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The
Functional Capacity Evaluation:
The Science Behind Functional
Capacity
Evaluations
Interview with Alan Blitzblau
In a
continuing series featuring medical professionals
in the workers’ compensation
system, Marjory Harris interviews Alan
Blitzblau, a biomechanist and software
architect who designed the ARCON/VerNova
Functional Evaluation System.
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HARRIS: Alan, you pioneered
3-D motion analysis software design
for use in occupational medicine,
rehabilitation, and sports. What
career path led you into FCE design?
BLITZBLAU: While 3-D motion analysis
is “exciting” science
than can yield a tremendous amount
of information about human performance,
it has always been too complex and
expensive a technology to apply
as widely as one might wish.
Back in 1992, when I was first introduced
to FCE methodology while consulting
for Arcon Inc, I saw an opportunity
to apply my experience in software and hardware development to
what was then a very
“low-tech” industry. The marketplace
for FCE services was vigorous and
profitable, but the process relied
too much on observation and manual recording and presentation of
data, and was inefficient, as well
as prone to human error.
While
I had no formal background in functional evaluation, I knew that
I could make improvements in the process of collecting the FCE
data as well as automating the
presentation of that data in a well-structured,
consistent report. I shared my ideas with the owner of the company
(Arcon), and before long I found myself working there full time.
The rest, as they say, is history.
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The process relied too much on
observation and manual recording and presentation of data, and was
inefficient, as well as prone to human error. I knew that I could
make improvements in the process of collecting the FCE data as well
as automating the presentation of that data in a well-structured,
consistent report. [For a sample
report, see sidebar at end of article] |
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HARRIS: Your
company’s primary focus is to assist doctors and therapists
by developing automated FCE hardware and software. What do your
products do?
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BLITZBLAU: Basically,
they make the process of performing
an FCE simple, reliable and consistent.
Every FCE attempts to quantify the
same set of physical abilities – strength,
movement, postural tolerance, dexterity/coordination and aerobic
capacity. We all utilize similar evaluation protocols. The Arcon
FCE software and hardware automates the data collection process as
well as the generation of the final
report. This allows the clinician
to focus on the performance of the subject while being confident
that all measurements have been made and saved correctly.
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Every FCE attempts to quantify the
same set of physical abilities – strength,
movement, postural tolerance, dexterity/coordination and aerobic
capacity. |
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HARRIS: What
science underlies the ARCON/VerNova system? Put another way, what
are you measuring and how is it
scientifically valid and reliable?
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BLITZBLAU: Every
one of our functional tests is based on independent, published
research. The Arcon FCE has no
proprietary or self-developed tests.
If you look at one of our reports,
each section contains citations
for the supporting publications.
When we measure strength or movement
or dexterity, we follow
peer-reviewed methods that have been generally
accepted as valid.
As for reliability and consistency – the
Arcon FCE software continually monitors this during an evaluation
using the same reliability measures
that were included in the test
design of the published evaluation
methods. Examples of this include
the five-position and
rapid-exchange grip tests, horizontal displacement
and heart rate response in static
strength testing, and coefficients
of variance on repeated trials of the same task.
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Every one of our functional tests
is based on independent, published
research. When we measure strength
or movement or dexterity, we follow peer-reviewed methods that have
been generally accepted as valid. |
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HARRIS: How
important is the training and attitude of the physical therapist
in this process? Can your equipment and software make up for any
deficits in the therapist’s
training or performance?
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BLITZBLAU: In
a clinical environment any evaluation process, no matter how well
designed, can be done incorrectly.
Our software assists the therapist
to perform a good evaluation in a number of ways. We check for
missing or out-of-range data, we perform multiple measures and
report a coefficient of variance,
we automatically sequence through
all required tests to avoid
unintentional omissions, and we collect
almost all data with calibrated
instruments so there are no errors
in reading or transcribing data.
We provide operator training for
our FCE software, as well as training in the process of performing
an FCE. In addition, our software can
display illustrated instructions
for each test, so the clinician can “brush up” on the
process at any time. In the end,
there is no substitute for practice
and experience in achieving high proficiency. The clinician who
performs a number of FCEs a month will generally do a better job
than someone who does them on an infrequent basis.
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In the end, there is no substitute
for practice and experience in achieving high proficiency |
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HARRIS: Do
your products “correct”
for lack of effort on the worker’s
part, whether caused by pain, fatigue, or improper motive, so as
to make the process more objective?
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BLITZBLAU: In
general, we don’t “correct” which would imply
that we alter the data based on the degree of observed effort.
Our software is designed to “identify” the presence
of sub-maximal or managed effort
and to report that using objective
criteria, along with the actual
demonstrated ability level.
When
a subject gives less than a full effort, it is impossible to say
what his or her maximal ability would be. We can report the highest
ability level demonstrated during the FCE
as their minimal ability,
and we can objectively document the degree of inconsistency and/or
the presence of managed effort behaviors in their performance.
If the subject is non-compliant, then the issue must be handled
administratively or legally –
it is no longer a medical decision.
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HARRIS: Some
doctors dismiss FCEs as useless and meaningless, claiming they
are subjective and reflect only the effort the patient wants to
give. How do you respond to that
criticism?
