Occupational therapy and the management of soft tissue injuries

Information for insurance adjusters

How would one describe the practice of occupational therapists?
In an accident benefits/ medical-legal process occupational therapists can assist with file resolution by providing information about the degree to which a soft tissue injury results in disability including ability to work, perform activities of daily living and home management tasks, and engage in recreational and social activities. Occupational therapists are university-trained, regulated health professionals with knowledge of not only the medical and physical limitations of injuries and/or impairments but also the psychosocial factors that impact return to normal living. Revenue Canada recognizes occupational therapy as a tax-deductible medical expense.

Each province and territory regulates the practice of occupational therapy through its respective regulatory organization. They protect the public interest by ensuring occupational therapists practise in a competent, safe and ethical manner. Occupational therapists must register with their regulatory organization in order to use the title “occupational therapists” or “OT”.

The acts governing occupational therapy practice may vary from province to province and insurance adjusters are advised to refer to each province/ territory’s regulatory organization for further information.

How does the profession assess soft tissue injuries?
Occupational therapy assessment is conducted within various contexts – home, school, workplace and community. Occupational therapists look at the context within which the person functions, evaluating and commenting on the person’s ability or inability to perform daily tasks.

Findings, conclusions and recommendations reached by the occupational therapists are generally based on the following four areas.

• Document review and/or information gathered from family and health care providers;
• Claimant interview to determine pre-accident activity level, pre-existing health status, accident-related history, course of treatment, progress to date, perception of injuries and functional implications;
• Physical assessment conducted using formalized and standardized testing provides objective information regarding musculoskeletal status and physical capacity;
• Functional assessment in which a claimant demonstrates the ability to perform (within medical restrictions) actual tasks within the home or workplace; review of daily activity schedule establishes activity tolerance.

What role does the profession play in the management of soft tissue injuries and what does the “treatment” look like?
When intervention is recommended, the occupational therapist will devise an individualized treatment plan geared toward timely return to work or previous functional status. The plan would consider the person, the context or environment in which they perform daily tasks and the actual tasks and activities that need to be performed.

The plan may consist of any combination of the following:

• Provide occupation-based therapy on a one-to-one or group basis to increase the person’s ability to meet job demands. Examples: work hardening in clinics or at the workplace or home, work/home trials, assertiveness training, chronic-pain programs and stress management;
• Provide instruction in symptom control strategies such as body mechanics, joint protection and energy conservation techniques;
• Fabricate and provide splints, orthotics; and
• Prescribe adaptive and safety equipment and modify home and/or workplace using ergonomic principles.

Can occupational therapists do third party assessments?

Occupational therapists can conduct a variety of assessments such as:

• Physical demands analysis,
• Work site assessments,
• Ergonomic assessments,
• Activity of daily living assessments,
• Functional capacity and disability evaluations, and 
• Post-job-offer assessments (largely for employers).

Assessments can offer the following kinds of information:

• Provide information about a person’s abilities and limitations for return-to-work planning or everyday living;
• Prescribe aids, adaptations and modifications to the environment to increase the person’s ability to meet activity demands;
• Determine a viable graduated return-to-work or regular activity plan;
• Provide an independent opinion about a worker’s abilities that can enable parties to manage conflict and focus on return-to-work planning; and
• Assist with determining the cost of future care and adaptive equipment.

What evidence is there concerning the role of the profession in the management of soft tissue injuries?
Research supports that an individual’s health and well-being is influenced by his/her ability to engage in life’s “occupations”. Occupational therapists consider life’s occupations to be everything you do in your day from self-care, paid or unpaid work and leisure activities. Withdrawal or changes in occupation can lead to increased dependency, lack of confidence and depression. Conversely by restoring an individual’s ability to function independently (after a soft tissue injury or impairment or disability) and exercise choice and control over his/her daily activities increase productivity and life satisfaction.
(source: Law, M. Steinwender, S., & Leclaior, L. (1998). Occupation, health and well-being. Canadian Journal of Occupational Therapy, 65, 81-91. Download PDF.)

Research does suggest that cognitive-behavioral interventions may be beneficial for people with chronic pain particularly when compared with no intervention. The profession hopes that future research on the effectiveness of cognitive-behavioral interventions for people with chronic pain could focus on functional outcomes related to quality of life, and participation in activities, which are important aspects of the role of an occupational therapist.

(source: The effectiveness of cognitive-behavioural interventions with people with chronic pain. A critical review of the literature by the Occupational Therapy Evidence-based Practice Research Group, McMaster University, Hamilton, Ontario. Download PDF.)

Other OT outcomes can be found on this site by clicking here

What tips would you offer to an insurer to assist them in making decisions whether or not to fund occupational therapy treatment/service recommendations?

Occupational therapy intervention can be effective for acute, sub-acute and chronic phases of disability. Occupational therapists look at the inter-connections between the person, his/her environment and the activities he/she needs and/or wants to perform; as a result, they can often develop an effective treatment plan that leaves few factors to recovery untouched.

Our profession would suggest that people may benefit from the help of an occupational therapist when:

• Medical and other interventions such as physical therapy may not be helping the person much as you thought they would;
• Everyday tasks seem overwhelming to the person; and/or
• The person’s daily schedule is out of balance for work, leisure and self-care.

We like to think that occupational therapists should be doing themselves out of a job. Treatment should be intense at first but then decrease quickly as the individual recovers, becomes more independent and shows that he/she is using the skills for which the occupational therapist has provided instruction. The insurer should look for rationale to support each of the occupational therapy treatment recommendations.

Treatment Decision-Making and File Management

Regular, open communication and a clear understanding of roles and relationships between all parties - claimant, insurer, lawyer, occupational therapist and other health care providers – promotes cooperation and a common understanding of the claimant’s impairments and how proposed treatments or recommendations might maximize function.

Initial communication should:

• Verify the occupational therapist’s working knowledge of the insurance regulations that are in effect for the file in question;
• Upon referral, communication up front should clarify the fee-payer expectations for the outcome of the program approved as well as verbal and written communication as the file progresses;
• Approaching discharge, the occupational therapist should verify with the fee-payer that the program meets the expectation and is provided within the time-frame specified; and 
• The occupational therapist should be expected to explain any departure from the approved program.

(source: Bell, C. (2002). Assessing function post-accident: Role of the occupational therapist. Challenges and champions, 4, 5, 5-6.

Occupational therapists have a responsibility to provide treatment and service pertinent to the accident injury without unnecessarily escalating related claim costs.

Acknowledgements

The above information was compiled by the Canadian Association of Occupational Therapists (CAOT) from various sources. Special thanks to Linda Hirsekorn of Community Therapists in Vancouver; Hilary Drummond of Creative Therapy Consultants in Oliver, B.C., and Christine Bell of Nancy Haston & Associates Inc. in Toronto. Information found in this document is intended as a general guide only; occupational therapists may vary in both their assessments and interventions, modifying these to meet the given client’s needs.

Additional Information

Fact Sheet: The Occupational Therapy Advantage (Acrobat PDF format)

The Adobe Acrobat PDF reader may be downloaded free from the Adobe web site.