Allen Thompson, MS, ATC, LAT, PES, CES, CSIWCP, CIEE, CAE

Director of Industrial Rehab, MSDrayer Physical Therapy, Elite PT, Tupelo PT,

Batson PT, Rehab at Work, Performance Rehab

The Good, The Bad, and the Ugly

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5What is a defensible FCE? Is that

possible?

The testing process is essential to objective measurements. We will evaluate the testing processes and the understanding the results

given by the therapist.

Should research be the final determination for the results of the test? We will evaluate the different

models of FCE reporting.

The Medical exam should match the medical history. The importance of the medical history should allow the therapist to distinguish self-limiting verses

appropriate or organic verses inorganic.

Explaining the FCE process and the importance of the type of FCE is performed may or may not be informative to the effectiveness of the results.

FCE Models Medical HX Testing Conclusions Defensible

The FCE process can be complex due to the multitudes of models within the

state and the country. We will look at some models to show the differences and their

benefits and potential hardships.

There are no current models that stipulate

purity in all forms.

All models have their benefits but also

their potential hardships.

The medical history can bring about some

misconceptions. Many doctors do not

understand the reason or importance

of the medical history.

However, many therapist do not understand the

importance of the history themselves.

History is the indicator for the

rationale for restrictions.

Testing processes differ between all FCE

models; however, there are parts of the

FCE which are consistent.

Understanding the process of the

evaluation and what determines PAIN or

SELF-LIMITING behaviors is essential for a successful FCE.

Should conclusions be based upon

computer model, human model, or mixture model?

Should conclusions be based upon active

research?

Determination of the restrictions and conclusions are essential for a

successful report.

The reliability and validity of the FCE is

essential for defensibility. Are

they peer reviewed or successfully

defended itself within a court setting?

Has it been evaluated for inter and intra

reliability?

I can say this, I have done some good

FCES, some bad FCEs, and some ugly FCEs.

• How can we stop ugly and bad FCEs from coming into the market?

• How can we make it efficient?

• How do we stop

The madness?

• Definitions• Reliability: “refers to the consistency of a measure” & “Reliability research

establishes the objectivity of the evaluation.” (Lechner, 1991)

• Interrater reliability: The ability to achieve similar scores on the evaluation when administered by different evaluators (Portney & Watkins, 1993)

• Intrarater reliability: Refers to the consistency of an evaluation performed by the same examiner at different points in time (Portney & Watkins, 1993)

• Validity: “refers to the accuracy of the evaluation (Portney & Watkins, 1993)

• Concurrent validity: “refers to the test’s ability to determine current abilities”

• Predictive validity: “refers to a test’s ability to determine future abilities” (Portney & Watkins, 1993)

• Objective: “objective means that measure is as free as possible from observer bias (Rothstein & Echternach, 1993)

FCE Models and their roles

• Understanding is knowledge!

• There are misunderstandings in those definitions!

• 1. Some clinicians confuse validity with the concept of sincerity of effort.

• 2. Clinicians believe validity is measured solely on consistency of effort.

• 3. Test validity is altered by the client’s cooperation.

• The validity and reliability of the test never changes but the intentions of the clients do! Thus, the test demonstrates what the client is willing to do.

• 4. Referral sources will continue to refer for reliability despite validity.

• 5. Waddell’s test proves self limitations only?

• A test should be performed neutral of bias. The examiner must remove personal beliefs and opinions from the report and testing process. • Good: Examiner relates truly upon objective facts of the

evaluation. Presenting organic evidence to substantiate the findings.

• Bad: Examiner leans consistently or partially to one party. The report in inconsistent of findings or objective and subjective reporting provides confusion.

• Ugly: The examiner performs a got-you report. Constantly looking for faults without evaluation causes. They are usually therapist who are hard left or right. These reports may also constantly report subjective evidences are true restrictions.

Good, Bad, and Ugly Definitions

• Medical History means more to the FCE than most people give credit.• Establishes a baseline of injury and consistency of

related information• Remember Docs-You have seen them for months-Me=Today

• Gives progress and clinical observations• Unexplained reduction in ability may establish true objective

measurements.

