Ever since the Division of Workers' Compensation (DWC) in California issued sweeping changes in its payment structure and policies back in 2004, occupational therapists working in industrial rehab jobs across the country have been nervous.

In half a year, the DWC denied some $56 million in occupational therapy claims in the Golden State. OT had been knocked off the rehab team in Workers' Comp because the profession wasn't listed in the practice guidelines of the American College of Environmental and Occupational Medicine, the organization that decision-makers had chosen as their model for rehab treatment. A fast-paced joint study of the problem by AOTA and the Occupational Therapy Association of California (OTAC) corrected it, but not in time for many.

California clinics folded like card houses. One of them was Mary Foto's 13-year-old industrial rehab practice. "I gave up," said Foto, OT, FAOTA, CCM. "There was just no way I could keep it going."

Today the former AOTA president and longtime entrepreneur still has a consulting business in the industry but is spending much of her time teaching the powers that be about OT. Foto was named to the California Workers' Compensation Medical Evidence Committee, set up by the state legislature to evaluate the evidence base for proposed medical treatment guideline regulations the DWC published in July 2006.

"The guidelines are very, very good," Foto told ADVANCE enthusiastically last month. "There is probably only one that is diagnosis-based that I wish were different, and that's carpal tunnel. The reality is that there just is not evidence for [non-postsurgical] ongoing treatment for it."

In fact, most of the guidelines do relate to post-surgical medicine. "We have a very nice understanding about those visits and about the request for medical necessity beyond those visits," Foto said.

The committee was made up mostly of physicians, nine of them, in the fields of orthopedics, occupational medicine, acupuncture, psychiatry, pain, neurology and neurosurgery, family medicine, internal medicine and physiatry. Only OT, PT and chiropracty were included as non-medical professionals.

It all worked out much better than Foto had expected. "I was dreading it," she confessed. "But the committee was very receptive to occupational therapy, and all of the doctors supported us."

In fact, Foto will stay on for another two years as the committee continues to do research. Its model currently comes from the Academy of Physiatry.

Such OT "intervention" in medical politics will be key to whether or not occupational therapy achieves its 2017 Centennial Vision goal: to be a well-respected, well-positioned service provider in all six practice areas, one of which is work and industry. While that dream may be harder to make manifest in some arenas, doing it in industrial rehab is a real possibility.

In recent years, Workers' Compensation boards in several states have been changing their approach to getting people back to work. Transitional work programs, for instance, support job/jobsite accommodation that gets people back on the job as soon as they have medical clearance and can do some form of modified work. They may still be working on residual physical limitations in therapy, but therapy involves real work tasks graded to allow the worker to gradually work up to full skill and endurance levels.

Employers are also now asking for functional goals in industrial rehab. They want the process to simulate their employees' real work tasks as much as possible. Of course, all this is right up OT's alley, but there is a catch to it: transitional work programs require more resources than work hardening or clinic-based industrial rehab. Employers must team with medical professionals and safety experts to find alternative jobs or job tasks during the recovery period, and make accommodations when necessary. The cost comes out of the employers' pockets, and in the current economy, that's a problem.

"They often don't want to spend the money," said Melanie Ellexson, DHSc, MBA, OTR, FAOTA, associate professor of occupational therapy at Governors State University just south of Chicago. Those that have tried it have often been induced to do so by grant monies that Workers' Comp boards have been able to unearth for them or other funding that will offset the cost of the effort.

But it's hard evidence of savings that will convince companies to try this, and that's one big reason occupational therapists need to do their homework. The more providers can link occupation-based treatment strategies with savings to industry, the more employers will be interested in trying them.

The Evolution of Evidence

The latest trends in industry indicate that while the number of work injury claims is falling annually, the total cost of those claims has been rising, due mostly to the use of higher-tech diagnostics and treatment, more types of medical treatments, and litigation. The Providence Business News reported online in October 2007 that since the mid 1990s, the key factor driving up claims costs "has [not been] price, but growth in the number and mix of medical treatments." Between 1997 and 2002, for all diagnoses combined, the number of treatments for injured workers increased 45 percent. The use of physical therapy in that time period increased 67 percent! Because of the price rise, reimbursement has not kept pace, and therapists are feeling the bite.

