Questions and Answers: Clinical and Technical
Questions
- Why is it necessary to select tests that have been developed through the use of the “Test Factors Hierarchy”?
- Why is it necessary to use tests that have been demonstrated to be safe in peer-reviewed published research?
- Why is reliability important?
- Why is validity important?
- Why is it necessary to use normative data that are based on peer-reviewed published research?
- Why is standardization of a Functional Capacity Evaluation (FCE) test necessary?
- How do I use FCE results to determine 8-hour functioning?
- How do I measure the evaluee’s constant lifting ability?
- How do I measure the evaluee’s overhead lifting and reaching ability?
- What is serial FCE testing?
- Why is serial testing useful to the insurance carrier?
- Why should each clinic have a range of functional capacity evaluations available?
- Can technicians or aides provide FCE services?
- How much should I charge for my services?
- The terms frequent and infrequent that are used in the Dictionary of Occupational Titles and in the PDC Chart don’t seem to conform with the usual meaning of those terms. How did that happen?
- How was the safety rule of not assessing a client high blood pressure and pulse rate on the EPIC determined?
- How were the RPC-I ranges established?
- If your client’s RPC-I scores do not fall within the range for each PDC level (suggesting that his/her responses were not consistent), are the reliability and validity of the RPC-T score significantly altered or affected? If so, how should I document these findings?
- If you have a client who is inappropriate for testing on the EPIC, do you test carrying and push-pull?
- Can the EPIC Lift Capacity be used for preplacement screening?
- I am concerned about the recorded blood pressure rates I am seeing in the African American population at my rehabilitation center in Florida. Have you or any EPIC evaluators have come across this problem before?
- We recently bought the EPIC Hand Function Sort. I was wondering how to answer this question from a client: “Do I answer these questions as if I was trying to do the task with my injured hand or with the hand I would typically use to do the task?”
- An arbitrator’s decision in an Ontario case revolving around job simulation functional testing supported the right of the company to do specifically job-related testing when an employee moves from one job to another, provided that the physical demands of the jobs are “significantly” different. However, the arbitrator also ruled that the employee does not have to participate in any prescreening, such as resting blood pressure, completing a PAR-Q, or even seeing his or her doctor. This leaves me and many others in a bit of a bind. As certified kinesiologists we always do a prescreening; doing so is taught in our courses, including the Matheson system.
- When an FCE is performed, does the correct diagnosis need to be entered into the record to get an accurate score?
- I am looking for some definitions of frequent, occasional work. The classic time-related DOL definitions are well known. I am aware that rate based definitions are also used; ie, so many lifts per hour or quarter hour. What I need is a reference to substantiate the existence of those rate based definitions.
- Is there a resting heart rate limit (restriction) for taking the FCE?
- With my FCE testing as of late, I have come across several situations that involve the relationships between HR, blood pressure, and subjective pain ratings. I have had discussions with Workers’ Compensation Case Managers suggesting that I should report an FCE invalid due to the fact that the patient continually reports high levels of pain, despite HR and blood pressure being “normal”. Is there any data out there that would help in this situation? To my knowledge, significant research does not exist that suggests that HR and BP should get to a certain level to consider pain and/or effort valid as an entire rating for the FCE. I know that during dynamic lifting, there is the 10 bpm cuttoff to empasize whether the lift is considered valid or invalid, but how does/can this play a role in circumstances where the patient reports that he cannot perform a lift and declines?
Answers
All responses by L. N. Matheson, PhD
- 1. Why is it necessary to select tests that have been developed through the use of the “Test Factors Hierarchy”?
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There are many amateur FCE test developers that have become commercially successful. Unfortunately, professionals who rely on these test developers are stuck when they are faced with a lawsuit to defend themselves against malpractice when an evaluee claims injury or brings a civil rights claim because on unfair test results. The test developers leave the professional in a no man’s land that only makes defense of the professional more difficult. This is especially unfortunate because there are well-developed standards for test developers that are readily available.
