated by Farant, the participants that had a nap or night of recovery sleep also had reduction in their measured leukocyte levels. Naps lowered the mean arterial pressure among participants under psychological stress as measured by Conklin.38,39 While caffeine in small amounts, when sleepy is suggested for adequate performance, excessive caffeine was found to mask circadian rhythm signal in participants and resulted in fragmented sleep.40 Many have identified psychosocial factors related to shift work schedule of workers. Those with dependents and that smoked cigarettes had poorer sleep quality than those rail safety workers that didn’t.13, 34 A time-lagged research design was used by Blau of the Human Resource Management Department of Temple University of sleepiness and general activity in Emergency Medical Service workers.7 The findings of this study identified the significant relationship between general activity difficulty due to sleepiness.

Sandmark surveyed white collar workers and found that 9% had returned to work after 34 months and rated less negative consequence of sick leave

Table 1. National Sleep Foundation 2012 Sleep in America Poll: Planes, Trains, Automobiles and Sleep

Control Pilots Truck Drivers Train Operators Bus Taxi/LimoReported less sleep than needed workdays 27% 41% 19% 34% 18%

Sleep disability 10% 10% 10% 18% 7%

Serious error at work due to sleepiness 5% 20% 6% 9% 7%

Sleep problems every night/almost every night 59% 51% 54% 52% 54%

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impact on their career and had better quality of sleep than those that did not return to work. Worker limitations occur when they are sleepy.26 Research has identified that workers who experience ≥3 nighttime awakenings compared to those with fewer, had work performance and productivity impairments.41

Recommendations for the Occupational Professional

Sleep has been underestimated by the general population and somewhat neglected by organizations. Workplace factors contribute to poor sleep quality such as backward shift rotation, shift length and stress in the workplace.42, 43 In measurements of more extreme states such as shift work schedule and sleep quality, research findings have underscored the need to carefully set up sleep schedule and routines for sleep and wake time. Thus, in a traditional work schedule where excessive daytime sleepiness from poor sleep quality, erratic bedtimes and fragmented sleep are common, the injured/recovering from injury worker has additional complicating factors that disturb their sleep. The sleepy worker results from the common factors affecting sleep and, additionally, factors related to this discomfort secondary to their injury or recovery. The detection and management of sleep workers is necessary and can be addressed by utilizing team member rotations, giving sleep workers familiar tasks and caffeine.44, 45

Agreement between sleep schedule and job satisfaction was found to be more prominent than chronotype (i.e., person’s natural sleep interval time in the 24 hour day). Particular attention to works on shift schedules must be made. Ohayon and colleagues measured the effects of normal circadian rhythm disturbance with irregular work schedules. The reduction in sleep duration, overall, often co-occurred with fragmented sleep, greater use of sick days, more complaints of daytime sleepiness and more work related accidents.3, 46 Additionally, measured cognitive changes in shift workers as compared to healthy workers were found in terms of sensory memory reduction and attention hyper-reaction to novel sound. Wall conducted an assessment using clinical interviews and psychological measures and self-report surveys. Injured workers reported higher levels of neuroticism, trauma symptoms, depressive symptoms, somatic complaints, anxiety and sleep disturbance as compared to non-injured workers.49, 50, 51 Thus,

facilitating adaptations to injury and vulnerability to injury is needed and the purposeful attention to the workers sleep schedule and quality is one way to assist the injured/recovery worker with this task.

Studies that have utilized a telephone survey of 7,428 employed health plan subscribers and found that insomnia was associated with lost work performance due to presenteeism (x2 = 39.5 p< 0.001) but not absenteeism.30, 47 These workplace costs were estimated by to be at a $2,280 individual capital level or 252.7 days/$63 billion estimated population level.3,484 Furthermore, a statistically significant association of shiftwork and metabolic syndrome exists that highlights this need, by the Occupation Professional to focus on the injured/recovery worker’s sleep quality. It is important to take workers’ sleep quality in account when considering their healthcare needs.49,50

Injured/recovering workers with significant sleep disturbances need to be referred to a sleep specialist for assessment and treatment.11, 5, 51 The use of all night PSG studies, sleep-specific self-report measures, logging of sleep and clinical interview are used to determine a sleep disorder diagnosis. Prescription medications are used in severe cases (i.e., hypnotics for Insomnia, low dose anticonvulsants for Restless Leg Syndrome).52 Cognitive Behavioral Therapy approaches that utilize a collaborative, interactive approach with the patient to educate and facilitate self-correction of behaviors more conducive to self. (See Appendix I ,II & III for further information.)

In summary, sleep quality is essential to health. Literature reviewed in the general area of sleep issues implicates impaired functioning with poor sleep quality. An emphasis in the sleep literature with workers’ sleep quality is found largely in the area of shift work schedules.2, 27 A portion of the literature addresses consequences of poor sleep quality in work factors of absenteeism, low performance and dissatisfaction with work.9, 13,26 Injured and recovering workers’ sleep quality need is more salient28, 31 as the physiological processes that correspond to good sleep quality such as reduction in pain, reports of less physical symptoms and fewer cardiovascular symptoms is essential.33, 50-52It is recommended that the Occupational Healthcare worker include assessment and planning for good sleep quality in their patients’ treatment plans.

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Appendix ISexton-Radek, K. and Grace, G. (2009). Combating Your Sleep Problems. New York: Plenum Press.

This book contains specific information about CBT or Sleep Disorders. The overall process and session by session activity is explained in each chapter.

Appendix IIResources and referrals for the diagnosis and care of sleep disorders can be found at:

American Academy of Sleep Medicine2510 North Frontage RoadDarien, IL 60561(630) 737-9700http://www.aasmnet.orgSociety of Behavioral Medicine National Office2510 Frontage RoadDarien, IL 60561(630) 737-9706http://www.behavioral sleep.org

Appendix IIIBibliography

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Cartwright, R.D., Lloyd, S.,Lilie, J., & Kravitz, H. Sleep position training as a treatment for sleep apnea syndrome: A preliminary study. Sleep, 1985. 8: 87-94.

Morin, C.M., Caulier, B., Barry, T., & Kowatch, R.A. Patient’s acceptance of psychological and pharmacological therapies for insomnia. Sleep, 1992. 15: 302-305.

Roehrs, T., & Roth, T. Hypnotics, alcohol, and caffeine: Relation to insomnia, In M.R. Pressman & W. C. Orr (Eds.), Understanding Sleep: The evaluation and treatment of sleep disorders (pp. 339-355). 1997, Washington, DC: American Psychological Association.

