cover for fce course compendium software user · 2020-04-09 · 4 functional capacity evaluation...

II National Research and Training Center 3921 30th Ave – Suite A – Kenosha, WI 53144 P: 866-470-4440 ▪ F: 866-520-5557 ▪ www.occupro.net

OCCUPRO, LLC © 2020 www.occupro.net

Functional Capacity Evaluation Certification Course

Training Compendium

2

1

OccuPro3921 30th Ave Suite AKenosha, WI 53144


INTRODUCTION

Training Site TourInstructor introductionAttendee introductionsCourse Overview


SITE TOUR

Bathrooms Exits Breaks

1

2

3

1

2


INTRODUCTIONS

Instructor(s) introductions Attendee introductions


WHO WE ARE

Functional Capacity Evaluation Software Return to Work Software Post Offer Employment Testing Software Return to Work and Stay at Work Continuing

Education Certification Employer based services Research


COURSE OVERVIEW

Foundational Principles of FCEs Industrial Rehab Principles Setting up and maintaining your program Performing FCEs using evidence based testing

methodologies FCE practicum

4

5

6

2

3

INTRODUCTION TO FUNCTIONAL

CAPACITY EVALUATIONSHistory of FCEs

FCEs in rehab

Purpose of FCEs


HISTORY OF FCES

Began as tools to help determine disability Disability originally and still today is primarily

decided by AMA guide to impairment Functional testing was incorporated Job Specific FCEs were developed


FUNCTIONAL CAPACITY EVALUATIONSAND THE REHAB PROCESS

Used to determine an individual's ability to safely return to work full time or on modified duty

Used to determine if work restrictions, job modifications, or reasonable accommodations are necessary to prevent further injury

Used to determine the extent to which impairment exists or the degree of physical disability for compensation purposes

Used to determine the need for work conditioning/hardening The Functional Capacity Evaluation assesses the individual's:

•Flexibility•Strength•Balance•Coordination•Repetitive Activities

•Cardiovascular condition•Lifting•Carrying•Push/pull abilities•Body mechanics

7

8

9

3

4


FCE PURPOSE

Criteria that would suggest a patient is ready to have an FCE performed: Patient who has completed a course of therapy Patient that is close to return to work Patient who has achieved maximum medical improvement Patient who reports issues related to re-injury and return

to work Permanent Disability and or Permanent Partial Disability Individuals who need their function quantified prior to

vocational job search and/or return to work Individuals who require quantification of their physical

function for medicolegal reasons


APTA CURRENT CONCEPTS IN FUNCTIONAL CAPACITYEVALUATION: A BEST PRACTICES GUIDELINE


APTA CURRENT CONCEPTS IN FUNCTIONAL CAPACITYEVALUATION: A BEST PRACTICES GUIDELINE

FUNCTIONAL CAPACITY EVALUATION = A comprehensive performance based medical assessment of an individual’s physical and or cognitive abilities to safely participate in work and other major life activities.

The four major components of an FCE include Intake interview Medical records review Physical examination Content valid functional testing

10

11

12

4

5

Functional Capacity Evaluation Certification Course 13

International Classification of Functioning, Disability, and Health

Work Activities


ICF KEY DEFINITIONS

Body Functions: physiological functions of body systems (including psychological functions)

Body Structures: Anatomical parts of the body, such as organs, limbs and their components.

Impairments: Problems in body function or structure such as a significant deviation or loss. ICF uses five point scale to rate degree of

impairment (no impairment, mild, moderate, severe and complete).

AMA uses percentage system to rate impairment for the area or body as a whole.


ICF KEY DEFINITIONS (CONT.)

Activity: Execution of task or action by an individual.

Activity Limitation: Difficulties an individual may have in executing activities.

Participation: Involvement in a life situation.Participation Restrictions: Problems an individual

may experience when involved in life situations.Environmental Factors: Make up the physical, social

and attitudinal environment in which people live and conduct their lives.

13

14

15

5

6

THE OCCUPRO EVALUATION

PHILOSOPHYEvaluation FrameworkConsistency of EffortReliability of PainBorg Rating of Perceived ExertionPsychophysical vs. Kinesiophysical


OCCUPRO EVALUATION FRAMEWORK

1. Safety2. Reliability3. Validity4. Practical test5. Objective


SAFETY

Patient Safety Evaluator Safety

16

17

18

6

7


RELIABILITY

Intra-Rater Reliability When one person measures the same item twice and

the measurements are compared this is intra-rater reliability.

Inter-Rater Reliability When two or more persons measure the same item

and their measurements are compared this is called inter-rater reliability.

Standardized Tests!!!!


TYPES OF VALIDITY

Face Validity This occurs when an FCE appears to measure what it intends to measure and

is a plausible method to do so. Content Validity

This occurs when the individual test items in an FCE accurately represents the overall performance domain the test is intended to measure.

Criterion Related Validity Does your FCE testing meet the level of a “gold standard” (no gold standard

in FCE’s). Concurrent Validity

Looks at the FCE’s ability to determine current abilities. To establish this the FCE must compare the results to the client’s current work

status. Predictive Validity

Refers to your FCE’s ability to determine future abilities. To establish this you must follow your patient for a period of time.

Construct Validity Measures whether your FCE can be shown to measure a hypothetical

construct.


VALIDITY EXAMPLESFace and Content Validity

Is your FCE assessment relevant to the needs of the client, therapist, employer, insurer and physician?

Criterion-Related Validity Does your FCE predict successful return to

work? Does your FCE predict continued/sustained

successful return to work?Construct Validity

Does your FCE discriminate between different groups such as those with and without back pain or can or cannot work?

19

20

21

7

8


ARE FCES VALID?Out of all the commercially based FCEs,

“validity ranged from poor to good”. (1)Out of all the commercially based FCEs,

only partial aspects of them had moderate to good validity. BTE, EPIC Lift Capacity, ERGOS Work

Simulator, Ergo Science, Spinal Function Sort, and Valpar

There was no commercially based FCE system “that demonstrated moderate to good validity in all areas”. (1)

Why are FCE’s not valid?


FCE REPORTS AND VALIDITY?????

Validity Criteria Valid or Invalid FCE Sincerity of Effort and Validity Consistency of Effort and Validity In your FCE documentation you should never say

anything as to whether the patient or FCE was valid.

Validity is a statistical measurement.


PRACTICAL

Can the test be performed in a reasonable amount of time?

Does the test measure job specific items?

22

23

24

8

9


OBJECTIVE

Are you performing your FCE as a medical evaluation or are you just letting the patient do what they subjectively think they can do?

Objective Documentation is a must! Includes documenting the clinical objective findings

that support the end points of each test.

Having objective documentation helps to protect you in a court of law!


CONSISTENCY OF EFFORT

Valid test vs. Invalid test????? Sincerity of Effort vs. Consistency of Effort?????? Sometimes have been related to:

Symptom magnification Pain


CONSISTENCY OF EFFORT (CONT.)

It should be the assumption of the evaluator that each an every client is putting forth full effort during testing and this opinion should not change until objective data gathered during the test would suggest otherwise.

Consistent effort suggest full effort was put forth.

Inconsistent effort suggests self limiting behaviors and/or sub-maximal effort.

Throughout the course, various consistency of effort tests will be discussed.

25

26

27

9

10


RELIABILITY OF PAIN

Is the level of pain being reported a reliable level of pain? i.e. “I am a 10 out of 10 today” i.e. “I am a 12 out of 10 today” i.e. “I have a high pain tolerance”

Questionable Pain Are the reports of pain levels reliable?

If they are reliable, then pain may be a limiting factor If the pain level being reported is not a reliable level of

pain, focus on a kinesiophysical approach and the demonstrated mechanics.


PAIN

Pain may be a warning and should be respected. Is the client’s pain at a level that affects their

functional abilities??? Is the pain level being told to the evaluator an

accurate level of pain or is the client exaggerating their pain level????

Pain can be very subjective both from the evaluator and the patient.


PAIN

If a client reports an increase in pain, one of the following three evidence based things should occur and if one of the following three things does not occur, it could be considered a reliability of pain issue for that particular test. Increase in heart rate by 8-12 bpm within 8 seconds

after the increase in pain. Increase in heart rate due to pain is associated with a test

to test format and is not an increase based on the initial resting heart rate.

Pain behaviors Mechanical changes

28

29

30

10

11


PAINPain is a warning and should be respected!0-10 OccuPro Pain Intensity Scale

Developed as a functional pain scale. Correlates a client’s pain to a level of function. Increases the objective nature of pain. Takes a therapist’s feelings of pain out of the equation. Pain may be a limiting factor. A kinesiophysical approach needs to always be used. If client reports increased pain, then we should see

appropriate pain behaviors. By monitoring heart rate, the evaluator will be able to see

physiological heart rate responses with physical exertion.


HEART RATES AND PAIN LEVELS

Heart rates: Will provide vital information as to:

How the client is tolerating the activities.How much endurance the client has.How much effort the client is putting forth.Resting heart rate: at least sitting for 10 minutesAerobic Limiting Factor is 85% of max adjusted heart

rate as a stopping point (220 – age times .85)

OccuPro Functional Pain Scale and heart rates Together these will provide a glimpse of the

physiological response.


PAIN SCALE

31

32

33

11

12


BORG SCALE

This scale is used to assist with physiological responses and exertion by the client during activities that increase heart rate.

Specifically, frequent material handling and climbing activities.

6-20 numerical scale 6 = no exertion at all 7 = extremely light 9 = very light (easy walking slowly at a comfortable pace) 11 = light 13 = somewhat hard (it’s quite an effort, you feel tired but can

continue) 15 = hard (heavy) 17 = very hard (very strenuous- feel very fatigued) 19 = Extremely hard (you can not continue for long at this

pace) 20 = Maximal exertion (exhaustion)


PSYCHOPHYSICAL VS. KINESIOPHYSICAL Who determines the stopping point of a test?

Patient Evaluator

How hard should I push the client? Patient’s comfortable end point Mechanical changes Mechanical deficits


PSYCHOPHYSICAL

The client being tested reports that they are unable to continue a test secondary to psychophysical reasons.

They feel from a psychophysical standpoint that they are unable to go on.May be pain related, mechanic related or anxiety

As evaluators, we need to substantiate these psychophysical reports and agree or disagree.

Our agreement or disagreement with this would be based off of mechanics.

34

35

36

12

13


KINESIOPHYSICAL

Based on our medical knowledge of biomechanics, physiology, anatomy, cardiovascular endurance and the diagnosis, we decide whether a client has performed at their maximum effort. Mechanical changes vs. Mechanical deficits A mechanical change may not be unsafe.

i.e: Shoulder hiking, lumbar extension, compensatory technique or substitution pattern

A mechanical deficit would be a mechanical breakdown in which the client demonstrates mechanics which would be considered to be unsafe or that the client has met a kinesiophysical endpoint and the client would be unable to perform at that level in a competitive work environment.


JOB SPECIFIC FCE COMPARISON

Job Demands Match worksheet Software

Individual task comparison Overall return to work comparison United States Department of Labor Physical Demand

Classification System

PRINCIPLES OF PERFORMINGFCESPhysical Demand Categories

FCE definitions

37

38

39

13

14


US DEPT OF LABOR PHYSICALDEMAND CATEGORIES

The primary tool to compare a patient’s abilities to their job is to classify their abilities using the United States Department of Labor, Employment and Training Administration, Dictionary of Occupational Titles.

This tool is widely used by occupational analysts who perform job site analysis, ergonomics and functional capacity evaluations.


PHYSICAL DEMANDS -STRENGTH RATING The Physical Demands Strength Rating reflects

the estimated overall strength requirement of the job, expressed in terms of the letter corresponding to the particular strength rating.

It represents the strength requirements which are considered to be important for average, successful work performance.

The strength rating is expressed by one of five terms: S - Sedentary L - Light M - Medium H - Heavy V - Very Heavy


S-SEDENTARY WORKExerting up to 10 pounds of force

occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

40

41

42

14

15


L-LIGHT WORK

Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace, entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.


M-MEDIUM WORK

Exerting 20 to 50 pounds of force occasionally and/or 10 to 25 pounds of force frequently and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work.


H-HEAVY WORK

Exerting 50 to 100 pounds of force occasionally and/or 25 to 50 pounds of force frequently and/or 10 to 20 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.

43

44

45

15

16


V-VERY HEAVY WORK

Exerting in excess of 100 pounds of force occasionally and/or in excess of 50 pounds of force frequently and/or in excess of 20 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Heavy Work.


CLASSIFICATIONS OF FREQUENCYAND DURATION

Occasional 1-1/3 of the work day or 1-33% 1-20 minutes per hour 1-499 repetitions per day for material handling

Frequent 1/3-2/3 of the work day or 34-66% 21-40 minutes per hour 500 to 999 repetitions per day for material handling

Constant 2/3-3/3 of the work day or 67% -100% 41-60 minutes per hour 1000+ repetitions per day for material handling

*Avoid IF the client is unable to perform the requested task

secondary to mechanical deficits, does not meet AROM requirements or if they are unsafe to perform this task on the job.


NON-MATERIAL HANDLING/POSITIONAL

TOLERANCES

Activities that are performed during the course of a day that are performed repetitively and need to be classified in regards to avoid, occasional, frequent or constant. Walking Reaching

Forward reaching Above shoulder reaching

Bending (repetitive) Squatting (repetitive and sustained) Kneeling (repetitive and sustained) Crawling

46

47

48

16

17


NON-MATERIAL HANDLING

Balance (up off of the ground)Static Dynamic

Stair & Ladder Climbing


UPPER EXTREMITY TESTING

Grip Testing Pinch Testing Fine Motor Coordination Gross Motor Coordination


SIT AND STAND

Workers’ Compensation based tests want sitting and standing classified using occasional, frequent or constant.

Disability based FCEs want sitting and standing classified in regards to the number of hours in a workday the client can sit and stand.

A client’s sitting and standing ability generally helps to define if a person can work full time or part time.

49

50

51

17

18


MATERIAL HANDLING ABILITIES

Occasional, Frequent and Constant Lifting Job Specific/Bend LiftingSquat LiftingPower LiftingShoulder LiftingOverhead LiftingUnilateral Lifting

Occasional, Frequent and Constant CarryingTwo Handed CarryingUnilateral Carrying

Occasional, Frequent and Constant Pushing/Pulling


DISTRACTION BASED TESTING

A clinical testing situation in which the client being tested is unaware of all information being gathered.

For instance: Observing someone putting on their jacket with full

shoulder flexion but not being able to achieve full shoulder flexion during musculoskeletal testing.

FCE DOCUMENTATIONDiscuss proper FCE documentation

Perform Documentation

52

53

54

18

19


PURPOSE OF THE EVALUATION

State the purpose of the evaluation in work related terms: The purpose of this functional capacity evaluation is

to determine this client’s functional abilities as they relate to the physical demands of their job as a police officer.

The purpose of this baseline FCE is to determine this client’s overall return to work functional abilities.


INDIVIDUAL TEST DOCUMENTATION

Functional abilities a client is able to perform Mechanics

Mechanical Changes and/or Mechanical Deficits Pain

Pain Level Pain Location Pain Behaviors Reliability of Pain Reports

Physiological Responses Heart Rate

Limiting factors Inconsistency or Consistency noted during tests Normative Data comparison


RESULTS/RECOMMENDATIONS

Lift, Carry, Push and/or Pull Functional Abilities to Job Demands Match

What percentage of the physical demands can the client tolerate?

Return to Work Recommendation (if appropriate) OccuPro Predictive Validity Research would suggest that if a

client can perform 80% or more of the physical demands, than a Return to Work Recommendation is warranted.

Consistency of Effort/Reliability of Pain What percentage of the test is consistent/reliable?

Client/Occupation Physical Demand Level What physical demand level can the client tolerate? What physical demand level is the job?

55

56

57

19

20


RESULTS/RECOMMENDATIONS (CONT.)

Limiting Factors What were the limiting factors during testing?

Recommendations General overall recommendations in regards to

the client’s functional abilities.Rehab Recommendations

If appropriate, make a rehabilitation recommendation.FCE Rehab Recommendation is very questionableFPN and FDS should always have a Rehab

Recommendation.


OBJECTIVE DATA

All documentation should be objective. NEVER PUT YOUR OPINION INTO A REPORT Objective data protects you from an attorney

questioning your FCE if you are deposed in a deposition and/or court of law.


STANDARDIZED TESTING

There may be times that you perform a standardized test in a non-standardized fashion. Make sure you document why you performed the test

in that way and what your results were. May also be done as a job simulated test.

58

59

60

20

21


CONSISTENCY OF EFFORT ANDRELIABILITY OF PAIN REPORTS

If someone is consistent/reliable, make sure the documentation reflects this.

If a client is inconsistent or unreliable, make sure the individual tests they were inconsistent or unreliable in have extra documentation outlining the evidence based items that helped you to determine the unreliability or inconsistency. Requires significant objective documentation

Your final summary documentation requires an overall summary of the testing that was unreliable or inconsistent if the overall test was inconsistent or unreliable.


LIMITING FACTORS

Limiting Factors Reasons “why” a specific task was terminated

or a client was unable to meet what the physical demand of the job were. Some limiting factors may be:

Increased PainMechanical ChangesMechanical DeficitsCompensatory TechniquesSubstitution PatternsMaximum EffortInadequate Strength Client AnxietySafety Concerns


LIMITING FACTORS (CONT.)

Evaluator StoppedClient TerminatedGeneral Fatigue Limited Range of MotionPoor PostureSelf Limiting BehaviorsHeart Rate Exceeded Aerobic Limiting FactorAbnormal SensationExtra Ordinary Muscle Recruitment

61

62

63

21

22


PAIN BEHAVIORS

Research tells us that the main way we are able to substantiate an increase in our client’s pain is through observation of pain behaviors, including: Facial Grimacing Verbal Grunting Sweating Crying Rubbing Holding Many others


FINAL THOUGHTS

An FCE report should tell a story and the reader should be able to start at the beginning and know what your client can and can’t do by the end of the story. FCE story is from date of injury to the date of FCE

testing.

Need to refrain from to many acronymsComplete sentences and spell checked

HOW TO GET A HIGH QUALITYREPORT TO YOUR REFERRAL

SOURCEThe OccuPro FCE work template

Creating your own FCE template

Dictation

OccuPro FCE Software

Other FCE software systems

64

65

66

22

23


FCE PAPER BASED DOCUMENTATION TOOL

Tool to help document the testing methodologies used.

Goes in order of the testing procedures Replicates the same testing procedures in the

OccuPro FCE software.


CREATING YOUR IN-HOUSE TEMPLATE

Create a word or excel document that has fill in the blank areas.

Type in your results as you go. Write your results down and fill in later. Microsoft Excel template allows for easy

calculations.


DICTATION

Many organizations have dictation systems. Create a template in which a transcriber fills in

the dictated blanks.

67

68

69

23

24


SOFTWARE

OccuPro’s – FCE Software Matheson’s – The Workstation ErgoScience – Physical Work Performance

Evaluation Work Well – FCE Workability Network J-Tech – Tracker FCE system Key Method – MEDLEY Blankenship Medigraph ARCON Others


OCCUPRO’S FUNCTIONAL CAPACITY

EVALUATION SOFTWARE

Web Based testing systemPost-test documentation completed in

minutesTests are generated immediately and

include: Custom length FCE report One page summary One page abilities report

Software knows if you are doing a job specific FCE or baseline FCE


CONSISTENCY OF EFFORT ANDRELIABILITY OF PAIN

OccuPro software has 98 separate consistency of effort/reliability of pain criteria. 38 are specific to consistency of effort 60 are specific to reliability of pain reports Plug and chug data and results are completed

for you There are also 7 custom consistency of effort

and 7 custom rliability of pain test options.