An excellent introduction to these standards is available through either of these resources:
- Matheson, LN. Basic requirements for utility in the assessment of physical disability. American Pain Society Journal, 1994;3(3)
- Matheson, LN. The Functional Capacity Evaluation. (2003). In Andersson GBJ, Demeter SL, Smith GH, eds. Disability Evaluation (2nd edition). American Medical Association. Chicago, IL, Mosby Yearbook [abstract available]
If you use tests that have been developed according to the “Test Factors Hierarchy,” you can be assured that you will spend less time in court, and if you are summoned, your test procedures and results will be defensible.
- 2. Why is it necessary to use tests that have been demonstrated to be safe in peer-reviewed published research?
Safety is the primary consideration in FCE. The FCE procedures are being used with people whose lives have already been disrupted by injury or disease and who often are concerned about experiencing further injury. When a test has been demonstrated to be safe in peer-reviewed publication, the publication can be shown to the evaluee to allay the evaluee’s fears. Also, the evaluator’s certification and experience can be useful in dealing with the evaluee’s concerns. Finally, should any problem occur, such as an exacerbation of symptoms, the fact that the certified evaluator has used test procedures that have been demonstrated to be safe in a peer-reviewed scientific journal will provide assurance to the evaluator’s employer and attorney that there was no professional malpractice.
- 3. Why is reliability important?
Reliability is synonymous with dependability. Validity is dependent on reliability. If your results are not dependable, they are worthless. When you are defending your results in court, the opposing attorney will start with the issue of reliability, because he knows that if he can show that the data are not reliable, your opinions will be worthless and should be disregarded.
The rigorous methods that EPIC has instituted to demonstrate the reliability of the EPIC Lift Capacity scientifically and to establish the reliability of the certified evaluators allows EPIC Lift Capacity results to go without serious challenge. If an EPIC Lift Capacity evaluator goes to court as a witness, the most serious challenge he or she will get is “Are you certified and did you administer the EPIC Lift Capacity in the standard manner?” If you can handle these questions, you will not have any difficulty making your results stand up in court.
- 4. Why is validity important?
Validity has to do with the application of the test results; whether they are consistent with the evaluee’s actual ability and can predict how the evaluee will do on the job. Without validity, your results are not useful. It is possible to have reliability but not validity. In fact, this is the most important problem with many of the tests in use today, such as those that use isometric strength testing to predict lift capacity.
There is a poor relationship between isometric strength and lift capacity. When I first started doing such testing many years ago, I was hopeful that it would be useful to predict lift capacity. Thus far, we have performed many such studies in our laboratory, with poor results, which is why I only endorse certain types of isometric testing.
As an example, one of our studies (Matheson, LN, Danner, R, Grant, J, Mooney, V. Effect of computerized instructions on measurement of lift capacity: Safety, reliability, and validity. Journal of Occupational Rehabilitation, 1993;3(2), 65–81 [abstract available as “Effect of Instructions on Measurement of Isometric Whole Body Strength: Reliability and Validity”]) demonstrated a good relationship between “whole body pulling” on an isometric dynamometer only when instructions were used that are not safe for use with impaired persons. We used United States Marines! We have also demonstrated quite poor relationships between whole body pulling on an isometric dynamometer and activities that firefighters have to perform.
If you decide to use whole body isometric testing, be sure you have a validity study to help defend your procedures and results. Don’t rely on your test purveyor’s opinion that the procedures and results are defensible.
- 5. Why is it necessary to use normative data that are based on peer-reviewed published research?
Normative data allow one person to be compared with a group of other people. Normative data are very difficult to develop in a manner that is acceptable to the scientific community. How do you know if the norms you want to use are acceptable to the scientific community? If they are published in a peer-reviewed scientific journal.
The EPIC Lift Capacity is the only lift capacity test that offers norms for men and women of various ages based on peer-reviewed published research. No other test comes close. Although the PILE and WEST both offer normative data, the norms are quite limited.
- 6. Why is standardization of an FCE test necessary?
Standardization is necessary for the protection of the patient and to limit your professional liability. If an injury occurs during a nonstandard FCE, it is difficult for the professional to provide an adequate defense. This can ruin a professional career. Injuries are much less likely to occur during a standardized FCE that has been peer-reviewed for safety, like the EPIC Lift Capacity. The EPIC Lift Capacity is in use in hundreds of clinics in the U.S. and Canada, with no reports of injuries.
