Work Wells FCE V 2 Work Well Prevention

Work. Well’s FCE V. 2 Work. Well Prevention & Care

Work. Well’s FCE V. 2 Objectives • Participants will understand – Sections included in reports and importance of each. – Policies each facility should have in place – Using quantitative and qualitative scoring criteria and correlating test activities – Answers to your questions

Work. Well’s FCE V. 2 • Meets established guidelines for the performance of FCE – In context with APTA Standards of Practice for Physical Therapy – Defined protocols – Performed by those trained by a Work. Well faculty member and working for a facility that owns the copyright.

Work. Well’s FCE V. 2 Evaluation • Functional Capacity Evaluation – Professional responsibility • A thorough history and physical examination prior to testing. • Identify contraindications / precautions for testing • Client safety

Work. Well’s FCE V. 2 Clinic Policies and Procedure • • Contraindications to testing Blood pressure Heart rate Safety (lifting, postural, pacing/control) Observers Videotaping Medical Records

Work. Well’s FCE V. 2 Contraindications • Professional responsibility to keep client safe – Identify if there absolute contraindications to testing – Identify if certain tests are contraindicated – Any contraindication or restriction must be documented

Work. Well’s FCE V. 2 Blood Pressure / HR • Determine clinic guidelines for testing – What is the maximum – What is the time frame for BP or HR to return to below the maximum – Physiologic response in an activity may be the limiting factor

Work. Well’s FCE V. 2 Safety Safe test environment and test procedures • Safe testing is not necessarily picture perfect body mechanics • Observe compensatory muscle recruitment or changes in body mechanics • Modifications required for safe testing • Not safe to proceed with test

Work. Well’s FCE V. 2 Observation / Video taping • Observation of testing may influence the client’s performance – Adhere to your written policy – Others are welcome to sit in waiting room but can not be in testing area

Work. Well’s FCE V. 2 Medical Record – FCE report (4 parts) • History, Phys. Exam, Grid and Summary – Protected under HIPPA • Know your facilities medical record policies – Requires client’s consent for release of medical record • Disability insurer referrals – client should obtain copy from the insurer

Work. Well’s FCE V. 2 Spend time up front • Client consent form • Explain process to client – – Safe testing protocol Feedback from client Max. effort with/without physical limitations Pain acknowledged but safe maximum is established on each test based on objective scoring criteria

Work. Well’s FCE V. 2 Restrictions • MD restrictions – Obtain information at time of referral • Client reported restrictions – PAR-Questions done in advance – Verify if testing is to comply with restrictions or test to safe maximum • Document in summary: Description of test done – Work. Well Core FCE with MD restriction of no kneeling, crouching, squatting secondary to bilateral TKA.

Work. Well’s FCE V. 2 Self report questionnaire and Spinal Function Sort • Client completes during 30 min. sitting test – At least one Self report questionnaire – Spinal Function sort • Explain scores – In summary of day 1 (Physical Exam section) – In Consistency of Performance (FCE Summary) – Scores are “client’s perception” • Does client’s perception match abilities during FCE?

Work. Well’s FCE V. 2 Client’s History Common critique suggestions • Explain injury / medical history / treatment • Functional Status / Activity Level – Client ‘s report of current abilities or limitations. – Ask client to quantify the amount of walking, sitting, driving, lifting, hobbies, etc. • Goals – Client’s goals.

Work. Well’s FCE V. 2 Physical Exam • Standard of Practice physical exam prior to testing – Document exam results. • Do not leave blank tables or cells in report. – The physical exam provides correlations for physical and functional limitations. • Limitation to kneeling, crouching consistent with physical limitations of decrease knee ROM/Strength.

Work. Well’s FCE V. 2 FCE Summary – Explanations required • Internet tools - pick comments – Some of the pick comments are “conclusions”. Support the statements with what you observed during testing. • Client gave maximum effort on most tests. • Client’s performance was inconsistent.