70

71

72

24

25

DEVELOPING/ESTABLISHING

PROGRAMFCE program

Full industrial rehab program

Financial success


FCE PROGRAM

Stand alone FCE programPart of an industrial rehab programHow to get started?

Marketing First steps

Building a referral base Referral sources Job Specific Disability

Are FCEs financially successful?

EQUIPMENT AND SPACEDetermining Equipment needed

Setting up your testing space

73

74

75

25

26


EQUIPMENT

Basic equipment available on the open market Some systems have proprietary equipment you

have to purchase Bells and whistles with some equipment

Equipment hooks up to laptop Wireless equipment


STANDARD EQUIPMENT

Grip and Pinch Testing Fine Motor and Gross Motor Testing Lifting station and lifting boxes


SETTING UP YOUR SPACE

Does not require a lot of space

76

77

78

26

27

FCE OVERVIEW

FCE performanceTypes of FCEsReferral questionsDifficult patientsEvidence Based FCEsValidity, Reliability and Daubert


GENERAL FCE PERFORMANCE

Interview Job Demands Analysis Musculoskeletal Testing Functional Testing Job Simulated Testing Report Write Up


THERE ARE TWO TYPES OF FCES:

Baseline/General Purpose FCE An objective assessment of the individual's

physical abilities to perform a variety of tasks related to the physical demands of work.

Job Specific FCE An evaluation of the individual's physical

abilities to function within the parameters of an identified job. The job specific FCE is based on critical physical demands of the essential functions of the job. Work simulation activities are often an integral component of the evaluation.

79

80

81

27

28


DEFINITION

An effective FCE determines whether there is a match between the individual's functional capabilities and the physical demands of work.


FCE BENEFITS

Helps to establish treatment plan Full duty or light duty job placement Independent Medical Exam Helps to establish consistency of effort with patients Helps to establish PPD ratings at end of healing


FUNCTIONAL CAPACITY EVALUATIONS The Functional Capacity Evaluation (FCE) you will be

taught uses a systematic process of assessing an individual's physical capacities and functional abilities.

This methodology matches human performance levels to the demands of a specific job or work activity or occupation.

The FCE is useful in determining job placement, job accommodation or return to work after injury or illness.

Used to make objective and reliable assessments of the individual's condition.

It’s precise data format provides information that can be used in various contexts.

82

83

84

28

29


FCE PERFORMANCE

The primary goal to be completed prior to performing the FCE, is to obtain the physical demands of the patient’s job.

If the client being tested does not have a specific job to return to, then you will need to calculate the specific Department of Labor physical demand category. This can be used for any of the following

situations:Permanent Partial Disability Rating from the

physicianClient is disabled and vocational placement is neededDocumented functional abilities for a patient

pursuing Social Security Disability Income


FCE PERFORMANCE (CONT.)Comprehensive evaluation completed in 3 to 4

hoursOrdered by physicians, chiropractors, attorney’s,

case managers, employers and can certainly be suggested by therapists


ASSESSMENT PURPOSE/REFERRAL

QUESTION

Needs to be answered in every FCE Ultimately becomes your purpose Disability? Job Specific? PPD? MMI? Return to work?

Full duty Light duty

Legal Questions Consistency of Effort Reliability of Pain Disabled?

85

86

87

29

30


DIFFICULT PATIENTS

Inconsistent Unreliable Not talkative No information Crying Excessive pain


EVIDENCE BASED TESTINGMETHODOLOGIES

Every test that is being used in your FCE should have evidence based research to back it up. The testing methodology as a whole needs to be

validated and reliable Each individual test needs validity and reliability All of this needs to be peer reviewed and published


WHAT THE HECK IS DAUBERT?For an FCE to be admitted as evidence:

Reliable Valid Relevant “The Supreme Court held in the Daubert case

that this rule required the judge to consider whether the expert’s underlying methodology or technique had been or could be tested; whether it had been subjected to peer review; whether it had a known or potential rate of error; and whether and to what degree the methodology or technique had been accepted within the relevant scientific community.” (3)

88

89

90

30

31


FCE CREDIBILITY AND DAUBERT

Do not rely on the FCE testing methodology! No FCE had average to good Validity

You need to analyze and interpret the data correctly based on evidence based practice.

FCEs should only be performed by health care providers who have the legal authority to perform them.

A kinesiophysical vs. a biophysical vs. a psychophysical approach

Make sure you know the legal questions as well. Be careful how you report consistency of effort and

reliability of pain. “In the end, it is a well written, rational opinion that tips

the credibility scale.” (3)

FCE INTAKE AND ASSESSMENTSETUPPre-Testing Procedures

Intake and Interview


PRE-TESTING PROCEDURES

Obtain a referral This can be established in different ways

The referral can come directly from the Physician or Chiropractor.

The treating therapist may feel that an FCE will benefit the rehabilitation process.

The insurance company may directly order an FCE based on their need of this documentation.

The patient’s employer may ask for an FCE to be performed and they may directly pay for the service.

An attorney’s office may request an FCE for return to work or disability purposes. (Make sure you are aware of the specifics of your state

licensure regarding your ability to perform testing without a physician’s referral.)

91

92

93

31

32


SITTING AND STANDING

Needs to be evaluated from the start of the evaluation.

Total Sitting and length of sitting at one time should be timed off to the side.

Total standing and length of standing at one time should be timed off to the side.

At the end of your FCE, you will use the time in your FCE to establish occasional, frequent or constant abilities.

If you are performing a disability test, you will ask further questions to establish the number of hours the client can sit and stand.


CONSENT TO EVALUATE

Prior to performing the FCE, a consent to evaluate form must be filled out by the client. This will explain what the test is How long it will take What activities will be performed The client will sign and date at the bottom of this

form prior to starting the FCE


INTERVIEW AND CONSENT

94

95

96

32

33


INTERVIEW/DEMOGRAPHICS

During the initial interview stages of the FCE some important information must be completed and gathered. Client’s name Employer Occupation and/or Job Title Referring Physician Diagnosis Evaluator Date of Birth Date of FCE Date of Injury Date of Surgery

The dates are very important, as they give the evaluator the first glimpse at the time frame that some major events may have taken place during the injury to full rehab process.


BASIC DIAGNOSTICS

Anthropometry Height Weight Hand Dominance


BASIC DIAGNOSTICS (CONT.)

Pre-evaluation diagnostics Heart rate- resting Blood pressure- resting

Watch for the guidelines! Consult the MD if BP is 160/100 or higher and do not

perform the test without medical clearance first.

97

98

99

33

34


BASIC DIAGNOSTICS (CONT.)Aerobic Limiting Factor

This is the maximum heart rate level = 220 - age x .85

If the client’s heart rate meets or exceeds this number, then the current test should be stopped.

If this is exceeded often, then the entire test may need to be stopped.

Need to check blood pressure if this level is exceeded

Main indicator of cardiovascular/endurance issues


BASIC DIAGNOSTICS (CONT.)

Weight Limiting Factor This is the maximum “safe” weight limit for the

client. 60% of client’s weight A level in which you need to increase your awareness

of your kinesiophysical approach.


BASIC DIAGNOSTICS

100

101

102

34

35


BASIC DIAGNOSTICS (CONT.) OccuPro Functional Pain Scale

Following the presentation of OccuPro’s functional pain scale, did this client report that they understood the pain scale?

0-10 functionally based scale Present Functional Pain Level Worst Functional Pain Level (within the past week) Least Functional Pain Level (within the past week) Average Functional Pain Level (within the past week)

Following the client’s report of their present, average, worst and least pain level, did they report a reliable level of pain prior to functional testing based on the OccuPro’s Functional Pain scale?


HISTORY OF PRESENT CONDITION

The next area to be completed is the history of the present condition.

This area should tell a story of the injury up to the date the FCE is being performed.

Some of the information that needs to be gathered includes the following:

What happened on the date of injury? Was this an injury or an illness? When did you seek medical attention? What did the medical professionals do?

What medications were given? What recommendations were given? Was surgery performed?

How was this course of treatment and was it beneficial? What diagnostic tests were performed? What type of rehabilitation programs have you participated in? Have you been back to work on full duty or modified duty since the injury? What activities were you performing at work?


HISTORY OF PRESENT CONDITION

103

104

105

35

36


PAST MEDICAL HISTORY

The next section pertains to past medical history information that may adversely affect this evaluation. Has the client had other surgeries, broken

bones, strain or sprains that may affect their performance in the test outside of the present diagnosis?

Also, are there any health concerns that may effect the evaluation outside of their present diagnosis? For instance, is there a history of heart problems,

breathing problems, diabetes, high blood pressure or other systemic diseases?


PAST MEDICAL HISTORY


RECORDS REVIEWED

It is common to review medical records prior to your FCE. You should document what records were reviewed.

106

107

108

36

37


PRESENT STATUS

The next section pertains to the present condition of the patient following the rehabilitation process and the medications they are taking based on the diagnosis.

The information that needs to be gathered for the present status category includes: How does the client feel they are presently

doing? What aspects of rehab have been beneficial? What daily activities have become easier or are

still a challenge? What activities help any continued deficits or

pain symptoms?


PRESENT STATUS


MEDICATIONS

The following questions should be asked regarding medications: What type of medications are you currently taking? Dosage and when this was last taken? Are any other medications taken on “PRN” status?

109

110

111

37

38


MEDICATIONS


ASSESSMENT PURPOSE/REASON FOR

REFERRAL

Document the overall reason why you are performing the FCE and/or the reason for the referral and who it came from. Is it for return to work? What position are they attempting to return to? Is it for SSDI? Is it for long term commercial disability?

JOB DEMANDS ANALYSISJob Specific FCE

Performing an On-Site Analysis

Gathering data from the patient

112

113

114

38

39


JOB DEMANDS ANALYSIS

Systematic approach to gather the physical demands of an employee’s job

Used to more precisely treat the injured worker Allows faster return to work Used in conjunction with all FCEs and Work

Hardening/Conditioning patients



Physical Demands obtained from? Was there a job demands analysis performed? Do you have a formal job description from the

employer? Utilizing the DOT (Dictionary of Occupational

Titles) Asking the client some of the positional/physical

demands and levels of their job

What is their current work status?


JOB DEMANDS ANALYSIS (CONT.)

Vocational Status: More in depth information on their current job status How long have they been off of work? How long they have been employed with the company? Are they in a union? What Local #? How long have they been in their occupation? How many hours/week & days/week did they work? Voluntary or Mandatory Overtime? How often? May enter brief description of the job

115

116

117

39

40



Gathering the physical demands What is the total amount of time you need to

sit/stand during your shift? How long at one time to you need to be in the

standing or sitting position until you can take a break during your shift?

Total Sitting Required Input in hours

Total Sitting at one time Required Input hours

Total Standing Required Input in hours

Total Standing at one time Required Input in hours


JOB DEMANDS ANALYSIS (CONT.) Material Handling Input weight in Pounds

Occasional Squat Lift Frequent Squat Lift Constant Squat Lift Occasional Power Lift Frequent Power Lift Constant Power Lift Shoulder Lift Overhead lift Unilateral lift Occasional Carry Frequent Carry Constant Carry

Occ. Unilateral Carry

Freq. Unilateral Carry

Occasional Push Frequent Push Constant Push Occasional Pull Frequent Pull Constant Pull



Asking the client Always ask the Occasional Material Handling

questions first

What is the heaviest weight you need to lift/carry/push/pull from _____________?

Do you need to lift/carry/push/pull 500 to 1000 times per shift? If so, what heights or distances?

Do you need to lift/carry/push/pull 1000 times or more per shift? If so, what heights or distances?

118

119

120

40

41



Walking Bending Squatting Sustained Squatting Sustained Kneeling Repetitive Kneeling Crawling Climbing

Static Balance Dynamic Balance Stair Climbing Ladder Climbing

Forward Reaching Above Shoulder Reaching Fine Motor Coordination Gross Motor Coordination Simple Grasping Firm Grasping Pinching

Positional Tolerances What percentage of your shift do you need to perform

__________________? 1%- 33% = Occasional 34% - 66% = Frequent 67% - 99% = Continuous

The various things a client will need to do include:



Job Simulation Tasks Tasks 1 to 10 options to perform a job

simulated test based off job demands What percentage of your shift do you need to

perform __________________?



121

122

123

41

42

CONSISTENCY OF EFFORTCommon Terminology

Evidence Based Practice

Testing used for Effort


CONSISTENCY OF EFFORT

Refers to a client’s overall effort during testing from objective measures that are observed by the evaluator.

Was the client consistent in their biomechanical abilities?

If they were consistent, it can be assumed the client put forth full effort.

If they were inconsistent in a test, they would be considered to have been a self limiter or have put forth sub maximal effort.


OBSERVATIONAL CONSISTENCY OFEFFORT

ROM consistencies MMT consistencies

124

125

126

42

43


BIOMECHANICAL CONSISTENCIES

Biomechanical lifting consistencies Occasional vs. Frequent lifting consistencies One handed vs. Two handed consistencies Dual inclinometric consistencies


UPPER EXTREMITY CONSISTENCIES

Coefficient of Variation Bell Shaped Curve Rapid Grip Exchange


INCONSISTENT OR CONSISTENT

What do we do if someone is inconsistent? Objective documentation Results may not be accurate, secondary to sub-

maximal effort. USE A KINESIOPHYSICAL APPROACH Self Limiting Behaviors? Sub Maximal Effort? Your decisions may increase based on other tests!

You can use the functional performance from other tests to make decisions on tests in which the client was self limiting.

127

128

129

43

44

RELIABILITY OF PAINDefinition

Evidence Based Practice

Tests Used to Determine


RELIABILITY OF PAIN REPORTS

Objective testing that allows us to better assess the dependability and accuracy of a client’s subjective pain reports. In the case that a client’s subjective reports of pain are unreliable, they should not be ignored, but we should focus on the objective kinesiophysical findings.


TYPES OF RELIABILITY OF PAIN

Does the client follow the OccuPro Functional Pain Scale?

Psychometric Tests Waddell Signs Borg Rating of Perceived Exertion vs. Heart Rate Pain vs. Heart Rate, Pain Behaviors and

Mechanical Changes Pain correlating with diagnosis

130

131

132

44

45


PSYCHOMETRIC TESTS

McGill Pain Questionnaire Ransford Pain Drawing Oswestry Low Back Disability Index Oswestry Neck Disability Index Fear Avoidance Belief Questionaire


WADDELL SIGNS

5 original tests7 test based on newer research This is for lumbar spine clients only

There are 5 tests that comprise this section This should be performed prior to any physical

activitySuperficial/Non-Anatomical TendernessSimulation TestDistraction Straight Leg Raise (supine vs.

sitting)Regional DisturbancesOverreaction to ExaminationInput “Positive/Negative” after each test


RELIABLE OR UNRELIABLE?

What if someone is unreliable in regards to their pain? Functional Pain Scale documentation is required Objective Documentation Results may not be accurate since the main thing we

may have stopped a patient for is pain. USE A KINESIOPHYSICAL APPROACH If the pain reports are unreliable, you should push

the client to the kinesiophysical end point.

133

134

135

45

46

MUSCULOSKELETAL TESTINGGoniometric vs. Dual Inclinometric

AMA guide to impairment ratings


MUSCULOSKELETAL SCREEN

Posture Overall view of posture

Palpation To area of injury Note any hyper-sensation/reaction to palpation noted

by a withdrawal response or “grading of response” Note depth of palpation (mild, moderate, deep) Also may palpate to any other problem areas

Reflexes Basic reflex testing if necessary



Assistive Devices

What type are currently used and how often?

Are they using any device during the evaluation?

What may they use at home?

136

137

138

46

47



Circumferential/Volumetric Measurements Pre-evaluation Post-evaluation Summarize findings May want to evaluate distal and proximal to area of

injury



Two point discriminationSharp/Dull AwarenessSensation CommentsSemmes WeinsteinLower Extremity SensationAbnormal Sensation

Identify any abnormal sensations – numbness or tingling Is it constant or intermittent? Identify the dermatome patterns identified or specify

location


MUSCULOSKELETAL TESTING

Range of Motion and Manual Muscle Testing Cervical ROM Lumbar ROM Thoracic ROM Lower Extremity ROM/MMT Upper Extremity ROM/MMT Thumb ROM/MMT Index Finger ROM/MMT Middle finger ROM/MMT Ring finger ROM/MMT Pinky Finger ROM/MMT

139

140

141

47

48



Goniometric vs. Dual InclinometricManual Muscle Testing

Test all muscle groups of the affected body part Note if there are inconsistent responses

For example: muscle breaking, clasp knife response, or inability to hold test position with minimal resistance applied



Comment section Summarize the findings of your

Musculoskeletal Testing Input heart rate during this part of the

evaluation and pain levelIf numerous pain rating are given, then you

may provide a range in the comment section.Note observed behaviors during ROM/MMT:

facial expressions, body language, and quote any comments pertinent to this section.

UPPER EXTREMITY TESTINGGrip TestingPinch TestingFine Motor CoordinationGross Motor Coordination

142

143

144

48

49


GRIP STRENGTH TESTING

Grip Strength Dynamometer Test bilateral hands in position II of the

dynamometer Test in seated position 3 trials on each hand Elbows flexed to 90 degrees and in

adduction holding against gravity Compare the highest result to Matheowitz

age and gender norms


FIVE SPAN GRIP TESTING

CONSISTENCY OF EFFORT TEST Test bilateral hands, alternating, in all

five positions one time in each grip span Test in seated position This will determine a bell shape curve or

a lack of curveA non-bell shaped curve may suggest an

inconsistent effortPositions 1 and 5 should be lower

numerically than 2, 3, and 4 positions.


RAPID EXCHANGE GRIP STRENGTH

CONSISTENCY OF EFFORT Test bilateral hands in position II Rapid fashion with elbows flexed at 90

degrees, arms adducted and holding against gravity, sitting position, and forearms in neutral position

If the RGE grip strength performed during this test are GREATER than position 2 of the five span and/or the three trial,then the client’s performance is INCONSISTENT.

If the RGE grip strength is LESS than position 2 of the five span and/or the three trial then the client’s performance is consistent.

145

146

147

49

50


SIMPLE GRASPING DECISION CHART


FIRM GRASPING DECISION CHART


GRIP STRENGTH DOCUMENTATION

Abilities CAN TOLERATE SIMPLE GRASPING WITHIN THE FOLLOWING

FREQUENCY Avoid, Occasional, Frequent, Continuous

CAN TOLERATE FIRM GRASPING WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits

Pain Pain rating - Pain location - Pain Behavior

Heart Rate Limiting Factors Normative Data Reliability of Pain Consistency of Effort

148

149

150

50

51


GRIP STRENGTH TESTING


FIVE SPAN GRIP TESTING


RAPID EXCHANGE GRIP

151

152

153

51

52


INCONSISTENT EFFORT IN GRIP TESTING


PINCH STRENGTH

Key Pinch/Lateral Pinch 3 trials for each hand using the DI and the lateral aspect

of DII with forearm in neutral position

Palmar Pinch/Three Point Pinch/3 Jaw Chuck using the DI, DII, and DIII in a series of 3 trials

Tip Pinch/Two Point DI and DII in a series of three trials

Test in seated position Compare the highest demonstration to the

Matheowitz age and gender norms


PINCH STRENGTH DECISION CHART

154

155

156

52

53


PINCH STRENGTHDOCUMENTATION

CAN TOLERATE PINCHING WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous





PINCH STRENGTH


FINE MOTOR COORDINATION

Many fine motor tests on the open market: Nine hole peg Purdue pegboard Moberg’s pick up test Crawford’s Small Parts Dexterity Various other tests

Ultimately, we are deciding if someone does or does not have fine motor coordination abilities.

