Chronic Pain Abilities Determination (CPAD) Focus 10 September2015 1.

Chronic Pain Abilities Determination(CPAD)

Focus 10 September2015

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Functional Capacity Evaluations (FCE)

Definition

“The FCE is a comprehensive objective physical evaluation of an individual’s current capabilities

to perform work-related tasks in order to determine whether or not they meet the

demands required to undertake either their own or alternative forms of employment”


Claims Manager/Underwriter

SittingStandingCervical Range of Movement (ROM)Wrist ROMReachingWalkingStoopingClimbing StairsManual DexterityGrippingPinchingLiftingCarrying


Measuring Function

1. Range of Movement (ROM)Inclinometry/Goniometry


Measuring Function

2. Endurance Methods-Time-Measurements (MTM)


Work Day Tolerances


Frequency Percentage of Day

Duration of Day

Occasional 1-33% Up to 2.5 hours in total

Frequent 34-66% Up to 5.5 hours in total

Constant >67% Over 5.5 hours

Measuring Function

3. Strength Gripping, Pinching, Carrying, Lifting,

Pushing/Pulling


Work Day Tolerances

Physical Demand Characteristics Of Work(Dictionary of Occupational Titles - Volume II, Fourth Edition, Revised 1991)

PDL OCCASIONAL FREQUENT CONSTANT

Sedentary 1 - 10lbs Negligible Negligible

Light 11 - 20lbs 1 - 10lbs Negligible

Medium 21 - 50lbs 11 - 25lbs 1 - 10lbs

Heavy 51 - 100lbs 26 - 50lbs 11 - 20lbs

Very Heavy Over 100lbs Over 50lbs Over 20lbs


Measuring Function

4. CardiovascularHeart RatesBlood Pressure


Home Visits

Exactly the same tests are undertaken at homeGather vital information on home environment (adaptations, interactions with family)Often more relaxed at homeIndividuals not required to travel long distances, which they often cite as a reason for re-injury and poor performance.Required for individuals who report not being able to leave the home or travelOoops……….


FCE Validity

• Validity of the FCE is essential in order to be able to rely on the objective results to make an informed decision on whether an individual is able or unable to RTW

• A significant number of validity criteria are incorporated within the FCE

• Validity is based on standardised, peer-reviewed procedures for administrating and scoring tests


Validity ExamplesGrip Testing•Bell-shaped 5-position Grip-Strength Graphs•Rapid Exchange Grip Testing (REG)•Coefficient of Variation (CV)•Distraction observations – walking stick, door handle, stair rail


Bell-shaped 5-position Grip-Strength Graphs - Valid


17/09/2014 12:39:01

0102030405060708090

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Bell-shaped 5-position Grip-Strength Graphs - Invalid


23/09/2014 13:14:23

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Left Right

Rapid Exchange Grip Testing (REG) and CV - Valid


Demonstrated Activity

Avg. Force (lb) Norm (lb) % age Norm % age CV Difference Test Date

Left Right L R L R L R Prev Total MMVE, Hand Grip Position 1

76 57 0% 0% 17/09/2014 12:36:26

MMVE, Hand Grip Position 2

89 73 4.2% 5.81% 17/09/2014 12:36:54


89 75 0% 0% 17/09/2014 12:38:10


86 63 0% 0% 17/09/2014 12:38:37


71 50 0% 0% 17/09/2014 12:39:01

Hand Grip Rapid Exchange

88.33 72 4.32% 5.38% 17/09/2014 12:40:29

Rapid Exchange Grip Testing (REG) and CV - Invalid


Demonstrated Activity

Avg. Force (lb) Norm (lb) % age Norm % age CV Difference Test Date

Left Right L R L R L R Prev Total MMVE, Hand Grip Position 1

47 62 0% 0% 10/09/2014 11:41:13


28.33 66.33 17.61% 1.88% 10/09/2014 11:41:42


30 73 0% 0% 10/09/2014 11:42:47


28 66 0% 0% 10/09/2014 11:43:11


24 52 0% 0% 10/09/2014 11:43:35

Hand Grip Rapid Exchange

37.83 76.33 26.1% 8.03% 10/09/2014 11:45:04

Validity Examples

Pinch Testing•Tip v Palmar•CV•Distraction – Fine Dexterity Test, Handling Test, holding a mug

