Functional Capacity Evaluations (FCEs): Medical Evidence .

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Functional Capacity Evaluations(FCEs): Medical Evidence orHearsayJoe Castronovo, PT, DPT, MTCIndustrial Rehabilitation Manager

FCE Article – The Benefits of aQuality Functional spxhttps://wcla.info/resources/Documents/WCLA FALL2017 FINAL.pdf

Are FCEs Important?Impairment Does Not Equal Function

FCEPremise1) Determine SafeFunctionalWork Level2) DetermineSincerity of Effort

FCE OutcomesA. Valid and Met Job DemandsB. Invalid1. Met Job Demands 2. Did not meet job demands C. Valid results and did not meet jobdemands PERCENTAGES?

IL WC Reform1) FCEs need to Beindependent – directedby carriers and notfrom same facility2) FCEs need to beperformed by aphysical therapist,occupational therapist,physician assistant, orphysician3) FCEs need to bestandardized

A FCE to Determine Effort and/orMalingering§ What is the Difference?§ What are Non-Organic Signs?§ How do you find non-organic signs?§ Are they Quantifiable?

A FCE to Determine Effort and/orMalingering§ How Do You Determine Effort?§ What is a coefficient of variation?§ How does Heart Rate andperceived effort play a part?§ Does the FCE have StatisticalSignificance?

ALWAYS VALID?BASED ON WHAT?

Types of FCEs –10 Well KnownSystemsI. Two Categories:1) Controlled2) UncontrolledContent Validity!II. Two Sub-Categories:1) Actual Simulation2) Predicts Ability

DeterminingMaximum AbilityA.PsychophysicalB.KinesiophysicalC.Evidence Based Prediction

Chicagoland/IllinoisBlankenship/J-Tech :Uncontrolled with actual jobsimulations, based on isometricNIOSH predictionsMatheson/Epic:Controlled with predictionmoduleKey :Controlled with predictionmoduleOccupro:Uncontrolled with actual jobsimulation.ErgoScience:Controlled/Prediction

The National Institute forOccupational Safety and Health &APTAAn FCE should:1.Be safe2.Be reliable3.Be valid at prediction of safe work ability (ContentValidity)4.Be specific and flexible to work related abilities(Uncontrolled)5.Predicts future risk6.Answers The Referral Question7.Follows U.S. State Specifications8.Based on Medical and Researched Evidence,“generally accepted” by a meaningful segment of thescientific community

FCE Components1) Paperwork – Pain Scales, drawings,function, depression, Fear/Anxietymedical history, body language2) Interview3) Physical Examination4) Warm-up5)Grip Testing

FCE Components – cont.6) Cardio Testing7) Isometric Strength Testing8) Dynamic Lifts9) Positional Tolerances10) Job Specific Testing11) Post Testing Paperwork12) Analysis13) Report Presentation

Important FCE ComponentsPre-Testing Paperwork

Functional Questionnaires1) Does the client’s self reporting make sensewith the diagnosis2) Does the client’s self functional reportingcorrelate to the activity during the FCE3) Do the symptoms correlate to the injury anddiagnosis4) Available in multiple translations

Physical Examination! A physical exam helps determine if the client is consistentwith previous examinations. Baseline Measurements: A physical exam is compared totesting activity for consistency. A physical exam is needed for determining non-organicsigns that helps determine effort and malingering. A physical exam determines contraindications to testingor parts of testing that need to be monitored more closely. Therefore, a FCE that does NOT include a physical examjeopardizes a patient’s safety.

Physical Exam – Needed1) Waddell, Korbon’s, etc.2) ROM3) Neurological Signs4) Muscle Strength Testing – Force Gauge5) CogwheelingAre the findings Consistent with Diagnosis?

Muscle Testing With AForce Gauge

Rapid ExchangeGrip (REG)ExampleStandard Validity Testing

Grip Testing1)No Determination of WorkFunctionMatheson L,Isernhagen S, and Hart D.2) Consistency and ValidityA) Force Curves & FatigueB) Coefficient of Variation3) Major TestsA) Maximum GripB) 5-Position – Bell ShapedCurveC) Rapid Exchange Grip – isGrip Stronger than Max Grip

Isometric Lifts:Creating an AccuratePrediction ModelOther FCE Systems Are SelfLimitingFloor to Waist Lift (Leg,Squat, Floor)Matheson L, Isernhagen S,and Hart D. RelationshipsAmong Lifting Ability, GripForce, and Return to Work.Physical therapy202;82:249-256.

The NIOSH Lifting Equation is:LC x HM x VM x DM x AM x FM x CM RWLwhere LC is the load constant (23 kg) and otherfactors in the equation are:HM, the Horizontal Multiplier factorVM, the Vertical Multiplier factorDM, the Distance Multiplier factorFM, the Frequency Multiplier factorAM, the Asymmetric Multiplier factorCM, the Coupling Multiplier factorRWL, the Recommended Weight Limit

Isometric Lift Example

DynamicLifting1)Extrapolate from NIOSH2)Confirm or Disprove by patientreports and observed bodymechanics.3)Determine Maximal Occasional Lifts4)Test for Frequent or Constant Lifts ifneeded for workThe Alternative – repetitive liftingbased on psychophysical andkinesiophysical testingFatigue Component!

