Gwu fce

Functional Capacity Evaluations

Naomi Abrams, MOT, OTR/L, CEASFor GWU 12/13/10

Describe the purpose of FCEs Understand the method of development of a

legal FCE Describe the basic components of a FCE Understand the interpretation of results Begin to understand the documentation

process

Objectives

© 2010 Worksite Health & Safety Consultants

Used to prove that a worker cannot work Used to prove that a worker is lying The same for every job Always right

FCEs are not:


A tool for determining:◦ An employee’s readiness to return to work after

an injury◦ A potential employee’s ability to perform work

tasks◦ Goals for treatment of an injured worker and

monitoring the treatment process(King et al., 1998)

FCEs are:


Packaged and standardized◦ Simulated task◦ Max values

Homemade◦ Standardized ◦ Non-standardized

Two types of FCEs


Blankenship System ◦ 1-4 hours◦ Simulated tasks◦ Standardized methods with training available

IWS (Isernhagen) ◦ 5 + hours over 2 days◦ Simulated tasks◦ Standardized methods with training required

Matheson◦ Time varies◦ Simulated tasks with Matheson tools◦ Standardized methods with training required

Examples of Pre-packaged FCEs


Tools of the Simulated Task FCE


http://www.roymatheson.com/products/all-products/matheson-dexterity-and-range-motion-panel-system

http://www.roymatheson.com/sites/default/files/imagecache/product_full/Medium%20Screw%20-%20Portable%20Panel%202.JPG

http://www.roymatheson.com/products/all-products/matheson-integrated-lift-evaluation-system-isoinertial-and-pile-package

http://www.roymatheson.com/products/all-products/complete-minnesota-dexterity-test

http://www.roymatheson.com/products/all-products/bennett-hand-tool-dexterity-test

http://www.roymatheson.com/products/all-products/jamar-hand-dynamometer

http://www.roymatheson.com/products/all-products/polar-heart-rate-monitor

http://www.roymatheson.com/products/all-products/purdue-pegboard


http://www.roymatheson.com/products/all-products/push-pull-sled

http://www.roymatheson.com/products/all-products/shovel/levering-station

Max values Some FCEs require the measurement of

static force maximum capabilities. Extrapolate these values to work

capabilities Example:

◦ Lift test: avg. 65# Extrapolate: You could be in a jobthat requires lifting 65# occasionally(1-33% of the day)


Uses materials found on the job Attempts to recreate a day on the job at its

worst May or may not be tested for validity and

reliability Must be standardized for each job Must allow for objective measurement Poses unique challenges

Homemade FCEs


At minimum: Long enough to include the essential work activities identified in O*Net (the new Dictionary of Occupational Titles)

Should be long enough to test all items related to the job

Length of FCE

PushingPullingCrawlingStoopingBendingLiftingCarryingForward workFine motor work

Climbing stairsClimbing laddersBalancingTurning headSitStandWalkKneelOverhead workRepetitive foot motion



http://online.onetcenter.org/

Occasionally: 1-33% of the day Frequently: 34-66% of the day Constantly: 67-100% of the day

Definition of frequency


Based off of old Dictionary of Occupational Titles, still used in general terms; however, not in O*NET

Definition of exertion levels


www.socialsecurity.gov

Other factors play a larger role in RTW than physical capabilities such as gender and time off work.

It is only as valid as what is tested. Often based off of self-reports from the

employee regarding job demands. All use algorithms to extrapolate an

employee’s ability to complete work during an 8 hour day.

Very difficult to take into account environmental and organizational factors.

Limitations of FCEs in general


Job demands assessment must be done prior to selecting tasks for the FCE

Workers currently completing the job should evaluate the job demands assessment validity

An FCE is designed to simulate all job demands either using job materials or standard measurement tools

The FCE is assessed by workers currently completing the job for validity

Reliability (inter- and intra-) should be assessed

Development or Selection Process (Best case)


Components of a FCE


Heart rate monitor Visual scale of pain (faces or numeric) Borg visual rate of perceived exertion (RPE)*

Tools required regardless of type of test


http://www.roymatheson.com/products/all-products/polar-heart-rate-monitor

Taken for safety and as a baseline Medical conditions Medications Current work status Supportive apparatus currently using Current activity level self-report Heart rate (calculate MHR) Blood pressure Current pain levels and locations

Medical history


ROM Gait (general description) Strength

◦ Manual muscle testing (major muscle groups)◦ Trunk strength (curls, back extension, crawling)◦ Lower extremities (toe raises, knee squats, heel walk)◦ Grip (JAMAR)* and pinch

Muscle tone Balance (observation)

Note any significant findings

Musculoskeletal status


Often will use a series of questionnaires such as:◦ Visual Analog◦ McGill◦ Pain Drawing◦ Numeric ratings◦ Oswestry Back or Neck◦ Modified Somatic◦ “Inappropriate Symptoms Questionnaire”◦ Dallas

