Functional Capacity Evaluations have been a topic addressed previously within this blog, as we attempted to highlight who should be performing your FCE and four items every FCE report should include. Today’s discussion will focus on the FCE itself, and review the scope and components that should be included within a FCE, per the 2018 publication “Current Concepts in Functional Capacity Evaluation: A Best Practice Guideline.”
Now, it is important to clarify that a Best Practice Guideline is quite different from a Clinical Practice Guideline (CPG). You may recognize the term Clinical Practice Guideline, and that’s because this blog has also published content recently addressing CPGs following the August 2021 publication in the Journal of Orthopedic and Sports Physical Therapy (JOSPT) related to “Clinical Guidance to Optimize Work Participation after Injury or Illness: The Role of Physical Therapists.” CPGs, as you may recall, serve as evidence-based guidelines, and are to be used in conjunction with other published guidelines (related to diagnosis, treatment, examination, patient management) and standards of care. A Best Practice Guideline, while drawing from available literature, may also rely on expert opinion and clinical experience (in this case from physicians, PTs, and OTs) to offer guidance to clinicians and stakeholders.
The Best Practice Guideline (BPG) regarding FCEs was published to serve as a primary resource for clinicians who perform FCEs as well as for other stakeholders, including physicians, adjusters, case managers, and attorneys. While FCE products may vary state to state, or vendor to vendor, the intent of this BPG was to provide a baseline framework for what should be included in testing, as well as how to interpret reporting.
For purposes of our blog post today, we will focus on a few aspects of the BPG, including:
The Functional Capacity Examiner, as outlined within the BPG is “a physical therapist or occupational therapist licensed in the jurisdiction in which the services are performed, who is able to demonstrate evidence of education, training, and competencies specific to the design, administration, and interpretation of FCEs.”
The Examiner should possess knowledge and skills as it pertains to:
1. Examination
Thorough understanding of anatomy and physiology, cardiovascular/pulmonary systems, musculoskeletal system, neuromuscular system, psychosocial principles, body mechanics, and work behaviors.
2. Design and Administration of FCEs
Employ clearly defined test endpoints during testing that include physiological, biomechanical, and psychophysical factors.
3. Ability to Evaluate the Individual as a “Whole”
Consider the physiological, biomechanical, and behavioral indicators of effort, assess for movement and performance consistency, and understand pain neuroscience theory.
4. Communication
Establish rapport with the evaluee during the FCE; Must be able to write an FCE report that addresses the referral source’s questions and clearly identifies the individual’s functional abilities and limitations.
The Design of an FCE (in terms of the test and measurements used) should address and meet the following criteria:
1. Safety
First and foremost, the test should not be expected to result in injury. Relying on physical and occupational therapists thorough understanding of physiology, biomechanics, and psychosocial considerations ensures the evaluee’s safety during testing, while still allowing the examiner to assess the evaluee’s safe functional maximum.
2. Reliability
The measurements from tests should produce consistent results (if measured today, tomorrow, and again next week, the findings should be consistent).
3. Validity
The tests measure what they were intended to measure (strength, consistency of effort, aerobic capacity, etc.).
4. Practicality
The time and cost involved in the design, administration, interpretation, and reporting should be reasonable (Yes, it may be best to evaluate an injured worker for 40 hours, in the workplace, to determine feasibility for return to work at full duty. However, this approach poses challenges from a cost and time consideration. Therefore, testing in performed in a clinical setting, and for 4-8 hours).
5. Utility
The results should be comprehensible to non-medical readers and the results provide useful information.
When considering Test Components, there are multiple elements that should be included when performing a FCE:
1. Medical Record Review
Including the mechanism of injury, relevant objective diagnostic tests, surgeries, and the injured workers’ response to treatment to date.
2. Informed Consent
Include exam procedures, discuss release of FCE findings, despite the testing process and address any concerns from the injured worker.
3. Intake Interview
Establish the injured worker’s perspective on the injury, treatment to date, work status, past medical history, and current Activities of Daily Living (ADL) status.
4. Psychosocial Screening
Use evidence-based psychosocial/psychometric screens, observe the injured workers’ pain behavior throughout testing, and measure the individual’s physiological response following acute episodes of increased pain (to see if correlation exists).
5. Systems Review
Cardiovascular, integumentary, musculoskeletal, neuromuscular, and cognitive.
6. Postural Abilities Testing
Balance, manual dexterity, sitting, standing, walking, squatting, bending, crawling, etc.
7. Material Handling Tests
Lifting, carrying, pushing, pulling, grasping and pinching.
Finally, and perhaps most importantly, Interpretation of all the tests and measures must result in meaningful and useful information, which can easily be understood by the referral source.
Examiners should focus on 3 key areas:
1. Performance or Effort Level
The Best Practice Guideline specifically addresses testing to determine “sincerity of effort.” The reality is that most singular methods for establishing sincerity of effort (grip testing, isometric testing compared to dynamic lifting, rapid exchange grip testing, etc.) are not supported by current research. In fact, the article states that the use of these testing methods alone for classifying an individuals’ performance or effort level is “not supported by the preponderance of evidence.”
Rather, it is recommended that “the examiners make determinations about effort based on the presence of physiological and biomechanical signs (i.e. heart rate, respiration rate, muscle recruitment, and consistency of movement patterns) in combination with clinical examination findings and symptom reports.”
2. Effect of pain or other systems on test performance
Pain, or the anticipation of pain, can influence testing. Examiners need to determine, based on objective evidence, how reliable the evaluee’s reports are pertaining to their pain. Ultimately, report of pain or other symptoms “should correlate with objective changes in physical signs including, but not limited to heart rate, blood pressure, muscle spasm, joint warmth, and/or swelling.” Should it be determined that the evaluee’s pain or report of other symptoms “are not consistent with objective medical evidence, and the evaluee’s test performance showed less than good effort, the examiner should not rely on the individuals self-reports of pain or other symptoms as a basis to adjust their functional abilities.” Additionally, some recommendations pertaining to their residual capacity may need to be withheld secondary to a lack of ability to reliably assess.
3. Residual functional capacity of the evaluee
The examiner must address what the evaluee can still perform, despite any functional limitations resulting from their injury. While this includes providing recommendations related to material handling and postural abilities, the Best Practice Guideline specifically addresses that examiners should “avoid the use ofstatic (isometric) testing.” While isometric testing has been used extensively in some FCE products to assess lifting, pushing, and pulling, recent research indicates that static strength testing does not accurately predict dynamic lifting capacity. Since most work tasks are dynamic (moving an item from one point to another), valuating the evaluee’s dynamic ability better simulates their work activity.
The content provided above addresses much of the Best Practice Guideline. It is worth noting that Results Physiotherapy, in a fashion consistent with our mission statement to offer best-in-class care, adheres to all of the recommendations listed. By doing so, evaluees and our clients are provided with a FCE product consistent with current best practices. Should you be curious about our FCE product, documentation, or training, please reach out to Chris Scoma, Director of Workers’ Compensation Quality and Education at: chris.scoma@resultspt.com.