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BLITZBLAU: Unfortunately,
many FCEs are useless and meaningless. This frequently has more
to do with the skill of the
practitioner and the type of FCE performed,
than with FCEs in general.
While the FCE protocol is science, there
is still the “art” of the clinician in establishing
a degree of rapport with the subject to encourage them to show
their true abilities. I have seen
this many times. A subject presents
uncooperative and hostile, but with
some good questions, sympathetic
listening, and honest encouragement, better performance can often
be elicited.
There are, of course, some subjects who will intentionally
give little effort, regardless of encouragement. Studies have shown
that true malingerers or those intentionally cheating the system
are actually a small percentage of the work comp population. More
often subjects are guarded or hostile because they believe that
the “system”
doesn’t care about them. The treating
physician is limited in the amount of time he or she can devote
to each patient, but in the course
of a 3-4 hour FCE the evaluator
can establish a degree of rapport that can have a positive effect
on the outcome of the FCE.
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| While the FCE protocol
is science,
there is still the “art”
of the clinician in establishing
a degree of rapport with the subject
to encourage them to show their
true abilities. |
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HARRIS: There
is always the question of whether
the worker is capable of sustained
use, even if able to briefly do something in a doctor's office
with the limited testing done for an impairment rating, or with
a physical therapist at an FCE. How do you show that sustained
use on the job is or is not feasible? Does your system require
a longer period of testing than we
generally see in “quickie” FCEs,
and why is that important?
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BLITZBLAU: It
is common practice to predict ability over a full work day based
on short-duration tests. By and
large, these predictions are reliable
but they are by no means
infallible. The reality of the workers’
compensation
marketplace is that reimbursements
only permit 3-4 hours of subject
contact time for an FCE (and in some states, even less). The goal
is to deliver the best FCE possible in that time.
Years ago there
were full-day FCEs, or even two-day FCEs. I have observed some
of these, and my conclusion is that
they did NOT simulate the subject’s
actual work experience. Subjects
would still claim that they could
sustain the FCE, but that after a couple of days on the job they
had to go home. So the question is this – how long would
we need to evaluate a subject before we were certain that they
could meet the physical demands of their job?
The answer is that
no one really knows how long. I know of no research showing that
an 8 hour FCE is a better predictor of abilities than a 4 hour
FCE. At some point an FCE can become so short that there is simply
not enough time to measure a full set
of physical abilities. Cooperative
subjects can complete an FCE more
rapidly than uncooperative subjects.
Finally, I am aware that some
providers do perform “quickie” FCEs.
They may spend as little as an hour or an hour and a half with
the subject. Often there is a lack
of objective evidence of abilities
in these studies, with the
evaluator reporting work tasks as
“observed”.
These FCEs do not stand up well under scrutiny and are frequently
discredited if the case goes to court.
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| I know of no research showing
that an 8 hour FCE is a better predictor of abilities than a 4 hour
FCE. |
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HARRIS: What
should attorneys and adjusters be looking for when considering
referrals to FCE outfits? What questions should we ask when we
get the report?
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BLITZBLAU: When
looking for an FCE provider, ask what FCE system they use. Most
of the established vendors have a
good product. Avoid practitioners
who say “we have our own FCE”. Ask how long they have
performed FCEs, and how many they
do each month. If possible, request
a blinded copy of an actual FCE
they have performed recently. This
is a bit of extra work for the provider, but it will give you a
good impression of the quality of their work.
Verify that reported
abilities are correlated with objective measurements (numbers,
graphs, etc), and not merely with observations. Check that the
report includes a discussion of subject reliability of effort,
preferably substantiated by objective measures. If the report is
an “own occupation” FCE, has the provider obtained
a description of essential physical
job demands from the subject’s
employer? This is a step that is often omitted, as it takes extra
time and effort, however it produces in a much more valuable FCE.
Does the report clearly state the purpose of the FCE and list any
specific referral questions? Do the results of the FCE fulfill
that purpose and answer those questions?
Finally, does the report
contain any “red flags”?
These would include conclusions
that are not based on actual data from the FCE, the inclusion of
any type of diagnosis that was not
provided by the treating physician
(an FCE is not a diagnostic test),
any recommendation for additional
treatment (the FCE provider is an
impartial observer, not a subject
advocate), and the inclusion of job restrictions or modifications
unless specifically requested by the referral source (these are
more properly addressed by the
treating physician and the subject’s
employer).
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A sample report from Arcon is
a model of what to look for in our FCEs.
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With over 30 years’
experience pioneering 3-D motion analysis
software design and implementation, including innovative custom
software and hardware applications
in occupational medicine, rehabilitation,
and sports, Alan provides an
incomparable match of dedicated frontline
experience. His career positions as Senior Analyst, Chief System
Architect, R&D Director,
Product Development Director and Executive
Vice President of Information Technologies have been focused on
the same technology development
avenues and consumer-based markets
targeted by BioMotion of America.
He is responsible for developing
3-D applications for the Ariel Performance Analysis System and
designing the ARCON/VerNova Functional Evaluation System.
Alan
earned his BS in Physics and Computer
Science from Brown University.
Contact Alan
at alan@fcesoftware.com.
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