These numbers are what led California to do what it has done, and they are leading other states to adopt newer ways of dealing with injured workers.

The federal Agency for Healthcare Research and Quality is behind the evidence-based practice phenomenon. In 1997 it established 12 evidence-based practice centers (EPCs) to develop assessments on treatment and other issues relative particularly to Medicare and Medicaid populations, with an eye to decreasing costs. AHRQ now reviews the validity of suggested clinical guidelines from private and public organizations and may accept them for its national guidelines clearinghouse.

One of its science "partners" is the Work Loss Data Institute (WLDI), an independent database development company with offices in California and Texas that produces products marketed to government, employers and Workers' Comp boards. Its Official Disability Guidelines provides benchmarking data for every reportable work injury condition.

WLDI has contributed clinical guidelines to AHRQ and publishes its own medical treatment guidelines for work-related conditions. WLDI's products seem to be becoming the standard for evidence-based medicine in industrial rehab, and they are very gradually being adopted in states across the country. WLDI has listed 10 goals that underlie its treatment approach. Two of them are:

• To. focus on restoration of functional capacity through. health care based on the best medical evidence, and

• To improve clinical practice. by indexing procedures adjacent to a summary of their effectiveness based on supporting evidence, provided by way of link, in abstract form.

AOTA is about to publish its own guidelines for evidence-based practice in industrial rehab, expected out sometime this spring. The Occupational Therapy Process for Assessment and Treatment of Individuals with Work Related Injuries and Illnesses will offer evidence-based interventions in the treatment of low-back; elbow; hand, wrist and forearm; and shoulder injuries, drawn from literature reviews on those topics.

Ellexson said that she has long used other resources out there to provide evidentiary support for treatment.

"I was asked to consult on a case in which the patient had compartment syndrome," she said, "as well as right-hand and arm deficits. The employer wanted information about one-handed work and using the good arm to assist, in order to continue occupational therapy. I pulled up data from O*NET that supported adapting work for that particular individual."

O*NET upgraded and replaced the former Dictionary of Occupational Titles, a resource that many professionals used to find information on particular jobs and the cognitive and physical skills necessary to do them. O*NET offers specific resources to aid in finding job accommodations it describes as "a change in the work environment, the way a specific job is performed, or the use of special equipment." These can be found online at the Job Accommodation Network, a division of the U.S. Department of Labor's Office of Disability Employment Policy.

Using Evidence

Last year Jim Mecham, MS, OTR/L, counseled his colleagues in industrial rehab in the Work and Industry SIS to look at the functional capacity evaluation (FCE) as the main tool in their tool chests. Mecham, who is certified as a professional ergonomist, suggested that they make sure all the tests they use are literature-backed (see "Under Closer Scrutiny," ADVANCE, July 8, 2008). The trick is to maintain standardized reliability (those factors that all people can do the same way) and to increase validity (tests that measure the clients' ability to do the actual or simulated job tasks).

AOTA has several online tools on its Web site at www.aota.org to help in searching for evidence to back treatment. The Evidence-based Practice Resource Directory links users to databases in occupational therapy, rehabilitation and health outcomes. These include national and international evidence-oriented sites from universities, government and private organizations.

Evidence Briefs are short summaries of level-I and -II studies that included control groups, which increase their validity, indexed by topic.

Critically-appraised topics (CATs) and critically-appraised papers (CAPs) are the products of AOTA's Evidence-based Literature Review Project. They are synthesized groups of articles that answer specifically focused literature review questions, as well as summaries of selected individual papers. Right now Workers' Compensation is one of five available topics under CATs. There are four questions that deal with the four treatment areas selected in AOTA's new guidelines for industrial rehab. The AOTA site also contains other resources for accessing and using evidence in practice.

'Work' in All Contexts

Ellexson believes that "work" should be considered occupationally in almost all practice arenas, including school-based, whether it be preparatory, transitional or actual. She is particularly happy that the Accreditation Council for Occupational Therapy Education (ACOTE) now includes in its Standards a requirement that OT schools specifically educate their students about environmental modification and adaptation processes (including using ergonomic principles).

"If we are to be true to our vision, and '[meet] society's occupational needs,' we must find ways to support and encourage the inclusion of work-related practice into both education and everyday practice," she told WISIS colleagues last year.

E.J. Brown is editor of ADVANCE.