157

158

159

53

54


PURDUE PEGBOARD Testing for coordination and speed of work

Performed with bilateral coordination simultaneously

There are 4 subtests Right hand (30 seconds) Left hand (30 seconds) Both hands (30 seconds) Assembly (60 seconds)

Are there coordination issues? Does further testing need to be performed?


MOBERG’S PICK UP TEST

Used to determine if fine motor deficits are hand eye or sensation deficits

2 trials for each hand Eyes open

Pick up objects then place in container as fast as possible Score: time to pick up and place all 12 objects into a box Trial 1: 10 to19 seconds Trial 2: 9 to 16 seconds

Eyes closed Client manipulates the object in hand and names it as fast

as possible. Score: time it takes to recognize each object on each of 2

trials (normative is within 2 seconds per object)


FINE MOTOR DECISION CHART

160

161

162

54

55


FINE MOTOR DOCUMENTATION

CAN TOLERATE FINE MOTOR COORDINATION WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous





PURDUE PEGBOARD


MOBERG’S PICK UP TEST

163

164

165

55

56


GROSS MOTOR COORDINATION

Many tests on the open market to choose from Box and Block Minnesota Manual Dexterity Test Bennett Hand Tool Various Valpar tools Matheson Bench

Your entire test requires gross motor coordination


BOX AND BLOCK

Test each hand independently This is a timed test

For 1 minute in duration Input the number for each hand


GROSS MOTOR DECISION CHART

166

167

168

56

57


GROSS MOTOR DOCUMENTATION CAN TOLERATE GROSS MOTOR COORDINATION WITHIN

THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous





BOX AND BLOCK

NON-MATERIAL HANDLINGLearn to perform these tests

Introduce Decision charts

169

170

171

57

58


NON-MATERIAL HANDLING

Testing aspects of function that are considered to be repetitive.

Test according to the physical demands of the job or for baseline testing.

If a test was not conducted, do not put any documentation in that area.

This section is a high kinesiophysical section with biomechanics playing an important role.

Identify their functional ability “avoid, occasional, frequent or constant”.


FAST PACED WALKING TEST

Test for 100 yards Tell the client: “This is a timed test.” Observe gait pattern:

antalgic or non- antalgic Performance of pivot/turn- noting any loss of balance or

inability to perform Observe equal/non-equal stride length Compensatory patterns- holding body part?

Time to complete Physical pain behaviors - facial grimacing, labored

breathing, holding injured area, profuse sweating, and heart rate

Input heart rate and pain levels and note the location of pain

Document findings in the comment section


PROLONGED WALKING

This is to determine if the client is able to tolerate walking on a continuous basis.

Test on a treadmill 15 minute walk test on the treadmill 3.0 mph +

Note the treadmill speed, duration and incline

This may be used to simulate an activity on the client’s job.

172

173

174

58

59


WALKING DECISION CHART


WALKING DOCUMENTATION

CAN TOLERATE WALKING WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits Stride length, antalgic/non-antalgic gait, speed

Pain Pain rating - Pain location - Pain Behavior Pain correlates to diagnosis

Heart Rate Limiting Factors Reliability of Pain Consistency of Effort


WALKING

175

176

177

59

60


FORWARD REACHING

Bilateral upper extremity to 90 degrees of shoulder flexion.

Input % of ROM after each test Test 1 time

Input heart rate and pain level Test 10 times

Input heart rate and pain level Test 10 times fast

Input heart rate and pain level


FORWARD REACHING DECISION CHART


FORWARD REACHINGDOCUMENTATION

CAN TOLERATE FORWARD REACHING WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits % shoulder reach, speed, scapulohumeral rhythm, Compensatory Techniques

Pain Pain rating - Pain location - Pain Behavior Pain correlates to diagnosis? Crepitus


178

179

180

60

61


FORWARD REACHING


ABOVE SHOULDER REACHING

Bilateral upper extremity to full range of motion of true shoulder flexion

Input % of ROM after each test Test 1 time

Input heart rate and pain level Test 10 times

Input heart rate and pain level Test 10 times fast

Input Heart Rate and Pain for each!


ABOVE SHOULDER REACHING DECISION CHART

181

182

183

61

62


ABOVE SHOULDER REACHINGDOCUMENTATION

CAN TOLERATE ABOVE SHOULDER REACH WITHIN THE FOLLOWING FREQUENCYAvoid, Occasional, Frequent, Continuous

Radio buttons and drop down menus.% above shoulder reach speed scapulohumeral rhythm,Pain correlates with diagnosis Compensatory techniques crepitus

Pain location, limiting factors, and inconsistencies


ABOVE SHOULDER REACHING


BENDING

Lumbar flexion with legs straight and shoulder width apart

Test 1 timeInput % of ROM demonstratedInput heart rate and pain level

Test 10 timesInput heart rate pain level and ROM

Test 10 times fastInput heart rate, pain level, and ROM

184

185

186

62

63


BENDING DECISION CHART


BENDING DOCUMENTATION CAN TOLERATE BENDING WITHIN THE FOLLOWING


Mechanics Mechanical Changes - Mechanical Deficits % of full bend, movement pattern, speed, compensatory techniques, hamstring

tightness

Pain Pain rating - Pain location - Pain Behavior Pain correlates to diagnosis?



BENDING

187

188

189

63

64


SQUATTING

Squatting to 90 degrees of knee flexion-functional

Input % of ROM to each test Test 1 time

Input heart rate and pain levelInput ROM demonstrated

Test 10 timesInput heart rate and pain levelInput ROM demonstrated


SQUATTING DECISION CHART


SQUATTING DOCUMENTATION

CAN TOLERATE SQUATTING WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits % of full squat, movement pattern, speed, compensatory techniques, equal

weight bearing



190

191

192

64

65


SQUATTING


SUSTAINED SQUATTING

Will be performed in a job simulation fashion The only factor to determine avoid, occasional,

frequent or continuous is how long the client can tolerate the activity you set up


SUSTAINED SQUATTING DECISION CHART

193

194

195

65

66


SUSTAINED SQUATTINGDOCUMENTATION CAN TOLERATE SUSTAINED SQUATTING WITHIN THE

FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits % of full squat, movement pattern, speed, compensatory techniques, equal

weight bearing




SUSTAINED KNEELING Tall kneel position with equal weight distribution

bilaterally Hold for 2 minutes in duration

Input heart rate and pain level Radio buttons and drop down menus

Time tolerated Movement pattern Pain correlates with diagnosis Compensatory techniques Equal Weight Bearing Requires upper extremity assistance Crepitus


SUSTAINED KNEELING DECISION CHART

196

197

198

66

67


SUSTAINED KNEELINGDOCUMENTATION CAN TOLERATE SUSTAINED KNEELING WITHIN THE


Mechanics Mechanical Changes - Mechanical Deficits Time tolerated, movement pattern, speed, compensatory techniques, equal

weight bearing, upper extremity assistance




SUSTAINED KNEELING


REPETITIVE KNEELING

Test 10 times Input heart rate Input pain level Input % ROM performed

Radio buttons and drop down menus. % of full kneel Speed Movement pattern Pain correlates with diagnosis Compensatory techniques Requires upper extremity assistance Equal weight bearing Crepitus

199

200

201

67

68


REPETITIVE KNEELING DECISION CHART


REPETITIVE KNEELING CAN TOLERATE REPETITIVE KNEELING WITHIN THE


Mechanics Mechanical Changes - Mechanical Deficits % of full kneel, movement pattern, speed, compensatory techniques,

equal weight bearing, upper extremity assistance




REPETITIVE KNEELING

202

203

204

68

69


CRAWLING

Test both forward and backward mobility Test for 1 to 20 minute in duration Test for 21 to 40 minute duration Test for 41 to 60 minute duration Input heart rate and pain level


CRAWLING DECISION CHART


CRAWLING DOCUMENTATION CAN TOLERATE CRAWLING WITHIN THE FOLLOWING


Mechanics Mechanical Changes - Mechanical Deficits % of full crawl position, movement pattern, speed, compensatory techniques,

equal weight bearing in all four extremities



205

206

207

69

70


CRAWLING

BALANCE TESTINGDynamic Balance testing

Static Balance testing


BALANCE TESTING

Entire test requires normal foot to floor balance Static and Dynamic balance testing is formally

tested when the job specific FCE you are performing requires any type of climbing which ultimately requires balance as well.

208

209

210

70

71


STATIC BALANCE

Romberg’sEyes openNeed to complete 30 secondsFor Occasional Balance


STATIC BALANCE

Sharpen Romberg’s Eyes openNeed to complete 30 secondsFor Occasional Balance


STATIC BALANCE

Functional Reach Assessment Norms:

Young male 18-35=17 inches Young female 18-35=15 inches Middle age male 35-55=15 inches Middle age female 35-55= 14 inches Elderly male 55+ = 13 inches Elderly female 55+ = 10 inches

211

212

213

71

72


STATIC BALANCE

Single leg stance Eyes Open Bilaterally for 30 seconds For Frequent level of testing


STATIC BALANCE

Single Leg Stance Eyes closed Bilaterally for 30 seconds For Continuous level of testing


STATIC BALANCE DECISION CHART

214

215

216

72

73


STATIC BALANCEDOCUMENTATION

CAN TOLERATE STATIC BALANCE WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits movement pattern, compensatory techniques, loss of balance




STATIC BALANCE


DYNAMIC BALANCE

Functional Gait Assessment

9 dynamic balance testsGait on level surface

Instructions: “Walk at your normal speed from here to the next mark (6 m (20 ft)).”

Pass – Walks 6 m (20 ft) in less than 5.5 seconds, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside of the 30.48 – cm (12-in) walkway width.

Occasional Level of Testing

217

218

219

73

74


DYNAMIC BALANCE

Change in gait speed Instructions: “Begin walking at your normal

pace (for 1.5 m [5 ft]). When I tell you “go,” walk as fast as you can for (1.5 m [5 ft]). When I tell you “slow,” walk as slowly as you can for (1.5 m [5 ft]).

Pass – Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. Deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.

Occasional Level of testing


DYNAMIC BALANCE

Gait with horizontal head turnsInstructions: “Walk from here to the next mark 6 m

(20 ft) away. Begin walking at your normal pace. Keep walking straight; after 3 steps, turn your head to the right and keep walking straight while looking to the right. After 3 more steps, turn your head to the left and keep walking straight while looking left. Continue alternating looking right and left every 3 steps until you have completed 2 repetitions in each direction.”Pass – Performs head turns smoothly with no change

in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.



DYNAMIC BALANCE

Gait with vertical head turns Instructions: “Walk from here to the next mark (6

m [20 ft]). Begin walking at your normal pace. Keep walking straight; after 3 steps, tip your head up and keep walking straight while looking up. After 3 more steps, tip your head down, keep walking straight while looking down. Continue alternating looking up and down every 3 steps until you have completed 2 repetitions in each direction.”

Pass – Performs head turns with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.


220

221

222

74

75


DYNAMIC BALANCE

Gait pivot & turn Instructions: “Begin with walking at your normal

pace. When I tell you, “turn & stop,” turn as quickly as you can to face the opposite direction and stop.”

Pass – Pivot turns safely within 3 seconds and stops quickly with no loss of balance

Frequent Level of Testing


DYNAMIC BALANCE

Step over obstacle Instructions: “Begin walking at your normal

speed. When you come to the shoe box, step over it, not around it, and keep walking.”

Pass – Is able to step over 2 stacked shoe boxes taped together (22.86 cm [9 in] total height) without changing gait speed; no evidence of imbalance.

Frequent level of testing


DYNAMIC BALANCE

Gait with narrow base of supportInstructions: “Walk on the floor with arms folded

across the chest, feet aligned heel to toe in tandem for a distance of 3.6 m [12 ft]. The number of steps taken, in a straight line, is counted for a maximum of 10 steps.”Pass – Is able to ambulate for 10 steps heel to toe with

not staggering.

Continuous level of testing

223

224

225

75

76


DYNAMIC BALANCE

Gait with eyes closedInstructions: “Walk at your normal speed from

here to the next mark (6 m [20 ft]) with your eyes closed.”Pass – Walks 6 m (20 ft), no assistive devices, good

speed, no evidence of imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. Ambulates 6 m (20 ft) in less than 7 seconds.



DYNAMIC BALANCE

Ambulating backwards Instructions: “Walk backwards until I tell

you to stop”. Pass – Walks 6 m (20 ft), no assistive devices,

good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.



DYNAMIC BALANCE DECISION

226

227

228

76

77


DYNAMIC BALANCEDOCUMENTATION

CAN TOLERATE DYNAMIC BALANCE WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits movement pattern, compensatory techniques, loss of balance




DYNAMIC BALANCE

OCCASIONAL MATERIALHANDLINGDetermining Occasional abilities

229

230

231

77

78


OCCASIONAL MATERIAL HANDLING

Could be considered the most important aspect of testing

To test for the client’s ability with lifting, carrying and push/pull in a variety of positions and levels

Obtain a baseline heart rate and pain level prior to material handling testing

KINESIOPHYSICAL APPROACH Mechanical Changes vs. Mechanical Deficits Peak Weight vs. Occasional Weight Lifting- testing for the “MAXIMUM” SAFE abilities

using a 100% kinesiophysical approach!!!!


BEND/JOB SPECIFIC LIFT

Using the top handles Floor to waist level with pivot/turn Mechanical Changes vs. Mechanical Deficits Occasional weight vs. Peak Weight Identify limiting factors Document heart rate Document pain level reported

Bend Lift mechanics Need to take into account

Mechanics of this lift Prior surgery SAFETY YOU WILL ONLY PERFORM THIS LIFT IF THE JOB IS

DESIGNED IN A WAY THAT MAKES THE CLIENT LIFT IN THIS MANNER


BEND/JOB SPECIFIC LIFT

232

233

234

78

79


SQUAT LIFT (FLOOR TO WAIST)

Using the bottom handles Floor to waist level with pivot/turn Mechanical Changes vs. Mechanical Deficits Occasional Weight vs. Peak Weight Identify limiting factors Document heart rate Document pain level reported


SQUAT LIFT


POWER LIFTING (12 INCHES TO WAIST)

Using top handles 12 inches to waist level with pivot/turn Mechanical Changes vs. Mechanical Deficits Occasional Weight vs. Peak Weight Input heart rate Document pain level reported Document limiting factors

235

236

237

79

80


POWER LIFT


SHOULDER LIFTING

Using the Bottom handles Waist level to shoulder level Identify the limiting factors- why the test was terminated Mechanical Changes vs. Mechanical Deficits Occasional Weight vs. Peak Weight Document heart rate and pain level Document the body mechanics used


SHOULDER LIFT

238

239

240

80

81


OVERHEAD LIFTING

May use handles or the bottom of the box Functional lifting: perform from waist level to overhead

level Job lifting: may be floor to overhead or shoulder level to

overhead Mechanical Changes vs. Mechanical Deficits Occasional Weight vs. Peak Weight Document heart rate and pain level Document body mechanics used


OVERHEAD LIFT


OCCASIONAL MATERIAL HANDLING

DOCUMENTATION

One of the most important areas for documentation for all bilateral lifting tasks




241

242

243

81

82


UNILATERAL LIFTING

Testing affected/unaffected or dominant/non-dominant extremity May perform at various levels dependent upon job and

occupation of task Mechanical Changes vs. Mechanical Deficits Occasional weight vs. Peak Weight Pain

Pain rating - Pain location - Pain Behavior Heart Rate Limiting Factors Reliability of Pain Consistency of Effort


BASELINE UNILATERAL LIFT


JOB SPECIFIC UNILATERAL LIFT

244

245

246

82

83


BILATERAL CARRYING Using the bottom handles

Test for function- 50 feet total in distance 25 feet out and 25 feet in return Test for job specific- distance will vary 3-100 feet With pivot/turn, holding bottom Pain

Mechanical Changes vs. Mechanical Deficits Occasional weight vs. Peak Weight Pain



BILATERAL CARRYING


UNILATERAL CARRYING Test bilaterally for 25 feet

Walk a distance of 1 feet to 300 feet- depending on job tasks Unilateral carrying may use dumbbell or simulated tool box

Mechanical Changes vs. Mechanical Deficits Occasional weight vs. Peak Weight Pain


247

248

249

83

84


UNILATERAL CARRYING


PUSHING/PULLING: Dynamically using a resistive sled – measured in Horizontal

Force Pounds (HFP) Functional testing at 25 feet May vary the distance for job specific

Mechanical Changes vs. Mechanical Deficits Observe gait pattern, BUE posture and gripping

Occasional weight vs. Peak Weight Pain Pain rating - Pain location - Pain Behavior Heart Rate

Limiting Factors Reliability of Pain Consistency of Effort


PUSHING/PULLING

250

251

252

84

85


KINESIOPHYSICAL LIFTING SCENARIO


UNRELIABLE PAIN RATING IN LIFTING


INCONSISTENT EFFORT LIFTING – 0 POUNDS

253

254

255

85

86

JOB SIMULATION TESTINGEvaluate and Implement Job Sim


JOB SIMULATED FUNCTIONAL ABILITIES

Testing for a specific activity and body positions in order to perform their job. Look at job description Look at the job demands analysis Ask the client

Is there something that “you” think we could test- this puts some responsibility to the client and gives them some control during the evaluation


JOB SIMULATED FUNCTIONALABILITIES

Description of the job simulated activity Input the title of the job simulated Describe what the task is and what it will

simulate Note the type of equipment used or the

set-up position Document the task with parameters of

duration, repetition, and sets Input what the level “Occasional,

Frequent, or Continuous” that is trying to be achieved

256

257

258

86

87


JOB SIMULATED FUNCTIONALABILITIES

Document the client’s ability to perform this task. Identify the level “Occasional, Frequent,

or Continuous” that they are performing within.