Spielman, A.J., Saskin, P., & Thorpy, M.J. Treatment of chronic insomnia by restriction of time in bed. Sleep, 1987. 10:45-56.

REFERENCES1. Buysse, D.J., Monk, T.H., Reynolds, C.F., III, Mesiano, D., Houck, P.R., & Kupfer, D.J. Patterns of sleep episodes in young and elderly adults during a 36-hour constant routine. Sleep, 1993. 16:632-637.

2. Brugére, D., Barrit, J., Butat, C, Cosset, M., & Volkoff, S. Shiftwork, age, and health: An epidemiologic investigation. International Journal of Occupational and Environmental Health, 1997. 3 (Suppl. 2): 15-19.

3. Kuppermann M, Lubeck DP, Mazonson PD, Patrick DL, Stewart AL, Buesching DP, Fifer, SK. Sleep problems and their correlates in a working

population. 1995. J. Gen Intern Med. 10:25-32.

4. Dinges, D.F., Pack,F.,Williams, K.,Gillen, K.A., Powell, J.W., & Ott, G.E. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep, 1997. 20:267-277.

5. The Gallup Organization. Sleep in America, 2012. Los Angeles: National Sleep Foundation.

6. Stepanski, E., Lamphere, J. Badia, P., Zorick, R., Roth,T. Sleep fragmentation and daytime sleepiness. Sleep, 1984. 7: 18-26.

7. Blau, G. Exploring the impact of sleep-related impairment on the perceived general health and retention intent of an Emergency Medical Services (EMS) sample. The Career Development International, 2011. 16(3):238-253.

8. Van Cauter, E., Leproult, R., & Plat, L. Age-related changes in slow wave sleep and REM sleep and relationship with growth hormone and cortisol level in health men. JAMA, 2000. 284: 861-868.

9. Bonnet, M.H. Performance and sleepiness as a function of frequency and placement of sleep disruption. Psychophysiology, 1986. 23: 263-271.

10. Ancoli-Israel, S. & Roth, T. Characteristics of insomnia in the United States: I. Results of the 1991 National Sleep Foundation Survey. Sleep, 1999. 22 (Suppl. 2): 347-353.

11. Sexton-Radek, K., & Grace, G. Combating Sleep Disorders. 2009. New York: Plenum Press

12. Ancoli-Israel, S., Kripke, D.F., Klauber, M.R., Mason W.J., Fell, R., Kaplan, O. Sleep disordered breathing in community-dwelling elderly. Sleep, 1991b. 14: 486-495.

13. Phillips, B.A., &Danner, F.J. Cigarette smoking and sleep disturbance. Archives of Internal Medicine, 1995. 155: 734-737.

14. Koyama, R.E., Esteves, A.M., Silva, L.O. et al. Prevalence of and risk factors for obstructive sleep apnea syndrome in Brazilian railroad workers. Sleep Medicine, 2012. 13(8):1028-1032.

15. Dement, W.C., & Mitler,M.M. It’s time to wake up to the importance of sleep disorders. Journal of the American Medical Association, 1993. 269(12): 1548-1550.

16. Leger, D., Scheuermaier, K., Philip, K., Paillard, M., & Guilleminault, C. SF-36: Evaluation of quality of life in severe and mild insomniacs compared with good sleepers. Psychosomatic Medicine, 1993. 63: 49-55.

17. not found

18. Soldatos, C.R., Alaert, F.A., Ohta, T., Dikeos, D.G. How do individuals sleep around the world? Results from a single day survey in ten countries. Sleep Medicine, 2005: 5-13.

19. Mathias J, Alvaro P. Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury.: A meta-analysis. Sleep Medicine, August 2012; 13(7):898-905.

20. Schwartz, S., Anderson, W.M., Cole, S.R., Cornoni-Huntley, J., Hays, J.C., & Blazer, D. Insomnia and heart disease: A review of epidemiologic studies. Journal of Psychosomatic Research, 1999. 47: 313-333.

21. White, D.P., Lombard, R.M., Cadieux, R.J., & Zwillich, C.W. Pharyngeal resistance in normal humans: Influence of gender, age and obesity. Journal of Applied Physiology, 1985. 58: 365-371.

22. Stepanski, E.,Rybarczyk, B., & Stevens, S. Assessment and Treatment f Sleep Disorders in Older Adults: A Review for Rehabilitation Psycholgists, 2003, 48:23-36.

23. Stradling, J.R., Barbour, C., Glennon, J., Langford, B.A., Crosby, J.H. Prevalence of sleepiness and its rlation to autonomic evidence of arousals and increased inspiratory effort in a community based sample population of men and women. J Sleep Res,9:381-388.

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24. Leger, D., The cost of sleep-related accidents: A report for the National Commission on Sleep Disorders Research. Sleep, 1994; 17:84-93.

25. Nakashima, M., Morikawa, Y., Sakurai, M. et al. Association between long working hours and sleep problems in white-collar workers. Journal of Sleep Research, 2011, 20: 110-116.

26. Sandmark, H. Health, sleep and professional career in female white-collar workers back to work after log-term sick-listing due to minor mental disorders. Scandinavian Journal of Public Health, 2011; 39: 823-827.

27. Kubo, T., Takahashi, M., Tachi, M. et al. Characterizing recovery of sleep after four successive night shifts. 2009, Industrial Health, 47: 527-532.

28. Mignot, E., Why we sleep: The temporal organization of recovery. PLOS biology, 6(4); e106. doi 10.1371.

29. Day, K., Making the Connection: Sleep and Injuries, www.drfranklipman.com/making-the-connection-sleep-and-injuries, May 2, 2011.

30. Kawada, T., Shimizu, T., Kuratomi, Y. et al. , Monitoring the sleep patterns of shift workers in the automotive industry. Work, 2009, 163-167.

31. Takahashi, M. Prioritizing sleep for healthy work schedules. Journal of Physiological Anthropology, 2012, 31:6.

32. Hoefelmann, L.P., Lopes, A.S., Silva, K.S., Silva, S.G., Cabral, L.G., Nalas, M.V. Lifestyle, self-reported morbidities, and poor sleep quality among Brazilian workers. Sleep Medicine, 2012, 13(9), 1198-201.

33. Melamed, S., Oksenberg. Excessive daytime sleepiness and risk of occupational injuries in non-shift daytime workers. Sleep, 2002; 25(3):315-322.

34. 2012 Sleep in America Poll: Planes, Trains, Automobiles and Sleep. National Sleep foundation. http://www.sleepfoundation.org.