• Denotes doctor’s professional opinions, in regards, to surgeries, MRI’s, NCS, and other related studies.

• Doctors have become much more specialized. If we only go off of studies, we may begin a miscommunication between the doctor and the therapist.

• Provides clarity to the desires of the physician.

Medical History and the Relevance

The Good The Bad The Ugly

The therapist was provided all relative medical information.

The therapist was able to review the material

due to the ability to expedite the medical

communication.

The therapist has a clear plan and

understanding of the injury and all

subsequent medical findings.

The therapist was provided some

medical information but many of the

studies were absent.

Other medical providers were not stated leaving large

gaps.

The medical information was

provided less than one week before the

test.

The therapist receive demographics to say

the least.

No studies were reported or provided. Maybe surgical notes was all to evaluation.

The medical information was provided the day

before or the day of the exam. Request for next day report was

made.

Medical History and the Relevance

• All movement patterns are relative to the test.• The physical exam is a PHYSICAL EXAM!

• Range of Motion, Strength Testing, Neurologic, and Mechanical Testing.

• The physical exam should be in correlation with the medical history.• There should be a measure of consistency with the

outcomes of the physician and the therapist.

• Objective findings should be the basis of all impairment ratings and restrictions!• Too many opinions are based upon subjective evidence

paraded as objective. The evidence must present to suggest objective findings consistent to the AMA regulations.

Physical Exam and the Rationale

• Benefits to a Physical Exam• Sets Restriction Parameters

• Allows Objective evidence to be presented efficiently to all parties

• Can allow outcome measures to be implemented

• Allows clarity to the therapist about potential hazards during the test

• May determine if any tests should be avoided during the examination

Physical Exam and the Rationale

The Good The Bad The Ugly

Physical Exam and the Rationale

Therapist performs an extensive physical

examination and denotes any organic or objective evidence of limitations.

The therapist is competent in their evaluation and has a history and professional

experience.

The report indicates all physical restrictions and compared to the FCE for

any inconsistencies.

The therapists performs a basic examination

indicating some of the parameters for a physical

examination. The therapist may indicate

some nonorganic factors as organic.

The therapist is competent but cannot

explain the process of the evaluation.

The report does not truly indicate inconsistencies.

The therapist performs no physical

examination other than the basic impairment

requirements.

The report presents with no indications of

inconsistencies between the physical exam and the physical abilities. The report is

scattered with nonorganic parameters

that effectively diminishes the FCE.

- This is important. What makes a FCE consistent? When the objective facts match the objective reflection of the patient. This means the patient’s radicular complaint is consistent to the location of the nerve root injury and demonstrates appropriate changes to the overall function or biomechanical function of the patient.

- The definition of self-limiting or inconsistent tasks indicate an undetermined reason or effort by the patient that presents without cause for the notion.

- Possible Reasons: Pain, fear of re-injury, anxiety, depression, poor understanding of instructions, or conscious or unconscious attempt to manipulate the results of the test.

Testing Miscalculations - Inconsistencies

• Possible Test Inconsistencies• Unexplainable improvement on endurance tasks

• There are possibilities of improvement. However, the improvement should be minor in nature or equal to the same quality as tested earlier.

• Comparing self-reported function to test performance• Inconsistent reporting during the testing process may help determine the true validity of

self-limitations. Ex. Radicular symptoms do not occur when lifting but increases with standing.

• Comparing test results to diagnosis or impairment• The individual has knee surgery but the back is the complaint during the test. You may

see increased carpal tunnel complaints despite little organic evidence.

• Comparing test performance to casual observations• Inconsistent cane use. Ex. Uses cane in the facility but walks normal outside of the

facility. The entire time is considered part of the testing process.

• Comparing subjective pain statements and pain behaviors/movement• Movement patterns should match pain score. The pain behavior or movements must be

in align to the nature of the injury itself.