Work. Well’s FCE V. 2 Disability FCE Most referrers do not want • Any return to work or work recommendations • Recommendations for further medical care • Recommendations to test activities (FCE Grid)

Work. Well’s FCE V. 2 Self-limited • Self-limited – client stops test prior to max. effort – – Usually due to c/o pain / fear of reinjury Is NOT a consistent performance Explain which tests were self-limited Watch for conflicting statements • Client gave max. effort on all tests conflicts with client limited some tests. – Explain self-limited tests reflect what the client was willing to do secondary to (pain / fear) and not max. effort.

Work. Well’s FCE V. 2 Consistency of Effort with/without limitations • Consistent effort with some physical / functional limitations if: – Max effort with physical limitations (decreased ROM, strength, fatigue, compensatory ms. recruitment, etc) – Max effort – at kinesiophysical max. and unsafe to go any further

Work. Well’s FCE V. 2 Consistency of Effort • Consistency (defined) – Free from variation or contradiction, represents close to a true value • IF a client self-limits (stops due to pain, without physical limitations observed indicating max. effort) • THEN – the client is NOT consistent in all tests. – Client was consistent in 12 of 16 tests, giving max. effort. All 4 of the material handling tests were self-limited, scores reflect what the client was willing to do within his pain tolerance and not max. safe ability.

Work. Well’s FCE V. 2 FCE Summary: Abilities and Limitations • Write a paragraph explaining – Tests that demonstrate “abilities/strengths” – Tests with limitations – Explain the limitations in a paragraph • What test was limited and why

Work. Well’s FCE V. 2 FCE test results (grid) Frequency Weighted Effort Level Posture/Amb. Results % of Workday Timeframes Never Contra. Indicated Not Possible 0% Rarely Max. Effort Significant Limitation 1 -5% 1 - 24 min. Occasionally Heavy Effort Some Limitation 6 -33% 25 min. to 2’ 40” Frequently Low Effort Slight/No Limitation 34 -66% 2’ 41” to 5’ 15” Self-limited Sub-max effort Stopped due to pain Observed at least

Work. Well’s FCE V. 2 Scoring Criteria • 2 parts to determining score – Quantitative – Qualitative

Work. Well’s FCE V. 2 Quantitative – Amount of weight – Distance – Time

Work. Well’s FCE V. 2 Qualitative Observations of problems or limitations during the test activity • Postures • Movement patterns • Muscle recruitment • Physiologic response

Work. Well’s FCE V. 2 Describing limitations Client with limitations decision points: • Significant (Rare 1 -5%) • (1 min. to 24 min. ) • Some (Occasional 6 -33%) – Low end of occasional 6 -20% • (25 min to 1 hr. 36 min) – High end of occasional 20 -33% • (1 hr. 37 min. to 2 hrs. 40 min)

Work. Well’s FCE V. 2 Test results summarize Client response (pain) AND objective limitation to activity Test Unable Elevated Work X Significant Limitation Some Limitation Slight/No Limitation c/o R shld. pain, Decreased ROM, strength, unable to assume position Standing Work X C/o LBP. freq. weight shifting, leaning for support Walking X Requires cane for support/balance. Slow, steady pace with antalgic gait Stairs X Safe, slow pace. Walking limits ability to do freq. Recommend

Work. Well’s FCE V. 2 Quantitative and Qualitative scoring example: Kneel / half kneel – Client does the full 10 min. of kneel/1/2 knee – Limitations in testing: • frequent weight shifting, unequal weight bearing on knees – Physical exam: • Limitations in R knee ROM/Strength consistent with diagnosis of R knee injury – Conclusion: • Client has some limitation ability) (occasional

Work. Well’s FCE V. 2 6 Minute Walk Test • Quantitative (age related distances) – Rare (below 328 yds. ) – MUST have dx. to support this low a distance. • Factors that reduce distance in manual • Qualitative – Antalgic gait / use of assistive device

Work. Well’s FCE V. 2 Correlating test activities • Walking – 6 MWT (walk FAST) – Ability through out FCE – If limited • Some (occasional) • Significant (rare). – If limited – correlate walking activity with other tests that require walking. EXAMPLE: front carry, stairs and ladder will be affected.