Input post heart rate level and pain rating

Document any observed behavior


EXAMPLES OF JOB SIMULATED TASKS

Unilaterally Carrying Test for distance 5-100 feet

May test with ladder climbing or stair climbing

Static- push/pull Feet static in position Horizontal ADD/ABD push/pull of box to simulate “line

work” a factory worker on an assembly line Simulate height of work station


EXAMPLES OF JOB SIMULATEDTASKS Performing lifting-

Specific heights and distances to the job Carrying:

100 pounds for 5 feet with a pivot/turn Crawling:

On stomach with fire gear on for 50 feet Donning/doffing: fire gear under 1 minute 4 point position: with a 2x4 or using a trowel

in kneeling for a cement finisher

259

260

261

87

88


EXAMPLES OF JOB SIMULATED TASKS

Obstacle course- ambulating over and around objects in the floor- simulate debris or job site

Unilateral carrying while ladder climbingWashing windows/mirrors- simulate

cleaning chores, washing a car, etc.Using a swiss ball/medicine ball rolling in

forward bent position- simulate fire hose roll/unroll

FREQUENT MATERIALHANDLINGDetermining Frequent abilities


FREQUENT MATERIAL HANDLING

Three approaches on the market 50% approach Psychophysical approach Kinesiophysical approach

Exceeds Aerobic Limiting Factor Mechanical Changes Muscle Endurance

Decrease in in-repetition cadence/pace

262

263

264

88

89


FREQUENT MATERIAL HANDLING Lifting

Testing the client’s ability to lift frequently KINESIOPHYSICAL APPROACH For all the lifts will enter in the “peak weight” and the

“frequent weight”These may be the same or slightly differentBefore the first lift note the baseline heart rate and

pain level Identify the body mechanics usedPost each lift- note heart rate, pain level and identify

Borg Rating of Perceived Exertion level CR-20 scale


FREQUENT SQUAT LIFTING (FLOOR TO WAIST)

Performed using the bottom handles of the box from floor to waist level with pivot/turnWeight should be 50-70% of their maximum

abilityInput in the weight performedComment on the body mechanics usedTest weight at 5 repetitions and then increase

weight until max. achievedA minimum of 5 consecutive repetitionsInput heart rate pre/post, pain level, and

Exertion levelIdentify the Limiting Factors


FREQUENT SQUAT LIFTING

265

266

267

89

90


FREQUENT POWER LIFTING (12 INCHES TO WAIST)

Performed from the floor to waist level using the top handles with pivot/turnWeight is 50-70% of the maximum abilityTest weight for 5 reps and then increase

weight A minimum of 5 consecutive repetitionsInput heart rate pre/post, pain level, and

exertion levelIdentify body mechanicsIdentify the limiting factors


FREQUENT POWER LIFTING


FREQUENT SHOULDER LIFTING

Lifting the box from waist level to shoulder level Test 5 reps then increase until peak weight achieved Performing a minimum of 5 repetitions consecutively Performed from the floor to waist level using the top

handles with pivot/turn This weight should be 50-70% of their maximum ability Input heart rate pre/post, pain level, and exertion level Identify the body mechanics used Identify the limiting factors

268

269

270

90

91


FREQUENT SHOULDER LIFTING


FREQUENT TWO HANDED CARRYING

Two handed carrying for 25 feet using the bottom handles Test 5 reps then increase until peak weight is

achieved

Weight should be 50-70% of the maximum ability

A minimum of 5 consecutive repetitionsInput heart rate pre/post, pain level, and

exertion level


FREQUENT BILATERAL CARRYING

271

272

273

91

92


FREQUENT PUSHING/PULLING

Push/pull resistive sled for 25 feetTest 5 reps then increase until peak weight

achievedPerforming a minimum of 5 repetitions

consecutivelyThis weight should be 50-70% of their maximum

ability Input heart rate pre/post, pain level, and

exertion levelIdentify the body mechanics usedIdentify the limiting factors


FREQUENT PUSHING AND PULLING


FREQUENT UNILATERAL LIFTING

Lifting the weight from the level of the box to waist or shoulder levelTest 5 reps then increase until peak weight

achievedPerforming a minimum of 5 repetitions

consecutivelyThis weight should be 50-70% of their maximum

ability Input heart rate pre/post, pain level, and

exertion levelIdentify the body mechanics usedIdentify the limiting factors

274

275

276

92

93

SIT / STAND / CLIMB


STAIR CLIMBING

Can use any stairs you would like Perform 0 – 36 steps = Occasional Perform 37 – 72 steps = Frequent Perform 73 – 108 steps = Continuous A step up and down equals 1 step


STAIRS DECISION CHART

277

278

279

93

94


STAIR CLIMBING DOCUMENTATION

CAN TOLERATE STAIR CLIMBING WITHIN THE FOLLOWING FREQUENCY Avoid, Occasional, Frequent, Continuous

Mechanics Mechanical Changes - Mechanical Deficits speed, movement pattern, speed, compensatory techniques, gait pattern, use of

hand rails, pivot/turn


Rating of Perceived Exertion Heart Rate Limiting Factors Reliability of Pain Consistency of Effort


STAIR CLIMBING


LADDER/OTHER CLIMBING

Document heart rate and pain level prior to testing

Test 4 rungs for 1 repetition

Occasional 1-5 repetitions, Frequent 6-15 reps, Continuous 16-25 reps.

Avoid if unable or safety concerns.Input heart rate, pain level, and Borg-

exertion scale post testing

280

281

282

94

95


LADDER/OTHER DECISION CHART


LADDER/OTHER DOCUMENTATION CAN TOLERATE LADDER CLIMBING WITHIN THE


Mechanics Mechanical Changes - Mechanical Deficits speed, movement pattern, speed, compensatory techniques, gait pattern,

pivot/turn


Rating of Perceived Exertion Heart Rate Limiting Factors Reliability of Pain Consistency of Effort


LADDER CLIMBING

283

284

285

95

96


JOB SPECIFIC WORK COMP SITTING AND

STANDING

Workers’ Compensation based FCE’s would like your sitting and standing to be documented based on occasional, frequent or constant.

This is figured first based on what percentage of your test did the person sit versus stand total as compared to the length of the FCE

It can also be based on 1-20 minutes of non stop standing is occasional, 21 to 40 minutes is frequent and 41 to 60 minutes is constant


JOB SPECIFIC WORK COMP SITTING AND

STANDING


DISABILITY BASED SITTING

Questions to obtain Sitting abilities In a 24 hour period, how many hours are you lying down or

sleeping

How long did it take to drive to this evaluation How long were you sitting prior to this evaluation? How many more hours will you be sitting today? How long did the client sit during the FCE?

What is the most you could now sit during the course of a day? What was the longest the client sat at one time during this

evaluation How long can the client tolerate sitting at one time?

286

287

288

96

97


DISABILITY BASED STANDING

Questions to obtain Standing abilities How many hours are left today

Need to add up the sleeping or lying down with the clients demonstrated and reported sitting ability today.

Take this number form 24 hours and you will have then number of hours left in the day in which the clients self report and demonstration of standing should be close to.

How long did the client stand prior to the evaluation? How long did the client stand during the FCE? How many more hours will the client stand after the test

What was the longest duration the client stood at one time? How many hours does the client stand within a 24 hour

period? How many hours can the client stand at one time?


DISABILITY SITTING AND STANDING

POST TEST ACTIVITIESFCE completion

FCE report writing

289

290

291

97

98


FCE COMPLETION

What information do you provide the client Work comp Disability

How comfortable are you telling them results


FCE REPORT WRITING

Dictation Template Commercially based software


FCE REPORT WRITING

Documentation Percent of the job the client is able to do Overall physical demand level Consistency of Effort Reliability of Pain

Pain Behaviors Limiting Factors Return to work recommendations Rehab recommendations Individual physical demand level abilities of client

Compare to physical demand levels of the job Fluff and buff the rest of your documentation

292

293

294

98

99

FCE AND LEGAL PROCEEDINGSBeing deposed

Deposition preparation

Testifying as an expert witness


BEING DEPOSED

What happens Is it scary What do they want to know Will you have to testify in court


PREPARING FOR YOUR DEPOSITION

Gather evidence based research for each testing methodology you use

Gather reliability and validity research on FCE system you use

Hopefully your documentation is objective Contact the company you purchased your

commercially based system from and they better become your best friend.

295

296

297

99

100


EXPERT WITNESS

No matter what side you are on you are considered an expert

You were referred this patient because you are an expert in this field

FCE CERTIFICATIONBecoming a Certified Functional Capacity Evaluator TM


CERTIFIED FUNCTIONAL CAPACITYEVALUATOR

Perform 15 FCE’s Request Application packet Submit the 15 FCE’s OccuPro requests 5 of those FCE’s to be reviewed

by 3 CFCE’s Or participate in the Advanced FCE course

298

299

300

100

101


CERTIFICATION

Is it necessary? Marketing What does it take

MARKETINGMarketing your program

Increasing referrals


MARKETING

Brochures? Dr luncheons? Full industrial Rehab program Specialist in the treatment of the injured worker Functional Progress Notes TM

301

302

303

101

102

FCE PRACTICUMPerform a full FCE using case studies

FCE PRESENTATIONSPresent your FCE findings


304

305

306

102

Functional Capacity Evaluation Consent


We would like to thank you for choosing us for your functional capacity evaluation. Your Doctor has requested your participation in this evaluation but you should be aware that this is a voluntary evaluation and we need your permission to perform it. Functional Capacity Evaluation (FCE): This is a comprehensive evaluation designed to determine your tolerance and physical abilities to perform your required job demands or to test your overall functional abilities at this time. You have the right to stop any test during this evaluation however the medical tester will be looking for your maximum effort during testing.

This evaluation requires your maximum effort during all tasks in order to determine accurate recommendations to your physician and or employer.

o There are tests that tell us if you are giving your best effort during testing. This effort is determined by the testing procedures and the objective data gathered and in no way is based on an opinion of your evaluator

This evaluation may take 3-4 hours in order to complete in the entirety. It is possible for your pain to increase during this evaluation

Some pain may be normal when you perform activities but this does not necessarily mean you have been injured.

During testing we will be using a functionally based pain scale. This is being used to specifically determine how your pain effects you from performing functionally in a competitive work environment

You must determine how much pain increase is acceptable for you. The evaluator will be monitoring your pain throughout this test.

We do not expect you to perform activities that increases your pain to a level that you feel is unsafe

There will be testing procedures that help to determine if the pain reports you provide can be considered reliable pain reports

The therapist will send the report to your doctor, case manager, employer, and insurance adjustor. This evaluation will be conducted in several stages: 1. The first is obtaining a brief history of your injury/illness, conducting a musculoskeletal

evaluation, and discussing your job duties. 2. The second will consist of demonstrating positional abilities such as: squatting, bending,

kneeling, walking, reaching, stair/ladder climbing, and balancing tasks. 3. Next will consist of lifting, carrying, and push/pull. This section will be focused on your

maximum ability to perform occasional and frequent abilities. 4. The last aspect may be performing a job simulated task that is appropriate.

At the end of the evaluation, the therapist will discuss the results with you. If at any time during the evaluation if you have any questions/concerns please let us know.

I hereby have read, reviewed, and am willing to participate in this Functional Capacity Evaluation

Patient Signature Date

103


Functional Job Demands Form Patient Use Only Please complete all of the following information. We pride ourselves in offering the best care possible and this information is extremely important in providing you with the best possible care.

Name: Referring Dr.: Phone Number: Date of Injury: DOB: Employer: Diagnosis: Employer Contact: Job Title: Employer #: Work activities that are a problem? What percentage of your day is spent performing the following tasks:

Task Frequency: 0% Nothing

1-33% Occasional

34-66% Frequent

67-100% Continuous

Standing Sitting Lift 20 to 50lbs. Lift 50+ lbs. Carry 20 to 50lbs. Carry 50+ lbs. Push/Pull Bend/Squat/Kneel Grasping/Pinching Below Shoulder Reaching Above Shoulder Reaching Balance Climbing

THERAPIST USE ONLY

Present Work Status: (circle two) Part Time Full Time Regular Duty Modified/Light Duty Off of Work? Y N Why: Surgery? Y N JDA needed?(presently) Y N Ergo consult needed? Y N FCE needed?(end of treatment) Y N Work Hardening needed? Y N FPN needed?(during treatment) Y N FDS needed?(at end of treatment) Y N Does this job require balancing? Y N Therapist Name:

Clinic (Please Circle): Comments:

104

CODE DESCRIPTION CODE DESCRIPTION

97750 Functional Capacity Evaluation 97537

97750 Functional Progress Note 97537 Ergonomic Consultation

97750 Functional Discharge Summary WORK REINTEGRATION TRAINING:

TRAVEL TIME:

97750

WH/WC Functional Progress Note 99056

97750

WH/WC Functional Discharge Summary

99050

97001 PT EVALUATION 99052

97003 OT EVALUATION 99054

For walk in work hardening evals

97002 PT RE-EVAL PHONE CONSULTATION:

97750

WORK HARDENING:

JDA/ERGONOMIC CONSULTATION:

STATE:

Industrial Rehabilitation Service Provided

Services between 7:00 PM - 10:00 PM.

Services between 10:00PM - 8:00 AM.

Services on Sundays and Holidays.

Work Hardening/Conditioning Evaluation

PATIENT NAME: TIME:

Job Demands Analysis

Services provided in a location other than a physicians office. (Non-timed)

DATE:

EMPLOYER:

FCE, FPN, FDS:

Direct one on one contact by provider for training in daily activities / work environment modification, task analysis.

OccuPro Industrial Rehabilitation Charge Ticketlit

atio

n C

harg

e T

icke

t

DIAGNOSIS:

THERAPIST:

CLINIC:

97002 PT RE EVAL PHONE CONSULTATION:

97004 OT RE-EVAL 9937197750 15 Min. TEST/MEASUREMENT

For patients already in your clinic

97545 2 hr. WORK HARDENING

97546 1 hr. ADDITIONAL HOURS 99372

97110 15 Min. THER EXERCISE(Strength, End., ROM, Flex)

97112 15 Min. THER EXERCISE(posture, balance, pnf, coordin., kin, sense, prop)

99373

97530 15 Min. THER ACT/ FUNC/ PERF(Dynamic act., Funct. Performance)

97124 15 Min. MASSAGE

97116 15 Min. GAIT TRN/CLIM CASE CONFERENCE:

97535 15 Min. ADL/SELF CARE/ADAPTIVE EQ. 99361

97032 15 Min. TENS/INFERENTIAL 99363

97033 15 Min. IONTOPHORESIS

97034 15 Min. CONTRAST BATH97035 15 Min. ULTRASOUND

97035 15 Min. PHONOPHORESIS

97010 HOT/COLD PACK Service:

97022 WHIRLPOOL Company

97012 MECHANICAL TRACTION Address

95831 MAN. MUSC. TEST Amount to be billed:


Phone call to patient or physician for coordination of medical care. Simple, brief for purpose of clarifying previous instruction, adjusting therapy plan, or report results of a test.

Intermediate phone call to provide advise to an established patient, coordinate care of a new condition that may arise, initiate a new plan of care, or discuss new information.

BRIEF

INTERMEDIATE

Medical conference with a physician for the purpose of coordinating the activities and care of patient.

Complex call for lengthy consultation, discussion with distraught patient / family member, coordination of complex services with several health care providers working on same patient.

COMPREHENSIVE

30 MINUTES

60 MINUTES

ON-SITE OR INVOICE BILLING

Occ

uPro

Ind

ustr

ial R

ehab

il

105

CURRENT CONCEPTS IN FUNCTIONAL CAPACITY EVALUATION: A Best Practices Guideline

(Adopted April 30, 2018)

Steve Allison, P.T., DPT, MHS; Jill Galper, PT, MEd.; David Hoyle, PT, DPT, MA; Jim Mecham, OTR/L, MS

Intent and Scope

The primary intent of this document is to provide guidelines for the proper design, administration, and interpretation of Functional Capacity Evaluations (FCEs), and to recommend qualification standards for Functional Capacity Examiners (Examiner) in order to promote clinical excellence, accountability, and consistency. This document is not meant to be part of the Clinical Practice Guidelines of the Orthopaedic Section of the American Physical Therapy Association, part of the Occupational Therapy Practice Framework: Domain & Process of the American Occupational Therapy Association, or meet specific criteria to be included in the National Guideline Clearinghouse. This document is meant to serve as a primary resource for clinicians who perform FCEs, and for consumers of FCEs including physicians, adjusters, case managers, vocational rehabilitation counselors, and attorneys practicing in workers compensation and disability management. The recommendations contained in this document were developed by a panel with expertise in the design, administration, and interpretation of Functional Capacity Evaluations. The expert panel relied on available literature and clinical experience to arrive at these guidelines. The guidelines were reviewed by stakeholders including physical therapists, occupational therapists, and physicians who either have expertise in FCEs as researchers or examiners or who use the results of FCEs in the administration of workers’ compensation or disability claims. The reviewers’ comments were considered and incorporated into the guideline as deemed appropriate by the expert panel. Readers of this document should understand that the reviewers’ participation in the development of this document does not constitute their endorsement of the final product. The guideline is provided as current best practice as opposed to standards of practice. An Examiner may deviate from these FCE guidelines when necessary and appropriate in the course of using independent and judicious clinical reasoning in an effort to provide the best information possible as to the functional abilities and limitations of the individual being evaluated in light of the questions posed by the referral source(s). This document is intended to be used in conjunction with the most current versions of the APTA Standards of Practice for Physical Therapy1, the APTA Guide to Physical Therapist Practice, the AOTA Occupational Therapy Practice Framework: Domain & Process2, and the International Classification of Functioning, Disability and Health3. Examiners should have a full understanding of potential limitations of FCEs which include but are not limited to issues related to validity and reliability (test selection and individual

136

performance), the influence of an individual’s behavior and symptoms on overall test results, Examiner bias, and standardization of testing and reporting. A Glossary of terms commonly used in FCEs has been developed as part of the guideline. Please refer to the Glossary for definitions of the terms used in this document.

Introduction A Functional Capacity Evaluation (FCE) is a comprehensive performance-based medical assessment of an individual’s physical and/or cognitive abilities to safely participate in work and other major life activities.2-5 The four major components of an FCE include4-7: 1. Intake interview 2. Medical records review 3. Physical examination 4. Content valid functional testing. An FCE attempts to identify an individual’s ability to safely participate in work and other major life activities. In instances where an individual has an illness, medical condition, or disorder that impairs his/her ability to safely participate in work or other major life activities, functional limitations may be present. Residual functional capacity represents what an individual can still do despite functional limitations resulting from a medically determinable impairment(s) and impairment-related symptoms. In determining an individual’s residual functional capacity, Functional Capacity Examiners should rely on objective clinical measurements and observations during content valid functional testing in combination with objective evidence gathered from a physical examination and a review of medical records. Functional Capacity Examiners should also consider subjective evidence from the individual’s self-reported pain and disability reports, which may include standardized questionnaires as well as subjective information provided by the individual through an interview as part of the FCE.8 Historically, return-to-work decisions were based upon diagnoses and prognoses of physicians, but did not include objective measurements of an individual’s functional abilities. Most physicians are not trained to assess the full array of human functional abilities required for comprehensive disability determinations9 or return to work recommendations. The physician or treating provider determines diagnosis and medical prognosis, but should rely on functional testing to more objectively identify an individual’s functional abilities and limitations rather than their use of estimates, commonly called restrictions.10 In an evidence-based medical model, measurements are preferable to estimates.4,11 Medically determinable impairments combined with the results from content valid functional testing administered by qualified Functional Capacity Examiners form the basis for establishing the severity of functional limitations and functional impairments.12,13

137

FCE Utilization FCEs are routinely utilized in cases involving workers’ compensation, personal injury, long term disability, and Social Security Disability claims to determine an individual’s ability to safely participate in work and other major life activities. FCEs are commonly requested by physicians, attorneys, insurance claims adjusters, medical case managers, employers, and vocational rehab counselors. Individuals with self-reported activity limitations may also request an FCE to provide objective documentation of their ability to safely participate in work and other major life activities. Frequent indications for an FCE include, but are not limited to, the following: 1. Functional testing performed as part of the work rehabilitation process such as safe entrance

into an advanced work rehabilitation program. This may involve the Examiner selecting the most relevant tests for gap analysis between the individual’s safe abilities and the job demands. The results are used for program development, to assess progress during the episode of care and as the basis for work recommendations and accommodations, if appropriate.

2. The individual has been participating in ongoing treatment and performance measures used during treatment may be used in combination with further testing to reach conclusions about the individual’s ability to safely participate in work and other life activities during their recovery.

3. The individual has reached maximum rehabilitation potential. Current physical and/or cognitive abilities are requested to assist with claim closure.

4. The individual is working, but difficulty performing job tasks has been reported or observed. A job specific FCE should clearly identify whether there are gaps between safe functional abilities and job demands.

5. Healthcare provider’s report that there is a discrepancy between the individual’s subjective complaints and objective findings, and the FCE is requested to identify the individual’s level of participation, consistency, and behaviors during the evaluation.

6. Physical and/or cognitive abilities data are needed for case management, disability determination, determination of loss of earning capacity, litigation settlement, or case resolution.

7. Physical and/or cognitive abilities are needed to help with a job-placement decision.

8. Physical and/or cognitive abilities are needed to assist with future rehabilitation or vocational planning.

138

The FCE Guidelines are intended for use by: 1. Examiners to properly design, administer, interpret and report FCEs.