- 7. How do I use FCE results to determine 8-hour functioning?
This is impossible to do unless you are using a standardized FCE that has been demonstrated to be valid in prediction of full-day workplace tolerance, like the EPIC Lift Capacity. One of the benefits of the EPIC Lift Capacity research that is important to professionals is that it has been demonstrated in peer-reviewed research to be valid as a predictor of full-day workplace tolerance. If the evaluator chooses, it is also possible to conduct a full-day FCE at a particular level of work demand, although you should first perform a standard EPIC Lift Capacity to determine the evaluee’s safe work demand level. Because this is so demanding and expensive, it is rarely undertaken.
- 8. How do I measure the evaluee’s constant lifting ability?
There is a standardized extension of the EPIC Lift Capacity that can be performed after the standard six-test EPIC Lift Capacity is concluded. It uses results of the standard EPIC Lift Capacity to select a safe range of work demand for measurement of the evaluee’s constant lift capacity. Because this is so demanding and expensive, it is rarely undertaken, although it is readily available.
- 9. How do I measure the evaluee’s overhead lifting and reaching ability?
First use a job analysis to determine the vertical range of lift or reach and the upper end of that range, then conduct the standard six-test EPIC Lift Capacity. After the evaluee has rested, administer EPIC Lift Capacity test #3 with these ranges, but do not exceed 75% of the load achieved in the standard EPIC Lift Capacity test #3.
- 10. What is serial FCE testing?
Serial FCE testing uses a baseline FCE that is performed early in the patient’s treatment program, followed by testing at 2-week or 3-week intervals until the patient has plateaued or is ready to return to work. The first test is usually comprehensive, while the follow-up tests are specific to those functional abilities that are the focus of treatment. These types of FCE are relatively inexpensive, with report that are provided to the physician and insurance carrier almost immediately. In medicine, it is analogous to a laboratory blood test or bacterial culture. It helps to direct the treatment plan.
- 11. Why is serial testing useful to the insurance carrier?
In these days of managed care, serial testing is used to demonstrate that the evaluee is continuing to make progress and has not yet achieved return to work status. With these results, the claims person can make a decision to authorize payment on a rational basis.
- 12. Why should each clinic have a range of functional capacity evaluations available?
Each functional capacity evaluation should be standardized. However, each situation in which FCE should be used is not like all of the others. The different situations require different FCE models. Also, in order to develop and maintain good relationships with physicians and insurance carrier representatives, it is necessary to use FCE in a cost-responsible manner. That means you should not use a comprehensive FCE when a focused FCE will do, and will cost much less.
- 13. Can technicians or aides provide FCE services?
Yes, given proper training and supervision, and the use of test protocols that have been developed for use by technicians or aides. There are many tests that have not been developed for use by technicians or aides. Be sure to ask the test purveyor.
- 14. How much should I charge for my services?
It depends on how skilled you are. These services have usually been pre-authorized or are paid on a by-report basis. You can work with managed care providers, either with workers’ compensation or regular health care patients, to help them measure progress in treatment and readiness for return to work. Additionally, I always encourage people to maintain as much of an independent practice as they can manage.
The best resources for payment based on your skill level involve referrals from insurance claims managers (usually long-term disability or liability carriers) and defense or plaintiff attorneys (usually personal injury litigation). Generally speaking, fees for FCE services are twice your usual clinical treatment rate, based on the actual time you spend in the evaluation plus a reasonable time for report preparation. The FCE fees are higher than the treatment fees because higher levels of skill and certification are required, as are the additional equipment and space. Additionally, the FCE requires more continuous 1:1 involvement with the patient than many types of treatment.
The hourly fee at the Work Performance Clinical Laboratory at the Washington University School of Medicine is $240 per hour. Many clinics have standardized FCE services (such as the Cal-FCP), which are charged at a lower rate ($450 per evaluation). The lower fee is due to the potential for higher volume, given the ability to use a technician to assist with the evaluation. For example, with a professional evaluator (OT, PT, CVE) and one technician (RN, COTA, PTA) working together, four Cal-FCP evaluations can be completed safely in one eight-hour day.