Work. Well’s FCE V. 2 Test results: Walking is limited Lift/ carry Unable Front Carry Posture/ Flexibility/ Amb. Unable Max Heavy Low Limitation 35 30 0 Unable to carry frequently due to walking limitation Significant Limits Some Limits Slight/ No limit Limitation 6 MWT Walking X Antalgic gait, favors L LE, slower than age related distance. Stairs X Safe on stairs, unable to walk up/down frequently due to walking limitations

Work. Well’s FCE V. 2 Test results if self-limited • Why are test results not entered into the FCE grid? – Entering a score in the test results (grid) indicates the client’s safe test ability. – IF the client self-limits the observed ability is documented in the limitation column. • Doc. client’s ability prior to terminating test • Provides information, but not the max. ability

Work. Well’s FCE V. 2 Self-limited test results Lift/ carry Unable Max Heavy Low Floor to Waist Lift Posture/ Flexibility/ Amb. Limitation Self-limited due to c/o LBP. Observed 10# low effort, 20# heavy effort Unable Significant Limits Some Limits Slight/ No limit Limitation Elevated Work Self-limited due to c/o LBP, Observed ability to perform at least rarely Walking Self-limited with c/o LBP. Self-selected slow pace, observed ability to walk at least occasionally

Work. Well’s FCE V. 2 Example - Confusing test results Lift/carry Unable Max Heavy Low Front Carry 55 50 45 20 Limitation Unable by definition is contraindicated or not possible = 0% No weight should be entered in the unable column.

Work. Well’s FCE V. 2 Example: Confusing test results Posture/ Flexibility/ Amb. Forward Bend Standing Unable Significant Limitation Some Limitation X Slight/ No limit Limitation Client able to complete 2 minutes. Some Limitation by definition = Occasional (6 -33%) or 25 min. to 2 hr. 40 min. Referral source is not trained in FCE protocols. Keep terminology in the Rare, Occasional, Frequent as explained in the test results key. Limitations – always explain the objective limitation

Work. Well’s FCE V. 2 Example: Confusing test results Posture/ Flexibility/ Amb. Unable Significant Limitation Standing Work Walking Some Limitation Slight/ No limit Limitation X X Standing work includes time client is in a weight-bearing capacity while doing other test activities. Slight / no-limit means client was walking/standing 30 minutes. Significant limitations in walking = Rare (1 -5%) = 1 to 24 min. in 8 hour day

Work. Well’s FCE V. 2 FCE Report • Use of Internet tools and Word doc. – Internet score sheets and notes reflect the details that support your final report – Report (4 sections) should summarize and include all pertinent information – Additional tests / job specific may be added – Protocol and documentation format using Work. Well methodology

Work. Well’s FCE V. 2 Flexibility in testing • Therapist’s clinical decisions – Additional tests in physical exam – Add functional tests based on • Referral source questions • Need to determine continuous • Job specific testing

Work. Well’s FCE V. 2 Work. Well clinical support • FCE testing must follow the Work. Well methods / protocols – Standardized method with clear scoring criteria • Integrating other tests in report – Additional tests may be added based on your clinical judgment. • Work. Well does not support other FCE protocols being integrated into testing. • Clinical tests or additional tests must be used cautiously if you are doing a return to work FCE.

Work. Well’s FCE V. 2 Frequently asked Questions

Work. Well’s FCE V. 2 Referral source asks for Validity • Validity refers to the strength of the conclusions, inferences or propositions being made – FCE test IS valid. Expand your section on Consistency of Performance. – Referral sources are asking – do the test results and conclusions reflect the client’s abilities and limitations? • Identify what tests reflect max. effort • Identify tests that had physical limitations with resultant functional limitations • Those tests that were self-limited should be identified as what the client was observed to do prior to stopping due to c/o pain / fear / etc. – This provides valuable information even though it does not reflect the client’s safe maximum for that activity.

