This article first appeared in the autumn 1997 issue of the Expert Witness.
For more than a decade occupational therapists have been establishing their role in the field of personal injury litigation. The steady growth of that role as their contributions gain recognition is discussed by Irene Harris et al. in their article, “The occupational therapist as an expert analyst on the cost of future health care in legal cases” (Canadian Journal of Occupational Therapy, 61(3), 1994, 136-148). In particular, changes in the law regarding compensation for loss of capacity to perform household services has led to increased demand for occupational therapists’ assessment skills to determine the impact of impairment on individuals’ abilities to perform unpaid labour such as housekeeping, child care or yard work and the cost of replacing this labour. Judges now require detailed information on functional abilities. Individuals such as entrepreneurs or farm wives, whose work is multi-dimensional, can benefit from the occupational therapist’s ability to analyze and describe their jobs and relate this to their past, present and potential function. It is a positive sign that occasionally both sides in a dispute will agree to share the cost of an occupational therapy assessment and analysis of costs of future care.
What is an occupational therapist?
Occupational therapists’ education includes knowledge of biological, behavioral, social and occupational sciences. This provides them with a unique perspective and set of skills that are particularly well suited to the questions to be answered in personal injury cases. The Canadian Association of Occupational Therapists notes in “Profile of occupational therapy practice in Canada” (Canadian Journal of Occupational Therapy, 63(2), 1996, 81) that “The impact of the disease process, physical and mental health as well as methods of adaptive functioning are underpinned by the acquisition and application of knowledge from such areas as occupational therapy theory and practice, anatomy, physiology, psychology, psychiatry, medical conditions, neuroanatomy, neuropsychology, human development, human occupation, pathology, sociology, economics, management, political science and ergonomics.” Alberta occupational therapists complete four years of university education, a minimum of 1,000 hours of supervised clinical training and a national certification examination before becoming eligible to enter basic practice. Occupational therapy is a regulated profession so practitioners must be registered with the provincial professional association. Considerable experience is usually advisable prior to practising in the area of personal injury litigation and some occupational therapists have postgraduate degrees with relevant specializations.
The “occupation” in occupational therapy refers to more than just paid employment. It encompasses everything that “occupies” a person’s time, in other words all the activities (including thinking) that are part of our engagement with living. Canadian occupational therapists use a model of practice that focuses on occupational performance. E. Townsend in Enabling occupation: An occupational therapy perspective (1994) refers to the ability “to choose, organize, and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after oneself, enjoying life, and contributing to the social and economic fabric of the community.” Physical and mental occupation is a fundamental human need and health depends on people having meaningful occupations. This perspective takes into account the dynamic relationship between persons, the social, cultural and physical environment and occupation. Also central to the practice of occupational therapy is the recognition that people are unique spiritual beings whose personal experience of meaning in everyday existence nurtures them through life events and choices.
At the time of referral the occupational therapist establishes the suitability of the referral with the referring lawyer. It is important to clarify what questions are to be answered. Both parties need to ensure that the evaluation process is mutually understood and that deadlines can be met. It must also be an appropriate time for evaluating the individual.
Once the referral is accepted the occupational therapist reviews relevant background material which usually includes the individual’s history, reports from physicians, psychologists, therapists, vocational evaluators, resumes, work history, school marks and portions of hospital records. In some cases the occupational therapist may request clearance from the individual’s physician before proceeding with physical components of the assessment. In cases where the individual has sustained severe or catastrophic impairments the physical component of assessment may be restricted to observing and evaluating the individual as they are cared for and interviewing the caregivers.
A detailed interview and completion of questionnaires provide information on medical, work, education, leisure and psychosocial aspects of the individual’s situation. The interview is usually conducted in the home. This helps to put the individual at ease and provides additional information on lifestyle, family and leisure interests, housekeeping roles, and cultural and social contexts. The individual’s perceptions of their abilities and information on their attempts to adapt to reduced function or to pain are an important part of the evaluation. This self-report provides a context for planning further evaluation. The occupational therapist looks for consistency and compatibility between the diagnosis, reported activities and performance during the next stage of the assessment.
Standardized testing and functional performance assessment (functional capacity evaluation) is usually performed in a clinical setting. Objective testing and skilled observation are used to measure factors such as work aptitudes, strength, flexibility, motor skills, perception, activity tolerance, ability to remember and follow directions, and work behaviors. Ability to stand, walk, sit, kneel, squat, reach, lift, and manual dexterity, or other factors specific to the individual situation are measured. In some cases the occupational therapist performs a work site job analysis or sets up simulated work. The occupational therapist may obtain consent to interview other family members, work associates, or teachers particularly in cases of brain injury where individuals may lack the ability to evaluate their own occupational performance.
There are numerous names for functional capacity evaluations and many variations on techniques. Some approaches use “high tech” equipment and computer generated reports. Despite manufacturer’s claims there is little evidence that these machines meet requirements for reliability and validity or that they are any better than simpler methods. Focusing too much on strictly physical components can blind the assessor to important psychosocial, environmental and other factors that are critical for the individual.
The assessment results are summarized in a clear report which describes the individual’s functional abilities as they relate to self-care, leisure and productivity (including paid and unpaid work), nature of impairment and the impact on their capacity to carry out specific life tasks. The report also comments on the impacts on other family members. Where appropriate, the occupational therapist makes recommendations regarding training, treatment, modified or adapted work, ergonomic alterations, housing or care needs, assistive devices, equipment or techniques. The occupational therapist can also prepare a cost of future care report detailing the need for equipment, medical services, support services, adapted housing, transportation, clothing, education or other needs and their associated costs.
In the next issue of The Expert Witness, Part II of this article will discuss the specific relevance of the occupational therapist’s expertise in a litigation setting and compare it to the role of other experts. A case study will provide an example.