We often don't think about our ability to function until we can't. Then, performing the most routine task can seem scary and fraught with danger. But life goes on, and eventually, the injured worker must return to the job, or some form of the job—preferably one that matches the patient's modified functional abilities. Enter the PT who, using a functional capacity evaluation (FCE), can help to determine the level of a patient's function and set to rest the anxieties of the patient, the concerns of the employer, and the misgivings of payors.

"The primary goal is to determine what this person is capable of performing safely and how often they can perform a particular task, and from that, we can address the specific referral question," says Scott Ege, PT, MS, president of Ege WorkSmart Solutions, PC, in Rockton, Ill.

Referrals for FCEs can come from physicians, insurance carriers, or employers, who are also beginning to use them more frequently in determining a prospective employee's physical capabilities before he or she starts work. According to Ege, physicians often make referrals to determine what type of work restrictions, if any, should be set for the patient; insurance companies want a fair and accurate assessment of what the patient is capable of doing; and the employer wants to be able to return the patient to productivity without reinjury. And patients? They just want to function.

"A lot of clients come in with an idea of what they feel they can do but have not been tested to that maximum ability level and need affirmation that what they think they could do, they can do, which gives them confidence returning to work. Often, the patient wants to function, be safe, and not reaggravate injury," Ege says.

The FCE will match performance levels to general and specific work functions. A number of products exist to help achieve these goals, many requiring the user to be a physical or occupational therapist. Because of the nature of the process, there are many similarities among these products, but they are able to set themselves apart through differing philosophies, processes, and specific tools.

TECHNOLOGY AND OBJECTIVITY

Therapists at Select Physical Therapy and NovaCare Rehabilitation, owned by Select Medical Corp, headquartered in Mechanicsburg, Pa, use a proprietary protocol based on current, peer-reviewed research and evidence-based protocols common in the industry, according to Kathy Beckett, PT, national clinical director of WorkStrategies for Select Medical. That protocol can incorporate use of the ER—Functional Testing System from BTE Technologies, Baltimore.

The ER is a freestanding unit attached to a computer that provides electronic measurement of a variety of physical tests, including those measuring forces and weights. The device is adjustable to accommodate anthropometric differences and offers attachments to measure job-specific tasks, such as lifting and pulling.

"The BTE gives us the ability to capture data as it is occurring," Beckett says. This data includes heart rate and physiological response, strength and range of motion, and force curves. The equipment allows for cross-reference validity testing and can gather information on the left and right sides of the body simultaneously.

Select has more than 100 BTE ER units in clinics across the country and has realized a number of benefits. "Number one, you are partnering with a third party in terms of developing testing protocols in an industrial setting, which is good for objectivity. Number two, the computerized testing equipment is more efficient and allows you to have more defensible results in legal terms," says Chris Throckmorton, PT, Select West Division president.

Throckmorton notes the device helps to determine pain, threshold, sincerity of effort, and the validity of testing and effort; and to have that information displayed on the computer screen while working through the evaluation. "We evaluated many products but didn't find one as good as the BTE unit we use today," Throckmorton says.

Because of its large size, the ER unit is used when FCEs are conducted in the clinics. Typically, the PT begins an assessment gathering medical information and then moves into data collection. Measurements start with range of motion, then strength, and then move into cardiovascular testing to capture aerobic fitness levels. Other tests measure dynamic abilities, such as pushing, pulling, and grasping motions. The BTE unit also can be used to perform job-specific testing through use of the attachments, including the peg board positional tolerance and time-motion testing system.

The FCE includes active measurement of the patient's physiological response—ie, heart rate—which also is used to look at consistent effort, maximal effort, and response to pain. "We look for consistent performance—within 15%—over three trials, which research shows is a valid and reliable effort throughout testing," Beckett says.

Reports are generated electronically through the BTE, and the format has been customized to match that of Select Medical. BTE also provides a report format that general providers can use.

BTE offers 2-day training courses for the ER in its Denver and Baltimore offices. Select PTs also undergo a company-specific training. "Select Medical has its own testing process that is quite intensive to make sure all of our clinicians are properly trained to collect and interpret the data they gather," Beckett says.

"The machine is very user-friendly in terms of job simulation embedded in FCE—measuring force, repetitions, and physiological responses. The ultimate outcome is not necessarily a better product, but in terms of ease of use and legal defensibility, it is better," Throckmorton says.

The unit has proven extremely useful not only in return-to-work situations but also in postoffer of employment screening and rehabilitation assessment. BTE and Select Medical worked with a large automotive manufacturer on a program designed to determine employee capabilities after hiring and before beginning work. The result was significant savings in workers' compensation costs.

"There are multiple uses [of the BTE machinery] from injury prevention through injury management and return to work," says Beckett, who stipulates that the ER unit is ultimately a tool to help the PT gather objective data. "The protocol doesn't differ if we use computerized equipment. The aim is to gather functional information to answer referral questions, which may include the ability to return to a job safely, maximum medical improvement, or level of impairment rating," Beckett says.