2. Referral sources to facilitate appropriate request for type of FCE needed and to integrate the

findings into case management.

3. Claims representatives from insurance companies, managed care organizations, and claims review organizations that request, authorize, review, and provide payment for FCEs.

4. State & Federal Workers’ Compensation regulatory agencies that request, authorize, review, provide payment, and to set reimbursement and regulations for FCEs.

5. Social Security Disability Administration as a resource document.

6. Employers, employees, organized labor, educators, students, researchers, and others as a resource document.

7. The individual being evaluated.

Functional Capacity Examiner In this document, a Functional Capacity Examiner (Examiner) is a physical therapist or occupational therapist licensed in the jurisdiction in which the services are performed, who is able to demonstrate evidence of education, training, and competencies specific to the design, administration, and interpretation of FCEs. Functional Capacity Examiners should utilize the best available evidence from clinically relevant research when designing and performing FCE protocols and when forming conclusions about an individual’s ability to safely participate in work and other major life activities.14-16 Functional Capacity Examiners should use a client centered approach in which the examiner gathers information to understand what is currently important to the individual and to identify past work experiences that may assist in the understanding of the current issues2. Functional Capacity Examiners should be able to demonstrate a post-professional level of knowledge and clinical expertise across a broad spectrum of medical, vocational, psychological, cognitive, and functional testing concepts. At a minimum, Functional Capacity Examiners should be able to demonstrate adequate knowledge and skills in the following areas17-22: 1. Examination (includes history, systems review and tests and measures)

a. Understanding of anatomy and physiology, and knowledge to choose the appropriate clinical examination test and measures to assess the involved area. This includes knowledge of1

i. Cardiovascular/pulmonary system, including understanding and application of exercise and work physiology principles

ii. Musculoskeletal system iii. Neuromuscular system

139

iv. Psychosocial principles v. Body mechanics and work behaviors

vi. Integumentary system.

2. Design and administration of FCEs, and interpretation of test results a. Proficiency with the FCE test process being used, and understand the process’

underlying safety, reliability, validity and practicality.23 b. Employ clearly defined test endpoints during testing that include physiological,

biomechanical, and psychophysical factors.24-29 c. The Examiner should be aware of his/her own fear-avoidant beliefs and biases as

there is evidence suggesting that these beliefs can impact an individual’s test results.30

3. Physical Demands of work a. Knowledge of physical work demands, activity frequency, repetitive movements and

sustained postures. b. Able to utilize information contained in a job analysis to design and test an

individual’s functional performance of a specific job. c. Understand essential versus marginal job functions. d. Understand activity analysis which “addresses the physical demands of an activity,

the range of skills involved in its performance, and the various cultural meanings that might be ascribed to it”31

4. Ability to evaluate an individual’s performance and participation with an understanding that “a focus on the whole is considered stronger than a focus on isolated aspects of human function2”

a. Consider the physiological, biomechanical and behavioral indicators of effort demonstrated during testing.

b. Ability to assess movement and performance consistency. c. Awareness of the facilitators and barriers that may impact the individual that includes

individual and work-related factors, such as organizational and environmental considerations.

d. Understand pain neuroscience theory.

5. Communication and coordination a. Ability to establish rapport with the individual during the FCE process. b. Able to write an FCE report that addresses the referral source’s questions and clearly

identifies the individual’s functional abilities and limitations. The report is discussed in detail in the Reporting section.

6. Laws and regulations relevant to FCE administration and use including a. Worker’s Compensation laws and regulations within the jurisdiction in which the

injury occurred and/or evaluation is completed b. Social Security Disability Administration criteria8 c. Americans with Disabilities Act and Americans with Disability Amendment Act32,33 d. Code of Uniform Guidelines for Employment Selection34 e. Health Insurance Portability and Accountability Act (HIPPA)35 f. Regulations regarding expert testimony-Federal Rules of Evidence-Daubert Standard

and Frye.36-38

140

Referral, Medical Records, Safety Considerations and Consent 1. Referral for an FCE

a. The referral source should clearly communicate the purpose of the FCE and specify any particular issues the examiner should address.

b. If a job-specific FCE has been requested, the examiner needs detailed information regarding the physical requirements of the essential and marginal duties. This can be obtained from review of a job description or job analysis. In the absence of adequate information an on-site job analysis is recommended prior to the FCE to identify this information. In cases where on-site analysis cannot be performed, the Functional Capacity Examiner may rely on occupational information from O*Net39 and the Dictionary of Occupational Titles40. These sources provide general information and may reflect a range of job demands that might not accurately reflect a specific job position. While the individual being evaluated can provide information about his job duties and requirements, this information should be confirmed with the employer. The Functional Capacity Examiner should document the source of the physical job demands in the FCE report.

c. If treatment recommendations are desired, this should be stated in the FCE referral.

2. Medical Records that provide background regarding the individual’s mechanism of injury or illness and subsequent treatment can provide helpful information to the Examiner. Records may include operative notes, recent diagnostic test reports, physician records, and occupational and physical therapy records.

3. Considerations for the Individual Being Tested a. The individual should be medically stable, or the FCE test protocol should be

administered within the safe confines of the individual’s health condition. During the FCE, the Examiner is responsible for ensuring the individual’s safety.

b. The individual must consent to participate in the FCE. A written informed consent specifically outlining the nature of the FCE is recommended. The consent should inform the individual of potential risks including but not limited to a temporary increase in symptoms, musculoskeletal soreness for several days, a temporary exacerbation of the current condition, re-injury of the affected body part, or an additional injury. The Examiner is responsible for ensuring that the individual fully understands the information presented, has an opportunity to ask questions, and all questions are answered in a manner the individual considers satisfactory.41

c. The Examiner should stay abreast of current evidence-based practice guidelines to ensure safe administration of functional tests. Common reasons not to conduct an FCE or to cease testing include but are not limited to:

i. Performance of the test would compromise the individual’s safety or medical condition6,42-45. As used herein, safety refers to preventing a new injury or adversely affecting an individual’s current condition. A transient increase in soreness or pain symptoms is not considered to be unsafe.46

ii. Communication barriers preclude understanding test instructions, communicating concerns, or interpreting the individual’s responses during the FCE.

iii. Individual does not provide consent to participate in the FCE.

141

iv. Caution should be used in testing during pregnancy as it may be difficult to differentiate functional impairment due to pregnancy from other more permanent conditions.47-49

Design

Functional Capacity Examiners should design and/or utilize established functional tests that meet the following criteria7,23. 1. Safety. The tests should not be expected to lead to injury. 2. Reliability. The measures from the tests should produce consistent results. 3. Validity. The tests measure what they were intended to measure. 4. Practicality. The time and cost involved in the design, administration, interpretation and

reporting of tests should be reasonable. 5. Utility. The results outlined in the FCE report should be comprehensible to non-medical

readers and the results should provide useful information. In addition, Functional Capacity Examiners should consider the following factors in the design and/or selection of functional tests50: 1. Is the test or measure supported in the literature with regards to:

a. Reliability i. Device

ii. Inter-rater iii. Intra-rater iv. Inter-session

b. Validity i. Face

ii. Content iii. Predictive iv. Concurrent v. Convergent

vi. Discriminant

2. In instances where a test does not have substantial accepted evidence, or the Examiner does not have access to the equipment/tools to use a test supported by evidence, the Examiner should consider significance of validity including:

a. Face b. Content c. Construct d. Concurrent

There are 2 primary types of FCEs: 1. Job/Occupation Specific FCE

a. The individual’s functional abilities are matched to the physical and/or cognitive demands of a specific job(s) or a specific occupation(s).

b. The individual has usually reached MMI.

142

2. Any Occupation FCE

a. The individual’s functional abilities are not matched to the physical and/or cognitive demands of a specific job(s) or a specific occupation(s).

b. Often used in long term disability claims and Social Security Disability claims, but also in workers’ compensation claims when it is known that the individual will not return to their prior job.

c. The individual has usually reached MMI. The Examiner is ultimately responsible for determining the amount of time necessary to design, administer, and interpret the FCE based on the complexity of the case. Common factors used to determine the amount of time necessary for an FCE include the: 1. Type of FCE needed (job/occupation specific or any occupation). 2. Physical and/or cognitive demands of the job/occupation. 3. Chronicity and severity of the individual’s physical and cognitive impairments. The FCE expert panel recommends an allowance of up to 8 hours for a FCE conducted over a 1 to 2 day period. However, less or additional time may be necessary depending on case complexity. The upper end of the recommended time allowance may be appropriate in the following situations: 1. Individual has chronic physical and/or cognitive impairments. 2. Individual has reached MMI and permanent work restrictions are needed. 3. Referral source requires information about an individual’s ability to safely participate in

work-related activities over multiple days. 4. The individual has reports of chronic fatigue or delayed onset pain. Shorter testing time periods may be appropriate in the following situations: 1. Individual has acute to sub-acute physical and/or cognitive impairments. 2. Individual has not reached MMI and temporary work restrictions are needed for early return

to work. 3. Baseline functional abilities are needed for participation in an advanced work rehabilitation

program. 4. To provide helpful information regarding an individual’s ability to work.51-53

Test Components

1. Referral Review

a. Reason for referral b. Relationship of individual to referral source.

2. Medical Record Review

a. Mechanism of injury b. Individual’s response to treatment to date c. Objective diagnostic tests

143

d. Surgeries e. Other relevant claims/medical history.

3. Informed Consent

a. Include risk for injury, exacerbation of symptoms, or possibility of soreness in response to testing.

b. Include the exam procedures that will help to reduce that risk. c. Discuss release of FCE information d. Describe the FCE testing process e. Address individual’s concerns.

4. Intake Interview

5. Psychosocial Screening and Comprehensive Pain Assessment includes54-59:

a. Use of evidence-based psychosocial/psychometric screens b. Observation of the individual’s pain behavior throughout the FCE examination. c. Measurement of the individual’s physiological responses following acute episodes of

increased pain d. Use of a pain scale with functional descriptors. e. Pain diagram.

6. Systems Review/Physical Examination1 a. Cardiovascular Respiratory b. Integumentary c. Musculoskeletal d. Neuromuscular e. Cognitive.

7. Cardiovascular Respiratory Abilities Testing60-63

8. Material Handling Testing —Ability to exert force to lift, push, pull, or carry objects39,64,65

a. Lifting/Lowering b. Carrying c. Pushing/Pulling d. Grasping/Pinching.

9. Coordination, Flexibility, Postural Abilities Testing- Testing should include sustained and/or

repeated observations of the ability to assume, maintain, and exit positions consistent with work including those defined by the DOL/DOT.

a. Dynamic Flexibility — the ability to quickly and repeatedly bend, stretch, twist, or reach out with your body, arms, and/or legs.

b. Extent Flexibility — the ability to bend, stretch, twist, or reach with the body, arms, and/or legs.

c. Gross Body Equilibrium — the ability to keep or regain your body balance or stay upright when in an unstable position.

d. Fingering and manual dexterity tasks. e. Common physical demand activities as reported by the Dictionary of Occupational

Titles include65,66 i. 1. Sitting

144

ii. 2. Standing iii. 3. Walking iv. 4. Climbing v. 5. Balancing

vi. 6. Stooping vii. 7. Kneeling

viii. 8. Crouching ix. 9. Crawling x. 10. Reaching

xi. 11. Handling xii. 12. Fingering.

10. Cognitive testing may be included dependent on symptoms, diagnosis or referral request and

may include: a. Cognitive factors b. Perceptual/sensory factors c. Communicative factors d. Behavioral factors e. Psycho-emotional factors.

11. Other Work Simulation Testing, as needed

12. Post Test Systems Review

13. Exit Interview and Instructions

Test Administration

Test administration should be sequenced and progressed to optimize the individual’s performance and safety. The Examiner should be aware of the reason for referral prior to commencing the FCE. The Examiner should use the initial intake interview and systems review to establish rapport with the individual and to determine the most appropriate test components to include in order to obtain the information requested. Any test that either does not provide the needed information or might place the individual at foreseeable risk of injury should be forgone. Throughout testing the Examiner should monitor the individual’s physiological, biomechanical, and psychophysical responses to activity. Physiological monitoring includes regular assessment of heart rate for safety reasons and also as an indicator of an individual’s effort level during testing. In cases when the individual’s heart rate and heart rate response may be affected by medication or other factors revealed in the medical history such as a pacemaker, alternative monitoring should be employed. Alternatives may include the use of the Borg Rating of Perceived Exertion Scale67 as well as more reliance on respiratory rate and blood pressure. Other physiological monitoring includes, but is not limited to, cardiac rhythm, blood pressure, respiratory rate, oxygen saturation, perspiration, color, and swelling.

145

Biomechanical monitoring should include, but is not limited to, clinical observations of muscle recruitment, movement patterns, stance, balance, and counterbalancing68-70. The Examiner should monitor an individual’s symptoms during the administration of an FCE for safety and as a component of a comprehensive pain assessment. Pain may be associated with a nociceptive response from injured tissue, an anticipation of a nociceptive response from injured tissue, or an individual’s perception of threat of pain or harm. A fundamental challenge for the Examiner is to consider the degree to which psychosocial factors and symptom reports impact performance during functional testing.71 The Examiner should incorporate a comprehensive pain assessment which includes psychosocial screening, pain behavior assessment, and physiological assessment in the administration of a FCE because research demonstrates that psychosocial factors influence performance.72-75 Psychosocial factors that influence performance include but are not limited to: 1. Perceived disability 2. Kinesiophobia/Fear Avoidance Beliefs 3. Catastrophizing 4. Anxiousness/Distress/Depressed Mood 5. Self-efficacy 6. Perceived Injustice. If information is requested about a client’s cognitive abilities, cognitive functional testing may be appropriate. Cognitive Functional Evaluations require specialized training above and beyond standard physical based Functional Capacity Evaluations. For more information on Cognitive Functional Evaluations please reference the Emerging Trends in Functional Capacity Evaluation Section. Test Component Administration: 1. Referral Review

The reason for referral is a key element in preparing for and designing an FCE to provide maximum utility for the referral source.

2. Medical Records Review Medical records may provide information regarding the individual’s medical history, extent of the injury, the treatment provided and the individual’s response, and condition stability. The individual’s medical history may include conditions directly related to or unrelated to the injury or illness that precipitated the referral, which should be considered by the examiner to ensure the individual’s ability to safely participate in an FCE. Examples may include heavy lifting or extreme postures in the presence of mal-union or frank joint instability or unstable cardiovascular disease.

3. Informed Consent Informed consent should be reviewed with the individual verbally and in writing and should include the purpose, risks, and benefits of testing.

4. Intake Interview An interview which includes questions about current, recent, and past levels of pain and function provides insight into the nature, severity, and irritability of the individual’s

146

condition. Information from the intake interview can be used to develop the sequencing and rate of progression of test components, and helps the examiner target specific response to monitor.

5. Psychosocial Screening and Comprehensive Pain Assessment As part of the comprehensive pain assessment the Examiner should incorporate evidence based psychometric/psychosocial questionnaires to determine how psychosocial factors influence pain reports and functional performance. The psychosocial/psychometric questionnaires used within the comprehensive pain assessment should not be used in isolation to make final conclusions in regards to the overall assessment of the individual’s pain response. Some useful questionnaires are listed below: 76-89

i. McGill Pain questionnaire ii. Dallas Pain questionnaire

iii. Orebro Musculoskeletal Pain Screening questionnaire iv. Oswestry Back Disability questionnaire v. Neck Disability questionnaire

vi. Quick DASH questionnaire vii. Lower Limb Outcomes questionnaire

viii. Pain Disability Questionnaire ix. Pain Disability Index x. Perceived Injustice Questionnaire

xi. Modified Somatic Perception questionnaire xii. Fear Avoidance Belief questionnaire

xiii. Tampa Scale of Kinesiophobia xiv. Functional Self Efficacy Scale xv. PHQ-9

xvi. WHODAS 2.0

As part of a comprehensive pain assessment, the Examiner should monitor physiological responses associated with an acute increase in pain.90,91 The Examiner should be aware of research that reports that physiological responses may be due to an increased pain stimulus or the anticipation of the pain stimulus. The Examiner should also be aware that physiological response changes can be associated with increased physical exertion during the FCE. Whether the acute physiological responses are due to exertion, anticipation of pain, or an increased pain stimulus, the evidence is clear that during an FCE there should be physiological response changes.92 When an individual reports an acute increase in pain during the FCE, the physiological responses monitored could include: 1. Increased heart rate 2. Increased blood pressure 3. Increased breathing rate 4. Diaphoresis 5. Pupil dilatation.

During testing, the Examiner should monitor pain behaviors and reported symptoms, and consider the correlation between the observed behaviors, symptom reports and clinical examination findings. Pain behaviors can include but are not limited to54-59,93,94: 1. Facial expressions: Frowning, grimacing, distorted expression, or rapid blinking. 2. Verbalizations/vocalizations: Sighing, moaning, calling out, or asking for help.

147

3. Body movements: Rigid, tense, guarding, fidgeting, increased pacing/rocking, biomechanical changes/compensations/substitution patterns and other mobility changes such as inactivity or motor restlessness.

4. Changes in interpersonal interactions: Aggressive, resistive, disruptive, or withdrawn. 5. Changes in activity patterns: Sudden cessation of common routines. 6. Mental status change: Crying, increased confusion, irritability, or distress.

The Examiner may consider utilizing a pain scale with functional descriptors (functional pain scale) during the comprehensive pain behavior assessment to provide further evidence in forming an opinion about how the individual’s pain affected observed function during testing.95-97 No single tool can be used to classify an individual’s pain report as an accurate representation of pain that affects function or an inaccurate representation of the individuals subjective pain response, and the Examiner should use a battery of the above-mentioned tools throughout the FCE to assist the examiner in determining how pain affects or does not affect the final functional abilities determination. 6. Systems Review/Physical Examination A full systems review should be done in accordance with the current Guide to Physical Therapist Practice 1 and/or the Occupational Therapy Practice Framework: Domain and Process2. Particular attention should be paid to cardiovascular status including resting heart rate and blood pressure as well as other conditions which might preclude safe testing of specific functions or to levels that may preclude further stressing certain body systems.47 Best evidence resources for exercise testing in general and for specific populations should be consulted when designing FCE protocols and considering specific medical conditions and findings and test development. Examples of organizations providing guidance on exercise testing include, but are not limited to, the American College of Sports Medicine42,98, the American Congress of Obstetricians and Gynecologists, the American Heart Association43, and the Centers for Disease Control.99

When conducting components of a physical examination including, but not limited to, range of motion testing, strength testing, girth measurements, temperature measurements, and other diagnostic testing, the Examiner should rely on tools and techniques that have demonstrated reliability and sensitivity to change. An example is volumetric measurement of small body parts rather than circumferential measures. Repeated trials and averages may be used in cases where this will increase reliability and sensitivity. Areas of impairment and those likely to change as a result of testing should be prioritized. 7. Aerobic Abilities Testing Aerobic response to work demands is an important factor in determining an individual’s ability to perform sustained work activity. Aerobic testing should be consistent with guidelines developed for safe test administration.42,100 Results of testing should be reported such that they relate to work demands and avoid reporting results that compare to age related normative values.100,101 The preferred method for reporting is in METs which can then be compared to functional activities both vocationally with regards to physical demand level or physical demand category, 100,102 or compared to specific task performance.60,103

148

There are several methods available for aerobic testing, including walking (on or off of a treadmill), stationary bicycle, steps, etc. The individual’s job demands and history are factors to consider when choosing a methodology. Job simulation tasks can also be used to determine an individual’s aerobic tolerance to specific activities and used to substantiate the ability to maintain functions for various intensities, frequencies, and durations. Research has clearly shown a linear relationship between aerobic capacity (oxygen consumption) and heart rate. Therefore, Examiners should use heart rate measurements obtained during functional capacity testing to reliably determine an individual’s physiological endurance for tolerating activities over an 8-hour work day. As noted earlier in the Guideline, Examiners should be aware of any medications or medical conditions that could invalidate the use of heart rate for this purpose. The following formula provides a relatively easy method to estimate an individual’s percent maximum aerobic capacity:62 % Maximum Aerobic Capacity = (Peak HR* – Resting HR)/[220-age] – Resting HR *maximum heart rate during activity. 8. Material Handling Testing The ability to exert maximum muscle force to lift, push, pull, or carry objects are essential functions of most occupations and are considered an essential component of an FCE.40,65 It is recommend that testing follow established protocols that are designed to be progressive and include monitoring of the cardiorespiratory, musculoskeletal, and psychophysical responses to testing.104-106 NIOSH indicates that the size and coupling of the load are key factors for control in addition to the height and weight.64 Therefore it is recommended that testing commence with an object that is approximately 8-20” deep, has handles, and with minimal weight but to which additional weight can be added, such as a crate fabricated or sold for this purpose or an industrial crate. Caution should be used to assure that the container is in good condition and is rated for the maximum load to be tested.