35. Lombardi, D.A. Independent effects of sleep duration and body mass index on the risk of a work-related injury: Evidence from the U.S. National Health Interview Survey. Chronobiology International, 2012. 29(5):556-564.

36. Nakata, A., Ikeda, T., Takahashi, M. et al. Sleep related risk of occupational injuries in Japanese small and medium-scale enterprises. Industrial Health, 2005, 43, 89-97.

37. Barnes, C.M. I’ll Sleep when I’m dead: Managing those too busy to sleep. Organizational Dynamnics, 40(1):18-26.

38. Moreno, C.R.C., Marqueze, E.C., Lemos, L.C. et al. Job satisfaction and discrepancies between social and biological timing. Biological Rhythm Research, 2012. 43(1):73-80.

39. Knudsen, H.K., Ducharme, L.J., Roman, P.M. Job stress and poor sleep quality: Data from an American sample of fulltime workers. Social Science & Medicine, 2007. 64(10):1997-2007.

40. Kessler, R.C., Berglund, P.A.,Coulouvat, C. et al. Insomnia and the performance of US workers: Results from the American Insonmia Survey. Sleep: Journal of Sleep and Sleep Disorders Research, 2011. 34(4):1161-1171.

41. Paterson, J.L., Dorrian, J., Clarkson, L., Darwent, D., Ferguson, S.A. Beyond working time: Factors affecting sleep behaviors in safety workers. Accident Analysis and prevention, 2012. 45:32-35.

42. Kerhofs, M., Boudjeltia, K.Z., From total sleep deprivation to cardiovascular disease: A key role for the immune system? Sleep: Journal of Sleep Research & Sleep Medicine, 2012. 35(7):885-896.

43. Wilson . L.G. Watson, S.T., & Currie, S.R. Daily diary and ambulatory activity monitoring of sleep in patients with insomnia associated with chronic musculoskeletal pain. Pain, 1998. 75: 76-84.

44. Ohayon, M.M., Lemoine, P., Arnaud-Briant, V. Prevalence and consequences of sleep disorders in shift workers population. Journal of Psychosomatic Research, 2002. 53(1):577-583.

45. Gumenyuk, V., Roth, T., Korzyukov, O.C. Shift work sleep disorder is associated with an attenuated brain response of sensory memory and an increased brain response to novelty: An ERP study. Sleep: Journal of Sleep and Sleep Disorders Research, 2012. 33(5):703-713.

46. Drake, C.L., Roehrs, T., Richardson, G., Walsh, J.K., Roth, T. Shift Work Disorder: Prevalence and consequences beyond that of symptomatic day workers. Sleep: Journal of Sleep and Sleep Disorders Research, 2004. 27(8):1453-1462.

47. Wall, C.L., Oyloff, J.R., Morrissey, S.A. Psychological consequences of work injury: Personality, trauma and psychological distress symptoms of non-injured workers and injured workers returning to or remaining at work. The International Journal of Disability Management Research, 2007. 2(2):37-46.

48. Moralo De Almendes, K., Araújo, J.F. Sleep Quality and Daily Lifestyle regularity in works with different working hours. Biological Rhythm Research, 2011. 42(3):231-245.

49. Farout, B., Boudjeltia, K.Z., Roussear, A. et al. Benefits of napping and an extended duration of recovery sleep on alertness and immune cells after acute sleep restriction. Rehabilitation Psychology, Brain Behavior and Immunity, 2011; 25(1): 16-24.

50. Morin, C.M.,Culbert, J.P., & Schwartz, S.M. Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy. American Journal of Psychiatry, 1994. 151: 1172-1180.

51. Murtagh, D.R.R., & Greenwood, K.M. Identifying effective psychological treatments for insomnia: A meta-analysis. Journal of consulting and Clinical Psychology, 1995. 63: 79-89.

52. Ancoli-Israel, S., Kripke, D.F., Klauber, M.R., Mason W.J., Fell, R., Kaplan, O. Periodic limb movements in sleep in community-dwelling elderly. Sleep, 1991a. 14: 496-500.

53. Brindle, R.C., Conkling S.M. Daytime sleep accelerates cardiovascular recovery after psychological stress. International Journal of Behavior Medicine, 2012. 19(1): 111-114.

24


Total Hip Arthroplasty Patients in Follow-Up Post-Physical Therapy: An Examination of Findings (page 6)

1. Total Hip Arthroplasties (THA) comprise ____ of all total joint procedures performed annually.a) 22~30% b) 33~50% c) 41~60% d) 58~70% 2. Based on the study in this article, higher BMI led to ______ outcomes.a) poorer b) better c) same as lower BMI d) unsure

3. It was estimated by the American Academy of Orthopedic Surgeons in 2007 that _____ total joint procedures are per-formed annually.a) 250,000 b) 375,000 c) 550,000 d) 750,000

4. Typical age for a THA is ___, and the majority of proce-dures in the United States are done for individuals _____ years old.a) 55; >50 b) 66; >60 c) 77; >70 d) 88; >80

CME QUESTIONS FILE THE FOLLOWING QUESTIONS ARE BASED ON THE FORGOING ARTICLES: Workers’ Compensation in Disability Medicine and the Case for Certification of Non-physician Healthcare Workers (page 2)Please pick the best answer of the 4 possible answers from the following

1. By 20th Century all states in U.S. required an examination to obtain a license to practice medicine, the National Board of Medical Examiners (NBME) was founded in 1915, the first national examination was conducted in:a) 1918 b) 1917 c) 1916 d) 1915

2. Professional certification is a (an):a) Designation earned by a person to assure competency to perform professional duties.b) Acknowledgement of educational achievement.c) Agency sponsorship intended to safeguard the public interestd) Individual honor and award

3. The theory that has been studied as to the efficacy of licensure/certification of an occupational group is:a) The Capture Theoryb) The Public Interest Theoryc) The Political Economy Theoryd) All of the above

4. In June 2010, the Certified Workers’ Compensation Healthcare Provider certification (CWcHP) was released to the public by: a) American Medical Association (AMA).b) The International Sports Professionals Association (ISPA).c) American Educational Research Association (AERA) d) American Physical Therapy Association (APTA)

5. The main professions eligible for CWcHp certification are:a) PT & PTAs (Physical Therapist & Physical Therapist Assistant)b) OTR & OTAs (Occupational Therapist & Occupational Therapy Assistant)c) DPT & ATCs (Doctor of Physical Therapy & Certified Athletic Trainer)d) PT/DPT; ATC & OTR

6. The CWcHP examination is comprised of 100 multiple-choice questions, of these questions __ refer to clinical-based knowledge; __ refer to legal-based knowledge and the remaining __ refer to information regarding the relationship between practitioners and the employer of the patient, the ramifications of their recommendations and employer rights.a) 50%; 30%; 20%b) 60%; 30%; 10%c) 70%; 20%; 10%d) 80%: 15%; 5%

Please pick the best answer of the 4 possible answers from the following.

