Worker Compensation in Commercial Drivers

Injury Prevention and Case Management

Brian Harrison, M.D.April 2014

Worker Comp (WC) in Commercial Drivers (CD)- Concepts• DOT Regulations reduce major WC Cases BUT:

– DOT Regulations may increase Lost Workdays in both major and minor cases

• Employers can improve primary prevention of CD WC Cases through – Safe work practices while performing non-driving duty– Truck driver wellness– Safe use of all medications (Rx and OTC)

• Case managers and adjusters should attend to all potential barriers to RTW in WC Cases

• Use Worker Rehab Program more liberally

3

Commercial Driving – Big Vehicles, Big Costs, Big Regulations

• Active Interstate Truck and Bus Companies (2004) 662,392– Between 2000 and 2010:

• truck and bus miles increased 20%; more carriers.

• Total Number of CDLs Issued 6-7 million

• FMCSA certification examinations for commercial motor vehicle drivers: 3-4 million exams annually

Source: Motor Carrier Safety Progress Report (September, 2004)

Vehicles Involved in non-Fatal injury per 100 Million Vehicle Miles Traveled by Vehicle Type

Professionals Drive More Safely Than We Do

They Live in Regulation Nation!

• 1939 – First Regs: Interstate Commerce Commission “Good physical & mental health, no addiction to narcotics, no excessive use of alcohol.”

• 1954 - Exams first required • 1970 – DOT created • 1999 - Ill bus driver liable for 22-death crash• 2000 – FMCSA created• 2005 – SAFE TEA – LU: Chief Medical Officer, Medical

Review Board, Medical Expert Panels; National Registry of Certified Medical Examiners proposed

• 2006 – Sleep Apnea: Joint Task Force Guidelines• 2014 – National Registry of Certified Medical Examiners

– Trained, Tested, Certified

6

Medical Standards (Regulations)of the FMCSA

• 13 standards directly related to medical requirements 4 standards are specific

• Medical examiner cannot interpret or alter • Vision, Hearing, Epilepsy, Insulin use9 standards are general (“likely to, which

interferes,” or satisfied by Skill Performance Evaluation or OK’ed by MD)

• Medical examiner decides if medical condition affects driver’s ability to safely operate a CMV

Joint Task Force Guidelines

Joint Task Force Guidelines

Two or more of the following:

1. Body mass index >35 kg/m2

2. Neck circumference in men >17” and in women 16”

3. Hypertension (new, uncontrolled, or unable to control with fewer than two medications)

An Observational Study ofCommercial Drivers at risk of OSA

915Index Exams

613 (67%)No

unaddressed OSA risk

302 (33%)At risk for OSA,

BMI ≥ 35

63 (21%)Lost to f/u

239 (79%)Available for

f/u at 3-9 mo.

19 (7.5%)Out of service

PSG (all positive)

219 (92%)To weight loss

option

1 (0.5%)To bariatric

surgery

87 (40%)At BMI < 35 in

3-9 months

49 (100%)Remained at

BMI < 35

132 (100%)Proceeded to PSG and treatment (if

indicated)

49 (56%)Seen for re-

cert (10.6 mo average f/u)

132 (60%)BMI still ≥ 35 at

3-9 months

When given optionto lose weight:

40% did, Average of33# !

And kept it offFor 1 year!!!

22nd Anniversary of DOT Drug Tests

• The Omnibus Transportation Employee Testing Act became law on Oct. 28, 1991– Seems like a long time ago: Packers went 4-12 in 1991 with Coach Infante and QB

Mike Tomczak• Illegal drug use among transportation

workers has since dropped 50%• Fatal accidents from alcohol use by truck

and bus drivers has since dropped 23%

CRASHOLOGY - THE SCIENCE OF DRIVING SAFELY

Large Truck Crash Causation StudyFMCSA 2007

Top 10 “Critical Reasons” (CR) for Truck Crashes

(2 mechanical, 8 operator)– Over loaded– Making illegal maneuver – Inadequate surveillance – Traveling too fast for conditions – Inattention – Following too close – Misjudgment of gap or other’s speed– Stop required before crash– External distraction – Brake problems

Top 10 “Associated Factors” (associated with CR)- Ranked By Frequency –

1. Brake problems2. Traffic flow interruption (congestion, previous crash)3. Prescription drug use 4. Traveling too fast for conditions5. Unfamiliarity with roadway6. Roadway problems7. Required to stop before crash (traffic control device, crosswalk)

8. Over-the-counter drug use9. Inadequate surveillance10. Fatigue

And, 5th most important byPreventable Fraction

Trucking Cost Conundrum

• Trucking Industry has improved safety, cut illegal drug use and alcohol misuse, and followed the rules

• Costs should have gone down, but haven’t, in:– Health plan– Worker comp– Turnover– Compliance costs– Accident Liability

Worker Comp Conundrum

• Trucking companies pay higher worker comp premiums every year, even as large truck crash rates continue to drop.

• Non-life threatening injuries suffered during non-driving duties make costs climb, despite fewer major injuries from crashes

Transportation: Highest rates of Lost Time(258, up from 251 in 2011)

258, up from 251 in 2011

Worker Comp Medical $ Climb

As Has the Cost of All Benefits

Worker’s Comp Conundrum – Root Causes

• Ill health and health-risking behavior underlie this conundrum, not a lack of driving safety – Individuals with multiple health risks are more likely to

submit claims – Workers Comp medical care and wage indemnity

costs are higher in high risk claimants – Organizations with higher prevalence of health risks

have higher Workers Comp costs• And – Drivers must WORK more safely, not just

DRIVE more safely!