Other •Reaching•Cervical ROM•Lumbar ROM


Validity Examples - Pain Levels


Validity Examples - Self-Perceived Exertion Levels v HR


Exertion Level Rating no exertion at all 6extremely light 7 8very light 9 10light 11 12somewhat hard 13 14hard (heavy) 15 16very hard 17 18extremely hard 19maximal exertion 20

Validity Examples - Self-Perceived Exertion Levels v HR

*Borg G. Borg's Perceived Exertion and Pain Scales. Human Kinetics. 1998 22

Perceived Exertion Rating (RPE)

Minimal Heart Rate

Mean Heart Rate

Maximal Heart Rate

no exertion at all 6 69 77 91extremely light 7 76 85 101 8 83 93 111very light 9 89 101 122 10 96 110 132light 11 103 118 142 12 110 126 153somewhat hard 13 116 135 163 14 123 143 173hard (heavy) 15 130 151 184 16 137 159 194very hard 17 143 168 204 18 150 176 215extremely hard 19 157 184 225maximal exertion 20 164 193 235

Outcomes, Conclusions and Recommendations

Good Reliability, No Symptom ExaggerationCompare demonstrated physical capabilities with Job Demands/Description•Able to RTW•Cannot RTW – Rehab/Ergonomic Adaptations•Cannot RTW – No recommendations•Cannot RTW – Baseline physical capabilities for alternative forms of employment


Outcomes, Conclusions and Recommendations

Provided Poor Reliability, Symptom Exaggeration • Cannot compare demonstrated physical capabilities with Job Demands/Description• Do not know true working capabilities• No Recommendations other than IME/Surveillance (telephone call)


Insurance Policies

• IP• EL• Critical Illness/TPD• Mortgage Protection• WOP add-on• Motor


Reasons for FCE Referral

• Diagnosis vs Function - Accept the diagnosis (musculo-skeletal or other), but can the individual work in either their own or any other occupation?

• Recommendations for Rehab/Ergonomic Adaptations For RTW• TPD/EA Claims • Stand Above Report – Conflict of medical evidence• Identification of “Red Flags” - Level of disability does not correlate

with diagnosis, Lack of Definitive Diagnosis, “Tip Offs”, Frequent flyer to GP, Lack of response to numerous forms of treatment

• Sparse medical evidence or no updated reports/treatment for years • Baseline Measures For Alternative Work (Any Occ)


Chronic Pain Abilities Determination (CPAD)

CPAD is a protocol for objective testing, designed to determine the working capabilities of individuals who suffer from various chronic disabling conditions, the outstanding prototypes of which are Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM).

CPAD is the only assessment to objectively determinewhether an individual is able or unable to RTW and is used extensively as the first “port of call” in addressing this issue.

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History and Development of the CPAD Protocol

FCE/IME1. The “good day- bad day” issue present with CFS and FM

individuals. 2. Assessments do not focus on sustained work or predict

what a person can do over an 8-hour work day.3. Appropriate questionnaires are in most cases not

completed4. Pain and exertion responses are not monitored prior to

and post exercise to evaluate the effects of fatigue5. Cognitive testing is in most cases not performed or

benchmarked


Addressing the Issues• Two-year extensive literature search, the most appropriate,

peer-reviewed and researched components of current methods for assessing physical and cognitive abilities were incorporated into the protocol, specific to the individual’s required job demands.

• CPAD undertaken over 2 days, with a rest day in between• Testing time lasts around 3-4 hours per day• CPAD focuses on specific RTW issues (job specific, any suited)• Physical and cognitive tests incorporated, with the same

assessor undertaking both components• The same tests are repeated on day 2 to monitor effects of pain,

and fatigue both physically and cognitively• Fatigue and pain questionnaires • Validity from both a physical and cognitive perspective


CNSVSThe CNSVS Neurocognitive Assessment is a researched, peer-reviewed battery of tests which provides precise, objective, valid, reliable and standardized baseline measures in the evaluation, diagnosis, and management of an individual’s neurocognitive health.

The core domains tested are memory, processing speed, executive function, psychomotor speed, reaction time, complex attention and cognitive flexibility.

