Functional Capacity Evaluation

Functional Capacity EvaluationAre they worth their weight??

Peg Hau OT/CHTAdvanced Physical Therapy & Sports Medicine1In developing diagnostic tests, we must remember that it is better to miss an insincere individual than to classify a sincere patient as insincere. Tests must be chosen carefully, and if multiple tests are used, they must be administered in a logical order.

Ahmer, 2007History of the FCE

A functional capacity evaluation is set of tests, practices and observations that are combined to determine the ability of the evaluated to function in a variety of circumstances, most often employment, in an objective manner1970s beginning2001critized as not being job specificReneman et al, 2001The FCE was said to begin in the 1970s when US physicians understood that a hx and physical was not enough to assess employability or work disability and they began to refer pts to OTs & PTs for a measurement of functional capacities for lifting, standing, walking, sitting and carrying.In 2001 Reneman critized the previous FCE as not job related or specific to the activities performed on the job.Traditional FCEs prior to 2000 ignore important individual differences in background, personality, motivation or vocational interest. Over the last decade many FCE batteries have begun to also include evaluation of cognitive demands if such testing is warranted.3What is an FCEEvaluates and individuals ability to perform work axs related to his/her employmentSimilar types of testingConsists of standardized assessmentsAdministered with care and safety in mind(Kuijer et al., 2011; Soer, et al., 2008). A functional capacity evaluation (FCE) evaluates an individual's capacity to perform work activities related to his or her participation in employment (Soer et al., 2008). The FCE process compares the individual's health status, and body functions and structures to the demands of the job and the work environment. In essence, an FCE's primary purpose is to evaluate a person's ability to participate in work, although other instrumental activities of daily living that support work performance may also be evaluated. Similar types of testing may also be utililzed such as a functional capacity assessment (FCA), physical capacity assessment or evaluation (PCA or PCE), or work capacity assessment or evaluation (WCA or WCE). A well-designed FCE should consist of a battery of standardized assessments that offers results in performance-based measures and demonstrates predictive value about the individual's return to work (Kuijer et al., 2011; Soer, et al., 2008). The FCE must be administered with care for the client's safety and well-being. -4Why are they orderedBaselinePre employmentJob SpecificMedical/legalAssisting with case closureFCEs may be required by law for some employers before an employee can return to work, as well as by insurers before insurance payments can be made. FCEs are also used to determine eligibility for disability insurance, or pension eligibility in the event that an employee is permanently unable to return to work. The United States Social Security Administration has its own FCE, called theAssessment of Disability. A newer FCE model is theWorld Health Organization'sInternational Classification of Functioning, Disability and Health.5Who can benefit from an FCEIndividual injured on the jobApplying for Social Security Disability Seeking to return to work after extended leaveSomeone seeking vocational rehabilitationTransition from school to work settingSomeone who has been injured on the job may benefit from an FCE to determine his or her ability to return to the job or alternate work. Someone applying for Social Security Disability benefits. Someone seeking to return to work or volunteer activities after an injury or illness. Someone injured in a catastrophic accident (i.e., automobile accident) for whom an FCE can determine performance skills and abilities related to resuming former employment or a new job Someone seeking vocational rehabilitation services Students receiving transitional services from school to the work setting to determine their skills and the extent of support required to perform in a job-6FCEs are done on a one-on-one basis and may range in length from 4 to 6 hours.

The FCE may take place over 2 consecutive days. Depending on the patients toleranceLength of an FCE can vary based on what is being evaluated. Time of testing can vary from approximately 2 hours to 2 days. On average, a whole body functional capacity evaluation lasts 3-4 hours.7Components of an FCEHistory review medical, vocational, socialScreening tests musculoskeletalPhysical functional testing based on DOTJob simulation when identified job is knownBehavior assessmentResults, data compilation, and recommendations

Types of FCEsMathesonErgo Science www.ergoscience.comARCON FCE http://fcesoftware.com/home.htmlIsernhagen Work SystemBlankenshipErgos Work Simuolator and Ergo Kit VariationHanoun MedicalWEST-EPICKeyAssessAbility

