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Guideline Summary
Guideline Title
Occupational therapy practice guidelines for individuals with work-related injuries and illnesses.
Bibliographic Source(s)
Kaskutas V, Snodgrass J. Occupational therapy practice guidelines for individuals with work-related injuries and illnesses. Bethesda (MD): American Occupational Therapy Association (AOTA); 2009. 176 p. [236 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Work-related injuries and illnesses, including:

  • Low back injuries and illnesses
  • Elbow injuries and illnesses
  • Injuries and illnesses of the forearm, wrist, and hand
  • Shoulder injuries and illnesses
Guideline Category
Evaluation
Management
Prevention
Rehabilitation
Treatment
Clinical Specialty
Chiropractic
Family Practice
Internal Medicine
Neurology
Orthopedic Surgery
Physical Medicine and Rehabilitation
Preventive Medicine
Psychiatry
Psychology
Rheumatology
Sports Medicine
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Chiropractors
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Utilization Management
Guideline Objective(s)
  • To provide an overview of the occupational therapy process for assessment and treatment of individuals with work-related injuries and/or illnesses that were sustained on the job
  • To define the occupational therapy domain, process, and intervention that occur within the boundaries of acceptable practice
  • To help occupational therapists and occupational therapy assistants, as well as the individuals who manage, reimburse, or set policy regarding occupational therapy services, understand the contribution of occupational therapy in treating individuals with work-related injuries and illnesses covered by state or federal workers’ compensation systems
  • To serve as a reference for health care practitioners, health care facility managers, health care regulators, third-party payers, managed care organizations, consumers, and families
Target Population

Individuals who experience work-related injuries or illnesses related to the low back, elbow, shoulder, forearm, wrist, or hand

Interventions and Practices Considered
  1. Evaluation
    • Developing the occupational profile
    • Analysis of occupational performance through observation and assessment
  2. Developing an intervention plan
  3. Intervention implementation through creating or promoting, establishing or restoring, maintaining, modifying (compensation/adaptation), and preventing deterioration of occupational performance
    • Interventions to the low back
    • Interventions to the elbow
    • Interventions to the forearm, wrist, and hand
    • Interventions to the shoulder
  4. Intervention review
  5. Documentation
  6. Discharge and discontinuation planning
  7. Follow-up
Major Outcomes Considered
  • Validity and reliability of assessment tools
  • Effectiveness of interventions
  • Pain intensity
  • Performance skills
  • Performance patterns
  • Body functions
  • Return to work
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Evidence-based Literature Review

Research Questions

The following four research questions guided selection of research studies for the review and interpretation of the findings:

  1. What occupational therapy interventions are effective in the rehabilitation of individuals with work-related low back injuries and illnesses?
  2. What occupational therapy interventions are effective in the rehabilitation of individuals with work-related elbow injuries and illnesses?
  3. What occupational therapy interventions are effective in the rehabilitation of individuals with work-related injuries and illnesses of the forearm, wrist, and hand?
  4. What occupational therapy interventions are effective in the rehabilitation of individuals with work-related shoulder injuries and illnesses?

For all questions, occupational therapy intervention approaches to be searched included restore, maintain, and modify.

Procedures

The group undertook a broad search to identify research reports for the review. Databases and sites searched included Medline, CINAHL, Ergonomics Abstracts, PsycInfo, OT Seeker, Pedro, TRIP, Rehab-Data, BIOSIS Preview, Science Citation Index, Social Work Abstracts, Healthstar, and NIOSHTIC–2. In addition, the search included consolidated information sources, such as the Cochrane Database of Systematic Reviews and the Campbell Collaboration. These databases are peer-reviewed summaries of journal articles and provide a system for clinicians and scientists to conduct evidence-based reviews of selected clinical questions and topics. In addition, the group checked reference lists from articles included in the systematic review for potential articles and hand searched the Journal of Hand Therapy.

The review authors, American Occupational Therapy Association (AOTA) staff, and a project consultant developed search terms for review by the advisory group. Terms used in the search are listed in Table A2 of the original guideline document. In addition, a filter based on one developed by McMaster University was used to narrow the search to research studies. The review author and the AOTA consultant reviewed the articles according to their quality (e.g., scientific rigor, lack of bias) and levels of evidence. Guidelines for reviewing quantitative studies were based on those developed by Law and colleagues (2002)* to ensure that the evidence is ranked according to uniform definitions of research design elements.

Articles were included in the review if they provided evidence for an intervention approach used in the rehabilitation of work-related injuries and illnesses of the low back, elbow, forearm, wrist, hand, and shoulder; had been peer reviewed; were published after 1986; and addressed an intervention approach within the domain of occupational therapy. Only studies determined to fit Level I, Level II, and Level III criteria were included (see "Rating Scheme for the Strength of the Evidence" field for definitions). Research studies were excluded if they were judged to be outside the domain of occupational therapy, were published before 1986, were Level IV or V evidence, used qualitative methods to the exclusion of quantitative methods, or were not peer reviewed. A total of 17,440 citations were reviewed, and 217 articles were reviewed to determine if they fit the criteria. The review authors, the AOTA consultant, and AOTA staff made the final selection of articles to be reviewed.

