|
|
|
  
| |
HARRIS: What
do you see as the value and purpose of the Functional
Capacity Evaluation (FCE) in today’s workers’ compensation
system?
RABIDEAU: The
value of the FCE is that it provides
objective identification of the client’s
functional abilities and limitations.
FCEs are designed so that the therapist
observes the client performing various
functional activities. The therapist,
skilled in neuromusculoskeletal function,
observes and documents client performance
including heart rate and blood pressure
changes, effort to complete an activity,
reason for stopping an activity, when
primary muscles recruit accessory muscles,
difficulties getting in/out of positions,
as well as posture, balance, coordination,
speed, movement patterns, reports of
pain, etc. The therapist pulls all
the information together to give a
complete picture of the client’s
functional abilities and physical limitations.
|
|
| “The
purpose of a Functional Capacity Evaluation (FCE) is
to provide an objective measure of a patient's/client's
safe functional abilities compared to the physical demands
of work.” To learn more about FCEs, click
here. |
|
|
|
HARRIS: What
are the components of the FCE?
RABIDEAU: The
Functional Capacity Evaluation (FCE) is a one or
two-day assessment of the client's functional capabilities.
The test safely and objectively measures and quantifies:
- repetitive lifting capacity at various levels
- repetitive
push, pull, and carrying capacities
- hand
grasp and pinch strength values
- tolerance
for elevated work
- prolonged trunk flexion
in sitting and standing
- prolonged trunk rotation
in sitting and standing
- prolonged crawl,
kneeling and sustained crouch positions
- repetitive
squat
- tolerance for prolonged sitting and
standing activity
- maximum walking, stair
climbing and stepladder capacity
- balance
- hand
coordination
An FCE can also test job specific activities
or activities of daily living if not already addressed
in the standard FCE protocol.
|
|
|
|
HARRIS: Are
there ways to measure functional limitations that
the physician does not undertake?
RABIDEAU: An
FCE as described by the APTA takes
anywhere from 4-8 hours and is performed
over 1 or 2 days. Most importantly
the therapist performs a preliminary
musculoskeletal assessment to obtain
a baseline of information, noting range
of motion, muscle strength, posture,
along with appropriate orthopedic and
neurological tests. During the actual
evaluation the PT/OT evaluates and
documents the client’s ability
to perform a variety of functional
activities. In contrast, the physician
asks the patient what they can do,
how much they can lift, how far they
can walk, how long they can sit, and
so forth. The physician does not have
the time/space/equipment to spend 4-8
hours evaluating function, and must
therefore rely on the client/patient
for the information. If the client
has accurate awareness of their abilities,
this format can work. However, most
clients are not aware of their specific
abilities and/or limitations, other
than in a general sense. The therapist
has the advantage of being able to
objectively identify the client’s
ability to reproduce and sustain performance
over time, report on client’s
consistency or inconsistency of effort.
The therapist can then take this a
second step and replicate job requirements
that may not have been tested in the
general FCE. In these cases, the final
FCE report will provide a summary of
the client’s physical abilities
compared to the job demand requirements,
indicating whether there is a job match.
|
|
| “The
therapist has the advantage of being able to objectively
identify the client’s ability to reproduce and
sustain performance over time…” |
|
|
HARRIS: There
is always the question of whether the worker can
sustain use, even if able to briefly do something
in a doctor's office. How do you show that sustained
use isn’t feasible?
RABIDEAU: The
FCE is designed so that it is performed over time,
ideally over two days. With the two day protocol
the therapist can objectively comment on the client’s
ability to repeat Day One’s performance. Subjectively
the client may report more discomfort on Day Two,
yet may be able to still repeat the same level of
function as Day One. The converse can be seen as
well, where Day One’s activities interfere
with Day Two’s performance. Day Two is therefore
a more realistic measure of the client’s true
ability to sustain the activity over time. Again,
the therapist has the advantage of several hours
of evaluation upon which to base the summary findings.
Therapists who perform FCEs can also perform job
specific testing when needed with various types of
job simulation equipment available.
|
|
| “Day
Two is therefore a more realistic measure of the client’s
true ability to sustain the activity over time.” |
|
|
HARRIS: How
can evidence from a physical therapist be of value
to medical evaluators or vocational experts?
RABIDEAU: The
Almaraz/Guzman decision is a positive
outcome for injured workers as well
as therapists who provide FCE services.
For years, therapists have evaluated
patients who have near full range of
motion yet who have functional limitations
that interfere in returning to their
previous occupation. Basing return
to work decisions on answering questions
such as “How injured is this
person?” on AMA Guides alone
does not tell the whole story. Let
me give you an example:
Two clients
sustained on the job shoulder injuries.