Over the past twenty years, many researchers have tried to develop functional capacity evaluation instruments. Matheson provided one of the earliest examples in 1984. Isernhagen followed in 1988 with the suggestion that a multidisciplinary team should assist in determining a person's functional capacity. Hart in 1994 also advocated a physician and physical therapist working in conjunction to assess a patient's resulting impairment. There are approximately 10 different types of commonly used functional capacity evaluations. These include the Blankenship, Ergos Work Simulator and Ergo-Kit variation, the Isernhagen Work System, Hanoun Medical, Physical Work Performance Evaluation (Ergoscience), Key, Ergos, ARCON, and AssessAbility.9Ergo ScienceDeveloped in 1988 by Deborah Lechner PT,MSAdministrators must complete 24 hours of instructionUsed in 850 clinicswww.ergoscience.com

Ergo Science was developed in 1988, Deborah E. Lechner, PT, MS, and her research colleagues at the University of Alabama at Birmingham (UAB), evaluated all commercially available FCEs for an outcomes research project. After extensive investigation and review, the research team found that none of the available systems met all their criteria for a well-designed and validated test. They changed the focus of their project to develop a new FCE protocol and to establish its reliability and validity.The ErgoScience FCE toughts themselves as being the only research-developed and fully validated measurement tool available to accurately and objectively measure an individuals physical capabilities. Our patented scoring system takes clinical guesswork out of determining an overall level of work, projecting performance for an 8-hour day and determining sincerity-of-effort. ErgoScience FCEs can only be performed by health professionals who have completed a training course consisting of 24 hours of instruction, and have demonstrated their competency by passing a series of examinations. ErgoScience has one of the largest clinic networks in the industry, comprised of over 850 clinics, located both domestically in the U.S. and internationally. Interested in purchasing a license to perform the ErgoScience FCE? Currently, ErgoScience offers two systems, depending up whether you want to focus exclusively on FCE or if you want to engage in job analysis and post-offer screening as well

10ARCON Sciencewww.fcesoftware.com30 yearsof development and refinement.1,000 clinics nation wide

Arcon's primary focus is to assist doctors, therapists and companiesin their evaluation ofan individualsfunctional capacity; bydeveloping, selling and supporting automatedFCE hardware and software.

While the Arcon FCE system uses state-of-the-art wireless evaluation tools, it is important to remember that the keyto everyFCE system is thesoftwareusedto collectand summarize data.

11ARCON continuedTheArconsystem includes:

* Computerized hand and pinch gauges.* Electronic goniometer.* Dual range of motion inclinometers.* Dynamic and isometriclifting system.* Carpal tunnel testing attachment.* Computerized heart rate monitor.

Testing protocols includes:

* Dynamic lifting.* Isometrictesting extremities & back.* Range of motion testing.* Dexterity testing.* Endurance testing.* Activities of daily living.12Iserhagen Work SystemSusan J. Isernhagen PT created the first functional capacity evaluation in the mid 1980s. Redeveloped in 2004Objectivity of results to replace the subjective estimates that were currently being usedMedical base to tie the functional capacity and limitations into current diagnosesInformation on level of effort, to identify those who used full effort and those who did not use full effort.Safety in functional tests so that this information could lead to safe return to workWork relatedness to determine abilities to perform specific jobs, http://dsiworksolutions.com/history.htm

The DSI FCA has three primary parts.History with medical, injury/illness and functional backgroundsPhysical exam to document any motion, strength or balance/coordination deficits that would be linked to safety issues or test endpoints.The FCA non-medical form which has all areas of function tested and scores placed in each functional category according to frequency of task performance, ergonomic recommendations and referral answers.

For work relatedness, the DSI FCA uses a comprehensive and repetitive mix of physical demands to identify endurance, differences in task performance and ability to sustain work activity. Its unique format is closest to actual job descriptions.