Work. Well’s FCE V. 2 Testing for Continuous • Standing, Sitting or Walking required on a continuous basis. – Continuous is 67 -100% of workday (5 hr. 15 min. to 8 hours) – In a job description standing, sitting and walking cannot all be required continuously (by definition) – Testing options • Expand test time based on job demand • Perform job specific testing and do job match

Work. Well’s FCE V. 2 US DOL PDL US Department of Labor – Physical Demand Level PDL Occasional 0 -33% Frequent 34 -66% Constant 67 -100% Sedentary 10 lbs Negligible Sit most of day Negligible Light 10 - 20 lbs 10 lbs Walk/Stand Negligible Medium 20 - 50 lbs 10 – 25 lbs. 10 lbs. Heavy 50 – 100 lbs 25 – 50 lbs 20 lbs. Very Heavy Over 100 lbs Over 50 lbs. Over 20 lbs.

Work. Well’s FCE V. 2 Explaining PDL Test results: Lifts 45 max. (waist to floor) Carries 50 max. Lifts 15 max. (waist to crown) Standing – frequent Walking – occasional

Work. Well’s FCE V. 2 DOL PDL Department of Labor Physical Demand Level 1. 2. Client is functioning in the medium range with the exception of waist to crown lift (15#) and walking ability (occasional). Refer to FCE test results for abilities and limitations. Client meets light PDL with exception of walking ability (occasional). Client is able to work into medium PDL range for floor to waist lift and front carry.

Work. Well’s FCE V. 2 Adjusting results for longer workday • Client works (3) 12 hour shifts – Test with no limitations • No expectation to be at higher risk than any other individual required to work extended hours. – Test with some limitation • Decreased performance over time should be considered. • For job match – extend testing period

Work. Well’s FCE V. 2 Client unable to work 8 hours • Describe limitations in detail. • Sum of sitting, walking and standing – Client’s abilities • Sitting (upper range of occ. ) • Standing work (low range of occ. ) 25” • Walking (low range of occ. ) 2’ 40” 25” – Combined ability of 3 = 3’ 30” – Client maximum abilities are limited to less than 4 hours/day

Work. Well’s FCE V. 2 Payment for FCE • Attorney referral, disability (including Social Security), other – – – Get prior authorization for payment Attorney – letter / call informing cost per 15 min. Negotiate cancellation fee upfront FCE not reimbursed by Medicare Social Security referrals – payment is very limited

Work. Well’s FCE V. 2 Documentation • FCE should “tell the story” – – How was the person injured What are the physical and functional limitations Review report for contradictory information No opinions – document observations, or indicate information per client’s report – Document client’s safety and responses

Work. Well’s FCE V. 2 FCE Scenario #1 • Client reports lifting restriction – therapist tests to safe max. (beyond restriction) – Client claims injury during testing – MD was not contacted to determine if restriction was to be followed during testing – Strength of case • Safe rather than sorry – follow reported restrictions • Document safety / client’s responses in FCE report

Work. Well’s FCE V. 2 Scenario #2 • Insurer requesting additional information / testing – Important to know prior to FCE – Insurer forms – results consistent with FCE. Alter the referral source forms as needed.

Work. Well’s FCE V. 2 Scenario #3 • Client observed in parking lot, hallway, waiting room – Ability during testing inconsistent with observation outside testing area • Document inconsistency • Do not include observations made outside of professional setting

Work. Well’s FCE V. 2 Scenario #4 • 2 -day FCE requested. Client does not show for day 2 – Call client and encourage attendance – If needed schedule with one day between test dates (no more than 1 day) – If client refuses – report results from day 1. • Document client’s reported reason for no show • Document results are from one day of testing

Work. Well’s FCE V. 2 Scenario #5 • Client unable to complete some test activities due to exceeding maximum HR / BP – Physiologic response to the activity is the limitation. • Lifting caused client’s HR to exceed max. and therefore testing was stopped. Floor to waist lifting maximum of 40# limited due to physiologic response.

Work. Well’s FCE V. 2 Scenario #6 – Difficult client • Client that self-limits, becomes hostile or presents with challenging behaviors – Document client’s comments and your observations • Client reported he did not understand why he had to do these tests. “this test is just going to make my pain worse, I won’t do anything that is going to cause more pain” • Client observed taking long sitting rest periods between tests despite therapist encouragement to continue. Pain behaviors of facial grimacing and frequent cursing during test activities. Client walked with trunk in forward bent position, slow pace during 6 MWT but during remainder of tests walked with upright posture.