25


Turning the Tables: Using an Employee’s Own Actions to Defeat Their Workers’ Compensation Claim (page 10)

1. What was the basic principle underlying establishment of workers’ compensation programs?a) Injured workers would receive benefits if fault is the employers or indiscernible. b) Injured workers would receive benefits without regard to fault and employers in return would receive limited liability.c) Injured workers would receive limited liability and employers in return would receive benefits without regard to fault.d) Injured workers and employers receive equal benefits and limited liability.

2. What was the key loss to employers with the enactment of “no-fault” workers’ compensation systems?a) The loss of contributory negligenceb) The loss of comparative faultc) The loss of assumption of the riskd) All of the above

3. Despite differences between each state’s treatment of the traditional common law defenses, what is their one common theme?a) The claimed injury must casually relate to the employmentb) Early investigation into facts and circumstances surrounding a claimed work-injuryc) The claimed injury must have taken place on company propertyd) The claimed injury must have taken place during normal work hours

4. What are some examples of personal risks unrelated to employment?a) Intoxicationb) Assaults and fights where the employee is the aggressorc) Acts for purely personal benefitd) All of the above

5. What is an example of deviation from employment?a) Violation of company rulesb) Foul playc) Coverage for a co-workerd) Training

6. To bar or reduce a claim for workers’ compensation based on a violation of a safety rule, which of the following are items that the employer must prove?a) At the time of an injury, the employer had in effect a rule or policy requiring the employee’s use of the safety appliance.b) The employee willfully and intentionally failed or refused to follow the rule or policy.c) A and B.d) The rule or policy was sufficient to protect all employees from injury.

Please pick the best answer of the 4 possible answers from the following.

5.The APTA released an independent study course on THA in 2010. In this study, the available evidence indi-cates in the rehabilitation setting, conservative manage-ment should focus on_____.a) strengthening the hip musculature & manual therapy b) strengthening the hip musculature & exercise instruc-tionc) exercise instruction & manual therapyd) none above

6. For those patients that have a fracture of the femoral head and/or neck, a _____ may be performed. a) acetabular replacement b) hemiarthroplasty c) both A and B d) none above

26


Current Perspectives: Sleep Disturbance in Injured Workers and Their Recovery (page 17)Please pick the best answer of the 4 possible answers from the following.

1. What are some of the consequences of poor sleep quality?a) Use of more health careb) Low absenteeismc) Adequate job satisfactiond) Moderate medical expenditures

2. Both __________ and __________ performance is impaired in sleep deprived people as seen by deficits in creativity, concentration and car accidents.

a) Sensory, Somaticb) Somatic, Motorc) Cognitive, Motord) Sensory, Motor

3. With aging, sleep patterns __________.a) remain the sameb) Show an increase in sleep lengthc) Show a decrease in sleep lengthd) Qualitatively change to small reductions in sleep, less REM and deep sleep, more wakeups from sleep.

4. When we are sleep deprived, we expend more/less energy.

a) Moreb) Lessc) Neither more or less, everyone is differentd) Depends on the time of the year

5. Sleep loss due to Insomnia was associated with lost work performance due to ______________

a) Absenteeismb) Presenteeismc) Boredomd) Careless mistakes

6._______________ is a treatment option for injured/recovering workers with sleep disturbances.

a) Prescription medication aloneb) Cognitive Behavior Therapyc) Healthcared) Decaffeinated beverage

ANSWER KEY FOR CME QUESTIONS FROM DISABILITY MEDICINE VOL 10, #1Questions on page 3: Health Literacy and Occupational Disability: The Barrier to Positive Health Care Outcomes 1.D, 2.B, 3.C 4.D 5.A 6.C

Questions on page 8: Total Knee Arthroplasty Patients in Follow- Up Post-Physical Therapy: An Examination of Finding1.D, 2.C, 3.A, 4.C, 5.C 6.B

Questions on page 8: Multiple Hazards as a Basis for Complex Disability in Electrical Injury Survivors.1.C, 2.B, 3.D, 4.A, 5.B 6.B 7.D 8.C 9.D 10.C 11.B

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RESEARCH DIGESTAs the Journal continues to grow and add new and beneficial recurring sections, we are pleased to announce the advent of “Research Digest.” The busy practitioner generally finds him/herself not having the time to keep up with the literature. This new section of the Journal seeks to remedy this by providing succinct updates from relevant and recently published peer review articles of interest or our readership. We will make selections from various journals for each issue in order to provide as much breadth and exposure as possible. We hope you find this new enhancement to be of benefit to your work.

1. Medical Services for Claims 20 or More Years OldIt is likely that more than 10% of the cost of medical benefits for the workplace injuries that occur this year will be for services provided more than two decades into the future. That percentage has been growing and might continue to grow. This study looks at workers compensation medical services provided beyond 20 years after the injury, with a view toward anticipating: • Which medical service categories will account for the largest shares of costs • Future treatment and utilization that will drive those costs NCCI first looks at the demographics of claimants who are still being treated for job-related injuries that were suffered more than two decades ago. The focus then shifts from patients to their medical care, looking at medical costs by service and diagnosis categories. Some key findings concerning services provided from 20 to 30 years following the date of injury are as follows: • Patients are predominantly male, more so than can be explained by historical gender differences in the workforce • Deteriorating medical conditions of the more elderly claimants is not a main cost driver; indeed, claimants younger than age 60 cost more per year, per claimant, to treat than those older than age 60 • Relative to services within the first 20 years after injury, care provided later has a significantly greater portion of cost going for prescription medications, supplies, home health services, and the maintenance of implants, orthotics, and prosthetics.

