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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


For a detailed CV, click here




 

> Reflections on Almaraz Guzman
> Pain & the Brain: Imaging Methods
> Functional Capacity Evaluation
> Defense Perspective: Mad as Hell
> Computer Corner: TextMap
> Editor's Rant: A Dog's Breakfast
The Functional Capacity Evaluation:
Interview with Marc J. Rabideau, PT

In a continuing series featuring medical
professionals in the workers’ compensation
system, Marjory Harris interviews
Marc J. Rabideau, PT, founder of Work Ability
Testing Services in San Francisco.