Work. Well’s FCE V. 2 Specific Questions Submitted by Providers

Work. Well’s FCE V. 2 If someone is released with occasional standing, sitting and walking, how many hours per day should they be released to? How do we document when we want to release a client to 4 hours per day? • Consider the client’s abilities during sitting, standing and walking. Test 6% 33% Sitting 25” 2’ 40” Standing 25” 2’ 40” Walking 25” 2’ 40” Totals 1’ 15” 8 hrs.

Work. Well’s FCE V. 2 How much detail do we provide to the client post-testing? • The client should not be surprised by what is written in the report. Determining safe max. effort is a collaboration between therapist and the client. • The client consent form states: – Client will be asked to work to safe Max. in test. – I may stop any test if unwilling or unable to continue safely. – I understand I will be informed of each test score and at the completion of the test, all test scores will be summarized for me.

Work. Well’s FCE V. 2 How do you document if someone completes the FB standing (frequent) but you know they can not tolerate that. • Scoring includes Quantitative and Qualitative scoring criteria. – Quantitative score (frequent means completed timed test) – Qualitative observations –supported by your observations of limitations. Examples include: • Changes in lumbar/thoracic flexion • Lateral flexion / shift and/or rotation of the spine • Loss of neutral spine • Decreased weight bearing on one extremity • Frequent weight shifting • Attempts to straighten up • Attempts to rest on elbows or hands

Work. Well’s FCE V. 2 Work. Well cites high reliability but what if any studies have been done concerning the accuracy of the classifications of effort during lifting? Although more than one evaluator may arrive at the same conclusion, that does not mean the conclusions are accurate. • • Scoring is done using specific criteria to identify effort level. – Inter-rater reliability studies published. Conclusions made have been studied in historic outcome reports. – Outcome studies support workers who returned to work based on FCE results were able to safely and successfully stay at work.

Work. Well’s FCE V. 2 Work. Well relies heavily on the visual estimation in the protocol. How is this not “subjective” when scrutinized during a legal proceeding? • Important points if scrutinized in a court of law: – Only professionals with background in musculoskeletal function, etiology of illness, understanding mechanism of injury and recovery process, and kinesiophysical response are trained to do FCE. – Your background and training in FCE provides you with the clinical skills to observe function and determine if there are limitations. – Objective criteria is used to score each test item (qualitative and quantitative) and research has proven inter-rater reliability and accuracy of FCE test results. Research concluded reliable assessment of abilities when examiners use the kinesiophysical definitions provided in training. – Subjective by definition is a subject’s perspective (feelings, beliefs) of their personal experience. Stopping a test because the client reports it hurts is subjective. Stopping a test based on objective scoring criteria of observed MAX effort is objective.

Work. Well’s FCE V. 2 Why doesn’t Work. Well address validity of effort during hand strength assessments? • Core FCE or Hand FCE – Core FCE – hand assessments are limited. Clinicians have the option to include additional tests IF there is a clinical rationale to do so. – Hand FCE must include all 5 positions in grips strength and coordination testing. • These tests have norms to compare the client’s abilities to. • The grip strengths should reflect a bell curve. The report includes information that compares the client to others of the same age/gender.

Work. Well’s FCE V. 2 How do you determine continuous in a job exploration when testing is done to a frequent level? • Return to / Job exploration FCE testing – Obtain a job description prior to testing – Understand the questions the referral source wants answered – Add job specific testing • Expand test time to simulate job requirements • Add tests that are not part of the CORE FCE

Work. Well’s FCE V. 2 When should I add tests and how do I report them? – Why add a test? • Clinical rationale • Answer a referral source question – Physical Exam – • Additional tests may be added to better understand the client’s injury • Add them at the end of your Physical Exam and explain results. – Functional tests – • Job specific testing – add at the end of the FCE testing – Expand time if continuous is required – Add job specific tests • Two-day FCE testing – repeat lifts/carries – repeat any additional test based on your clinical judgment

Work. Well’s FCE V. 2 Webinar conclusion Thank you for participating!