*Law M, editor. Evidence-based rehabilitation: a guide to practice. Thorofare (NJ): Slack; 2002.

Number of Source Documents

87 studies

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence Definition
Level I Systematic reviews, meta-analyses, and randomized, controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case control)
Level III One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The review authors critically appraised the 87 studies meeting inclusion criteria using structured categories, including study level, study design, number of participants, types of interventions and outcome measures, summary of results, study limitations, and implications of the study for occupational therapy.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

In May 2005, the American Occupational Therapy Association (AOTA) Representative Assembly passed a motion that, in part, directed AOTA to develop evidence-based occupational therapy treatment guidelines with an emphasis on the most prominent clinical conditions treated by occupational therapy practitioners and reimbursed by workers' compensation payers. An advisory group determined the priority clinical conditions that would serve as the focus of the systematic review. The advisory group was composed of members from within and outside of occupational therapy. The group also provided information on the top diagnoses in each area and the corresponding codes from the International Classification of Disease–Clinical Modification (ICD-9-CM; American Medical Association, 2008) in each area.

As a result of this collaboration, the advisory group developed four focused questions and search terms and recruited individuals to author reviews answering each question. All review authors are occupational therapists with content expertise in the area of persons with work-related injuries (workers' compensation). In addition, they had experience in reviewing the research literature from an evidence-based perspective. The review authors and an AOTA consultant, in conjunction with a medical librarian with experience in evidence-based reviews, searched the literature, selected research studies of relevance to occupational therapy, analyzed and critically appraised the studies, and summarized and synthesized the information with an emphasis on implications for occupational therapy practitioners.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendation

A - Strongly recommends that occupational therapy practitioners routinely provide intervention to eligible clients. The literature review found good evidence that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B - Recommends that occupational therapy practitioners routinely provide the intervention to eligible clients. The literature review found at least fair evidence that the intervention improves important outcomes and concludes that benefits outweigh harm.

C - Makes no recommendation for or against routine provision of the intervention by occupational therapy practitioners. The literature review found at least fair evidence that the intervention can improve outcomes but concludes that the balance of the benefits and harm is too close to justify a general recommendation.

D - Recommends that occupational therapy practitioners do not provide the intervention to clients. The literature review found at least fair evidence that the intervention is ineffective or that harm outweighs benefits.

I - Evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harm cannot be determined.

Note: Recommendation criteria are based on Standard Recommendation Language by the Agency for Healthcare Research and Quality (n.d.). Recommendations in this table are based on the findings of the evidence-based literature review in combination with content experts' opinions.

Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Initiation of Occupational Therapy Services

Interruption of a client's occupational performance can have many detrimental effects. Many clients begin to see themselves as "patients" whose role is to rest, take medication, and do stretching exercises. Therefore, it is important to help a client with a work-related injury or illness stay connected to his or her many roles, including the worker role. As soon as medically appropriate, the client should begin occupational therapy. The focus of assessment and treatment initially may be performance of daily self-care skills, but it will soon progress to performance of home, community, and work activities.

Work assessment can begin as soon as medically feasible. If the client has been in the patient role for an extended period, it may be difficult for him or her to envision resuming the worker role. The client must make this paradigm shift to succeed in work rehabilitation. Early work assessment will identify the client's work capacities to facilitate resumption of partial or restricted work duties at a level that is safe for the client. If a client begins work-focused occupational therapy early, the worker role will be maintained, and return to work will be easier. In some cases, the client may be able to return to work after the initial work assessment with only minor job accommodations. In other cases, the client must participate in an occupational therapy treatment program to achieve the tolerance levels needed to safely return to work.

Clients with limitations in their work performance are typically referred to the occupational therapist for evaluation and intervention. At times the referral may be for specific services, such as a functional capacity evaluation, work hardening, or work conditioning. The referral source should provide information including reason for referral, medical diagnosis, current treatment, medical clearance and restrictions, and current medications. In most states, the employer, insurance company, or client initiates the referral to occupational therapy. However, the occupational therapy practice act in many states requires a referral for occupational therapy services from a licensed physician or other health care professional. Several states require a physician's referral for treatment but not for occupational therapy evaluation or for prevention or ergonomic consultation.

In states where a physician referral is not required, many occupational therapy settings require a physician's referral to meet third-party payer requirements. Some settings require insurance preauthorization. Workers' compensation statutes and insurance requirements may also require a referral for services. If occupational therapy is being provided at the work site, the referral requirements dictated by the state occupational therapy practice act must be followed. The following are some common sources of referral for occupational therapy services:

  • Physicians of varying specialties, including but not limited to general practitioners, occupational medicine practitioners, physiatrists, orthopedists, neurologists, osteopaths, family medicine practitioners, internists, sports medicine practitioners, and psychiatrists
  • Case managers
  • Employers
  • Employee health nurses
  • Employer safety representatives
  • Human resource professionals
  • Workers' compensation insurance carriers
  • Third-party payers
  • Other rehabilitation providers
  • Psychologists
  • Social workers
  • Vocational evaluators and counselors
  • Attorneys
  • Chiropractic physicians.