The burden of chronic illness in an aging workforce is a culprit

you can seize!

Low Risk will Mean Low CostHigh Risk Will Mean High Cost

Elevated Body Mass IndexLack of physical ActivityHigh StressHigh CholesterolHigh Blood PressureSmokingExcessive AlcoholImperfect Safety Belt UseEstablished Chronic

Disease

Recreational Drug UsePerceived ill-healthDissatisfaction with lifeDissatisfaction with workDepressed mood

Overall Score:Low Risk (any 2 or fewer)Medium Risk (any 3 or 4)High Risk (any 5 or more)

Low Risk Will Mean Low Cost

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

23%29%30%

38%56%

65%63%62%

67%72%

77%79%78%

58%54%

55%48%

27%25%

25%25%

26%25%

19%18%19%

18%17%15%17%

17%10%

12%13%

6%3%4%3%3%

Low (0-2 Risks) Medium (3-4 Risks) High (5+ Risks)

Obesity and All Medical Costs

• 77% higher average medical costs (obese vs. ideal)

• Treatment of obesity-related diseases accounted for 27% of the rise in inflation-adjusted per capita medical spending between 1987-2001

– Thorp et al, “The impact of obesity on rising medical spending” Health Affairs 2004 supplement

Drive Down Trucker Trauma byReducing

Injuries Away From the Wheel

Personalized Care

Commercial Drivers Drive Safely, But Might Not Work Safely

• Commercial driver safety improvements have cut large truck crashes to half of what they were 10 years ago, per million miles driven.

• High rates of strains, sprains, bruises, and other conditions classified as musculoskeletal disorders (MSDS).

• While lumping freight, climbing in and out of the cab, and managing the trailer.

Get In And Out Safely!• Classic “3 points of contact” method.• When a 220 pound trucker jumps from the height of the

cab to the ground, they drive 1,637 pounds of force throughout their body.

• From the lowest step, a mere 16 inches from the ground, more than 300 pounds of force drives upward into the body.

• Mechanical lifts such as powered lift gates pay for themselves.

• Never climb onto cab tires to clear snow from windshields.

• Flashlights to inspect the ground outside their cab door.

Get Ergonomic Equipment

• Cranking landing gear of the trailer pulling the fifth-wheel “kingpin”.

• Air-ride seats and lumbar support.• Correctly use multi-position seats• Position the steering wheel directly in front

of the driver’s seat.

Motor Carriers Should Also Help Drivers to Handle Freight Safely

• Drainage holes in the floors of refrigerated trailers.

• Install handles at the rear of trailers that retract into the floor.

• Position folding steps at the back of the trailer.• Retrofit power lift gates if needed.• Straps to dangle from the bottom of rollup trailer

doors.• Help to handle unexpectedly heavy deliveries.

Combat the Sitting Disease!

• Weight goes up and fitness goes down• Diabetes and heart disease• Injuries happen more commonly• Prolonged sitting punctuated by short

bursts of strenuous activity

Off your seat & on your feet!

• Get drivers to walk whenever they can• Take laps around the truck plaza after

fueling• Walking 36 laps around a big rig equals 1 mile.• Walking 10 minutes 3 times a day briskly

will help fitness just as much as walking once for 30 minutes does.

Stop The Shake, Rattle, And Roll!

Age-related degenerative lumbar disk disease develops simply as a part of life. It makes some less able to tolerate the whole body vibration they absorb from work vehicles.Get Vibration-Canceling Equipment.

Prolonged Driving is Associated with Common Backache and Cervicalgia:

But studies specific to Disc Degeneration (LSP and CSP DDD) do not show this

correlation

LSP DDD Has Not Shown Association With Driving In More Recent Studies

• Twin study which used MRI (Videman, Lancet 2002 Nov 2; 360(9343):1369-74) found no effect of prolonged driving or occupational driving histories upon LSP DDD. – Some association was found with non-specific LBP,

but not with LSP DDD. “Although driving may exacerbate symptoms of back problems, it does not damage the disc. Our inability to identify structural damage should be encouraging to those employed in occupations involving motorized vehicles and operation of heavy equipment.”

– Earlier, the same author showed that MRI findings in professional racecar drivers are no different from controls (Videman, Clin Biomec 2000 Feb;15(2):83-6)

Case Manager BOTLO:• Claimant says “I can't work d/t WC injury” (but

then renews Fed Med card anyway!)• Wants to RTW but has non-WR obstacle that

disqualifies Fed Med; hides in WC instead of treating own health (or retiring)!

• Always ask to see Fed Med card; who signed it?• Resolve all RTW obstacles early in WC case,

even if non-WR disqualifiers• Untreated OSA plus benzos or opiates can kill!• Employer might not realize the trucker can't

drive if any restrictions (let them ride-along as trainer, or send to Worker Rehab Program)

Worker RehabProgram

Traumatic MSK Injuries Common to Commercial Drivers• Superior Labrum Ant-Post Tear (slipping

and hanging from cab or trailer door) • Crushed hand - wind slamming trailer door • Contused lower leg - stepping between

trailer threshold and dock plate

Common to CD

• Vertebral compression fx – stepping backward off trailer, hitting ground in sitting position (then concussion from hitting back of the head)

• Trimalleolar ankle fx, tibial plateau fx – jumping off flatbed trailer

• RC Tear – landing gear crank kicks back

Non-Work Related Look Alikes• Wrist pain when steering – DJD, old

scapholunate dissociation. – Carpal tunnel syndrome risk is NOT increased

by the frequency of vibration which comes from the steering wheel

• Neck pain while riding – age related spondylosis

• Back pain with prolonged sitting – lumbar degenerative disc disease