Why do we need formal functional capacity evaluations (FCEs)? Many systems have been developed over the years with slightly different methodologies, but all are used for the same basic reasons:
- Assisting with return to work in the same job aft er sustaining an injury and reaching maximum medical improvement.
- Assisting with return to work to a different job to make sure one can perform the physical demands of the job.
- Determining if someone can return to work in any capacity due to severe disability.
Insurance companies and Social Security have placed pressure on doctors and lawyers to provide objective clinical testing of functional limitations. Gone are the days when a physician could fill out a form based on their assumptions of their patients’ abilities that are largely based on the diagnoses and the patients’ subjective report of limitations. Social Security Ruling 96-8p requires a “function by function assessment of residual functional capacity.” Physicians need clinicians trained in the administration of FCEs to objectively measure functional limitations and abilities.
According to the AMA, impairment is defined as “a loss, loss of use, or derangement of any body part, organ system, or organ function.” Disability (activity limitation) is defined as “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of impairment.”
According to the “Guidelines to the Evaluation of Permanent Impairment,” impairment means an alteration of an individual’s health status that is assessed by medical means; disability, which is assessed by non-medical means, means an alteration of an individual’s capacity to meet personal, social, or occupational demands.
Who is qualified to evaluate functional limitations?
FCEs can vary widely from facility to facility and therapist to therapist. It’s important to find a good fit between evaluator and therapist. For instance, a person with a work-related injury that results in minor limitations may be a good fit for a short, four-hour evaluation with a physical therapist (clinician) or even an exercise physiologist (technician). But for someone who has a more complicated medical or psychological history, a longer evaluation (six to 13 hours) with an occupational therapist is the best option.
While there are “guidelines” in the state of Colorado regarding who should perform FCEs and how they should be performed, there are no rigid rules. A therapist or clinician does not have to have any specific formal training; on the job training will do. Again, this may be fine for straight forward, uncomplicated cases. But when the situation is more complicated, and there are “red flags” involved in the case, a highly trained therapist should be used. Looking at the therapist’s experience, training, background, and reputation is very important.
Exercise Physiologist: Use this technician when the limitations are physical only and pertain to straight forward testing such as cardiovascular endurance, lift ing capacities and gross mobility problems. They can confidently evaluate those with simple diagnoses such as fractures, mild degenerative changes, sprain and strain syndromes, etc.
Physical tHerapist: Use this clinician when the limitations are physical only but may be a bit more complicated involving neurological, orthopedic, musculoskeletal or a combination of these conditions.
Occupational tHerapist: Use this clinician when the limitations are physical, cognitive, visual-perceptual, psychosocial or any combination of these. The occupational therapist looks at how all aspects of the human experience affect function.
Both OTs and PTs may have a background in job site analyses which helps in determining whether or not a client can return to a specific job, field or occupation, but this usually requires additional training which both professionals are qualified to obtain.
What areas of human function and performance should be evaluated?
Again, different systems include different evaluation protocols; some are very rigid and do not deviate from the chronological protocols, and others rely on the “thinking therapist’s” judgement to pick and choose which protocols to apply to the FCE and in what order. It is my belief that the second approach bet fits the Practice Hierarchy: safety, reliability, validity, practicality, and utility. It makes sense to choose the tests that meet the needs of the client being tested, the referral source, the treating doctors, and answers the questions at hand. This could be physical, cognitive, visual-perceptual or psychological tests. It’s also important to remember that the evaluator has a responsibility to everyone to provide unbiased, accurate information regarding a person’s ability to perform activity over a prolonged period. We should not return someone to work in a job that places them at risk re-injury, creating a liability for the employer who has the right to hire the best and safest person for the job.