Measurement of level of effort is divided into two areas. The levels of effort proven reliable in research are used to objectively identify full effort or the lack of it. The second is ability/willingness to do repetitive items. The DSI method has a consistency checklist imbedded as each item is repeated at least twice in the one part test and four times in the two part test. To enhance the likelihood of full effort, objective criteria, and medical safety, promote willingness of the evaluee to provide full effort.

13Iserhagen continuedThe Relevance for Nondiscrimination Compliance by Susan Iserhagen - 2010BlankenshipA unique FCE calledtheWORKEVALTMand it helps Physicians, Case Managers and Employers determinewhat work limitations are appropriate for the injuredworker.We also provide Physicians with theobjective data they needtodetermine theinjured worker's Permanent and Partial Disability, or PPD. Thename forthis evaluation, whichwasdeveloped andpublished by the American Medical Association, is a PermanentImpairmentEvaluation. This evaluation process determines the percent of Permanent,Partial Impairment and that percentageis used to help Patients,Employers, Insurers and Attorneys negotiate the settlement of theWorkers' Compensation Case.

THE BLANKENSHIP WORKEVAL SEMINAR OBJECTIVES:This WorkEval Seminar that teaches how to perform the WorkEval withTHE R-FACTOR. It teaches aN 8-Point WorkEval Validity Profile, a Forensic Intake Interview, Pain and Disability Questionnaires, Non-Organic Signs by Waddell, Korbon and Sobel, a Clinical Evaluation of the Spine and Upper and Lower Extremities, a Basic Hand Function Assessment, Basic Strength Testing Techniques, Material Handling for Rare, Infrequent, Occasional and Frequent Frequencies, how to correlate the WorkEval data, how to make simple calculations from the data, how construct a concise, but High-Impact Written Report and how to complete the WorkEval Results Form.15Ergos Work Simulator

SummaryComplete systems cover:15 work demands defined by the Department of Labor are measured.21 work related tests are provided plus the ability to create custom tests:Strength Tests(Coefficient of Variation)Performance Tests(MTM)Static Lift strengthDynamic Lift strengthPush and pull strengthCarrying strengthPinch strengthFinger DexterityGrip strengthHandling dexterityWrist flexion strengthForward reachWrist extension strengthOverhead reachForearm pronation strengthStanding-Bending, StoopingForearm supination strengthKneeling, CrouchingUpper Extremity system covers:8 work demands defined by the Department of Labor are measured.13 work related tests are provided plus the ability to create custom tests:Strength Tests(Coefficient of Variation)Performance Tests(MTM)

16Hanoun Medical

Strength & dexterity testingProtocolsFatigue analsyis software????????????Hanoun Medical's UE System, which employs both strength and dexterity testing, is designed to assess upper extremity human performance, detect possible impairment and provide rehabilitation to patients with repetitive strain injuries, carpal tunnel syndrome and a wide array of other related conditions. With its advanced protocols, innovative applications and novel fatigue analysis software, the UE system can determine and quantify physical abilities and work-related performance on an extremely precise basis, incomparable with other technologies.17Assessability

http://www.assessability.net/fme-vs-fce.htmlFunctional Medicine Evaluation (FME) vs. Functional Capacity Evaluation (FCE)

Functional Medicine Evaluation is a Physician Exam plus Functional Testing.The FME is ordered by Prescription, and provides the Physician the objective medical evidence for the Workers' Compensation DWC-25 form, or other documentation for Auto and Personal Injury.Clinically Superior to the FCEPerformed by Board Certified Physicians who correlate functional test results to any specific clinical dysfunctions found on physical exam and diagnosticsOver 80 references regarding the validity and reliability of the methodologyThe FME is not CAPACITY testing! Our non-exertional criterion testing ensures patients do not get hurt.(used in over 12,000 North American workplaces)

18Key

Glenda KeyFounder and President

1987

300 clinics & 42 states

Double blind testing

Since 1987, KEY Network has been the leading provider of Functional Capacity Assessments in the Industrial Therapy market. The Company holds three Patents and provides equipment, software and training to our client base of over 1000 trained Physical Therapists, Occupational Therapists, Certified Athletic Trainers in over 300 therapy clinics, Corporations and hospitals located in 42 States and 6 countries.