Both have a 20 degree loss of shoulder
ROM in all motions. Both can lift/carry
20 pounds and can perform overhead
work occasionally. Client One is a
welder; he needs to perform sustained
overhead reaching work in order to
return to work. He also needs to lift/carry
50 pounds. Client Two is a drafter;
he performs no sustained overhead work
at work, and he lifts and carries no
more than 20 pounds. Client One cannot
return to work. Client Two can fully
perform his job requirements and is
able to return to his previous job
as a drafter.
The AMA Guides are of
limited value in quantifying Client
One’s loss of ability to work
as a welder. Almaraz/Guzman is important
in such cases to fully identify the
client’s loss of earning potential
and their loss of ability to perform
the required demands of their previous
job. Almaraz/Guzman states that the
physician must consider an individual’s
functional capacity as well as the
effect the injury has on their ability
to return to work and earn an income
in cases where the AMA Guides do not
adequately reflect the impact the injury
has on job performance or ability to
earn a living.
|
|
| Almaraz/Guzman,
the en banc decision of the Workers’ Compensation
Appeals Board issued 2/3/09, noted: "… If
an injury has resulted in a functional impairment not
adequately reflected by clinical measurement under the
AMA Guides, then an ALJ must consider impact on job performance.” (Court’s
emphasis; citations omitted).) “In addition, a
physician may take into account pertinent diagnostic
studies, such as functional capacity and rehabilitation
evaluations. AMA Guides, § 2.6a.4, at p. 21.) Finally,
if the employee has been evaluated by a vocational rehabilitation
expert, the physician may review and consider the vocational
specialist’s opinion regarding what jobs the employee
might be able to perform and what effect the injury may
have on his or her ability to earn.”(Id., § 1.9,
at p. 14.)" Almaraz v. Environmental
Recovery Services,
74 Cal. Comp. Cas. 201 (W.C.A.B. 2009) |
|
|
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?
RABIDEAU: It
is important to note that there are
clients who self-limit performance
during an FCE, are not willing to work
to maximum efforts, who do not give
consistent performance, and exaggerate
symptoms. However, the number of these
clients is extremely small. Most clients
are willing to work to their maximum
ability and provide consistent effort.
If a client self limits performance
therapists can only report the level
of activity the client was willing
to perform. The FCE report should clearly
identify whether or not there was consistent
full effort exerted.
Therapists are
trained to observe kinesiophysical
movement patterns. There are expected
movement patterns that take place as
the body completes an activity. The
range of movement patterns goes from “minimal
effort required/no limitations” to “maximal
effort/significant limitations” as
the activity is performed. Studies
have shown that therapists can reliably
identify effort levels by means of
observation. One Netherlands study
validated therapists’ consistent
ability to reliably identify effort
levels. Testing
Lifting Capacity: Validity of Determining
Effort Level by Means of Observation was
published in Spine, Vol. #30, No. 2,
January 2005 by Reneman MF, et al.
Clients experiencing true pain and fatigue will present
with consistent movement patterns, as opposed to clients
who do not have true pain and fatigue. The therapist
assesses consistency of effort in addition to use of
body mechanics, posture, positioning, gait, and biomechanical
factors from Day One to Day Two. For instance, a client
with legitimate weakness involving the left shoulder
musculature will have significantly limited difficulties
performing all activities stressing the left shoulder
girdle. This same client would also not be expected
to have difficulties performing activities not stressing
the left shoulder, such as balance, sitting, stair
climbing, kneeling, and/or fine motor coordination.
In addition, similar tested activities would be expected
to be equally affected, such as while using the shoulder
for elevated work during work simulation and when completing
elevated lift and carry trials. This consistency is
not evident in clients who do not have true weakness,
true discomfort, and actual symptoms of disability
and dysfunction.
In summary, FCEs truly have a very
critical role to play in identifying and quantifying
an injured individual’s safe, maximal functional
capabilities.
|
|
| “Most
clients are willing to work to their maximum ability
and provide consistent effort… The FCE report
should clearly identify whether or not there was consistent
full effort exerted.” |
|
|
|
Marc J. Rabideau, PT, is the founder of Work Ability
Testing Services.
Marc J. Rabideau, P.T.
Vocational/Functional
Work Evaluator & Registered
Physical Therapist
Work Ability
Testing Services (W. A. T. S.)
2410 - 18th Avenue @ Taraval
Street
San Francisco, CA 94116
Tel: (415) 681-9287
Fax: (415)
681-6329
|
|
|
|
|