Clients may self-refer in some states where a physician referral is not required.

Evaluation

The occupational therapist performs the evaluation in collaboration with the client on the basis of targeted information specific to the desired outcomes. The two elements of the occupational therapy evaluation are (a) the occupational profile and (b) the analysis of occupational performance. The occupational therapy evaluation process for a client with a work-related injury or illness is multidimensional. To establish a collaborative therapeutic relationship with the client early in the evaluation process, the occupational therapist first identifies the client's priorities to help guide the initial assessment. The desired outcome of treatment—engagement in work performance—serves as the focus of and drives the evaluation process.

Occupational therapists use a variety of assessment methods to perform the work performance evaluation, including client interview, observation, rating scales, questionnaires, diagrams, manual testing, performance testing, and work simulations. The occupational therapist may administer both standardized and nonstandardized assessments. Some assessments are compared to normative data, and others are compared to criterion-referenced data, namely the requirements of the job and the work setting. To understand the work environment and job demands, the occupational therapist uses a variety of assessment methods, including client interview, employer interview, job site analysis, and job description review and refers to national job data such as that provided by the Occupational Information Network (http://online.onetcenter.org/ External Web Site Policy).

The occupational therapy evaluation of a client with a work-related injury or illness is both client centered and job specific. The assessment of factors both intrinsic and extrinsic to the client provides the occupational therapist with a thorough understanding of the client's ability to function on the job (the client in his or her work context). The occupational therapist must ensure that any assessment instrument used is safe, reliable, and valid, a necessity in the highly litigious workers' compensation environment. The goal of the evaluation is to develop a fair and accurate understanding of the client's present work performance, potential to return to work, and interventions indicated to prepare for resumption of work duties.

Occupational Profile

The occupational therapist develops an occupational profile to gain an understanding of the client's perspective and background. Through both formal interviews and informal conversations, the occupational therapist learns what is currently important and meaningful to the client and identifies past experiences and interests that may contribute to the client’s current issues and problems. The purpose of developing the occupational profile is to determine who the client or clients are, identify their needs or concerns, and ascertain how these concerns affect engagement in occupational performance. Developing the occupational profile involves the following steps:

  • Identify the client or clients.
  • Determine why the client is seeking services.
  • Identify the areas of occupation that are successful and the areas in which the client is experiencing problems.
  • Discuss significant aspects of the client's occupational history.
  • Determine the client's priorities and desired outcomes.

Analysis of Occupational Performance

The occupational therapist uses information from the occupational profile to focus on the specific areas of occupation and the context to be addressed. The following steps are generally included in analyzing occupational performance:

  • Observe the client as he or she performs the occupations in the natural or least restrictive environment (when possible), and note the effectiveness of the client's performance skills (e.g., motor and praxis, sensory–perceptual, emotional regulation, cognitive, communication and social) and performance patterns (e.g., habits, routines, roles).
  • Select specific assessments and assessment methods that will identify and measure the factors related to the specific aspects of the domain influencing the client's performance.
  • Interpret the assessment data to identify what supports or hinders performance.
  • Develop or refine a hypothesis regarding the client's performance.
  • If intervention is indicated, develop goals in collaboration with the client that address the client's desired outcomes. The desired outcome of work performance as previously performed may or may not be possible.
  • Identify potential intervention approaches, guided by best practice and the evidence, and discuss them with the client.
  • Document the evaluation process, and communicate the results to the appropriate team members and community agencies. Interested parties may include the physician, the employer, workers' compensation insurance personnel, and the case manager.

Areas of Occupation

The main occupation of concern for clients with work-related injuries is work performance. However, the client's performance in other areas of occupation, such as driving, home maintenance, and leisure tasks, can affect the client's overall well-being and capacity to perform work tasks. Therefore, the occupational therapist may discuss or observe performance of these tasks during the evaluation process.

The occupational therapist gathers predictive evaluation data regarding the client's ability to return to work primarily through work performance testing. The therapist usually observes simulated or actual performance of work activities (tasks) after he or she has evaluated the client's body structures, body functions, and performance skills and understands the requirements of the job. The therapist must understand the client's current impairments to ensure that the client's safety is maintained throughout the assessment. These impaired functions may not necessarily be directly related to the current work-related injury, but they may be critical for safe work performance.

The occupational therapist closely monitors the client's tolerance for an activity and makes incremental increases in the work demands until the client reaches his or her maximum safe level of performance. The therapist observes the client’s work habits and ability to compensate for impairments and to manage his or her pain or other symptoms. The impact of the client’s impairments in body functions and performance skills on his or her ability to perform job tasks will become apparent during work performance testing, as will the client's habits and routines.

Performance Skills

The occupational therapist evaluates overt and subtle factors that may affect work performance. Performance skills are the abilities clients demonstrate in the actions they perform. The five types of performance skills are motor and praxis, sensory–perceptual, emotional regulation, cognitive, and communication and social skills.