To date, KEY is the only company that, during the design stages, surveyed to confirm that the results of the assessments are truly accurate and that the client can do the recommended amounts of time and weight without re-injury. No other assessment or evaluation tested their results in the same thorough way as KEY.

How do you know if your client is cheating the system during the Assessment? Are they lifting to their full capability? Most assessment systems dont provide complete proof. KEYs validity determinations underwent statistical analysis and confirmation with Dr. Andrew Ahlgren, head of the Statistics Department at the University of Minnesota and further defining through Personnel Decisions, Inc. of Minneapolis, Minnesota, and the Decision Science Department of the University of Minnesota.None of the other systems have ever gone through that process to confirm their determinations of consistency and participation.As an Assessor, do you want statistical evidence to support and define your decisions or do you prefer to rely solely on your judgment? Do you want to carry that burden? Will it be easy for you to defend your decision to the client, an employer, or especially in a court of law?19Physical ExaminationHeart rate and blood pressurePosture and gaitRange of motionStrengthBalanceOther special testing as warranted

Functional Testing continued:Sustained overhead activity

Climbing ladders

Crouching/squatting/ stooping

Functional testingFloor to waist/ shoulder/overhead lift

Carrying

Push/pull

22Functional Testing cont:Grip strength

Pinch strength

FMC/9 hole peg/Purdue

Stereognosis

Less than Full Effort PerformanceReasons for ..1. Medically determined impairments2. Malingering3. Factitious disorder4. Learned illness behavior5. Conversion disorder, pain disorder

Matheson, 2003Some of these may and usually do occur simultaneously. 24Continued:6. Depressive disorder7. Test anxiety8. Fear of symptom exacerbation or injury9. Fatigue10. Medication & psychoactive substance effects11. Lowered self-efficacy expectations12. Need to gain recognition for symptoms

Methods to identify inconsistancyIntra test inconsistencyAbsence of expected relationships among measures.Completion of tests and willingness to do moreCoefficient of variationRapid exchange gripCorrelation of heart rate with reported max effort Correlation of impairment (range of motion, manual muscle tests, etc. ) to function

Non-Organic SignsPain Questionaire Waddell McGill Pain Questionaire RansfordNumeric pain scaleMillion Visual AnalogueThe original "Waddell's Signs" are a group of inappropriate responses to physical examination:1. Superficial and non-anatomic tendernessSuperficial tenderness may be tested by lightly pinching over a wide area of lumbar skin. Excessive pain reaction to this is considered positive.Nonanatomic pain is described as deep tenderness felt over a wide arearather than localized to one structure. For example, complaints that "the whole left side of my body hurts".2. Simulation testThis is usually based on specific movements producing pain. Axial loading is one simulation test in which light pressure is placed on standing patient's skull by the examiner's hands. This is positive if low back pain is reported.The second simulation test is rotation. Back pain is reported when the shoulder and pelvis are passively rotated in the same plane, as the patient stands relaxed with feet together.3. Distraction straight leg raising (supine vs. sitting)There are several variations to this test. Most commonly the straight leg raise is done while the patient is lying fiat and then, while distracting the patient, in the sitting position. This may be positive if there is positive pain response while the patient is lying down, but no pain when the test is done while the patient is sitting.4. Regional disturbancesRegional disturbances involve a widespread area, such as an entire quarter or half of the body. The essential feature of this sign is the divergence of the pain beyond the accepted neuroanatomy. Examples include give-way weakness inmanymuscle groups and diminished sensation to light touch, pinprick or vibration that do not follow a logical dermatomal pattern. Example: The patient may have nerve root compression at L5 but claims numbness "in the entire leg".5. Overreaction to examinationThis may be the use of disproportionate verbalization, facial expression, muscle tension, tremor, collapsing, and even profuse sweating. This is the single most important physical sign.Although Waddell signs may be useful in physical assessment of a patient, many physicians are skeptical of their use and take extra care in not over interpreting a positive sign. A "Waddell" test is positive if the patient demonstrates inconsistent or nonanatomical physical signs in three or more of the five tests. All findings must be carefully considered together before concluding there is another basis for a patient's pain that cannot be explained by his/her illness or injury. It provides useful information only when used appropriately.