Pain


Ex. Pain drawing

Overall score of high (>=3 pts)or low (0-2 points)


Waddell’s signs◦ Tenderness

Superficial: pinch skin over thoraco-lumbo-sacral region Deep: apply deep pressure in same area

+=tenderness reported over large area

◦ Simulation test Axial loading: pt. stands, evaluator applies pressure to crown of

head Rotation: pt. stands, evaluator rotates the person’s pelvis and

shoulders as a unit += pt. reports pain secondary to evaluator actions

◦ Distraction test: straight leg raise supine and seated += marked improvement sitting compared to supine

◦ Regional disturbances Weakness (unexplained “breaking” with MMT) Sensory (light touch and pinprick sensory testing with ‘stocking’

pattern versus dermatomal)

◦ Overreaction: disproportionate verbalizations, expressions, collapsing or sweating during testing.

Symptom magnification/delayed recovery


Waddell et al. (1976)

Level lift (usually 5 ft. carry at waist height or table-top height in pre-packaged tests)

Weight carry (usually 100 ft. in pre-packaged tests)

Floor to table lift with 90 degree turn Overhead lift (usually waist to eye height) Unilateral weighted carry (usually 100 ft. in

pre-packaged tests) Pushing or pulling Cervical and Lumbar PILE

Job tasks: escalating measure


PILE testing


http://www.youtube.com/watch?v=W5MzJxvgntw&feature=player_embedded#!

One lift every 5 seconds Set of 4 lifts in 20 seconds Record heart rate before and after each set Record RPE after test Work until reach max safe heart rate or person can’t

lift anymore Increase weight by 5# for females and 10# for males

◦ If doing this during a multi-day test you would still start at 5 or 10 #

Extrapolation:◦ If have to stop test at 70# max safe lift =>◦ Can do 70# lifts occasionally throughout the day◦ 70# divided by 2 = 35# frequent lifting throughout the day

PILE Lumbar


Kneeling Sitting Standing Static pushing Static pulling

Job tasks: static tolerance


Unloaded repeated bending ◦ Upright to 18 inches below the waist

Repeated leg motion (pre-packaged may use a foot pedal or upright stationary bicycle)

Overhead work (eye height or 12 inches above AC joint)◦ Un-weighted◦ Weighted

Walking (1/2 mile in some pre-packaged tests – not on treadmill)

Balance Ladder or stair climb

Job task: repetition tolerance


Purdue Peg Board (compared to norms) Nuts and Bolts test Minnesota Rate of Manipulation Test

◦ Placing◦ Turning◦ Displacing◦ One-hand turning and placing◦ Two-hand turning and placing

Fine motor and speed


http://www.roymatheson.com/products/all-products/complete-minnesota-dexterity-test

http://www.roymatheson.com/products/all-products/purdue-pegboard

Firefighters, EMT, Police: body pull Firefighters: overhead hook push/pull Firefighters: hose crawl Police: Illinois Figure-8 Agility trials Mechanic: supine overhead tasks

Custom job tasks


You have been called to a nursing home to design a FCE. The manager tells you that there is a PT that wants to come back to work.

What tasks would you put in to the FCE and why?

What tasks would you not put in and why?

Design a FCE


OBJECTIVITY AT ALL TIMES Write what you saw and heard, never what

you think or feel NEVER use terms that may be construed as

having value judgments The client did not work to his full potential The client was not giving full effortThe client was not sweating nor breathing hard

and his heart rate was near his resting average during the task that he described as “very difficult.” The client stopped the test at this point.

Documentation


While many of the tests that we use can show that person is not giving full effort – we never ever use this word!

We can say that there appears to be signs of symptom magnification and we recommend this be addressed.

We can say that the FCE is not a good indicator of the client’s abilities because the client self-limited a number of test items and only represents the client’s perceived capabilities and disability. However, you better have data to substantiate this.

Malingering


The pre-packaged test comes with a guideline for extrapolating raw data to 8 hour days. For example:◦ Sit/stand/walk: Recommend --

Physical Capacities

Continuous

7-8 hrs/day If no symptoms, or problems with testing

5-6 hrs/day If weight shifting & minimal symptoms with testing

Frequent4-5 hrs/day If some symptoms and tolerates 20 minutes

3-4 hrs/day If some symptoms and tolerates 15 minutes

Occasional 1-2 hrs/day If has symptoms and tolerates less than 15 minutes

Rare/never 0-1 hrs/day If cannot complete test or significant symptoms


For weighted tests use the maximum tolerated to calculate the frequency◦ Never = 1# more than MAX◦ Occasionally = MAX x 0.65◦ Frequently = MAX x 0.25◦ Continuously = <1# to 1-Frequently

Example: Level lift tested to MAX = 55#

Physical Capacities

Task Rare Occasional

Frequent Continuous Never

Level lift 55# 36-54# 14-35# 1-13 # >55#


Essential job task Tested ability Meets demandYes No

Lift 20# continuously Continuous lift: 1-13#

Relate these findings back to job demands


As much as possible you want to tell the reader what limited each task so that they can use the FCE to establish goals.