REF: Lipton B, Robertson J, Corro D. Medical Services for Claims 20 or More Years Old. NCCI, Research & Outlook. Posted Date: January 21, 2013 .URL: https://www.ncci.com/documents/Med-Svcs-20yrs.pdf

2. American Medical Association Impairment Ratings and Earnings Losses Due to Disability

Over 21,600 work comp cases were studied to better understand the correlation between impairment ratings and earnings losses in an article, "American Medical Association Impairment Ratings and Earnings Losses Due to Disability" in the Journal of Occupational and Environmental Medicine.AbstractObjectives: To examine the association between impairment ratings and earnings losses.Methods: We conducted a case-control study of 21,663 workers' compensation claimants in California with impairment ratings under the AMA Guides, fifth edition. Earnings losses represented the percent difference between the earnings of cases and controls 3 years after disability onset.Results: Impairment ratings were strongly associated with earnings losses: losses for ratings of 1, 10, and 20 were 9.0%, 21.9%, and 34.6%, respectively (P < 0.01). Losses differed significantly across body regions. For example, losses were 21.0% for spine impairments compared with 18.4% overall (P = 0.014).Conclusions: Impairment ratings are accurate predictors of disability severity on average, but their

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ability to measure disability could be improved with additional information on how the relationship between ratings and earnings loss varies according to patient and injury characteristics.URL: http://journals.lww.com/joem/Abstract/2013/03000/AmericanMedical_Association_Impairment_Ratings.10.aspx?utm_source=Ennouncements+03-14-13&utm_campaign=Ennouncements+03-14-2013&utm_medium=emailREF: Seabury SA, Neuhauser F, Nuckols T. American Medical Association Impairment Ratings and Earnings Losses Due to Disability. JOEM: March 2013 - Volume 55 - Issue 3 - p 286–291. doi: 10.1097/JOM.0b013e3182794417

3. Alternative paradigm proposed for health and safety system As the health and safety system strives to keep up with today’s working world, the University of Washington’s Dr. Michael Silverstein has proposed a novel solution involving private workplace inspectors. He presented this idea at the Institute for Work & Health’s annual Nachemson lecture.Adopting an innovative prevention-based model that supplements traditional government oversight with a role for private-sector inspectors may enable regulatory standards and practices to keep pace with the changing world of work. This is according to Dr. Michael Silverstein, professor of Environmental and Occupational Health at the University of Washington’s School of Public Health, and long-time public administrator of occupational health and safety programs.Silverstein laid out his idea to roughly 140 attendees at the Institute for Work & Health’s annual Alf Nachemson Memorial Lecture, held in Toronto last November. Supportive of the recommendations in Ontario’s 2010 Report of the Expert Advisory Panel on Occupational Health and Safety, Silverstein suggested his plan shares many of the report’s tenets and may have legs north of the U.S.-Canada border.REF: At Work, Issue 71, Winter 2013: Institute for Work & Health, Toronto.URL: http://www.iwh.on.ca/at-work/71/alternative-paradigm-proposed-for-health-and-safety-

system?utm_source=Ennouncements+02-14-13&utm_campaign=Ennouncements+02-14-2013&utm_medium=email

4. Pharmaceutical Overdose Deaths, United States, 2010

Data recently released by the National Center for Health Statistics show drug overdose deaths increased for the 11th consecutive year in 2010.1 Pharmaceuticals, especially opioid analgesics, have driven this increase.2 Other pharmaceuticals are involved in opioid overdose deaths, but their involvement is less well characterized. Using 2010 mortality data, we describe the specific drugs involved in pharmaceutical and opioid-related overdose deaths.

REF: Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical Overdose Deaths, United States, 2010. JAMA. 2013;309(7):657-659. doi:10.1001/jama.2013.272

URL: http://jama.jamanetwork.com/article.aspx?articleid=1653518#ref-jld130001-1&utm_source=Ennouncements+02-28-13&utm_campaign=Ennouncements+02-28-2013&utm_medium=email

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JDM Manuscript Submission Guidelines The Journal of Disability Medicine (JDM) is an internationally circulated journal, acclaimed for bringing pragmatic insights to bear upon the prac-tice of physicians and others who regularly confront impairment, disability assessment and medical-legal issues. The journal includes articles and commentaries on topics of interest in disability medicine and related areas of law and policy. It also addresses issues in dis-ability medicine research and education and a broad range of other related topics, providing authoritative and comprehensive coverage of the growing field of disability medicine. Manuscripts must not be under simultaneous consideration by any other publication, before or dur-ing the peer-review process. Articles published in the JDM may not be published elsewhere without written permission from the publisher. Manuscripts should cite any other work by one or more of the co-authors that is relevant to the subject matter of the current submission or that used any of the same subjects, being reported in the cur-rent submission. This includes manuscripts that are currently under preparation, are being considered by journals, are accepted for publication, or already pub-lished. In any of these cases, the relationship to the current submission should be made clear. Articles intended for the “Current Perspec-tives” section of the JDM are solicited by the acquisi-tions editor, Chris E. Stout, PsyD, ([email protected]). Please do NOT submit articles for this section without prior approval of the topic by Dr. Stout; a query letter should be sent to Dr. Stout regarding pro-posed material, guest editors, or suggestions for this section.

Submissions Authors should submit manuscripts to Dr. Stout at [email protected] When manuscripts have been received by the editorial office, the corresponding author will be sent an acknowledgment giving an assigned manuscript number, which should be used with all subsequent

correspondence for anything related to that particular manuscript.

The following items are required for submission:1. Blinded manuscript including the abstract

and figures legends. No identifying informa-tion should appear in this manuscript. Please remove author names, initials, and institutions.

2. Journal Contributor Publishing Agreement and the JDM Author Disclosure Statement. These forms are available by request from Dr. Stout. The corresponding author must complete the forms and return them to JDM by e-mail.

3. A copy of the IRB or other agency approval if human subjects or health information were used.

Cover letter, acknowledgments, and suggested reviewers are optional. If a paper has more than 5 authors, a cover letter detailing the contributions of all authors should be included. Only those involved in writing the paper should be included as coauthors. Others should be listed as a footnote or acknowledg-ment. While there is no limit on the number of au-thors, no more than 12 will be listed on the masthead of the published article; additional authors will be listed at the end of the article.

Manuscript Formats Manuscript pages should be double-spaced with consecutive page numbers and continuous line numbers. The abstract should be included with the manuscript. Manuscripts should be 6000 words or fewer (including abstract and references). There are also limitations on figures, tables, and references; see guidelines below. Word format is preferred.