TheMcGill Pain Questionnaire, also known as McGill pain index, is a scale of ratingpaindeveloped atMcGill UniversitybyMelzackand Torgerson in 1971. It is a self-report questionnaire that allows individuals to give their therapist a good description of the quality and intensity of pain that they are experiencing. Users first select a single word from each group that best reflects their pain. Users then review the list and select the three words from groups 1-10 that best describe their pain, two words from groups 11-15, the single word from group 16, and then one word from groups 17-20. After completing the questionnaire, users will have selected seven words that best describe their pain. Users can use some words more than once.

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Million Visual Analogue ScaleThe Million visual analogue scaleThe Million visual analogue scale (MVAS) (Table15) is a 15-item questionnaire about disability and pain intensity in patients with LBP.38The 15 questions investigate the body functions (pain, sleep, stiffness and twisting), daily activities (walking, sitting, standing and work) and social life. Information about item selection process is not available. Score is given on a 100 mm visual analogue scale(VAS). For example, if patients are asked to quantify the severity of his pain (like the first question), they mark a point on a 100-mm line in which the end points are labelled as no pain and intolerable. In each question, it is possible to obtain an index of severity of symptoms in a patient-specific fashion measuring the distance of the marked point from the origin of the line. The final score is calculated by adding up the equally weighted scores.

Physical Demand Characteristics of Work

ReferencesChapman-Day, K. M., Matheson, L. N., Schimanski, D., Leicht, J., & DeVries, L. (2011). Preparing difficult clients to return to work.Work (Reading, Mass.),40(4), 359-367. doi:10.3233/WOR-2011-1247; 10.3233/WOR-2011-1247Gouttebarge, V., Kuijer, P. P., Wind, H., van Duivenbooden, C., Sluiter, J. K., & Frings-Dresen, M. H. (2009). Criterion-related validity of functional capacity evaluation lifting tests on future work disability risk and return to work in the construction industry.Occupational and Environmental Medicine,66(10), 657-663. doi:10.1136/oem.2008.042903; 10.1136/oem.2008.042903Gouttebarge, V., Wind, H., Kuijer, P. P., Sluiter, J. K., & Frings-Dresen, M. H. (2010). How to assess physical work-ability with functional capacity evaluation methods in a more specific and efficient way?Work (Reading, Mass.),37(1), 111-115. doi:10.3233/WOR-2010-1084; 10.3233/WOR-2010-1084Streibelt, M., Blume, C., Thren, K., Reneman, M. F., & Mueller-Fahrnow, W. (2009). Value of functional capacity evaluation information in a clinical setting for predicting return to work.Archives of Physical Medicine and Rehabilitation,90(3), 429-434. doi:http://dx.doi.org.ezproxy2.library.drexel.edu/10.1016/j.apmr.2008.08.218Westbrook, A. P., Tredgett, M. W., Davis, T. R., & Oni, J. A. (2002). The rapid exchange grip strength test and the detection of submaximal grip effort.The Journal of Hand Surgery,27(2), 329-333.Wind, H., Gouttebarge, V., Kuijer, P. P., Sluiter, J. K., & Frings-Dresen, M. H. (2009). Effect of functional capacity evaluation information on the judgment of physicians about physical work ability in the context of disability claims.International Archives of Occupational and Environmental Health,82(9), 1087-1096. doi:10.1007/s00420-009-0423-8; 10.1007/s00420-009-0423-8