Table 1 in the original guideline document summarizes the performance skill areas and provides work-related examples.

Client Factors

Client factors are specific abilities, characteristics, or beliefs that reside within the client and may affect performance in areas of occupation. The client factors include body functions; body structures; and the client's values, beliefs, and spirituality. These underlying client factors are affected by the presence or absence of illness, disease, deprivation, and disability. The client factors support the performance skills.

Body functions within the occupational therapy practitioner’s domain of practice and work-related examples are outlined in Table 2 in the original guideline document.

Performance Patterns

Performance patterns "refer to habits, routines, roles, and rituals used in the process of engaging in occupations or activities." Performance patterns help occupational therapy practitioners understand the frequency and manner in which performance skills and occupations are integrated into the client's life. Adaptive habits and routines may help a client compensate for impairments in body functions and performance skills.

During the evaluation process, the occupational therapist begins to identify habits and routines that are useful and detrimental to the client in the workforce.

Context and Environment

Occupational therapists acknowledge the influence of cultural, personal, temporal, and virtual contextual factors and physical and social environmental factors on occupations and activities.

Cultural Factors

The evaluation process should include awareness of the client's cultural beliefs and behaviors regarding work. The occupational therapist should identify beliefs or client information that is critical to a successful return to work.

Personal Factors

Some client personal attributes, such as gender, socioeconomic status, age, and level of education, should be factored into the evaluation process.

The occupational therapist must ensure that the assessment is not discriminatory due to use of age- or gender-driven norms or differences in testing protocols on the basis of personal attributes.

Temporal Factors

The occupational therapist must consider the temporal context when working with a client recovering from a work-related injury or illness. On the client level, temporal context may refer to the point in the person's life span.

Temporal context also may refer to the point in the progression of or recovery from an injury or disease, such as the preventive, acute, or rehabilitative phase or the long-term process of dealing with a chronic illness.

On a smaller scale, temporal context refers to the amount of time the client is capable of participating in the evaluation. The occupational therapist can make a more accurate appraisal of a client's ability to work if the assessment schedule simulates the normal work schedule.

Virtual Factors

Interface with the virtual environment is required at some workplaces; therefore, occupational therapists in rehabilitation settings may assess related skills. Many workers are required to use virtual communication through airways or computers to substitute for physical contact. They may navigate the Internet and communicate via e-mail, videoconferencing, or radio transmissions. The therapist may use similar technologies to assess the client's ability to use the workplace virtual environment. In addition, occupational therapists may use work simulation equipment, driving simulators, and other virtual technology during rehabilitation to assess the client's performance skills and simulate job demands.

Physical Factors

The physical environment must be considered during the evaluation and treatment process. The physical environment at the workplace must be conducive to the client's recovery.

To ensure a successful return to work, the physical environment at the workplace may need to be modified to support the client's performance within his or her capacities. The occupational therapist is well prepared to analyze the workplace and make appropriate environmental modifications to support work performance.

Social Factors

Many social factors in the home, community, rehabilitation setting, and work site affect recovery. During rehabilitation, the client's relationships with the physician, rehabilitation team, case manager, insurance company, and employer are important, as are the client's social interactions in the family and community.

The occupational therapist in collaboration with the rehabilitation case manager can facilitate communication among the individuals in the client's social environment.

Activity Demands

Activity demands refer to the specific features of a task that influence the type and amount of effort required to perform the activity. The occupational therapist must understand the demands of the various activities that make up the client's job to make an accurate assessment of the client's ability to work. These factors may include the work tasks that the client performs; work procedures and processes; productivity expectations; the design of the work space; the equipment, materials, and tools used on the job; time demands; and the skills and functions required to perform job tasks. The occupational therapist uses information about the job to guide aspects of the evaluation process such as simulating the work environment, work pace, and work tasks and selecting the required performance skills and body functions to be evaluated.

Considerations in Using Assessments

The occupational therapist designs an assessment battery that is tailored to meet the individual needs of the client. Each assessment in the battery should be safe, reliable, valid, and practical according to the National Institute for Occupational Safety and Health (NIOSH).

Legal and Professional Guidelines and Standards

The occupational therapist follows all national and state guidelines that govern assessment in occupational therapy. When decisions affecting employment are being made, the therapist must adhere to the federal guidelines for employee testing described in the Uniform Guidelines for Employee Selection (U.S. Department of Labor, 1978). These guidelines require that a test not discriminate on the basis of gender, race, or age. When testing individuals with disabilities, the therapist must comply with the Americans With Disabilities Act (ADA; 1990). The therapist must make reasonable accommodations during the assessment, including allowing use of mobility devices, assistive technology, and modified testing methods. Although these accommodations may decrease the reliability of the test, they will ensure the safety of the client and improve the usefulness of the results. The U.S. Department of Labor Web site describes many employment laws (http://www.dol.gov/compliance/laws/main.htm External Web Site Policy).