- 15. The terms frequent and infrequent that are used in the Dictionary of Occupational Titles and in the PDC Chart don’t seem to conform with the usual meaning of those terms. How did that happen?
In the original Handbook for Analyzing Jobs (1972), published by the United States Department of Labor (DOL), the strength demands of work were presented in terms of five levels. Each level carried a connotation of maximum number of pounds to be lifted on a frequent basis. However, frequent and infrequent were not defined. In A Guide to Job Analysis (1982), published by the Materials Development Center at Stout Vocational Rehabilitation Institute at the University of Wisconsin Stout, several major improvements of this job analysis technique were introduced, including modification and definition of these terms. Instead of infrequent, the term occasional was substituted, defined as “under 20 percent of the time.” Frequent was defined as “between 20 percent and 80 percent of the time.” Constant was defined as “over 88 percent of the time.”
This is the format incorporated into the Physical Demands Job Analysis (1981) and in the 1982 supplement to the fourth edition of the Dictionary of Occupational Titles. In the 1986 supplement to the Dictionary of Occupational Titles, a further revision of the rating structure for strength was introduced. This is presented in the current PDC chart. Occasionally is defined as up to 33% of the time. Frequently is defined as 34% to 66% of the time. Constantly is defined as more than 66% of the time. In my opinion these references use the term frequency incorrectly. If we think of frequency as a qualifier for work demands in terms of human performance, the appropriate reference is the number of repetitive cycles over a period of time before a rest break. For example, I would define frequency in terms of number of repetitions per minute for the duration of a task, also expressed in minutes.
Unfortunately, the DOL took a position that is relevant for people who are performing job analysis but not the best position for people who are evaluating human performance. I argue that the job analysts should follow the lead of the human performance experts rather than the other way around. I may have contributed to the problem by incorporating these terms and definitions into the PDC Chart, but I thought it necessary to follow the lead of the Department of Labor. Before the DOL had defined these terms in this manner, I had been using the definitions from the National Institute of Occupational Safety and Health (NIOSH).
- 16. How was the safety rule of not assessing a client high blood pressure and pulse rate on the EPIC determined?
The resting blood pressure and heart rate values are taken from the American College of Sports Medicine guidelines for non-physician supervised tests. They are presented in the document from the ACSM that describes their guidelines. I believe the most recent version of this document is (c) 1993. I don’t have an address for them, but I would expect they are on the Web.
In our clinic at the University, I find that approximately 10 to 15 percent of our referrals are unable to be tested because their blood pressure is too high. This is unfortunate, but considering that the risk for a cardiac event or stroke is significant for people who are hypertension performing a physically demanding task, we decided to integrate this restriction as a standard part of the EPIC Lift Capacity protocol. The ACSM considers this level of pre-test screening a necessary safety restriction, as do we.
Of course, how the case is handled when an evaluation cannot be conducted is crucial. In the first place, I make it clear that hypertension is an important health concern that the person needs to take seriously. Secondly, I communicate with the referring physician or other health care professional that the protocol requires that we not go forward with the test due to the evaluee’s hypertension, and that if this can be controlled, the test can be undertaken.
Keep in mind that if the controls involve medications that stop the heart from adapting to increased load, such as beta blockers, it still may not be possible to perform the test without physician supervision and the immediate ability to respond to a cardiac emergency. There is no doubt in my mind that these are necessary restrictions; other tests that do not include them are placing the evaluee at an unnecessarily increased risk of serious injury or death.
As an aside, when I hear about people using physically demanding to test protocols that do not include cardiac and blood pressure guidelines, I always point out that the cardiac demands of lifting are substantial and must be considered to be a significant safety issue. When we began to develop the EPIC Lift Capacity, we rejected the order of testing of the PILE for this reason, recognizing that evaluees we tested with the PILE who were older or unfit frequently were exposed to increased cardiac risk early in the test experience.