Manuscript PreparationAbstract: Abstracts should summarize the contents of the article in 350 words or less. The abstract should be structured in the following format:Background: In one or two sentences, summarize the scientific body of knowledge surrounding your study

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and how this led to your investigation.Hypothesis/Purpose: State the theory(ies) that you are attempting to prove or disprove by your study or the purpose if no hypothesis exists. Study Design: Identify the overall design of your study. See list below.Methods: Succinctly summarize the overall methods you used in your investigation. Include the study population, type of intervention, method of data col-lection, and length of the study.Results: Report the most important results of your study. Only include positive results that are statisti-cally significant, or important negative results that are supported by adequate power, Report actual data, not just P values.Conclusion: State the answer to your original ques-tion or hypothesis. Summarize the most important conclusions that can be directly drawn from your study. Clinical Relevance: If yours was a laboratory study, describe its relevance to disability medicine. Key Terms: Provide at least 4 key words for index-ing. What is known about the subject: Please state what is currently known about this subject to place your study in perspective for the reviewers. What this study adds to existing knowledge: Please state what this study adds to the existing knowledge. The last two items are for reviewers only and are not included in the word count, but should appear at the end of the abstract in the uploaded text.

Study DesignsMeta-analysis: A systematic overview of studies that pools results of two or more studies to obtain an overall answer to a question or interest. Summarizes quantitatively the evidence regarding a treatment, procedure, or association. Systematic Review: An article that examines pub-lished material on a clearly described subject in a

systematic way. There must be a description of how the evidence on this topic was tracked down, from what sources and with what inclusion and exclusion criteria.Randomized Controlled Clinical Trial: A group of patients is randomized into an experimental group and a control group. These groups are fol-lowed up for the variables/outcomes of interest. Crossover Study Design: The administration of two or more experimental therapies one after the other in a specified or random order to the same group of patients. Cohort Study: Involves identification of two groups (cohorts) of patients, one which did receive the exposure of interest, and one which did not, and following these cohorts forward for the outcome of interest. Case Series: Describes characteristics of a group of patients with a particular disease or who have un-dergone a particular procedure. Design may be pro-spective or retrospective. No control group is used in the study, although the discussion may compare the results to other published outcomes.Case Report: Similar to the case series, expect that only one or a small group of cases is reported. Descriptive Epidemiology Study: Observational study describing the injuries occurring in a particu-lar sport.Controlled Laboratory Study: An in vitro or in vivo investigation in which 1 group receiving an experimental treatment is compared to 1 or more groups receiving no treatment or an alternate treat-ment.Descriptive Laboratory Study: An in vivo or in vitro study that describes characteristics such an anatomy, physiology, or kinesiology of a broad range of subjects or a specific group of interest. Authors should choose the design that best fits the study. The Editor will make the final determination of the study design and level of evidence based on the Center of Evidence Based Medicine guidelines.

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Text In general, follow the standard IMRAD (Intro-duction, Materials and Methods, Results, Discussion) format for writing scientific articles. The author is responsible for all statements made in the work, includ-ing copyeditor changes, which the author will have an opportunity to verify. Papers including human sub-jects must include a statement of approval by ap-propriate agencies in the text, and a copy of the ap-proval letter must be uploaded with the submission. The institution should not be mentioned in the blinded manuscript, but should be added on acceptance. Use generic names of drugs or devices. If a par-ticular brand was used in a study, insert the brand name along with the name and location of the manufacturer in parentheses after the generic name when the drug or device is first mentioned in the text. Use metric units in measurements (centimeter vs. inch, kilogram vs. pound). Abbreviations should be used sparingly. When abbreviations are used, give the full term followed by the abbreviation in parentheses the first time it is men-tioned in the text, such as femur-ACL-tibia complex (FATC). Use of a CONSORT flow diagram is recom-mended to illustrate the grouping and flow of patients in all clinical studies, whether randomized clinical trials or otherwise. See www.consort.com for further details. Statistical methods should be described in detail. Actual P values should be used unless less than .001. Reporting of 95% Confidence Intervals is encour-aged.

Acknowledgment Type the acknowledgments in the box provided on the submission page. Give credit to technical assis-tants the professional colleagues who contributed to the quality of the paper but are not listed as authors. Please briefly describe the contributions made by persons be-ing acknowledged.

References References should be double-spaced and comply with the AMA manual. Check style in the 10th edition. Except for review articles, references should be limited to 60. When au-thor entries are the same, alphabetize by the first word of the title. In general, use the Index Medicus form for abbreviating journal titles and the AMA Manual of Style (10th ed) for format. Note: References must be retrievable. Do not include in the reference list meeting presenta-tions that have not been published. Data such as presentations and articles that have been submit-ted for publication but have not been accepted must be put in the text as unpublished data im-mediately after mention of the information (for example, “Smith and Jones (unpublished data, 2000) noted…”). Personal communications and other references to unpublished data are discouraged. For review purposes, unpublished references that are closely related to the submit-ted paper or are important for understanding ti should be uploaded as supplemental files. References will be linked to Medline citations for the reviewers. To ensure that the references are linked correctly please provide the PMID number from Medline at the end of the reference. For further help with AMA style please look at the following websites: http://healthlinks.washington.edu/hsl/style-guides/ama.html http://www.docstyles.com/amastat.htm

Generally, references should not be older than five years. Try to limit references to 25 because of space constraints. Use primary references whenever possible. Do not use refer-ence material available only online and only by subscription; most readers will not be able to access it without paying a fee. If you use an ar-ticle that appears in a subscription journal that is available both online and in print, include both the URL and the print reference information ac-

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cording to AMA style (see reference examples below). That way, readers without a subscription can access the article without cost at a library. Number the footnotes consecutively in the text. Once a citation has a number, it keeps it throughout the narrative, and it should cor-respond to the numeric order of the reference list. For examples of this style see the following:

Reference Guidelines

General Rules

1. Use AMA style. (Refer to AMA Manual of Style, 10th edition.)

2. List footnoted citations under a "Reference" head-ing. Number citations consecutively in the text. Once a citation has a number, it keeps it throughout the narra-tive.

3. List general references not specifically cited in the text under a "Bibliography" heading.

4. Abbreviate journal names according to AMA style. (i.e., according to the National Library of Medicine ab-breviations. For more information go to www.nlm.nih.gov/pubs/factsheets/constructitle.html).

Examples of Citations

• Up to six authors, list all Hron G, Kollars M, Binder BR, Eichinger S, Kyrle PA. Identification of patients at low risk for recurrent venous thromboembolism by measuring thrombin gen-eration. JAMA. 2006;296:397-402.

• More than six authors, list first three, et al. Carpenter C, Fischl MA, Hammer SM, et al. Antiret-roviral therapy for HIV infection in 1997: updated recommendations of the international AIDS society, USA panel. JAMA. 1997;277:1962-1969.