Occupational therapists should follow the Occupational Therapy Practice Framework when performing assessments, including work assessments (see "Availability of Companion Documents" field). In addition, occupational therapists may adhere to guidelines from other professional organizations when performing a work evaluation, such as the guidelines developed jointly by the American Educational Research Association, the American Psychological Association, and the National Council on Measurement in Education and those of the American Congress of Sports Medicine.

The Functional Assessment Network, affiliated with McMaster University in Hamilton, Ontario, Canada, has developed guidelines for the assessment of individuals with work-related injuries. This network's guidelines address assessments that measure a client’s ability to perform work. (http://www.fhs.mcmaster.ca/rehab/FA%20Guidelines.pdf External Web Site Policy).

Guidelines and Standards for Safety, Reliability, and Validity

In order to meet NIOSH criteria for the development and selection of work-related assessments, the assessment must demonstrate safety, reliability, validity, practicality, and utility. The following hierarchical framework for testing derived from these guidelines and standards is very useful when performing work assessment:

  1. Safety—The client's safety must be the first priority of the therapist throughout the assessment.
  2. Reliability—The results should be consistent across therapists and clients and from one time to the next.
  3. Validity—The results should reflect the client's true ability.
  4. Practicality—The costs, interpretation, and reporting should be reasonable and useful.

As with all hierarchies, criteria toward the top of the list are more important than those lower on the list. Therefore, if the test instrument has high reliability but the safety of the client cannot be maintained throughout the assessment, the results are not meaningful. Refer to the original guideline document for more information on safety, reliability, validity, and practicality of work assessments.

Standardized Evaluation Instruments and Batteries

Sample assessments that are potentially useful in work evaluations are listed in Table 3 in the original guideline document. Standardized assessments require a methodical process of administration and result in quantifiable information that compares to a norm group or a specific criterion, and research is usually available to demonstrate that the assessment actually is measuring what it claims to assess (validity). Therapists using standardized assessments must follow the procedure outlined in the administration manual and interpret the results as instructed, including ensuring that the client is similar to the norm group in age, diagnosis, and setting or that the reference criterion is accurate for the client's situation.

Role of Pain in the Work Assessment Evaluation

Clients referred for an occupational therapy work evaluation may be experiencing residual pain from the damaged body structures or the resultant limitations. The presence of pain does not mean that a client cannot work; however, pain can distract the client’s focus from the job duties and affect job safety and performance.

The occupational therapist seeks to understand the client's pain and its effect on performance. Throughout the work evaluation, the therapist uses instruments to measure the client's pain and observes the client's pain-related behaviors and ability to manage symptoms. By forming a therapeutic relationship with the client and gaining an understanding of the client's pain-related behaviors and management strategies, the therapist can make appropriate decisions regarding the progression of the work evaluation. If the client is taking medication to manage pain, the occupational therapist usually instructs the client to take the medication as prescribed during the evaluation. If the medication affects a client's ability to drive or operate machinery, the therapist takes this into consideration when making return-to-work recommendations. Some pain medications can affect a client’s mood, energy, cognition (e.g., concentration, processing speed), sensory functions (e.g., vision, balance), or motor functions (e.g., coordination, speed of movement). Therefore, the therapist proceeds with testing in line with the findings of the safety screen. If the client will not be allowed to work on the current medication regimen, it is best for the physician to wean the client off the medication before the evaluation so that the therapist can accurately appraise the client's capacity to work.

Evaluation Outcomes

A critical step in the occupational therapy evaluation process is the synthesis of the assessment results. The occupational therapist writes an evaluation report summarizing the results of the evaluation and making recommendations for future care. If treatment is indicated, the report includes a comprehensive intervention plan. If the evaluation is to determine if the client is able to return to work, the report compares the client's performance and results of the various assessments with the activity demands of the job and the contextual requirements of the work environment and makes recommendations regarding the client's return to work. If modifications to the work tasks, equipment or tools, or environment are needed to support the client's return to work, the evaluation report identifies them. If the client lacks the capacity to return to the job and the therapist believes that the client has the potential to return to work following occupational therapy intervention, the report recommends continued treatment and estimates rehabilitation potential. The evaluation report identifies areas that support and limit performance and problems related to the client's occupations, particularly work performance, but also performance in other daily activities and occupations such as self-care, home management, and leisure, which may have an effect on work performance.

Intervention

Intervention Plan

As part of the occupational therapy process, the occupational therapist develops an intervention plan that documents the client's return-to-work goals, the treatment approaches, and recommendations or referrals to other professionals if indicated. The plan outlines and guides the therapist's actions and is based on selected theories and frames of reference and the best available evidence to meet the identified outcomes.

The intervention plan includes different components depending on the results of the evaluation, the client's goals, the client's health status, and contextual factors.

In the intervention plan, the occupational therapist identifies intervention approaches to be used, as well as specific short- and long-term treatment goals. The long-term goals reflect functional levels of performance for the various occupations required for the client's specific situation. Goals included in the plan are specific and measurable, including the level of performance and time frame for achievement. The goals of treatment may vary during different phases of recovery.