NIOSH indicates that the height and symmetry of the load affects the abilities of individuals when lifting/lowering.64 Therefore, lifting/lowering should be assessed from and to various heights in an effort to replicate work demands. Predetermined end points for physiological, biomechanical, and psychophysical responses should be included in any lifting/lower test protocol to assure the safety of the individual.104,105 Physiological monitoring should include at a minimum heart rate and other variables such as respiratory rate, oxygen saturation, and cardiac rhythm when feasible or required for safe testing. Biomechanical monitoring should include body mechanics including stance and counterbalancing as well as muscle recruitment patterns69,70. This monitoring should be performed visually using predetermined categorical scales designed for the purpose.68-70,106

149

Psychophysical monitoring includes monitoring the individual’s perceived pain, other symptoms, and reported effort. Tools such as a numeric pain rating scale, visual analogue pain scale, rated perceived exertion scale,65 and rated perceived load scales provide an objective measure of the pain or perceived exertion.105 Testing strength, power and endurance for force exertion are needed for most occupations and are generally reported consistent with Dictionary of Occupational Titles (DOT) and Department of Labor (DOL) standards with regards to frequency. The DOT defines Occasional, Frequent, and Constant (see glossary). The DOT further categorizes force exertion related to work demands as Sedentary, Light, Medium, Heavy, and Very Heavy (see glossary).40

a. Lifting/Lowering a. Lifting/Lowering should be tested progressively beginning with weights expected

to be easily managed and in a manner that includes maximum opportunity for control.68,104,105 The vertical lift height should be noted.

b. Carrying a. Carrying should be tested progressively beginning with weights expected to be

easily managed and in a manner that includes maximum opportunity for control. Carrying can be tested unilaterally or bimanually and should be conducted to best provide information needed by the referral source.

c. Pushing/Pulling a. Pushing and Pulling are common vocational demands and can encompass moving

a number of objects including hospital beds and stretchers, pallet jacks, hand trucks, crates, doors, ropes, and wire.

i. The combination of the surface on which an object is pushed, the surface and weight of the object itself and the speed at which the object is being accelerated or decelerated determine the force needed to push or pull the object. In the case of a wheeled object the surface of the wheels and the supporting surface greatly affect the force needed to push or a pull a load of any given mass. The Examiner should use a calibrated force gauge to determine the forces exerted by the individual during testing.

ii. Pushing/Pulling testing should be progressive starting with the need for relatively little force and ending at maximum safe ability or the amount that provides the information needed by the referral source.

iii. Pushing/Pulling should, to the extent possible, be tested at the height and with similar equipment to that used or intended to be used by the individual.

iv. The individual’s ability to generate push/pull force should be reported in pounds of force or ft-pounds, and note the height at which the force was applied.

b. Grasping/Pinching i. The use of the hands for producing force in grasping and pinching are

essential to functioning in most work environments. Assessment of the ability to produce force for grasping and pinching should be measured in accordance with standard protocols.

9. Coordination, Flexibility, Postural Abilities Testing a. Work tasks require the worker to possess dynamic flexibility, extent flexibility, and

gross body equilibrium39 to complete occupational tasks including: Sitting, Standing,

150

Walking, Climbing, Balancing, Stooping, Kneeling, Crouching, Crawling, Reaching, Handling, and Fingering.40 Testing of the individual’s abilities related to flexibility and equilibrium and the ability to assume, maintain, and return from positions and complete handling and fingering tasks should be incorporated in the functional capacity evaluation in an effort to provide the referral source with needed information.

b. Testing should be completed by direct observation and completed in a way to extrapolate abilities consistent with the DOT and DOL definitions of occasional, frequent, and constant40 rather than compared to age related normal values or percentage of the population.

c. Where task performance can be performed unilaterally and the individual’s condition may affect performance of a single extremity, attempts should be made to provide abilities for each extremity independently. For example an individual with a history of a right shoulder injury may not possess the ability for reaching with the right upper extremity but may be able to reach with the left extremity frequently.

10. Other Work Simulation Testing To the extent possible the FCE should incorporate work simulation testing once standardized testing indicates that more specific testing is safe. An example is a worker who needs to lift a keg of beer weighing 160.5 lbs. The examiner should perform progressive lifting near the actual weight of the keg prior to attempting to perform lifting of the actual keg of beer. Another example is an individual whose job requires climbing a utility pole. It is prudent to perform ladder climbing prior to performing pole climbing. Work Simulation testing may need to be performed in the field or equipment borrowed from the employer to adequately test the individual’s abilities.

11. Post Test Systems Review, Exit Interview and Instructions

a. The Examiner should conduct a post test systems review to assure that the testing has not had an unexpected or adverse effect on the body systems. In the event the system review reveals possible changes in the individual’s status, further assessments of the relevant areas should be undertaken and documented by the Examiner.

b. The Exit Interview should assess the subjective response of the individual to the testing procedures including perceived changes in location and intensity of complaints including but not limited to pain. Tingling, numbness, stiffness, weakness, instability, and feelings of swelling or spasm are also changes that the individual may perceive and should be documented.

c. Exit instructions may include the individual’s rights with regards to access to the test results, and a timeframe as to when results might be available, if appropriate. The Examiner should provide instructions to actions that should be taken if the individual has any questions or concerns following testing, including reports of significant symptoms.

Interpretation Examiners should make every attempt to encourage an individual to report accurate levels of pain and other symptoms, and to put forth good effort during the FCE.

151

Examiner interpretation of test data requires triangulation of multiple data sets in order to provide meaningful and useful information to the requestor. The 3 primary areas of consideration include a determination of the individual’s: 1. Performance or Effort level 2. Effect of pain and other symptoms on test performance 3. Residual functional capacity including functional abilities and functional limitations.

1. Performance or Effort Level Examiners must consider the individual’s test participation and effort during the FCE, and make a determination about effort based on the preponderance of data. The determination should be based on the test endpoints (physiological, biomechanical, and psychophysical), the individual’s reported symptoms and associated behaviors, clinical examination findings, movement/performance consistency, and observed signs associated with pain. A variety of functional testing methods have been utilized extensively in functional capacity evaluations to assess what has been reported as an individual’s “sincerity of effort.” Some of these methods include: comparing an individual’s performance from static (isometric) lift strength testing to their performance during incremental dynamic lift testing, five-rung grip testing, rapid exchange grip testing, and using the coefficient of variance statistical measure with static lift testing and grip strength testing. However, the preponderance of evidence does not support the use of the term “sincerity of effort” nor the use of these testing methods alone for classifying an individual’s performance or effort level.107-132 Examiners should understand the proper use and limitations of these testing methods and use caution when applying these methods to make a determination about an individual’s effort during functional testing. It is recommended that Examiners make determinations about effort based on the presence of physiological and biomechanical signs (i.e., heart rate, respiration rate, muscle recruitment, and consistency of movement patterns) in combination with clinical examination findings and symptom reports.

A determination regarding the individual’s effort during the FCE informs the report user the extent to which the data approximates the individual’s ability to safely participate in work and other major life activities. When determining an individual’s effort or performance level, the Examiner should also consider the scoring patterns (performance patterns). A progressive score increase (increase in performance) may suggest a learning effect or improved confidence of the individual, while a progressive score decrease (decrease in performance) may reflect fatigue or an unresolved clinical condition. To more accurately predict an individual’s ability to safely perform work-related activities over an 8-hour period, it is recommended that Examiners utilize the following work physiology guidelines for interpreting the results of heart rate responses used for calculating percent maximum aerobic capacity:62

Duration % Max Aerobic Capacity 8 hours 33 1 hour 50 20 min 70 5 min 85

152

2. Effect of Pain and other Symptoms Pain or the anticipation of pain or other symptoms may influence an individual’s performance during testing. An individual may communicate pain verbally, through facial expressions, body posture and movements133-137. Examiners should consider the extent to which an individual’s reported pain or other symptoms impacted test performance. Significant changes in an individual’s reported pain or other symptoms that occur during or after testing should be correlated with objective changes in physical signs including, but not limited to heart rate, blood pressure, muscle spasm, joint warmth, and/or swelling. Examiners should use caution when interpreting an individual’s pain behaviors and reports since examiner bias and beliefs can impact interpretation136,138. If it is determined that an individual’s pain and other symptoms are consistent with objective medical evidence, and the individual has demonstrated signs associated with significant effort during testing, the Examiner should adjust the final recommendations about an individual’s functional abilities and functional limitations to reflect activity levels to one that is expected to better accommodate their safe work tolerances and be sustainable over time in a productive work environment.

However, if it is determined that an individual’s pain and other symptoms are not consistent with objective medical evidence, and the individual’s test performance showed less than good effort, the Examiner should not rely on the individual’s self-reports of pain or other symptoms as a basis to adjust their functional abilities and functional limitations. 3. Residual Functional Capacity Residual Functional Capacity represents what an individual can still do despite functional limitations resulting from a medically determinable impairment(s) and impairment-related symptoms. Static (isometric) strength tests have been used extensively in some functional capacity evaluations to assess maximum capacity for lifting, pushing, and pulling. Static testing involves exerting a force on an object without motion occurring. Some FCE Examiners have used this information to provide recommendations about an individual’s residual functional capacity. Because most work tasks are dynamic in nature (objects are moved from one point to another) as opposed to static, evaluating an individual’s dynamic ability better simulates the work activity. More recent research indicates that static strength testing does not accurately predict dynamic lifting capacity.139 Potential safety concerns with the use of static lift testing have also been identified.139,140 Therefore, Examiners should avoid the use of static strength tests to determine functional abilities unless a job specific static strength requirement exists. In determining an individual’s residual functional capacity, the Examiner should rely on objective clinical measurements and observations during content valid functional testing in combination with objective evidence gathered from a physical examination and a review of medical records. The Examiner should also consider subjective evidence gathered from multiple sources of self-reported pain and disability questionnaires along with subjective information provided by an individual.

153

In cases where the individual provided appropriate observable signs of effort or predictable compensatory strategies related to diagnosis and physical impairments along with pain behavior, the Functional Capacity Examiner should consider the individual’s subjective reports of pain, other symptoms and limitations when arriving at a final conclusion regarding functional abilities and limitations. For example, if an individual reports an increase in pain or other symptoms in conjunction with a functional activity circuit, the individual’s tolerance with the specific activities that caused the increase in pain or other symptoms should be adjusted to a lower functional level in order to ensure the individual’s activity tolerance on a safe and dependable basis. In cases where an individual consistently performs at a low activity level and has a high symptom-focus, the results reflect the individual’s activity tolerance or minimal functional abilities.

Reporting The FCE report is the product produced by the Examiner. The report should be clearly written and easily understood by nonmedical individuals. The use of abbreviations and jargon should be avoided. The results should be reported using generally accepted terminology as defined in this Guideline and supporting references. Each page should be numbered. If there are intentional blank spaces or pages in the report, it should be noted that this is intentional. The Examiner’s name and specialty should be identified. Often, a summary of findings listing functional abilities, functional limitations and the individual’s performance participation precedes the detailed report data, to facilitate application of the results. The report should contain the following components4, but not necessarily in this order: 1. Introduction: the reason(s) for the FCE/type of FCE performed.

2. Individual’s demographic and background information:

a. Individual’s data: age, sex, height, weight b. Diagnosis c. Occupation, if applicable d. Hand dominance e. Splints, braces or assistive devices worn during the FCE.

3. List and summary of medical records.

4. Summary of information from the individual interview.

5. Summary of results of activities of daily living or psychometric questionnaires with

discussion of the significance of the results.

6. Clinical examination findings. 7. Results of the functional tests including test endpoint reached and physiological,

biomechanical, and psychophysical results.

8. Discussion of individual’s performance level (effort and consistency) and pain behaviors.

9. Summary of functional abilities and limitations

154

a. Identification of accommodations to lessen impact of any functional limitations.

10. If job or occupation specific FCE, compare individual’s abilities with job and/or occupational demands.

11. Recommendations, if appropriate and requested, may include: a. Transitional work recommendations b. Treatment c. If requested, an opinion statement defining the functional limitations as temporary or

permanent i. If temporary, functional re-testing may be done at a later date to reassess safe

work tolerances, functional limitations, and restrictions ii. If permanent, the results of the FCE should be considered applicable for a

range of time up to 6 months. This is dependent on the nature of the injury/illness, and whether any other health condition, injury or other factor changes the individual’s health status or lifestyle. In the absence of any substantive change in the individual’s health status or lifestyle, a repeat FCE to update the individual’s functional status is recommended.

Emerging Trends in Functional Capacity Evaluations

Functional Capacity Evaluations will continue to evolve in response to updates in technology and research. Examiners should stay up to date on trends, legislation, legal precedent, technology and research occurring in the United States and abroad. Functional Capacity Examiners should be aware of current trends which include: 1. Bureau of Labor Statistics Occupational Requirement Survey

a. Beginning in 2012 the Bureau of Labor statistics began working with the Social Security Administration to collect information about the occupational requirements for workers in jobs throughout the United States. The Occupational Requirements Surveys “ORS” goal is to collect and publish occupational information that will be used by the Social Security Administration to help make decisions for their disability program. Examiners should monitor of the progress of the ORS as it may change definitions, classifications and terms associated with physical demands, environmental exposure, education/training and cognitive demands.

2. Cognitive Functional Capacity Evaluation a. Cognitive Functional Capacity Evaluations are a fast growing service line for

Examiners who receive special training in this specialized evaluation. i. Cognitive functional testing may address four essential and unique

components141-147: 1. An analysis of the essential cognitive demands required of an

occupation which include: a. Independent clinical judgment b. Work review and observation c. Work pace and the worker’s ability to control pace d. Changes in tasks, location, and work schedule e. Frequency and nature of work related individual interactions

155

f. Resources pertaining to cognitive demands (i.e. O*NET, Cognitive Abilities Profiler).

2. An ecologically valid measure of the individual’s function and suitability for return to work, with consideration for the individual (intrinsic factors), the environment (extrinsic factors) and the critical cognitive demands of the identified occupation.

3. A valid measure of work-oriented executive functioning, with attention to the individual’s approach to the task (i.e. initiation, execution, organization, planning, problem-solving, and task monitoring) and self (i.e. inhibition, impulse control, self-monitoring).

4. Evaluation of insight/awareness through interview, structured observation, questionnaires and collateral information.

ii. Given issues of complexity, mental stamina/activity tolerance and durability, a range of 6 to 8 hours over 1 to 2 days is recommended when cognitive functional testing is a desired component of the FCE.

iii. If an FCE is requested pertaining to an individual’s cognitive, perceptual-sensory, communicative, behavioral, and psycho-emotional factors, the Functional Capacity Examiner should incorporate standardized assessment of cognitive functioning including but not limited to the following assessments, with test selection determined by contextual factors (i.e. test content, injury severity, etc.):

1. Montreal Cognitive Assessment 2. Mini Mental Status Examination 3. Cognitive Assessment of Minnesota 4. Rivermead Behavioral Memory Test 5. Test of Everyday Attention 6. Multidimensional Task Ability Profiler 7. Rivermead Post-Concussive Symptoms Questionnaire 8. Headache Impact Test 9. Barrow Neurological Fatigue Scale 10. Awareness Questionnaire.

3. Wearable Technology

a. Wearable technology in therapy clinics and associated with ergonomics is advancing. Examiners should monitor the literature and be aware of applications of wearable technology for use in functional testing. Examples of wearable technology include electrogoiniometers, strain gauge sensors, piezoresistive/piezoelectric sensors, accelerometers, and surface EMG.148

4. Use of Population norms a. In cases where an individual self-limits performance throughout the FCE, or performs

erratically, some expert Examiners advocate estimating the individual’s abilities based on all other objective evidence including but not limited to diagnostic imaging from the individual’s medical records, physical examination findings, biomechanical and physiological responses during functional testing, and the use of age-gender based population norms for material handling and other functional activities.54,71,76,149-

160

156

5. Functional Capacity Evaluation Research, Court Precedent and Legislation a. Functional Capacity Evaluation research remains an important component of

providing a customer with a valid and reliable performance based medical evaluation. Their remains and always will be legal precedent disseminated by the court system in regard to Functional Capacity Evaluations. Federal and state legislation associated with FCE’s may change along with modifications in state practice acts, research and legal precedents. Examiners are encouraged to continually monitor research developments, legal precedent disseminated by the court system, and legislation that could alter documentation, testing procedures and a customer’s needs when performing FCE’s.

Authors Steve Allison, PT, DPT, MHS Functional Capacity Experts, LLC Bossier City, LA [email protected] Jill Galper, PT, MEd IMX Medical Management Services Malvern, PA [email protected] David A. Hoyle, PT, DPT, MA Select Medical Storrs, CT [email protected] Jim Mecham, OTR/L, MSIE OccuPro, LLC Kenosha, WI [email protected] Contributing Author Tania L. M. Percy, OT, BA Progressive Rehab, Orion Health Vancouver, BC Reviewers Richard Bunch, PT, PhD ISR Institute, Inc. New Orleans, LA

157

mailto:[email protected]




Deirdre Daley, PT, DPT, MSHPE WorkWell Prevention & Care Duluth, MN Herb Doerr, PT HHD Eagle Solutions Pleasantville, NY Michael Gerg, OTR/L, OTD Harcum College Bryn Mawr, PA Douglas Gross, PT, PhD University of Alberta Edmonton, Canada Kurt Hegmann, MD, MPH Rocky Mountain Center for Occupational and Environmental Health University of Utah Marcos Iglesias, MD Broadspire, a Crawford company Sunrise FL Susan Isernhagen, PT DSI Work Solutions, Inc. Duluth, MN Min Trevor Kyi, OT Functional Outcomes Rehabilitation Services Vancouver, BC Kathryn Mueller, MD, MPH Colorado School of Public Health Denver, CO Michiel Reneman, PT, PhD University of Groningen Groningen, Netherlands References 1. Guide to Physical Therapist Practice 3.0. 2014; http://guidetoptpractice.apta.org/. 2. Association AOT. Occupational therapy practice framework: Domain and process (3rd ed.).

American Journal of Occupational Therapy. 2014;68(Suppl. 1):S1-S48. 3. International Classification of Functioning, Disability and Health (ICF).

http://www.who.int/classifications/icf/en/. Accessed 11/17/17. 4. Genovese E, Galper J. Guide to the Evaluation of Functional Ability. Chicago: AMA Press; 2009.