The safety issue is not sufficiently emphasized in most of the test protocols that have been developed. The inadequacy or absence of cardiac guidelines in a test protocol is an important deficiency. Although the incidence of claimed injury during a functional capacity evaluation is low, it is not zero. There has never been a claim of injury with the EPIC Lift Capacity or the Cal-FCP.
- 17. How were the RPC-I ranges established?
The RPC-1 ranges were based on research that demonstrated the likely scores in each sector for a given total score. It is one more way that you can internally validate the evaluee’s responses.
- 18. If your client’s RPC-I scores do not fall within the range for each PDC level (suggesting that his/her responses were not consistent), are the reliability and validity of the RPC-T score significantly altered or affected? If so, how should I document these findings?
It all depends. If I get scores that do not fall within the range for each PDC level, I ask the evaluee about item scores that seem inconsistent in the affected sector. Often, I hear a very good explanation that allows me to accept the response as accurate. In these cases, I report that “internal consistency checks identified an abnormally low score in (name the sector). On further inquiry, it was established that Mr. Jones’ balance is also affected, along with right-side weakness as a consequence of hemiparesis due to the stroke.” This enriched information can only come from post-test inquiry. I never miss such opportunities!
On the other hand, if the evaluee gives me a response that suggests less than full effort, I report that “internal consistency checks identified an abnormally low score in (name the sector). Review of selected item responses indicates that Mr. Jones’s responses are suggestive of less than full effort/over-limiting due to fear/discouragement and depression…,” etc. Of course, I would be sure to “constructively confront” the evaluee so that we can make progress in the latter case. Often, a few days after such a confrontation, RPC scores are a lot higher and the evaluee appears to be making much more rapid progress in the rehab program.
Use the item responses, not just the score; the evaluee is able to tell you much more than the score indicates. The HFS test experience is a therapeutic encounter that can be very powerful!
- 19. If you have a client who is inappropriate for testing on the EPIC, do you test carrying and push-pull?
I use the same reasoning for the EPIC Lift Capacity as I do for the carrying, climbing and push-pull tests, since these are also physically demanding. The carrying test and climbing test use the person’s performance on the EPIC Lift Capacity sub test No. 3 as a starting point. Therefore, if the person cannot be safely tested on the EPIC Lift Capacity, the carrying test cannot be performed.
- 20. Can the EPIC Lift Capacity be used for preplacement screening?
Yes. Use a job analysis to determine the manual material handling job demands, then use the sub-tests of the EPIC Lift Capacity that are content-valid for that job, following the guidelines in the EPIC Lift Capacity Evaluation Manual. You also need to perform a validation study, which requires more explanation than I can provide here. Feel free to contact me at epiclift@aol.com for further information on this topic.
- 21. I am concerned about the recorded blood pressure rates I am seeing in the African American population at my rehabilitation center in Florida. Have you or any EPIC evaluators have come accross this problem before?
We have a similar problem here in St. Louis. The blood pressure readings for many African Americans tends to be higher than for the rest of the population, for a wide variety of reasons. Nevertheless, the guidelines developed by the American College of Sports Medicine for nonphysician supervised tests are consistent across all racial categories. For this reason, and we do not use a different standard related to racial or ethnic categories. When we have a person whom we are about to evaluate whose blood pressure exceeds the criteria for the EPIC Lift Capacity test, we do not proceed. If it appears that the person’s blood pressure is temporarily elevated due to the stress of the exam or recent coffee intake or other issues, we work with the person to attempt to bring down the blood pressure to a true resting level. If the person’s blood pressure is within guidelines addressed, we proceed. If, after having taken these measures, the person’s blood pressure continues to exceed the limits in the test protocol, we defer testing and recommend to the person that he or she seeks medical care before returning to be tested.
Aside from the safety and liability issues that this would lead to, using different standards would also create many other problems with the acceptability of the test results in legal settings in which employment is considered.
One of the key safety features of this test protocol that has allowed us to provide services without any injuries for tens of thousands of people is strict adherence to the cardiovascular guidelines. If you want to test people with hypertension or other cardiovascular diseases, it must be done under physician supervision, with the ability to respond immediately to cardiac emergencies. In the long run, this will pay off for everybody although in the short run, it will force us to not provide services to a significant proportion of the people who could otherwise benefit from the services.