Intervention Implementation

Treatment begins soon after the initial evaluation. The frequency of sessions varies, depending on the physician's orders, the occupational therapist's recommendations, and the client's situation, but usually ranges from daily to once or twice per month. The frequency of treatment may or may not be associated with the phase of recovery. The duration of the treatment session may also vary; session length may increase from weekly 30-min outpatient therapy visits to 3- to 8-hr work hardening sessions.

Factors that influence the intervention plan include the client's current and previous occupations, diagnosis, acuteness or chronicity of the condition, previous and current medical history, age, fitness level, other treatments (e.g., medication, surgery, therapy), availability for treatment, setting, preferences, physician's orders, compliance and follow-through, pain tolerance, and self-limiting behavior.

Occupational therapy practitioners tailor intervention approaches to enable clients to meet their goals.

The intervention approaches used may vary during the course of treatment and from client to client. Because the long-term goal of occupational therapy is to improve the client's occupational performance, the therapist uses the approaches that best match the client's needs. Occupational therapy intervention approaches, typically used in combination, include the following:

  • Create or promote occupational performance
  • Establish or restore occupational performance
  • Maintain occupational performance
  • Modify occupational performance
  • Prevent deterioration of occupational performance

Examples of occupational therapy interventions under the rubric of these five approaches as outlined in the Framework (see "Availability of Companion Documents" field) are provided in the table below. The occupational therapist considers the types of interventions available when determining the most effective treatment plan for a given client. The types of interventions include therapeutic use of self; therapeutic use of occupations and activities, which include occupation-based interventions, purposeful activity, and preparatory methods; consultation; advocacy; and education.

Table: Intervention Approaches and Examples of Occupation-Based Goals for Clients with Work-Related Injuries

Approach Focus of Intervention Examples of Occupation-Based Goals

Restore/remediate: Designed to change client variables to establish a skill or ability that has been impaired*

Body structures

Perform tendon-gliding exercises to allow finger to tightly grasp gun trigger

Body functions

Perform finger tapping quickly and accurately to prepare to type

Performance skills

Lift 50-lb box from floor to waist

Performance patterns

Establish appropriate rest–work cycle during assembly line work

Occupation

Accurately type monthly report

Modify, compensate, adapt: Designed to find ways to revise the task, method, or environment to support performance*

Body functions

Use jar opener to compensate for grip loss on the job

Performance skills

Use scooter for mobility from the parking lot

Occupation

Use voice activation software for word processing

Context

Lower desk height to avoid bending during pipette task

Activity demands

Reduce the weight of the load lifted overhead

Maintain: Designed to provide the supports that will preserve the performance capabilities clients have regained so they can continue to meet their occupational needs

Body functions

Perform exercise program to maintain fitness level for work

Performance skills

Use proper body mechanics while transferring patients

Context

Maintain clear walkways in work area to avoid falls while carrying

Performance patterns

Develop habit of wearing back brace when handling heavy loads

Prevent: Designed to prevent performance problems by supporting body structures and functions, performance skills, environment, and habits and routines

Performance patterns

Perform stretch before work shift and hourly throughout work day

Context

Use sit/stand workstation for typing tasks

Body functions

Use overhead lift to perform all lifting tasks

Activity demands

Decrease number of repetitions required on assembly line

Create/promote: Does not assume a disability is present or any factors interfere with performance; designed to provide enriched contextual and activity experiences that enhance performance for all persons in the natural contexts of life *

Context

Design barrier-free workplace

Body functions

Establish on-site wellness programs to promote fitness

Activity demands

Use assistive technology to eliminate manual material handling on the job

*Reference: Dunn, W., McClain, L. H., Brown, C., & Youngstrom, M. J. (1998). The ecology of human performance. In M. E. Neistadt & E. B. Crepeau (Eds.), Willard and Spackman's occupational therapy (9th ed., pp. 525–535). Philadelphia: Lippincott Williams & Wilkins.

Intervention Review

Intervention review is a continuous process of reevaluating and reviewing the intervention plan, the effectiveness of service delivery, and progress toward targeted outcomes. Reevaluation may involve readministering assessments or tests that were used at the time of initial evaluation, having the client complete a satisfaction questionnaire, or answering questions to evaluate each goal. Reevaluation substantiates progress toward goal attainment; indicates any change in functional status; and directs modifications to the intervention plan, if necessary.

When treating a client who is unable to work and is receiving workers' compensation benefits, the occupational therapist regularly reviews the client's progress and determines if return to work is safe and feasible.

Documentation

Occupational therapy practitioners carefully document their services in the areas of evaluation, intervention, and outcomes. For clients with work-related injuries or illnesses, practitioners document their recommendations related to work limitations and communicate them to the employer, physician, and other team members.

