Clients and Families
Concerns affecting clients and their families cover a range of issues, from how a spouse’s stroke affects a family to what resources are available for a person wanting to reenter the workforce after a long absence.
Dr. Matheson addresses these and other concerns in Common Concerns and Questions.
All responses by L.N. Matheson, PhD
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.
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.
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 EpicRehab 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.
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.
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.
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.
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.
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.
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.
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.
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.