Testing Miscalculations - Inconsistencies

• What’s the big deal? • Inconsistencies brings inconsistent results!• Too many self-limitations without Objective

evidence have been made permanent work restrictions without merit.

• Full ROM at doctor-Limited at FCE=Restrictions without merit.

• Inconsistencies are not comparable to self-limitations in nature, but you will see one side-by-side with the other

• Inconsistencies are present and can be due to self-limitations; but also FEAR! Thus, inconsistencies should be based on a comparative evaluation during the FCE process and not during one particular test.

• Can alter the testing process• Could affect the impairment score and may diminish

the patient’s overall Department of Labor score.

Testing Miscalculations - Inconsistencies

The Good The Bad The Ugly

The therapist would appropriately

distinguish Objective factors of

inconsistency and the relationship to the

outcome of the test.

The inconsistencies would discourage

inappropriate restrictions based on

non-conclusive evidence of organic factors; but rather,

Subjective.

The therapist recognizes that the patient presents

with inappropriate behaviors but cannot relate

if all actions are inconsistencies.

The FCE model may detect some irregularities but

some do not.

States or maybe mentions differences but still allows

the changes to become restrictions due to

misunderstandings.

The therapist administers the test

and reports self-limitations but does

not report inconsistencies.

They rely solely on the test parameters

to determine inconsistencies.

Relating the inconsistencies is not

the standard to computer reports.

Medical History and the Relevance

- All restrictions must be based upon objective and organic risk factors.

- American Medical Association, A Physician’s Guide to Return to Work (2nd ed.) and American Medical Association, Guides to the Evaluation of Permanent Impairment (6th ed.)

- The lack of understandings in the regards to restrictions have diminished the effectiveness of physicians. However, the physicians have the means in providing appropriate recommendations.

- Poor recommendations may lead to adverse reactions upon the patient or the company. The restrictions may hinder their ability to return to work or hinder their ability to find future work.

- Risk should be the basis of restrictions. AMA states risk, “chance of harm to the patient, or to the general public, if the patient engages in specific work activities.”

- Substantial Harm indicates, “objectively verifiable worsening in the patient-examinee’s condition, and not merely an increase in previously present symptoms, like pain or fatigue.”

Testing gives appropriate Restrictions

The Good The Bad The Ugly

The therapist will determine the

conclusions based upon reasonable, reliable, and valid

research.

The information will not report personal opinions; but rather,

factual objective evidence related to

specific and non-biased research.

The therapist will utilized the

conclusions made by their respective FCE

process.

There may be some indications within the

report on potential conflicts; however,

there is a lack of true evidence to support

their findings. May be biased to one side or

may present with some manners of

personal opinions.

The report will be a primarily the

interpretation of the respective FCE

process and the therapist will offer nothing more than

their signature.

Validation of test results or conclusions will be subjective and

based upon the physician.

Testing gives appropriate Restrictions

• FCEs• Only as Valid as the evidence and

the experience of the therapist.

• Only as Reliable as the information between the FCE and the physician and the judges. • The information must be evaluated

and delineated appropriately restrictions

• Interpreting with unbiased opinions the self limiting factions of the FCE

Conclusions and Reporting

The Good The Bad The Ugly

The FCE is performed without bias and represents true

objective evidence of risk for the patient to

participant in work activities.

The FCE is compared to the functional job description to rule

out risked participation.

Great communication!

The FCE is performed without a bias lean

but does not present objective evidence or

subjective/self-limiting potential

affects the outcome and the restriction

requirements.

No comparison to functional job

descriptions/doctor signs report without

noting objective restrictions.

The FCE could be biased and has little objective evidence but is riddles with

subjective outcome models.

The doctor signs the report “Per FCE” and the self-limitations are not addressed

and deemed permanent restrictions.

Medical History and the Relevance

• FCEs• Only as Valid as the evidence and

the experience of the therapist.

• Only as Reliable as the information between the FCE and the physician the physician. • The information must be evaluated

and delineated appropriately restrictions

• Interpreting with unbiased opinions the self limiting factions of the FCE

Conclusions