Discharging from WR after two visits
Sun, 12/13/2009 - 8:46pm
I have a patient that came to my WR program reluctantly after the FCE. He was able to participate in a 5+ hour FCE meeting up to the Medium physical demand levels for lifting, carrying, push, pulling. His job as a residential building inspector on requires lifting up to 20 pounds on an occasional basis. o the McGill, Waddell, Oswestry, NDI, Dallas, Spinal Function Sort and two placebo tests he was unreliable. His first day at WR he had multiple c/o pain at 6-7/10 with simple stretching of back and UE and 4 minutes on the ergometer before terminating the session. The second day he came and c/o of pain at 6/10 while sitting in a chair getting his BP taken with minimal participation in a two hour period. He did not report any new occurences of trauma or new injury between the time of the FCE and the commencement of the WR program. I discharged him from the program and am writing the note. I have already been contacted by his attorney and want to make sure I have my documentation correct. What he did at his FCE and what I saw last week are completely different. I even documented in my recommendation for the WR program that "Given Mr. X's inconsistency of effort during the evaluation today, questions should be raised as to the benefit Mr. X would receive from such a program if he were to continue to put forth the same level of effort during the 4-6 week program." How can I handle this situation, i've never encounted anyone so clever as this patient.
Mon, 12/14/2009 - 1:33am
#2
I think you are certainly on
I think you are certainly on the right track! Not only did you document his inconsistencies during your 5 hour FCE, but found that his behavior/reports were equally unreliable during an attempt of work conditioning to further provide him with an opportunity to improve his situation. Placing safety at the utmost pinacle of importance, allowing him to participate at his elected pace (at least to start), and the stipulation that he should notify you at the onset of symptoms/increases in pain, I think you have given this client every opportunity to accept your help. Key things for this kind of situation are to remain objective, use as many direct quotes from the client as are appropriate, and being highly aware of what transpires during the sessions. Being fair and objective with those difficult cases makes our work so much easier-and fair. Often, when someone meets their job requirements (he clearly met them with material handling!), and unreliable reports of pain and limitation, I elect to recommend a return to work without restrictions. I am not clear as to why that was not your decision in this case, but perhaps that is why the complicated cases are called just that! From my experience, and what you have said, perhaps the "seeing something completely different" means he realized that participating in the test with you to the extent he did-was not what he wanted. I refer to such cases (in my mind) as having "participant's remorse". The expressions during a review of the FCE sometimes clearly indicate that. I would be extra attentive to documenting any reports of injury (which you stated did not occur) and having another, valued therapist screen the client for changes/anatomical reports when they do occur.
These folks are always the fun ones to work with, they don't come along very often but are always fun!
Were his reports of pain based off of the functional pain scale? I really like that scale because it levels the playing field. If I have someone rating their pain at 7/10 on that scale and they are not crying, etc. I will ask them, "are you sure becuase this says..... and I don't see that." I actually had a client during an FCE say, "So I should be crying while I report my pain at 8/10." I simply responded, "Yes...according to this scale. Would you like to take another look at the scale?" You can have him report his pain level on the functional pain scale, document that, and then report that "his reports of pain do not match objective findings...Mr. XYZ is demonstrating pain more consistent with a 2/10 on the pain scale." or something similar and you can go into more specific objective findings such as quality of motion, doing a repettiive motion test, repeating a 50 feet walk test, etc.
You can also have "the talk" with these folks...sometimes that can be effective.
I am also curious as to why someone in the medium PDC could not return to work in the Light PDC if they did well during a job specific FCE. Like Jim mentioned, there are typically more to the "tough" cases than just a matter of PDC levels though. Is the employer willing to take him back?
In the really tough cases I have gone so far as to contact the claim manager and report the inconsistencies and the uncooperative behavior. They will sometimes issue a "letter of non cooperation" that doesn't look good in their file and can be a significant motivator for them to do more and provide more effort. I have a lady in work hardening right now that came up with every excuse in the book to get out of it the first week except for "dog ate my claim number" (faking dry heaves, I have no ride, etc.) and when we notified the claim manager of this she reported she would take care of it. We got a call from the claim manager the next day and she reported she talked to this lady's attorney personally and took care of the issues. We are in our 3rd week in work hardening now and she is a model client.
There can be multiple options for handling the situation and it seems to me like they all start out with addressing some issues with the client. Document the conversations and the inconsistencies being as objective as possible and you should come out just fine.
Have fun!
Jon Harrison, OTR/L, CWCE, CEES