As an aside, before the EPIC Lift Capacity test was developed, I participated in reviving two of my clients who had experienced cardiac arrest. When I began to work with my team to develop the EPIC Lift Capacity test, one of my goals was to never have to go through that experience again. When we applied for a patent, this particular issue was one of the most important to the patent examiner. I hope that you appreciate that, although this will limit your ability to provide services, and therefore limit your revenue, in the long run it will be the best approach for you to take in your practice.
- 22. We recently bought the EPIC Hand Function Sort. I was wondering how to answer this question from a client: “Do I answer these questions as if I was trying to do the task with my injured hand or with the hand I would typically use to do the task?”
In response to this question, explain to the evaluee that “This is an indicator of your current level of ability to perform the task in the writtern description. You do not have to do the task exactly as the drawing.”
Notice that the tasks are not described in such a way as to completely specify the manner in which the person is to do the task. This ambiguity is intentional, and allows us to get at the person’s perception of how their functional impairments have produced disability.
In addition, some of the items are designed in such a way that even a person who has mid-cervical quadriplegia is able to perform the task at some level. The example I like to use is HFS Item No. 10: “Turn a lever knob to open a door.” It does not read, “Turn a lever knob to open a door with your right hand.” It is also a lever knob, which was selected over a round knob because a person with mid-cervical quadriplegia normally uses this type knob to open a door. So a person who has a severe right hand injury who indicates that they are “unable” is quite different from a person who has the same severe right hand injury who indicates that they are “able” or “slightly restricted.” This also gets at the person’s perception of how their functional impairments have produced disability.
The HFS approach is based on a subtle but important emphasis in how we look at our patients' impairment, and its impact on their ability to work. Are we more interested in finding out the specifics of the impairment, or whether the impairment has convinced him/her that he/she is unable to work? I have taken the position that the latter is more important. If a person with a severe right hand injury says that he is “able” on Item No. 10, I know that the person is working around his impairment in order to minimize his disability. If, on the other hand, the person says that he is “unable” on Item No. 10, I know that he is taking the opportunity to communicate how disabling the impairment is, without regard to whether or not there are alternative approaches to open the door that would not impact him very much. This is one important indication of symptom magnification.
In practice, I find out if the person is prone to symptom magnification in several ways. One of the first indicators is if a person asks me during the administration of one of the Sorts, “Do I have to do this exactly as the picture shows?” This tells me that the person is thinking in terms of using the instrument to describe his impairment rather than how he is able to perform tasks using whatever strategy works for him. My response to this question is, “Respond like you normally would in your life. I want to find out how you are doing.”
Another way I find out if the person is prone to symptom magnification is by reviewing items afterwards with the person that appear to be more restricted than I expect and asking, “Is there another way that you can do this task that doesn't restrict you so much?” Let me give you an example.
Mr. Smith responds “unable” to item No. 10, “Turn a lever knob to open a door.” He also responds “unable” to Item No. 2, “Sort a deck of playing cards.” and “unable” to item No. 13, “Drink from a bottle of juice.”
Now, I see sitting in front of me a person who is well fed, with his fly zipped up and his shirt buttoned and his shoes tied. Unless he had his butler dress him that morning, I know that he can use both hands and I surmise that he is able to drink from a bottle of juice and open a door. I may even have observed him doing these things in the clinic; using a paper cup to get water from the fountain or going in and out of the bathroom door or front door of the clinic. So, I challenge him by asking why he gave me “unable” on the item that is likely to be easiest, usually item No. 10. In the normal course of events, the patient will back down and admit that this is something that he is able to do with little or no limitation as long as he uses his unimpaired left-hand. I then take the next most easy item, often No. 13 and ask him same question. Again the patient will back down and admit that this is able to be done with little or no restriction. Item No. 2 is placed where it is because it actually is fairly difficult to sort a deck of playing cards unless you have two pretty functional hands. So next we get to that item in my debriefing with the patient, and he says that this is actually difficult because he has a severe right hand injury. I point out that we are interested in what he can do, rather than what he can't do. We talk about this and all of the other patients in the clinic have had the same talk in one form or another, so the patient knows that we are different from the clinic down the block that wanted to know every little detail about what was WRONG and we are different from his attorney who wants him to point out every little detail about what he is UNABLE TO DO. We are interested in having him do the most with what he has left.