For example:◦ Manual material handling was limited due to

decreased back extensor strength, poor posture, and poor body mechanics.

◦ Client’s ability to tolerate sitting was limited secondary to reports of low back pain. Patient was consistent with these complaints and pain resolved within one minute of standing.

Explain the findings


Here is where you let the reader know how much they should believe the findings. ◦ Client worked to full capacity for all test items and

was consistent in effort based on objective findings; therefore, this FCE is an accurate indicator of the client’s safe maximum capabilities.

◦ The client self-limited a majority of the test items; therefore, this FCE is not an accurate indicator of the client’s capabilities. The FCE represents a minimum capability based on the client’s perceived ability. There is not objective evidence to conclude the client could not have done more.

Assess the validity of the findings


Part of the purpose of the FCE is to identify safety issues with return to work.

Identify any areas where there may be safety issues and therefore restrictions to duty.◦ Restrictions of activities such as being around

moving machinery and driving is recommended due to the client’s persistent double vision. This double vision is limiting his depth perception and he was observed frequently running into objects in the testing facility.

Restriction of activity


Take a moment to list any strengths observed during the testing. This section helps neutralize the tone of the report.◦ The client was on time to all testing◦ The client used good body mechanics after

education◦ The client verbalized good motivation for return to

work

Strengths


Explain the findings of the pain profile in both numeric terms and how that can be interpreted.◦ Client self-reported a very high pain level (88%)

on all tests. He scored “high” on the Dallas , Visual Analog, and Pain Drawing tests. Overall, pain was a limiting factor for his participation and there is indication that symptom magnification may be a strategy. Recommend addressing these symptoms with a pain specialist prior to return to work.

Pain profile


If possible, quote the client in the report either in the body of the report or in a separate section. Try to be detailed in your notes so that this section is accurate when writing your report.◦ “I don’t know what I am going to do about the

pain, nothing seems to work”◦ “I’m looking forward to returning to work since

being home is annoying”

Client input


The most important section! Recommendations can include:

◦ Return to work full duty◦ Return to work with modifications (list them)◦ Participate in a work hardening/conditioning

program prior to return to work If you give this recommendation, you must include

some goals for treatment If needed, you can recommend consultation

with a specialist such as pain management◦ Don’t write that the person needs to see psychiatry

Recommendations


The case manager will be looking to you to figure out the end result of work conditioning or therapy.

The client will return to work with the: ◦ Same employer and same job◦ Same employer and different job◦ Same employer and same job with modifications◦ Different employer and same job◦ Different employer and different job

Goals for Work Conditioning


Never recommend that the person does not

return to work or state that the person cannot

work


Unlike patient files, work comp does not always allow the client to see their file

Rules are different state to state and differ with each insurance company

The person you are testing is not the person who hired you

Only distribute your findings to the person who hired you and the client’s doctor of record (not their PCP)

A note on distribution


Job modification – ergonomics Case manager contact Legal contact Expert witness versus defend your findings

After the evaluation


FCEs should be based on job demands FCEs should demonstrate capabilities and

limitations for return to work Reports should be detailed enough to assist

with that person’s return to work immediately or in the future

Reports should be written objectively and with neutrality

The goal is always to get the person back to work in some fashion

Putting it all together


Questions?

Thanks for having me and good luck with your studies!

[email protected]

301-933-WORK

The Blankenship Center: http://blankenshipfcecenter.com/index.htmlIWS: www.workwell.com/FunctionalCapacity.aspErgoScience: http://www.ergoscience.com/index.phpO*NET: http://online.onetcenter.org/Social Security Administration: www.socialsecurity.govKing, P. M., Tuckwell, N., & Barrett, T. E. (1998). A critical review of functional

capacity evaluations. Physical Therapy, 78(8), 852-866.Lechner, D. E., Bradbury, S. F., & Bradley, L. A. (1998). Detecting sincerity of

effort: A summary of methods and approaches. Physical Therapy, 78(8), 867-888.

Lechner, D. E., Page, J. J., & Sheffield, G. (2009). Predictive validity of a functional capacity evaluation: The physical work performance evaluation. Work, 31, 21-25.

Mariani, M. (Spring,1999). Replace with a database: O*NET replaces the Dictionary of Occupational Titles. Occupation Outlook Quarterly, 1-9.

Ransford, A. O., Cairns, D., & Mooney, V. (1976). The pain drawing as an aid to the psychologic evaluation of patients with low-back pain. Spine, 1(2), 127-134.

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