1. Functional Capacity Evaluations Naomi Abrams, MOT, OTR/L, CEAS For GWU 12/13/10

2. 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

3. 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: © 2010 Worksite Health & Safety Consultants

4. 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: © 2010 Worksite Health & Safety Consultants

5. Packaged and standardized Simulated task Max values Homemade Standardized Non-standardized Two types of FCEs © 2010 Worksite Health & Safety Consultants

6. 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 © 2010 Worksite Health & Safety Consultants

7. Tools of the Simulated Task FCE © 2010 Worksite Health & Safety Consultants

8. © 2010 Worksite Health & Safety Consultants

9. 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 job that requires lifting 65# occasionally (1-33% of the day) © 2010 Worksite Health & Safety Consultants

10. 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 © 2010 Worksite Health & Safety Consultants

11. 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 Climbing stairs Climbing ladders Balancing Turning head Sit Stand Walk Kneel Overhead work Repetitive foot motion Pushing Pulling Crawling Stooping Bending Lifting Carrying Forward work Fine motor work © 2010 Worksite Health & Safety Consultants

12. http://online.onetcenter.org/ © 2010 Worksite Health & Safety Consultants

13. http://online.onetcenter.org/ © 2010 Worksite Health & Safety Consultants

14. http://online.onetcenter.org/ © 2010 Worksite Health & Safety Consultants

15. Occasionally: 1-33% of the day Frequently: 34-66% of the day Constantly: 67-100% of the day Definition of frequency © 2010 Worksite Health & Safety Consultants

16. 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 © 2010 Worksite Health & Safety Consultants

17. 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 © 2010 Worksite Health & Safety Consultants

18. 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) © 2010 Worksite Health & Safety Consultants

19. Components of a FCE © 2010 Worksite Health & Safety Consultants

20. Heart rate monitor Visual scale of pain (faces or numeric) Borg visual rate of perceived exertion (RPE)* Tools required regardless of type of test © 2010 Worksite Health & Safety Consultants

21. 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 © 2010 Worksite Health & Safety Consultants

22. 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 © 2010 Worksite Health & Safety Consultants

23. 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 © 2010 Worksite Health & Safety Consultants

24. Ex. Pain drawing Overall score of high (>=3 pts) or low (0-2 points) © 2010 Worksite Health & Safety Consultants

25. Symptom magnification/delayed recovery 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. Waddell et al. (1976) © 2010 Worksite Health & Safety Consultants

26. 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 © 2010 Worksite Health & Safety Consultants

27. PILE testing http://www.youtube.com/watch?v=W5MzJxvgntw&feature=player_embedded#! © 2010 Worksite Health & Safety Consultants

28. 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 © 2010 Worksite Health & Safety Consultants

29. Kneeling Sitting Standing Static pushing Static pulling Job tasks: static tolerance © 2010 Worksite Health & Safety Consultants

30. 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 © 2010 Worksite Health & Safety Consultants

31. 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 © 2010 Worksite Health & Safety Consultants

32. 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 © 2010 Worksite Health & Safety Consultants

33. 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 © 2010 Worksite Health & Safety Consultants

35. The client was not giving full effort

36. The 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 © 2010 Worksite Health & Safety Consultants

37. 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 © 2010 Worksite Health & Safety Consultants

38. The pre-packaged test comes with a guideline for extrapolating raw data to 8 hour days. For example: Sit/stand/walk: Recommend -- Physical Capacities © 2010 Worksite Health & Safety Consultants

39. 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 © 2010 Worksite Health & Safety Consultants

40. Relate these findings back to job demands © 2010 Worksite Health & Safety Consultants

41. 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 © 2010 Worksite Health & Safety Consultants

42. 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 © 2010 Worksite Health & Safety Consultants

43. 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 © 2010 Worksite Health & Safety Consultants

44. 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 © 2010 Worksite Health & Safety Consultants

45. 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 © 2010 Worksite Health & Safety Consultants

46. 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 © 2010 Worksite Health & Safety Consultants

47. 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 © 2010 Worksite Health & Safety Consultants

48. 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 © 2010 Worksite Health & Safety Consultants

49. Never recommend that the person does not return to work or state that the person cannot work © 2010 Worksite Health & Safety Consultants

50. 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 © 2010 Worksite Health & Safety Consultants

51. Job modification – ergonomics Case manager contact Legal contact Expert witness versus defend your findings After the evaluation © 2010 Worksite Health & Safety Consultants

52. 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 © 2010 Worksite Health & Safety Consultants

53. Questions? Thanks for having me and good luck with your studies! Naomi@workinjuryfree.com www.workinjuryfree.com 301-933-WORK

54. The Blankenship Center: http://blankenshipfcecenter.com/index.html IWS: www.workwell.com/FunctionalCapacity.asp ErgoScience: http://www.ergoscience.com/index.php O*NET: http://online.onetcenter.org/ Social Security Administration: www.socialsecurity.gov King, 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. Additional References and Resources © 2010 Worksite Health & Safety Consultants