THE KINESIO-PHYSICAL APPROACH

Ege WorkSmart Solutions' Ege notes that the vast majority of FCEs are done for one of two purposes: to identify a person's ability to perform activities or function as related to a home or work environment, or to identify a general level of ability so the client can be processed through the disability system. Ultimately, the FCE addresses the referral questions.

To achieve these aims, Ege employs the FCE program from DSI Work Solutions Inc, Duluth, Minn. The system is a low-tech approach, making it a portable tool that can be easily used at work sites.

The core concept for the DSI FCE is based on a kinesio-physical philosophy rather than a psychological-physical philosophy. "The psycho-physical approach typically places the client in charge of the test," Ege says, noting that this can lead to a self-limiting result. "This method communicates to the client that the client is not responsible, which can lead to a lack of effort or the stopping of an activity due more to fear rather than an objective conclusion," Ege says.

The kinesio-physical approach puts the educated therapist in charge of the test. "It's a nonadversarial approach that is truly based on objective criteria and the skills of the therapist evaluator," Ege says. Tools include dynamometers and a heart rate monitor. The data can be entered into an electronic template via a laptop or recorded in writing and entered digitally later.

"The key is to make sure you understand the referral question and that you have complete record information from a historical standpoint," Ege says. He starts the FCE by reviewing this information, asking about the tests that have been performed and where the patient is in their rehabilitation or treatment process. After this, Ege addresses the musculoskeletal evaluation. "The FCE can be used to get an overall picture of the person's abilities and, in that process, gather information specific to the person's job. If we have the particulars about a job, we can provide a specific recommendation for a match," Ege says.

The DSI solution emphasizes the importance of understanding the nature of a job and the exact tasks required to complete it. "It's difficult to take a generic set of tested activities, such as pushing or pulling, and automatically compare them to unique job tasks performed in the work site. Therapists are doing these clinical-based tests but not connecting them to the working world in terms of the environment that the worker is going back to, which challenges the therapist to go to the work site and see what is going on," Ege says.

Being on-site better enables the therapist to understand from the employer's and worker's perspective what is really required to complete a job. "So therapists can see what the patient can do in a clinic environment, but they should also want to go out and get a feel for a targeted job to come up with the ultimate positive result," Ege says, offering an injured stock handler as an example.

"Someone comes in working at company x as a stock handler and has injured their back. They've gone through therapy and plateaued, and the question is, ‘Can they go back to their original position?' " Ege says. It is not uncommon for therapy to have been ongoing for 5 to 7 months, and that person may or may not have been working in a light-duty position in the interim.

The first step is to determine where the patient is at. "This is where the FCE can be used to get an overall picture of the person's abilities. In that process, we are also trying to gather information specific to the person's job—how much do they lift? How often? What are the force requirements for pushing and pulling, grasping, bending, walking?" Ege asks.

Tests that look at position and movements provide insight into the patient's tolerance for performing certain activities. The FCE information is used to determine if that patient can return to their original job or if any modifications or restrictions are necessary.

RESEARCH AND EXPERIENCE

"When patients come to the point of having a FCE, they have a fair amount of questions, concerns, and anxiety about what they can do and whether it will be safe. The FCE helps me and the patient collectively to define what will be safe returning back to work," says Mark Blankespoor, PT, Work Systems Rehab and Fitness in Pella, Iowa. Blankespoor uses the FCE product from WorkWell Systems Inc, Laguna Hills, Calif, which also employs a kinesio-physical approach.

He finds the system useful not only for determining when it is safe for a patient to return to work in the workers' compensation process but also to provide objective measurement of a patient's abilities for physicians and insurance companies. The typical patients Blankespoor sees are individuals with limitations due to an injury. The FCE facilitates determination of what is safe and appropriate for the individual as he or she returns to work on a regular basis.

The initial factor is the musculoskeletal assessment, which looks at the range of motion and strength of an individual not just in the affected joint or region but also throughout the total body. "This provides a reference point," Blankespoor says. Additional beneficial testing factors include the physical demands of lifting, carrying, pushing, and pulling—"the whole laundry list of tasks and various positions," Blankespoor says.

The WorkWell system addresses consistency and validity factors, providing a number of items that the therapist references to determine if the patient is providing consistent and maximal effort. Documentation and reports are generated either through Microsoft Word or an Internet template available through WorkWell. Training on the system is completed with a 2-day course. "The therapist completes 16 hours of continuing education to be certified as a WorkWell provider," Blankespoor says.

Like the DSI solution, the WorkWell FCE is mobile and can be completed in the clinic or at the work site. The system is based on evidence-based practices and peer-reviewed research, and is supported by a large network and 15-plus years of use.

"I've seen a lot of interesting things as far as traumatic injuries and significant physical limitations," Blankespoor says, adding, "I would say the most satisfying cases are those where the patient has had significant limitations but is able to return back to work after we have defined what is safe through the FCE."

Renee DiIulio is a contributing writer for Physical Therapy Products. For more information, contact .