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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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> Doctor's Office: Psych
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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.

 





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]
 
 
HARRIS: Your company’s primary focus is to assist doctors and therapists by developing automated FCE hardware and software. What do your products do?
   
 
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.

 
Every FCE attempts to quantify the same set of physical abilities – strength, movement, postural tolerance, dexterity/coordination and aerobic capacity.
 
 
HARRIS: What science underlies the ARCON/VerNova system? Put another way, what are you measuring and how is it scientifically valid and reliable?
   
 
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.
 
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.
 
 
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?
   
 
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.
 
In the end, there is no substitute for practice and experience in achieving high proficiency
 
 
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?
   
 
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.
 
 
 
 
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?
   
 
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.
 
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.
 
 
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?
   
 
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.
 
I know of no research showing that an 8 hour FCE is a better predictor of abilities than a 4 hour FCE.
 
 
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?
   
 
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).
 
A sample report from Arcon is a model of what to look for in our FCEs.
arcon report
 
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.