- 23. An arbitrator’s decision in an Ontario case revolving around job simulation functional testing supported the right of the company to do specifically job-related testing when an employee moves from one job to another, provided that the physical demands of the jobs are “significantly” different. However, the arbitrator also ruled that the employee does not have to participate in any prescreening, such as resting blood pressure, completing a PAR-Q, or even seeing his or her doctor. This leaves me and many others in a bit of a bind. As certified kinesiologists we always do a prescreening; doing so is taught in our courses, including the Matheson system.
The basic issue is to separate the need to maintain safety in the evaluation from using medical information to determine the person's ability to work. These must be kept separate.
The standard of care throughout the United States is to screen for basic risk factors that can put a person in jeopardy in a test that is physically demanding. We routinely collect resting heart rate and resting blood pressure and have guidelines that allow us to objectively determine whether or not a person is able to be tested. To not collect such data would leave one open to malpractice liability in this country, notwithstanding the rules and procedures that various jurisdictions may have about prohibiting use of “medical tests” in preplacement screening and other such testing.
- 24. When an FCE is performed, does the correct diagnosis need to be entered into the record to get an accurate score?
It depends on which functional capacity evaluation you're using, or which test you're referring to, and whether or not the diagnosis is pertinent to the factors that you're testing. For example, with a test of grip strength, whether the person has a back injury or not would not be important, but whether the person has a hand injury would be important.
- 25. I am looking for some definitions of frequent, occasional work. The classic time-related DOL definitions are well known. I am aware that rate based definitions are also used; ie, so many lifts per hour or quarter hour. What I need is a reference to substantiate the existence of those rate based definitions.
The use of adjectives to describe degrees of frequent is a poor convention. The actual use of frequency in human performance measurement is on a times-per-minute basis for handling or times-per-hour for lifting.
The United States Dept of Labor was ill-advised when they adopted their convention for the DOT and related publications. It is used nowhere else in the world, nor does it have any basis in science or ergonomics or industrial psychology.
- 26. Is there a resting heart rate limit (restriction) for taking the FCE?
In every good FCE there is a resting HR limit or guideline; it depends on the FCE. The basic idea is that if you have a too-high resting HR, you are at greater risk for a “cardiovascular event” or other similar problem, such as a stroke, and extra care must be taken to keep you safe.
In FCEs that use the EPIC Lift Capacity test, the resting HR limit is 90 bpm. This is derived from the American College of Sports Medicine guidelines for “non-physician supervised tests”.
The ACSM publishes new editions of their guidelines every few years. Check on their website for the latest.
- 27. With my FCE testing as of late, I have come across several situations that involve the relationships between HR, blood pressure, and subjective pain ratings. I have had discussions with Workers’ Compensation Case Managers suggesting that I should report an FCE invalid due to the fact that the patient continually reports high levels of pain, despite HR and blood pressure being “normal”. Is there any data out there that would help in this situation? To my knowledge, significant research does not exist that suggests that HR and BP should get to a certain level to consider pain and/or effort valid as an entire rating for the FCE. I know that during dynamic lifting, there is the 10 bpm cuttoff to empasize whether the lift is considered valid or invalid, but how does/can this play a role in circumstances where the patient reports that he cannot perform a lift and declines?
I wish it were so simple.
We need to look at many characteristics of the person and of his/her test data to make a good decision concerning validity. For instance, the chronicity of the person’s pain is important. Often, people with high levels of chronic pain have blunted HR responses to nociceptive stimuli (such as FCE demands), while, in contrast, people whose pain is of recent vintage experience a fear avoidance response in response to the same stimuli.
I look at all of the patient characteristics and also their performance data before offering an informed opinion.
Always remember that the amateurs want you and me to come up with a simple system even they can use when, in reality, it takes seasoned judgment to make good decisions in this area.