CNSVS Computerised Tests assess poor concentration, poor memory, learning difficulties, “brain fog”, and poor problem-solving capabilities.Reliability and Symptom Exaggeration crosschecks


CPAD Validity

• Validity within CPAD is essential in order to be able to rely on the objective results to make an informed decision on whether an individual is able or unable to RTW

• A significant number of validity criteria are incorporated within CPAD

• Validity is based on standardised, peer-reviewed procedures for administrating and scoring tests

• Validity of physical component – See “FCE”

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CPAD Validity - Cognitive

Valid - No Impairment


Patient Profile:

Percentile Range > 74 25 - 74 9 - 24 2 - 8 < 2

Standard Score Range > 109 90 - 109 80 - 89 70 - 79 < 70

Domain Scores Subject Score

Standard Score

Percentile VI** Above AverageLow

AverageLow Very Low

Visual Memory 44 95 37 Yes x

Processing Speed 66 115 84 Yes x

Executive Function 48 103 58 Yes x

Reaction Time* 658 97 42 Yes x

Complex Attention* 9 94 34 Yes x

Cognitive Flexibility 45 101 53 Yes x

Total Test Time (min:secs) 19:48 Total time taken to complete the tests shown.

CPAD Validity - Cognitive

Valid - Impairment

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Patient Profile:Percentile Range > 74 25 - 74 9 - 24 2 - 8 < 2



Standard Score

Percentile

VI** Above AverageLow

AverageLow

Very Low



Executive Function 30 80 9 Yes x

Reaction Time* 727 91 27 Yes x

Complex Attention* 30 25 1 Yes x

Cognitive Flexibility 24 73 4 Yes x


CPAD Validity - Cognitive Invalid – Symptom Exaggeration


Patient Profile:

Percentile Range > 74 25 - 74 9 - 24 2 - 8 < 2



Standard Score

Percentile VI** Above Average Low Average LowVery Low



Executive Function -26 3 1 No x

Reaction Time* 1087 34 1 No x

Complex Attention* 55 -54 1 No x

Cognitive Flexibility -32 -3 1 No x


Scores are comparable to individuals suffering with severe brain injury, mental retardation and early dementia

CPAD Conclusions

Good Reliability, No Symptom Exaggeration

Compare demonstrated physical work-day tolerances and cognitive capabilities on day 2,

with Job Demands/Description

•Able to RTW

•Cannot RTW – Rehabilitation Options (physical and/or cognitive)/Ergonomic Adaptations

•Cannot RTW – No recommendations

•Cannot RTW – Baseline capabilities for alternative

employment


CPAD ConclusionsPoor Reliability, Symptom Exaggeration

•Cannot compare demonstrated physical and cognitive

capabilities with Job Demands/Description

•Do not know the individual’s true/actual working capabilities

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Reasons for CPAD Referral • Diagnosis vs Function - Accept the diagnosis, but can the individual

work in either their own or any other occupation?• Recommendations for Rehab/Ergonomic Adaptations For RTW• Stand Above Report – Conflict of medical evidence• Identification of “Red Flags” - Level of disability does not correlate

with diagnosis, Lack of Definitive Diagnosis, “Tip Offs”, Frequent flyer to GP, Lack of response to numerous forms of treatment

• Sparse medical evidence or no updated reports/treatment for years • Baseline Measures For Alternative Work


CPAD Genesis1. ValidationThe Team assembled had significant experience with

rehabilitation and work capacity issues specifically relating to individuals with CFS and/or FM

Peer-reviewed Paper in the IMJ Co-authors: Dr M Kelly (rheumatologist) Dr D Trail (International Fibromyalgia Association) Dr Gualtieri (neuro-psychiatrist) D Newman C Olney (physiotherapist) R Gagne (software/hardware developer)


CPAD Genesis2. Recognition

The impact of CPAD as a work-ability assessment for individual’s suffering with CFS and FM was recognised with a “highly commended” award at the Rehabilitation First Awards in 2009.


CPAD Genesis3. High Court Acceptance (Dublin) – May 2014

“The Court must accept the CPAD assessment as a recognised and effective tool to assess someone's physical and cognitive ability.”

“The Court accepts the validity of CPAD test process…”


CPAD Genesis4. EvolutionCPAD is also being undertaken on individuals suffering from the following conditions:•MS•Parkinson’s•Migraine•Cancer•Brain Injuries•Stroke•Chronic Pain•Narcolepsy / CataplexyThe outstanding reported symptoms are fatigue/pain which are preventing the individual from a RTW


Contact

David Newman (Director)

00447866573731

[email protected]

Questions?


Chronic Pain Abilities Determination (CPAD) Focus 10 September2015 1.

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