Positional Tolerances

FCE To Determine Effort?Validity Profile1) Coefficient of Variation2) Heart Rate – consistent with effort,maximum heart rate, or pain3) Rate of Perceived Exertion (RPE)4) Hand/Grip Tests5) Non-Organic Signs6) Static v. Dynamic Lift Comparisons7) Occasional v. Frequent Lift Comparisons8) Observed v. Unobserved Behavior9) Psychological Paper Tests v. ActualPerformance10) Minimum 20 tests, ideally 40

How To Analyze?#1. Who Performed The Test?#2. What was the Test Format?#3. Equipment Used?#4. Physical Exam Performed?#5. Objective, Subjective, or at least HighlyDetailed#6. Statistical Significance?29

#1 Who Performed the Test?#1Who is Performing the Test?Test Needs to be unbiasedBoard Certified?30

#1 Who Performed the Test? An ATC is responsible for the evaluation of athletesunder the supervision of the team physician. Anathletic trainer is educated and trained on theevaluation of sport injuries and on the field/courtinjuries. "Physical therapist assistant" means a person licensed toassist a physical therapist and who has met all requirementsas provided in this Act and who works under thesupervision of a licensed physical therapist to assist inimplementing the physical therapy treatment program asestablished by the licensed physical therapist. The patientcare activities provided by the physical therapist assistantshall not include the interpretation of referrals, evaluationprocedures, or the planning or major modification ofpatient programs.”31

#2 What FCE System Was Used?“A FCE outcome depends on the expertise of the testadministrator, not the system itself.”JJC32

#3 What Equipment was Used?I.Computerized v. Manual Test?II.Mechanical or Digital EquipmentIII. Calibrated?33

#4 Was a Physical ExaminationPerformed? A physical exam helps determine if the client isconsistent with previous examinations. Baseline Measurements: A physical exam iscompared to testing activity for consistency. A physical exam is needed for determining nonorganic signs that helps determine effort andmalingering. A physical exam determines contraindications totesting or parts of testing that need to be monitoredmore closely.Therefore, a FCE that does NOT include a physicalexam jeopardizes a patient’s safety.34

#4 Was a Physical ExaminationPerformed? Co-Morbidities? Drug Interaction? Fear Avoidance Pain Avoidance Psychological Perceived Function35

#5 Objective, Subjective, or at LeastHighly DetailedI. Objective v. SubjectiveA.PsychophysicalB.Objective Testing/ Evidence Based PredictionC. Kinesiophysical36

Kinesio-Physiological Response1) Biomechanical ChangesA) Changes in bodyMechanics/CompensationsB) Muscle RecruitmentPatternsC) Sweating, redness,SOB2) Heart Rate ResponseA) Is it Credible?B) Factors that CanChange?3) Other Physiological ChangesObservations need to bedetailed, individualized,specific to each activity,and abundant.37

#6 Statistical Significance38

What to ask your tester During aninterview or Deposition?1) When was the last time your equipment wascalibrated?2) How many tests have you performed?3) How were you certified in FCE Testing?4) Does your license allow you to evaluate? Under aphysician script for physical therapy?5) Did you know or work with patient prior to thisevaluation?

What to ask your tester During aninterview or Deposition?6) Is this test an evaluation or an assessment?7) Does the FCE system actively capture the data? Ifnot how do you know you captured the data correctly?8) Do you keep the supporting documentation?9) How do you determine a Valid test – explain eachtest.10) How do you determine maximum lifting capacity?

What to ask your tester During aninterview or Deposition?11) How do you correlate work ability?12) Explain the science behind “Blank” test13) How many Tests are used to determine effort in youranalysis?14) How familiar are you with the injury?15) How familiar are you with the client’s comorbidities?16) Do you Analyze the medications the client takes?For PMH or Injury? Beta Blockers!17) Do you perform ALL tests yourself?

Checklist For reading Report1) Is this a Quality TestPhysical/Occupational Therapist v. Athletic trainer or other?Was a physical examination performed?Were the tests performed relevant to the job demands of theclient?Were the tests performed using electronic /computerizeddevices v. mechanical devices?

Checklist For reading Report2) What was the Validity ProfileWere adequate tests performed to determine effort?Did Physical exam indicate inconsistent symptoms?Were there any Objective tests performed to predict liftingcapacity?Was there Fair or Poor effort given, yet not clearly stated inreport (would physician miss this language and agree to lowlifting demands?)

Checklist For reading Report3) Did the report explain the why behind each test,especially conclusions of not meeting certain jobdemands?4) Was all supporting documentation included?

QUESTIONS?

A FCE to Determine Effort and/or Malingering § How Do You Determine Effort? § What is a coefficient of variation? § How does Heart Rate and perceived effort p

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