158

http://guidetoptpractice.apta.org/

http://www.who.int/classifications/icf/en/

5. Gross DP. Are functional capacity evaluations affected by the patient's pain? Curr Pain Headache Rep. 2006;10(2):107-113.

6. Hart DL, Isernhagen SJ, Matheson LN. Guidelines for functional capacity evaluation of people with medical conditions. J Orthop Sports Phys Ther. 1993;18(6):682-686.

7. Matheson L. The Functional Capacity Evaluation. In: Andersson GBJ, Demeter S, Smith G, eds. Disability Evaluation. 2nd ed. Chicago: Mosby 2003.

8. Your residual functional capacity. In: Administration SS, ed. 416.945. 9. Clifton DW, Jr. The functional IME: A linkage of expertise across the disability continuum.

Work. 2006;26(3):281-285. 10. Duddleston DN, Blackston JW, Bouldin MJ, Brown CA. Disability examinations: a look at the

Social Security Disability Income System. The American journal of the medical sciences. 2002;324(4):220-226.

11. AMA Guides to the Evaluation of Work Ability and Return to Work. second ed. Chicago: AMA; 2011.

12. Ratzon NZ, Amit Y, Friedman S, Zamir S, Rand D. Functional capacity evaluation: does it change the determination of the degree of work disability? Disability and health journal. 2015;8(1):80-85.

13. Fore L, Perez Y, Neblett R, Asih S, Mayer TG, Gatchel RJ. Improved functional capacity evaluation performance predicts successful return to work one year after completing a functional restoration rehabilitation program. PM & R : the journal of injury, function, and rehabilitation. 2015;7(4):365-375.

14. McKibbon KA. Evidence-based practice. Bulletin of the Medical Library Association. 1998;86(3):396-401.

15. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ (Clinical research ed). 1996;312(7023):71-72.

16. Bernhardsson S, Larsson ME. Measuring evidence-based practice in physical therapy: translation, adaptation, further development, validation, and reliability test of a questionnaire. Phys Ther. 2013;93(6):819-832.

17. Disability Evaluation Under Social Security https://www.ssa.gov/disability/professionals/bluebook/general-info.htm. Accessed 8/31/17.

18. Titles I and V of the Americans with Disailities Act of 1990 (ADA). https://www.eeoc.gov/laws/statutes/ada.cfm. Accessed 8/31/17.

19. ADA Amendments ACt of 2008 2008; https://www1.eeoc.gov//laws/statutes/adaaa.cfm?renderforprint=1. Accessed 8/31/17.

20. Uniform Guidelines on Employee Selection Procedures. http://www.uniformguidelines.com/. Accessed 8/31/17.

21. Health Information Privacy. https://www.hhs.gov/hipaa/index.html/. Accessed 8/31/17. 22. OSHA. https://www.osha.gov/. Accessed 8/31/17. 23. NIOSH. Work Practices Guide for Manual Lifting. Cincinnati1981. 24. Gross DP, Battie MC. Construct validity of a kinesiophysical functional capacity evaluation

administered within a worker's compensation environment. J Occup Rehabil. 2003;13(4):287-295.

25. Legg SJ, Myles WS. Maximum acceptable repetitive lifting workloads for an 8-hour work-day using psychophysical and subjective rating methods. Ergonomics. 1981;24(12):907-916.

26. Sparto PJ, Parnianpour M, Reinsel TE, Simon S. The effect of fatigue on multijoint kinematics, coordination, and postural stability during a repetitive lifting test. J Orthop Sports Phys Ther. 1997;25(1):3-12.

27. Ayoub MM, Dempsey PG. The psychophysical approach to manual materials handling task design. Ergonomics. 1999;42(1):17-31.

28. Dempsey PG. A critical review of biomechanical, epidemiological, physiological and psychophysical criteria for designing manual materials handling tasks. Ergonomics. 1998;41(1):73-88.

159

https://www.ssa.gov/disability/professionals/bluebook/general-info.htm

https://www.eeoc.gov/laws/statutes/ada.cfm

https://www1.eeoc.gov/laws/statutes/adaaa.cfm?renderforprint=1

http://www.uniformguidelines.com/

https://www.hhs.gov/hipaa/index.html/

https://www.osha.gov/

29. Morgan M, Allison S, Duhon D. Heart rate changes in functional capacity evaluations in a workers' compensation population. Work. 2012;42(20):253-257.

30. Lakke SE, Soer R, Krijnen WP, van der Schans CP, Reneman MF, Geertzen JH. Influence of Physical Therapists' Kinesiophobic Beliefs on Lifting Capacity in Healthy Adults. Phys Ther.95(9):1224-1233.

31. Crepeau E. In: Crepeau E, Cohn E, Boyt Schell B, eds. Willard and Spackman's Occupational Therapy. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2003:189-198.

32. Americans with Disabilities Act. In: Labor UDo, ed1990. 33. Amendment of Americans With Disabilities Act Title III Regulations to Implement ADA

Amendments Act of 2008. In: Justice Do, ed. Vol Section 2 of Public Law 110-325, September 25, 20082016.

34. Uniform Guidelines on Employee Selection Procedure. In: Labor Do, ed. USAugust 25, 1978. 35. Health Insurance Portability And Accountability Act of 1996. In: Congress t, ed. Vol Public Law

104-911996. 36. Daubert v Merrell Dow Pharmaceuticals, Inc, (1993). 37. Dominick BK. Daubert & ADA Decisions: Will Functional Capacity Evaluations Hold Up In

Court? Journal of Forensic Vocational Analysis. 2004;7:119-126. 38. Frye v US, (DC Cir 1923). 39. O*NET OnLine-Physical Abilities.

https://www.onetonline.org/find/descriptor/browse/Abilities/1.A.3/ Accessed 10/24/17. 40. Selected Characteristics of Occupations as Defined in the Revised Dictionary of Occupational

Titles. In: DOL, ed. Vol PB94-116282: National Technical Information Service; 1993. 41. Wear S. Informed consent; patient autonomy and clincian beneficience within healthcare. 2nd ed.

Washington, DC: Georgetown University Press; 1998 42. ACSM's Guidelines for Exercise Testing and Prescription. Tenth ed: Wolters Kluwer; 2016. 43. Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific

statement from the American Heart Association. Circulation. 2013;128(8):873-934. 44. Sharman JE, LaGerche A. Exercise blood pressure: clinical relevance and correct measurement.

Journal of human hypertension. 2015;29(6):351-358. 45. Administration USDoTFMCS. What is the effet on driver certification based on FMCSA

hypertension stages? In:2014. 46. Soer R, van der Schans CP, Geertzen JH, et al. Normative values for a functional capacity

evaluation. Arch Phys Med Rehabil. 2009;90(10):1785-1794. 47. Exercise During Pregnancy-frequently asked questions: FAQ119. The American College of

Obsetricians and Gynecologists. 48. MacDonald LA, Waters TR, Napolitano PG, et al. Clinical guidelines for occupational lifting in

pregnancy: evidence summary and provisional recommendations. American journal of obstetrics and gynecology. 2013;209(2):80-88.

49. Waters TR, MacDonald LA, Hudock SD, Goddard DE. Provisional recommended weight limits for manual lifting during pregnancy. Hum Factors. 2014;56(1):203-214.

50. Portney L, Watkins M. Foundations of clinical research: Applications to practice. Upper Saddle River, NJ: Pearson/Prentice Hall; 2009.

51. Branton EN, Arnold KM, Appelt SR, Hodges MM, Battie MC, Gross DP. A short-form functional capacity evaluation predicts time to recovery but not sustained return-to-work. J Occup Rehabil. 2010;20(3):387-393.

52. Gross DP, Battie MC, Asante A. Development and validation of a short-form functional capacity evaluation for use in claimants with low back disorders. J Occup Rehabil. 2006;16(1):53-62.

53. Gross DP, Battie MC, Asante AK. Evaluation of a short-form functional capacity evaluation: less may be best. J Occup Rehabil. 2007;17(3):422-435.

54. Keefe FJ, Crisson JE, Maltbie A, Bradley L, Gil KM. Illness behavior as a predictor of pain and overt behavior patterns in chronic low back pain patients. Journal of psychosomatic research. 1986;30(5):543-551.

160

https://www.onetonline.org/find/descriptor/browse/Abilities/1.A.3/

55. Keefe FJ, Hill RW. An objective approach to quantifying pain behavior and gait patterns in low back pain patients. Pain. 1985;21(2):153-161.

56. Keefe FJ, Wilkins RH, Cook WA. Direct observation of pain behavior in low back pain patients during physical examination. Pain. 1984;20(1):59-68.

57. Ohlund C, Eek C, Palmbald S, Areskoug B, Nachemson A. Quantified pain drawing in subacute low back pain. Validation in a nonselected outpatient industrial sample. Spine (Phila Pa 1976). 1996;21(9):1021-1030; discussion 1031.

58. Ohlund C, Lindstrom I, Areskoug B, Eek C, Peterson LE, Nachemson A. Pain behavior in industrial subacute low back pain. Part I. Reliability: concurrent and predictive validity of pain behavior assessments. Pain. 1994;58(2):201-209.

59. Dirks JF, Wunder J, Kinsman R, McElhinny J, Jones NF. A Pain Rating Scale and a Pain Behavior Checklist for clinical use: development, norms, and the consistency score. Psychotherapy and psychosomatics. 1993;59(1):41-49.

60. Astrand PO, Rodahl K, Dahl H, Amme S. Textbook of Work Physioloty:-Physiological Bases of Exercise. 4th ed. Champaign: Human Kinetics; 2003.

61. Becker TJ. Functional Capacity Evaluations: The Work Physiology Component for Predicting Full-Time Work. Directions in Rehabilitation Counseling.18:177-186.

62. Becker TJ MJ, Stamper EE. Applications of Work Physiology Science to Capacity Test Prediction of Full-Time Work-Eight Hour Work Day. The Rehabilitation Professional.15(4):45-56.

63. Jiang BC, Smith JL, Ayoub MM. Psychophysical modeling for combined manual materials-handling activities. Ergonomics. 1986;29(10):1173-1190.

64. Konz S. NIOSH lifting guidelines. Am Ind Hyg Assoc J. 1982;43(12):931-933. 65. Dictionary of Occupational Titles. Vol II. Fourth ed: US Department of Labor; 1991. 66. The Revised Handbook for Analyzing Jobs. Washington, DC: US Department of Labor; 1991. 67. Borg G. Borg's Perceived Exertion and Pain Scales. 1998. 68. Isernhagen SJ, Hart DL, Matheson LM. Reliability of independent observer judgments of level of

lift effort in a kinesiophysical Functional Capacity Evaluation. Work. 1999;12(2):145-150. 69. Reneman MF, Fokkens AS, Dijkstra PU, Geertzen JH, Groothoff JW. Testing lifting capacity:

validity of determining effort level by means of observation. Spine. 2005;30(2):E40-46. 70. Trippolini MA, Dijkstra PU, Jansen B, Oesch P, Geertzen JH, Reneman MF. Reliability of

clinician rated physical effort determination during functional capacity evaluation in patients with chronic musculoskeletal pain. J Occup Rehabil. 2014;24(2):361-369.

71. Feuerstein M, Beattie P. Biobehavioral factors affecting pain and disability in low back pain: mechanisms and assessment. Phys Ther. 1995;75(4):267-280.

72. Oesch P, Meyer K, Jansen B, Mowinckel P, Bachmann S, Hagen KB. What is the role of "nonorganic somatic components" in functional capacity evaluations in patients with chronic nonspecific low back pain undergoing fitness for work evaluation? Spine (Phila Pa 1976). 2012;37(4):E243-250.

73. Carriere JS, Thibault P, Adams H, Milioto M, Ditto B, Sullivan MJL. Expectancies mediate the relationship between perceived injustice and return to work following whiplash injury: A 1-year prospective study. Eur J Pain. 2017;21(7):1234-1242.

74. Monden KR, Trost Z, Scott W, Bogart KR, Driver S. The unfairness of it all: Exploring the role of injustice appraisals in rehabilitation outcomes. Rehabil Psychol. 2016;61(1):44-53.

75. Sullivan MJ, Adams H, Horan S, Maher D, Boland D, Gross R. The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. J Occup Rehabil. 2008;18(3):249-261.

76. Fritz JM, George SZ. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002;82(10):973-983.

77. Gatchel RJ, Mayer TG, Theodore BR. The pain disability questionnaire: relationship to one-year functional and psychosocial rehabilitation outcomes. J Occup Rehabil. 2006;16(1):75-94.

161

78. Anagnostis C, Gatchel RJ, Mayer TG. The pain disability questionnaire: a new psychometrically sound measure for chronic musculoskeletal disorders. Spine (Phila Pa 1976). 2004;29(20):2290-2302; discussion 2303.

79. Soer R, Koke AJ, Speijer BL, et al. Reference Values of the Pain Disability Index in Patients With Painful Musculoskeletal and Spinal Disorders: A Cross-national Study. Spine (Phila Pa 1976). 2015;40(9):E545-551.

80. Soer R, Koke AJ, Vroomen PC, et al. Extensive validation of the pain disability index in 3 groups of patients with musculoskeletal pain. Spine (Phila Pa 1976). 2013;38(9):E562-568.

81. Bianchini KJ, Aguerrevere LE, Guise BJ, et al. Accuracy of the Modified Somatic Perception Questionnaire and Pain Disability Index in the detection of malingered pain-related disability in chronic pain. The Clinical neuropsychologist. 2014;28(8):1376-1394.

82. Crighton AH, Wygant DB, Applegate KC, Umlauf RL, Granacher RP. Can brief measures effectively screen for pain and somatic malingering? Examination of the Modified Somatic Perception Questionnaire and Pain Disability Index. Spine J. 2014;14(9):2042-2050.

83. Greve KW, Bianchini KJ, Brewer ST. The assessment of performance and self-report validity in persons claiming pain-related disability. The Clinical neuropsychologist. 2013;27(1):108-137.

84. Crook J, Milner R, Schultz IZ, Stringer B. Determinants of occupational disability following a low back injury: a critical review of the literature. J Occup Rehabil. 2002;12(4):277-295.

85. Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HL, Rosomoff RS. A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs. Pain Med. 2003;4(2):141-181.

86. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Is there a relationship between nonorganic physical findings (Waddell signs) and secondary gain/malingering? Clin J Pain. 2004;20(6):399-408.

87. Giordano PC, Alexandre NM, Rodrigues RC, Coluci MZ. The Pain Disability Questionnaire: a reliability and validity study. Revista latino-americana de enfermagem. 2012;20(1):76-83.

88. Kaplan GM, Wurtele SK, Gillis D. Maximal effort during functional capacity evaluations: an examination of psychological factors. Arch Phys Med Rehabil. 1996;77(2):161-164.

89. Neblett R, Mayer TG, Hartzell MM, Williams MJ, Gatchel RJ. The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance. Pain Pract. 2016;16(4):435-450.

90. Aissaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients. Anesth Analg. 2005;101(5):1470-1476.

91. Coghill RC, Talbot JD, Evans AC, et al. Distributed processing of pain and vibration by the human brain. J Neurosci. 1994;14(7):4095-4108.

92. Moltner A, Holzl R, Strian F. Heart rate changes as an autonomic component of the pain response. Pain. 1990;43(1):81-89.

93. Jensen IB, Bradley LA, Linton SJ. Validation of an observation method of pain assessment in non-chronic back pain. Pain. 1989;39(3):267-274.

94. Prkachin KM, Craig K. Expressing pain: The communication and interpretation of facial pain signals. Journal of Nonverbal Behavior. 1995;19(4):191-205.

95. Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients. Journal of pain and symptom management. 1999;18(6):438-446.

96. Gloth FM, 3rd, Scheve AA, Stober CV, Chow S, Prosser J. The Functional Pain Scale: reliability, validity, and responsiveness in an elderly population. Journal of the American Medical Directors Association. 2001;2(3):110-114.

97. Gross DP, Battie MC, Asante AK. The Patient-Specific Functional Scale: validity in workers' compensation claimants. Arch Phys Med Rehabil. 2008;89(7):1294-1299.

98. American College of Sports Medicine. http://www.acsm.org/. Accessed 10/24/17.

162

http://www.acsm.org/

99. Physical Activity Recommendations for Adults. https://wonder.cdc.gov/wonder/prevguid/p0000391/P0000391.asp#head007000000000000. Accessed 11/17/17.

100. Sartor F, Vernillo G, de Morree HM, et al. Estimation of maximal oxygen uptake via submaximal exercise testing in sports, clinical, and home settings. Sports medicine (Auckland, NZ). 2013;43(9):865-873.

101. Bains K, Kaur B, Mann SK. Measurement of energy cost of selected household and farm activities performed by rural women. Food and nutrition bulletin. 2002;23(3):274-279.

102. Jette M, Sidney K, Blumchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clinical cardiology. 1990;13(8):555-565.

103. Gunn SM, Brooks AG, Withers RT, et al. Determining energy expenditure during some household and garden tasks. Medicine and science in sports and exercise. 2002;34(5):895-902.

104. Mayer TG, Barnes D, Kishino ND, et al. Progressive isoinertial lifting evaluation. I. A standardized protocol and normative database. Spine (Phila Pa 1976). 1988;13(9):993-997.

105. Matheson LN, Mooney V, Grant JE, et al. A test to measure lift capacity of physically impaired adults. Part 1--Development and reliability testing. Spine. 1995;20(19):2119-2129.

106. Morgan MV, Allison S, Duhon D. Heart rate changes in functional capacity evaluations in a workers' compensation population. Work.42(2):253-257.

107. Sindhu BS, Shechtman O, Veazie PJ. Identifying sincerity of effort based on the combined predictive ability of multiple grip strength tests. J Hand Ther. 2012;25(3):308-318; quiz 319.

108. Robinson ME, Geisser ME, Hanson CS, O'Connor PD. Detecting submaximal efforts in grip strength testing with the coefficient of variation. J Occup Rehabil. 1993;3(1):45-50.

109. Wachter NJ, Mentzel M, Hutz R, Gulke J. Reliability of the grip strength coefficient of variation for detecting sincerity in normal and blocked median nerve in healthy adults. Hand Surg Rehabil. 2017;36(2):90-96.

110. Ashford RF, Nagelburg S, Adkins R. Sensitivity of the Jamar Dynamometer in detecting submaximal grip effort. J Hand Surg [Am]. 1996;21(3):402-405.

111. De Smet L, Londers J. Repeated grip strength at one month interval and detection of voluntary submaximal effort. Acta Orthop Belg. 2003;69(2):142-144.

112. Dvir Z. Coefficient of variation in maximal and feigned static and dynamic grip efforts. Am J Phys Med Rehabil. 1999;78(3):216-221.

113. Fairfax AH, Balnave R, Adams RD. Variability of grip strength during isometric contraction. Ergonomics. 1995;38(9):1819-1830.

114. Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain disability exaggeration/malingering and submaximal effort research. Clin J Pain. 1999;15(4):244-274.

115. Goldman S, Cahalan TD, An KN. The injured upper extremity and the JAMAR five-handle position grip test. Am J Phys Med Rehabil. 1991;70(6):306-308.

116. Gutierrez Z, Shechtman O. Effectiveness of the five-handle position grip strength test in detecting sincerity of effort in men and women. Am J Phys Med Rehabil. 2003;82(11):847-855.

117. Hamilton A, Balnave R, Adams R. Grip strength testing reliability. J Hand Ther. 1994;7(3):163-170.

118. Hoffmaster E, Lech R, Niebuhr BR. Consistency of sincere and feigned grip exertions with repeated testing. J Occup Med. 1993;35(8):788-794.

119. Lechner DE, Bradbury SF, Bradley LA. Detecting sincerity of effort: a summary of methods and approaches. Phys Ther. 1998;78(8):867-888.