• Books Sherlock S, Dooley, J. Diseases of the Liver and Bili-ary System. 9th ed. New York, NY: HarperCollins Publishers Inc; 2001.

• Books (chapter in edited book)

Schenk EA. Management of persons with neurologi-cal problems. In: Phipps WJ, Manahon Donovan F, Sands JK, Marek JF, Neighbors M. Medical-Surgical Nursing: Health and Illness Perspectives. 7th ed. St. Louis, MO: Mosby; 2002:1787-1865.

• CDs, Audiotapes, videotapes Wound Healing. [videotape]. Irvine, CA: Concept Media; 2006.

• Online materialIn citing data from a website, include the following elements (if available) in the order shown: Author(s), if given (often no authors are given). Title of the specific item cited (if none is given, use the name of the organization responsible for the site). Name of the website site. URL [provide URL and verify that the link still works as close as possible to publication]. Published [date]. Updated [date]. Accessed [date].

• Examples of online material:

Online journalsBurt RK, Loh Y, Pearce W, et al. Clinical applications of blood-derived and marrowderived stem cells for nonmalignant diseases. JAMA. 2008;299(8):925-936. http://jama.ama-assn.org/content/299/8/925.full. Pub-lished February 27, 2008. Accessed May 12, 2011.

WebsitesGuidelines and Recommendations: interim guidance about avian influenza (H5N1) for U.S. citizens living abroad. Centers for Disease Control and Prevention Web site. http://wwwnc.cdc.gov/travel/page/avian-flu-americans-abroad.htm. Published March 24, 2005. Updated January 13, 2011. Accessed May 12, 2011.

• Dissertation or master’s thesis Caruso E. An Examination of Organizational Mentor-ing: The Case of Motorola [dissertation]. London, England: University of London; 1990.

• Newspapers Include author (if given), title, name of newspaper, date of newspaper, section (if applicable), and pages. Newspaper titles are not abbreviated:

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Steinmetz G. Kafka is a symbol of Prague today; also, he’s a T-shirt. Wall Street Journal. October 10, 1996; A2, A6. • Poster Clawson LL. Treatment and research perspectives in amyotrophic lateral sclerosis: implications for nurses. Poster presented at: American Association of Neuro-science Nurses Annual Meeting, 1997, Houston, TX

Figures and Tables Figures and tables should not exceed 3 journal pages. One journal page equals 1 large table or figure, 2 medium-sized tables or figures, or 4 small tables or figures. Medium-sized tables and figures will be a page width and half the length of the page; small tables and figures are 1-column width and take up half the length of the page or less. Any materials that is submitted with an article that has been reproduced from another source (that is, has been copyrighted previously) must conform to the current copyright regulations. It is the author’s responsibility to obtain written permission for reproduction of copyrighted material and for providing the editorial office with that documentation before the material will be repro-duced in the Journal. Be sure to include figure legends in the text, to include figure legends in the text. The figure legend should include descriptions of each figure part and identify the meaning of any symbols or arrows. Terms used for labels and in the legend must be consistent with those in the text. All figures such as bar graphs and charges should be submitted in black and white. Figures for papers accepted for publication must meet the image resolution requirements of the publisher. Files for line-based drawings (no grayscale) should ideally be submitted in the format they were originally created. Charts and graphs can be submitted in the original form created (e.g., Word, Excel, or Power-Point). Photographs or scanned drawings embedded in Word or PowerPoint are not acceptable for publica-tion. If figures are embedded in the submitted manu-script for ease of reading they should also be submit-

ted as separate files for use in the publication process. All photographs of patients that disclose their identity must be accompanied by a signed photographic release granting permission for their likeness to be reproduced in the article. If this is not provided, the patient’s eyes must be occluded to prevent recognition. Tables should be numbered consecutively and have a title that describes the content and purpose of the table. Tables should enhance, not duplicate, information in the text.

Accepted Manuscripts Once an article is accepted and typeset, authors will be required to carefully read and correct their manuscript proofs that have been copyedited by the publisher. Any extensive changes made by authors on the proofs will be charged to authors at the rate of $2 a line. Authors are responsible for ordering reprints of their articles; a reprint order form is provided with the page proofs. Completed articles will be published on our website before print publication.

NIH-Supported Studies Authors of studies funded by grants from the National Institutes of Health can deposit a copy of their accepted final peer-reviewed manuscript and associated figure/table files (pre-typeset versions) to the NIH da-tabase after a 12-month embargo period from the time their article is published in the JDM.

Levels of Evidence Evidence-based practice is a conscientious, problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences, and a clini-cian’s expertise in making decisions about a patient’s care. Unfortunately, no standard formula exists for how much these factors should be weighed in the clinical decision making process. However, there are a variety of rating systems and hierarchies of evidence that grade the strength or quality of evidence generated from a research study or report. Being knowledgeable about evidence-based practice, and levels of evidence, is im-portant to every clinician as clinicians need to be confi-dent about how much emphasis they should place on a

34


study, report, practice alert or clinical practice guideline when making decisions about a patient’s care.

Gannett Education’s Rating System: The levels of evidence listed here have been de-veloped with the help of nurse experts and other indus-try resources. We thank those who have contribued to making our system relevant and applicable to determin-ing the levels of evidence that support our CE publica-tions. Evidence-based information ranges from Level A (the strongest) to Level C (the weakest):

Level A: Evidence obtained from:

Randomized control trials: the classic “gold standard” study design. In RCTs, subjects are randomly selected and randomly assigned to groups to undergo rigorously controlled experimental conditions or inter-ventions. Systematic review or meta-analysis of all rele-vant RCTs. A systematic review is a critical assessment of existing evidence that addresses a focused clinical question, includes a comprehensive literature search, appraises the quality of studies and reports results in a systematic manner. Meta-analysis a study design that uses statistical techniques to combine and analyze data from many RCTs. Clinical practice guidelines: based on system-atic reviews of RCTs. Evidence based clinical practice guidelines provide the strongest level of evidence to guide clinical practice because they are based on rigor-ous reviews of the best evidence on specific topics.

LEVEL B: Evidence obtained from:

Well-designed control trials without random-ization: In this type of study, random assignment is not used to assign subjects to experimental and control groups. Therefore, this type of research is less strong in internal validity because it can’t be assumed the sub-jects in the study are equal on major demographic and clinical variables at the beginning of the trial. Frequent problems with this type of study include intentional or unintentional bias in sample enrollment; nonblinding,

unclear criteria for participant selection; or unreliable or invalid tools.