The following types of documentation may be completed for each client, as required by legal requirements, the practice setting, third-party payers, or some combination of these:

  • Evaluation or screening report (including functional capacity evaluation report)
  • Occupational therapy service contacts
  • Occupational therapy intervention plan
  • Progress report
  • Prescription or recommendation for adaptive equipment
  • Reevaluation report
  • Discharge or discontinuation report

Discharge and Discontinuation Planning

Planning for discharge begins with the initial evaluation and continues during each subsequent visit. The occupational therapist must have a thorough understanding of the job duties and the work environment before recommending return to work. If the therapist determines that there is a match between the client’s work capacities and the work requirements, he or she initiates the return-to-work process, which may require modifications in the work duties, work schedule, and work environment or the use of devices or equipment the client needs to return to work. The occupational therapist documents these recommendations and describes current work capacities in the discharge or discontinuation report. If the client is still progressing in occupational therapy and continued treatment is indicated even though the client is returning to work, the report recommends continuation of care. If a client stops making progress in treatment or has reached a plateau, the report recommends discontinuation of treatment. At the time of discharge from services, some clients still do not demonstrate the capacity to return to work. In the discharge or discontinuation report, the occupational therapist outlines the client's present work capacity so that he or she can move on to the next phase of the process, be it disability determination, vocational rehabilitation, retirement, or other medical procedures.

Outcomes and Follow-Up

Potential outcomes of an occupational therapy program designed to facilitate the return to work include the client's return to his or her previous job on a full-time basis, return to the job with modified work duties or work schedule or light-duty work, transfer to a new job, or remaining off work. The occupational therapy practitioner follows up with clients who have returned to full-duty or modified work. Ongoing consultation with the employer may be needed to monitor the worker's response to the work duties and environment, to identify additional adjustments to the work modifications to best match the client's current capacities and prevent future injuries, and to recommend the resumption of full work duties when appropriate.

Recommendations (See Definitions for Recommendation Grades [A, B, C, D, I] at the end of the "Major Recommendations" field)

Table: Recommendations for Occupational Therapy Interventions for Clinical Conditions of the Low Back

  Recommendation Level
Low Back Clinical Condition Recommended No Recommendation Recommended Against
General low back Work conditioning or hardening combined with cognitive–behavioral approaches (B)
Exercise instruction combined with proper body mechanics training (back schools) in an occupational setting (B)
Environmental modifications (work site visit, ergonomic modifications) (B)
Heat wrap therapy for acute or subacute pain (B)
General back and abdominal strengthening (C)
Participation in nonspecific physical activities (e.g., walking at least 3 hours per week) (C)
Back-school training (C)
Application of cold (I)
Transcutaneous electrical nerve stimulation (I)
Bed rest (D)

Table. Recommendations for Occupational Therapy Interventions for Clinical Conditions of the Elbow

  Recommendation Level
Elbow Clinical Condition Recommended No Recommendation Recommended Against
Epicondylitis   Exercise (C)
Ultrasound (I)
Splinting (I)
Ionization (C)
Deep transverse friction massage (C)
Low-level laser therapy (C
 

Table: Recommendations for Occupational Therapy Interventions for Clinical Conditions of the Hand, Wrist, and Forearm

  Recommendation Level
Hand, Wrist, or Forearm Clinical Condition Recommended No Recommendation Recommended Against
Carpal tunnel syndrome, repetitive strain Splinting (B)
Pulsed ultrasound (B)
Nerve gliding (B)
Yoga (I)
Ergonomic keyboard (I)
Biopsychosocial rehabilitation intervention (inpatient or outpatient program that includes a physician consultation plus a psychological, social, or vocational intervention or a combination of these) (I)
Continuous ultrasound (D)
Magnet therapy (D)
Burns Passive exercise and static wrapping for secondary joint stiffness (B)
Gel sheeting (B)
Sensory focusing for pain relief (B)
Massage (B)
Distraction for pain control (includes self-selected music and music appreciation training) (I)
Pressure garment work gloves (C)
 
Rheumatoid arthritis, osteoarthritis General low-intensity exercise (B)
Splinting for osteoarthritis (B)
Hand exercise for rheumatoid arthritis (I)  
Acute injuries and hand fractures Early mobilization (B)
Splinting (B)
Ice plus exercise (B)
   
Strain, sprain, tenosynovitis Ice plus exercise (B)
Splinting (B)
Deep transverse friction massage (I)
Ultrasound (I)
 
General hand, wrist, forearm conditions Activities that simulate ADLs (B)
Individual exercise (A)
Continuous low-level heat wrap therapy (B)
Prevention and treatment of hypertrophic and keloid scars with silicone gel sheeting (B)
Workplace rehabilitation interventions (I)
Keyboards with force key displacement or alternate geometry (I)
Ergonomic modifications in the workplace (I)
Low-level laser therapy (I)  

Table: Recommendations for Occupational Therapy Interventions for Clinical Conditions of the Shoulder

  Recommendation Level
Shoulder Clinical Condition Recommended No Recommendation Recommended Against
Neck and shoulder pain Exercise—both high and low intensity may be effective (B)
Training in Feldenkrais (B)
Low-level laser therapy (C)
Multidisciplinary biopsychosocial interventions (I)
Ultrasound (I)
 
Frozen shoulder (adhesive capsulitis) Cyriax method: deep friction massage and joint manipulation (B) Supportive therapy—less aggressive techniques (C)
Low-level laser therapy (C)
High-grade mobilization (C)
 
Rotator cuff tears   Exercise (C)
Ultrasound (I)
Low-level laser therapy (I)
Mobilization (C)
Electrotherapy (I)
 
Shoulder instability   Conservative program: 3–4 weeks of immobilization followed by range of motion (ROM) and stability exercises (C)
ROM and stability exercises used in isolation (I)
Electromyography biofeedback (C)
 
Calcific tendonitis   Ultrasound (C)
Pulsed electromagnetic field therapy (C)
 
Proximal humeral fractures   Early mobilization with graded exercise (C)
Self-instructed home program (C)
 
Thoracic outlet syndrome   Conservative therapy with graduated stretching and then strengthening (C)  
Subacromial impingement   Joint mobilization with exercise (C)
Low-level laser therapy in isolation (C)
Ultrasound (I)
 

Definitions:

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence Definition
Level I Systematic reviews, meta-analyses, and randomized, controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case control)
Level III One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72.

Strength of Recommendation

A - Strongly recommends that occupational therapy practitioners routinely provide intervention to eligible clients. The literature review found good evidence that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B - Recommends that occupational therapy practitioners routinely provide the intervention to eligible clients. The literature review found at least fair evidence that the intervention improves important outcomes and concludes that benefits outweigh harm.

C - Makes no recommendation for or against routine provision of the intervention by occupational therapy practitioners. The literature review found at least fair evidence that the intervention can improve outcomes but concludes that the balance of the benefits and harm is too close to justify a general recommendation.

D - Recommends that occupational therapy practitioners do not provide the intervention to clients. The literature review found at least fair evidence that the intervention is ineffective or that harm outweighs benefits.

I - Evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harm cannot be determined.

Note: Recommendation criteria are based on Standard Recommendation Language by the Agency for Healthcare Research and Quality (n.d.). Recommendations in this table are based on the findings of the evidence-based literature review in combination with content experts' opinions.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Among the studies supporting the recommendations, 76 were Level I, 3 were Level II, and 8 were Level III studies.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

This guideline may be used to improve quality of care, enhance consumer satisfaction, promote appropriate use of services, and reduce cost by assisting:

  • Workers' compensation insurers, third-party administrators, self-insured corporations, and case management firms in understanding the services occupational therapists and occupational therapy assistants can provide to clients on workers' compensation and the efficacy of these services in promoting return to work
  • Occupational therapy practitioners in communicating about their services to external audiences, such as workers' compensation case managers and claims reviewers
  • Physicians, other health care practitioners, employers, unions, and health care facility managers in determining whether referral for occupational therapy services would be appropriate
  • Legislators, third-party payers, and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants relating to programs to improve work performance
  • Program developers, administrators, legislators, and third-party payers in understanding the scope of occupational therapy services
  • Program evaluators and policy analysts in this practice area in determining outcome measures for analyzing the effectiveness of occupational therapy intervention
  • Occupational therapy educators in designing appropriate curricula that incorporate the role of occupational therapy related to evaluation and intervention for clients with work-related injuries and populations of workers
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • This guideline does not discuss all possible methods of care, and although it does recommend some specific methods of care, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given procedure in light of a person's specific circumstances and needs.
  • This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Kaskutas V, Snodgrass J. Occupational therapy practice guidelines for individuals with work-related injuries and illnesses. Bethesda (MD): American Occupational Therapy Association (AOTA); 2009. 176 p. [236 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009
Guideline Developer(s)
American Occupational Therapy Association, Inc. - Professional Association
Source(s) of Funding

American Occupational Therapy Association, Inc.

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors: Vicki Kaskutas, OTD, MHS, OT/L, Instructor in Occupational Therapy and Medicine, Washington University School of Medicine, St. Louis, MO; Jeff Snodgrass, PhD, MPH, OTR/L, CWCE, Program Director and Associate Professor, Occupational Therapy Program, Milligan College, TN, Part-Time Faculty, School of Health Sciences, College of Health Sciences, Walden University, Minneapolis, MN

Series Editor: Deborah Lieberman, MHSA, OTR/L, FAOTA; Program Director, Evidence-Based Practice, Staff Liaison to the Commission on Practice, American Occupational Therapy Association, Bethesda, MD

Evidence-based Literature Review: Debbie Amini, MEd, OTR/L, CHT; Marian Arbesman, PhD, OTR/L; Paula Bohr, PhD, OTR/L, FAOTA; Jeff Snodgrass, PhD, MPH, OTR/L, CWCE; Rebecca von der Heyde, MS, OTR/L, CHT

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone:1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online at the AOTA Web site External Web Site Policy.

Availability of Companion Documents

The following is available:

  • Occupational therapy practice framework: domain and process (2nd ed.). 2008. American Journal of Occupational Therapy (AOTA), 62, 625–683. Electronic copies: Available to subscribers from the AOTA Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on October 27, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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