Clinical cohort study: an examination of groups of people who have common characteristics or expo-sure experiences to compare outcomes in those exposed vs. outcomes in those not exposed (e.g., development of heart disease after exposure or nonexposure to 10 years of secondhand smoke). Case-controlled study: use of an observational approach in which subjects known to have a disease or outcome are compared with subjects known not to have that disease or outcome. Subjects are matched on char-acteristics so that they are as similar as possible except for the disease or outcome. Case-control studies are generally designed to estimate the odds (using an odds ratio) of developing the studied condition or disease and can determine if an associated relationship exists between the condition/disease and risk factors. Uncontrolled study: studies that do not control participant selection or interventions (e.g., a conve-nience sample, such as patients on a given unit, may be studied because it’s the only group reasonably avail-able). Epidemiological study: studies •that observe people over a long time to determine risk or likelihood of developing diseases. These studies include retrospec-tive database searches or prospective studies that follow a population over time. Qualitative study/quantitative study: descriptive, word-based phenomena, such as symptoms, behaviors, culture and group dynamics. Quantitative studies use statistical methods to establish numerical relationships that are correlational or cause and effect.

LEVEL C: Evidence obtained from:

Consensus viewpoint and expert opinion: a study that obtains agreement about specific practices from all clinical experts on a review panel. Expert opinion involves obtaining agreement from a majority of clinical experts on a review panel. Note: This level of evidence is used when there are no quantitative or qualitative studies in a particular area.

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Meta-synthesis: a systematic review that synthe-sizes findings from qualitative studies using an interpre-tive technique to bring small study findings, such as case studies, to clinical application.

Evidence-based Practice Resources:Agency for Healthcare Research and Quality Evidence-based Practice Centers (www.ahrq.gov/clinic/epc)

The Cochrane Collaboration:Cochrane Reviews (www.cochrane.org/cochrane-re-views)

Evidence-based healthcare (www.cochrane.org/about-us/evidence-based-health-care)

National Guideline Clearinghouse:(www.guideline.gov/index.aspx)

References for EBP:Alfaro-LeFevre R. Critical Thinking, Clinical Reason-ing, and Clinical Judgment: A Practical Approach. 5th ed. Philadelphia, PA: Elsevier-Saunders; In Press, 2011.Ebell MH, Siwek J, Weiss BD, et al. Strength of recom-mendation taxonomy (SORT): a patient centered ap-proach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548-556. http://www.aafp.org/afp/2004/0201/p548.html. Published February 1, 2004. Accessed May 12, 2011. Evidence-based medicine toolkit. American Academy of Family Physician Web site. http://www.aafp.org/on-line/en/home/publications/journals/afp/ebmtoolkit.html. Accessed May 12, 2011. Is all evidence created equal? University of Illinois at Chicago University Library Web site. http://www.uic.edu/depts/lib/lhsp/resources/levels.shtml. Updated March 7, 2008. Accessed May 12, 2011. Levels of evidence. Centre for Evidence-Based Medicine Web site. http://www.cebm.net/index.aspx?o=1025. Published March 2009. Updated April 15, 2011. Accessed May 12, 2011.

Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare. A Guide to Best Practice. Philadelphia, PA: Lippincott Williams & Wilkins. 2005. Newhouse RP, Dearholt SL, Poe SS, Pugh LC, White KM. Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines. Indianapolis, IN: Sigma Theta Tau International; 2007. Strength of Recommendation Taxonomy (SORT). American Academy of Family Physicians Web site. http://www.aafp.org/online/en/home/publications/jour-nals/afp/afpsort.html. Accessed May 12, 2011. Understanding research study designs. University of Minnesota Bio-Medical Library Web site. http://www.biomed.lib.umn.edu/guides/understanding-research-studydesigns. Accessed May 12, 2011.

CME Questions and Answers

JDM provides CME credits based upon sci-entific articles it publishes. Please provide along with your manuscript six multiple-choice questions with four responses each, with an answer key and an indica-tor of where the corresponding answers are located in the body of the document. One to five points of explanation for the correct answer of each of the six exam questions. The points of explanation should not be a restatement of the an-swer — rather new information related to the content in the module and to what the question is covering. Your explanation points should be succinct.

For example:1. Three risk factors for suicide include —a. Male gender, alcoholism and depression.b. Female gender, married and high income.c. Female gender, living in a city and on welfare.d. Female gender, physical illness and three children.Correct answer: a

Explanation/Rationale1. Males complete suicide at a rate four times that of females.2. The risk of suicide in alcoholics is 50% to 70%

36


higher than in the general population.3. A relationship exists between depression and suicide: The risk of suicide is increased by more than 50% in depressed people.

Tips for Writing Test Questions

• Keep the questions and answers brief: a maximum of 350 words total.

• Make all questions multiple choice with four possible options, “a,” “b,” “c” and “d.”

• Remember that test questions should measure mastery of the objectives. After you have written the test, check that it includes ques-tions relating to each objective.

• Make sure the correct option is derived from the narrative and defensible as the best an-swer.

• Be certain that the three incorrect options are plausible.

• Do not write “multiple-multiple” questions, that is, those that present a list of options, then ask the test taker to choose “a and b,” “a, b and c,” etc.

• Avoid the options “None of the above” and “All of the above”. Also, do not phrase ques-tions in the negative, for example, using “all of the following EXCEPT.”

• Limit yourself to one question that involves statis-tics, number of cases or the like. Examples: “What percentage of ventilated patients develop ventila-tor-associated pneumonia?” “How many cases of HIV/AIDS were recorded in the U.S. in 2008?” “What is the prevalence of migraine among U.S. women?”

• Use the same terminology in the test as in the nar-rative. (For example, if the narrative refers only to “hypertension,” use “hypertension,” not “high blood pressure,” in the test.)

• Be sure the order of questions matches the se-quence of information in the narrative, e.g., ques-tion No. 1 should correspond to the information appearing in the narrative first.

• Avoid using words in the correct option that are also found in the stem (the first part of the ques-tion). Doing so provides “clues” to the correct answer.

• Make sure options are not mutually exclusive. For example, if option “a” reads, “Slows the heart rate,” and option “b” reads, “Increases the heart rate,” these two options are mutually exclusive. The test taker can be reasonably certain that “c” and “d” are extraneous, and that either “a” or “b” is the correct answer.

• Be sure that one or more of your options are not included in another option. For example, if option “a” reads, “Affects the heart rate,” and option “b”

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