120. Niebuhr BR, Marion R. Detecting sincerity of effort when measuring grip strength. Am J Phys Med. 1987;66(1):16-24.

121. Niebuhr BR, Marion R. Voluntary control of submaximal grip strength. Am J Phys Med Rehabil. 1990;69(2):96-101.

122. Shechtman O. The coefficient of variation as a measure of sincerity of effort of grip strength, Part II: sensitivity and specificity. J Hand Ther. 2001;14(3):188-194.

163

https://wonder.cdc.gov/wonder/prevguid/p0000391/P0000391.asp#head007000000000000

123. Shechtman O. The coefficient of variation as a measure of sincerity of effort of grip strength, Part I: the statistical principle. J Hand Ther. 2001;14(3):180-187.

124. Shechtman O, Anton SD, Kanasky WF, Jr., Robinson ME. The use of the coefficient of variation in detecting sincerity of effort: a meta-analysis. Work. 2006;26(4):335-341.

125. Shechtman O, Gutierrez Z, Kokendofer E. Analysis of the statistical methods used to detect submaximal effort with the five-rung grip strength test. J Hand Ther. 2005;18(1):10-18.

126. Shechtman O, Taylor C. How do therapists administer the rapid exchange grip test? A survey. J Hand Ther. 2002;15(1):53-61.

127. Shechtman O, Taylor C. The use of the rapid exchange grip test in detecting sincerity of effort, Part II: validity of the test. J Hand Ther. 2000;13(3):203-210.

128. Taylor C, Shechtman O. The use of the rapid exchange grip test in detecting sincerity of effort, Part I: administration of the test. J Hand Ther. 2000;13(3):195-202.

129. Tredgett M, Pimble LJ, Davis TR. The detection of feigned hand weakness using the five position grip strength test. J Hand Surg [Br]. 1999;24(4):426-428.

130. Tredgett MW, Davis TR. Rapid repeat testing of grip strength for detection of faked hand weakness. J Hand Surg [Br]. 2000;25(4):372-375.

131. Westbrook AP, Tredgett MW, Davis TR, Oni JA. The rapid exchange grip strength test and the detection of submaximal grip effort. J Hand Surg [Am]. 2002;27(2):329-333.

132. Townsend R, Schapmire DW, St James J, Feeler L. Isometric strength assessment, Part II: Static testing does not accurately classify validity of effort. Work. 2010;37(4):387-394.

133. Courbalay A, Deroche T, Descarreaux M, Prigent E, O'Shaughnessy J, Amorim MA. Facial Expression Overrides Lumbopelvic Kinematics for Clinical Judgements about Low Back Pain Intensity. Pain Res Manag. 2016;2016:7134825.

134. Prkachin KM, Schultz I, Berkowitz J, Hughes E, Hunt D. Assessing pain behaviour of low-back pain patients in real time: concurrent validity and examiner sensitivity. Behaviour research and therapy. 2002;40(5):595-607.

135. Prkachin KM, Solomon PE. The structure, reliability and validity of pain expression: evidence from patients with shoulder pain. Pain. 2008;139(2):267-274.

136. Schafer G, Prkachin KM, Kaseweter KA, Williams AC. Health care providers' judgments in chronic pain: the influence of gender and trustworthiness. Pain. 2016;157(8):1618-1625.

137. Craig KD, Hyde SA, Patrick CJ. Genuine, suppressed and faked facial behavior during exacerbation of chronic low back pain. Pain. 1991;46(2):161-171.

138. De Ruddere L, Goubert L, Stevens M, de CWAC, Crombez G. Discounting pain in the absence of medical evidence is explained by negative evaluation of the patient. Pain. 2013;154(5):669-676.

139. Feeler L, St James JD, Schapmire DW. Isometric strength assessment, part I: static testing does not accurately predict dynamic lifting capacity. Work. 2010;37(3):301-308.

140. Hansson TH, Bigos SJ, Wortley MK, Spengler DM. The load on the lumbar spine during isometric strength testing. Spine (Phila Pa 1976). 1984;9(7):720-724.

141. Baum CM, Connor LT, Morrison T, Hahn M, Dromerick AW, Edwards DF. Reliability, validity, and clinical utility of the Executive Function Performance Test: a measure of executive function in a sample of people with stroke. Am J Occup Ther. 2008;62(4):446-455.

142. Crosson B, P. BP, Velozo CA, et al. Awareness and compensation in postacute head injury rehabilitation. Journal of Head Trauma Rehabilitation. 1989;4(3):46-54.

143. Chappell I, Higham J, McLean AM. An occupational therapy work skills assessment for individuals with head injury. Canadian journal of occupational therapy. 2003;70(3):163-169.

144. Hartman-Maeir A, Katz N, Baum CM. Cognitive Functional Evaluation (CFE) Process for Individuals with Suspected Cognitive Disabilities. Occupational therapy in health care. 2009;23(1):1-23.

145. Lezak MD. THE PROBLEM OF ASSESSING EXECUTIVE FUNCTIONS. International Journal of Psychology. 1982;17(1-4):281-297.

146. Matheson L. Executive dysfunction, severity of traumatic brain injury, and IQ in workers with disabilities. Work. 2010;36(4):413-422.

164

147. Matheson L, Dodson M, Wolf T. Executive dysfunction and work: Tying it all together. Work SIS Quarterly. 2011;25(1):1-4.

148. Papi E, Koh WS, McGregor AH. Wearable technology for spine movement assessment: A systematic review. Journal of biomechanics. 2017;64:186-197.

149. Pincus T, Vogel S, Burton AK, Santos R, Field AP. Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence. Arthritis and rheumatism. 2006;54(12):3999-4010.

150. Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317-332.

151. Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62(3):363-372.

152. Vlaeyen JW, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain. 2012;153(6):1144-1147.

153. Geisser ME, Robinson ME, Miller QL, Bade SM. Psychosocial factors and functional capacity evaluation among persons with chronic pain. J Occup Rehabil. 2003;13(4):259-276.

154. Smeets RJ, van Geel AC, Kester AD, Knottnerus JA. Physical capacity tasks in chronic low back pain: what is the contributing role of cardiovascular capacity, pain and psychological factors? Disabil Rehabil. 2007;29(7):577-586.

155. Reneman MF, Jorritsma W, Dijkstra SJ, Dijkstra PU. Relationship between kinesiophobia and performance in a functional capacity evaluation. J Occup Rehabil. 2003;13(4):277-285.

156. Reneman MF, Geertzen JH, Groothoff JW, Brouwer S. General and specific self-efficacy reports of patients with chronic low back pain: are they related to performances in a functional capacity evaluation? J Occup Rehabil. 2008;18(2):183-189.

157. Asante AK, Brintnell ES, Gross DP. Functional Self-Efficacy Beliefs Influence Functional Capacity Evaluation. J Occup Rehabil. 2007.

158. Alschuler KN, Theisen-Goodvich ME, Haig AJ, Geisser ME. A comparison of the relationship between depression, perceived disability, and physical performance in persons with chronic pain. Eur J Pain. 2008;12(6):757-764.

159. Lacker JM, Carosella AM, Feuerstein M. Pain expectancies, pain, and functional self-efficacy expectancies as determinants of disability in patients with chronic low back disorders. Journal of consulting and clinical psychology. 1996;64(1):212-220.

160. Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early Identification and Management of Psychological Risk Factors ("Yellow Flags") in Patients With Low Back Pain: A Reappraisal. Phys Ther. 2011;91(5):737-753.

165

Reference Tables

Table 1 Physical Demand Reference Data1,2,3,4 Sedentary (1.5-2.1 METS)

Exerting up to 10 pounds force occasionally or a negligible amount of force frequently. Sitting is required frequently to constantly and the work may involve brief periods of standing or walking occasionally.

Light (2.2-3.5 METS)

Exerting up to 20 pounds of force occasionally, or up to 10 pounds of force frequently, or a negligible amount of force constantly to move objects. Standing or walking are usually required frequently to constantly and the work may involve brief periods of sitting occasionally. In a few occupations, sitting may be required frequently to constantly while operating arm or leg controls. Light work may also be production pace work requiring negligible force.

Medium (3.6-6.3 METS)

Exerting 21-50 pounds of force occasionally, or 11-25 pounds of force frequently, or greater than negligible up to 10 pounds of force constantly to move objects. Standing or walking are usually required frequently to constantly and the work may involve brief periods of sitting occasionally.

Heavy (6.3-7.5 METS)

Exerting 51-100 pounds of force occasionally, or 26 to 50 pounds of force frequently, or 11 to 20 pounds of force constantly to move objects. Standing or walking are usually required frequently to constantly and the work may involve brief periods of sitting occasionally.

Very Heavy (> 7.5 METS)

Exerting in excess of 100 pounds of force occasionally, or in excess of 50 pounds of force frequently, or in excess of 20 pounds of force constantly to move objects. Standing or walking are usually required frequently to constantly and the work may involve brief periods of sitting occasionally.

(N) Not Present Activity or condition does not exist. (O) Occasional Activity or condition exists up to 1/3 of the time; up to 2 ½ hours day; 1-12 repetitions per hour; or 1-100

repetitions per day. (F) Frequent Activity or condition exists more than 1/3 up to 2/3 of the time; more than 2 ½ hours day up to 5 ¼ hours per

day; 13-62 repetitions per hour; or 101-500 repetitions per day. (C) Constant Activity or condition exists more than 2/3 of the time; more than 5 ¼ hours per day; 63 or more repetitions per

hour; or more than 500 repetitions per day. Non-repetitive Activity is performed less than 30 times per hour or less than 240 times per day. Use of keyboard less than 4

hours per day. Sitting Remaining in a seated position. Standing Remaining on one’s feet in an upright position at a workstation without moving about. Walking Moving about on foot. Lifting Raising or lowering an object from one level to another (includes upward pulling). Carrying Transporting an object, usually holding it in the hands or arms or on the shoulder.

Pushing Exerting force upon an object so that the object moves away from the force (includes slapping, striking, kicking, and treadle actions).

Pulling Exerting force upon an object so that the object moves toward the force (includes jerking). CL Climbing Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs or hands

and arms. Body agility is emphasized. BA Balancing Maintaining body equilibrium to prevent falling when walking, standing, crouching, or running on narrow,

slippery, or erratically moving surfaces; or maintaining body equilibrium when performing gymnastic feats. ST Stooping Bending body downward and forward by bending spine at the waist, requiring full use of the lower extremities

and back muscles. KN Kneeling Bending legs at knees to come to rest on knee or knees. CR Crouching Bending body downward and forward by bending legs and spine. CW Crawling Moving about on hands and knees or hands and feet. RE Reaching Extending hand(s) and arm(s) in any direction. HA Handling Seizing, holding, grasping, turning, or otherwise working with hand or hands. Fingers are involved only to the

extent that they are an extension of the hand, such as to turn a switch or shift automobile gears. FI Fingering Picking, pinching, or otherwise working primarily with fingers rather than with the whole hand or arm as in

handling. 1. The Dictionary of Occupational Titles, 4th edition. U.S. Department of Labor. 1991. 2. Selected Characteristics of Occupations Defined in the Revised Dictionary of Occupational Titles. U.S. Department of

Labor. 1993. 3. Skilltran. Job Browser Pro. www.skilltran.com 4. Disability Evaluation. 2nd edition. American Medical Association. Mosby. 2003.

166

http://www.skilltran.com/

Table 2 Physical Demands Reference Data Supplement1 Strength Level

Sedentary Light Medium Heavy Very Heavy Total

% of all Occupations

11% 49.6% 29.6% 9.1% 0.7% 100%

# of all Occupations

1405 6326 3773 1165 92 12761

Physical Demand

O F C O F C O F C O F C O F C O F C

Climbing <1 0 0 7 2 <1 2 4 <1 21 9 0 33 22 1 10 3 4 Total % 1% 10% 7% 31% 56% 17% Balancing <1 0 0 3 <1 <1 8 3 <1 13 5 <1 21 21 2 5 2 <1 Total% 1% 5% 12% 19% 44% 8% Stooping 3 0 0 19 5 <1 36 19 <1 35 35 <1 26 51 2 24 11 <1 Total% 3% 25% 55% 71% 79% 36% Kneeling <1 0 0 31 1 0 18 6 0 20 12 0 22 36 1 11 4 <1 Total% 1% 32% 24% 32% 59% 16% Crouching 2 <1 0 1 2 0 25 10 <1 28 20 <1 23 43 1 16 6 <1 Total% 3% 3% 36% 49% 67% 23% Crawling <1 <1 0 1 <1 0 4 <1 0 6 1 0 18 13 0 3 <1 <1 Total% 2% 2% 5% 7% 31% 5% Reaching 23 63 11 9 78 12 2 89 9 <1 90 9 1 86 12 7 81 11 Total% 97% 99% 100% 100% 99% 99% Handling 22 64 12 8 79 12 2 89 9 <1 90 9 2 83 14 7 81 11 Total% 98% 99% 100% 100% 99% 99% Fingering 32 49 9 28 52 6 28 51 2 31 43 2 25 42 3 29 51 5 Total% 90% 86% 81% 76% 70% 85%

1. Skilltran. Job Browser Pro & Occubrowse. www.skilltran.com

167

http://www.skilltran.com/

Glossary Activity. The execution of a task or action by an individual. Activity limitation. Difficulties an individual may have in executing activities. It may also reflect an activity that an individual cannot perform. Activity restriction. An activity an individual should not do. This is different than an activity limitation, which is an activity an individual is unable to perform. Adverse impact. A substantially different rate of selection in hiring, promotion, or other employment decision which works to the disadvantage of members of a race, color, religion, sex, ethnic group, age group, or disability. Aptitudes. Capacities or abilities required of an individual in order to facilitate the learning of some task or job duty. There are 5 levels of aptitude requirements of jobs. There are 11 aptitudes used by the United States Employment Service for job analysis: 1) General Learning Ability; 2) Verbal Aptitude; 3) Numerical Aptitude; 4) Spatial Aptitude; 5) Form Perception; 6) Clerical Perception; 7) Motor Coordination; 8) Finger Dexterity; 9) Manual Dexterity; 10) Eye-Hand-Foot Coordination; 11) Color Discrimination. Atmospheric conditions. Exposure to conditions such as fumes, noxious odors, dusts, mists, gases, and poor ventilation that affect the respiratory system, eyes, or the skin. Balancing. Maintaining body equilibrium to prevent falling when walking, standing, crouching, or running on narrow, slippery, or erratically moving surfaces; or maintaining body equilibrium when performing gymnastic feats. Behavioral. Pertaining to reactions made in response to social stimuli. Biomechanical limitation. Termination of a particular functional test by an Examiner for safety purposes based on established observational criteria including but not limited to muscle recruitment, body mechanics, base of support, posture, and control and safety. Capacity. The highest probable level of functioning of an individual in a given domain at a given moment. Carrying. Transporting an object, usually holding it in the hands or arms or on the shoulder. Catastrophizing. To imagine the worst possible outcome of an action or event: to think about a situation or event as being catastrophe or having a potentially catastrophic outcome. Climbing. Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs or hands and arms. Body agility is emphasized. Cognitive Functional Capacity Evaluation (Cog FCE). An FCE with additional evaluation criteria pertaining to cognitive, perceptual/sensory, communicative, behavioral, and psycho-

168

emotional factors associated with a broad range of diagnoses, including but not limited to acquired or traumatic brain injury, cerebral vascular accident, and mental health diagnoses. Color vision. Ability to identify and distinguish colors. Compensation. Correction of an organic defect or loss by hypertrophy or by increased functioning of another organ or unimpaired parts of the same organ. Comprehensive Pain Behavior Assessment. An assessment during an FCE to determine if an individual’s self-reported symptoms and perceived limitations are consistent with objective medical evidence. Communicative. Tending to communicate: talkative. Constant activity. The activity or condition exists more than 2/3 of the time, or more than 5 ¼ hours in an 8 hour work day, or more than 62 repetitions per hour, or more than 500 repetitions in an 8 hour work day. Continuous activity. Remaining in a posture or performing an activity for a specified amount of time without interruption to change to a different posture. Content validity. Demonstrated by data showing that the content of a selection procedure is representative of important aspects of performance on the job. Construct validity. Demonstrated by data showing that the selection procedure measures the degree to which candidates have identifiable characteristics which have been determined to be important for successful job performance. Criterion-related validity. Demonstrated by empirical data showing that the selection procedure is predictive of or significantly correlated with important elements of work behavior. Crawling. Moving about on hands and knees or hands and feet. Crouching. Bending body downward and forward by bending legs and spine. Same as Squatting. Depression. Condition of general emotional dejection and withdrawal; sadness greater and more prolonged than that warranted by anyobjective reason. Depth perception. Three dimensional vision. Ability to judge distances and spatial relationships so as to see objects where and as they actually are. Diaphoresis. Profuse perspiration artificially induced. Disability. An umbrella term for impairments, activity limitations and participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors).

169

https://www.merriam-webster.com/dictionary/hypertrophy#h1

https://www.merriam-webster.com/dictionary/communicate

Distress. Great pain, anxiety, or sorrow; acute physical or mental suffering; affliction; trouble. Effort. The conscious exertion of physical and/or mental power to participate in an activity. Environmental conditions. The surroundings in which a job is performed. There are 14 environmental conditions: 1) Exposure to weather; 2) Extreme cold; 3) Extreme heat; 4) Wet/and or humid; 5) Noise intensity level; 6) Vibration; 7) Atmospheric conditions; 8) Proximity to moving mechanical parts; 9) Exposure to electrical shock; 10) Working in high exposed places; 11) Exposure to radiation; 12) Working with explosives; 13) Exposure to toxic or caustic chemicals; 14) Other environmental conditions. Environmental factors. Environmental factors make up the physical, social and attitudinal environment in which people live and conduct their lives. Essential job function. The basic duties than an employee must be able to perform, with or without reasonable accommodation. Evaluation. A dynamic process in which the physical therapist and/or occupational therapist makes clinical judgments based on data gathered during the examination. Examination. A comprehensive screening and specific testing process leading to diagnostic classification or, as appropriate, to a referral to another practitioner. The examination has three components: the patient/client history; the systems review; and tests and measures. Executive Functioning. A set of processes that all have to do with managing oneself and one's resources in order to achieve a goal. It is an umbrella term for the neurologically-based skills involving mental control and self-regulation. Exertional limitations. Functional limitations caused by an individual’s impairment(s) and related symptoms such as pain that affect an individual’s ability to meet the strength demands of jobs (sitting, standing, walking, lifting, carrying, pushing, and pulling). Exposure to toxic or caustic chemicals. Exposure to possible bodily injury from toxic or caustic chemicals. Exposure to electrical shock. Exposure to possible bodily injury from electrical shock. Exposure to radiation. Exposure to possible bodily injury from radiation. Exposure to weather. Exposure to outside atmospheric conditions. Extreme cold. Exposure to non-weather-related cold temperatures. Extreme heat. Exposure to non-weather-related hot temperatures. Far acuity. Clarity of vision at 20 feet or more.

170

Feeling. Perceiving attributes of objects, such as size, shape, temperature, or texture, by touching with skin, particularly that of fingertips. Field of vision. Observing an area that can be seen up and down or to right or left while eyes are fixed on a given point. Fingering. Picking, pinching, or otherwise working primarily with fingers rather than with the whole hand or arm as in handling. Frequent activity. The activity or condition exists more than 1/3 and up to 2/3 of the time, or more than 2 ½ hours up to 5 ¼ hours in an 8 hour work day, or more than 13 and up to 62 repetitions per hour, or more than 100 and up to 500 repetitions in an 8 hour work day. Functional ability. The ability to safely participate in work and/or other major life activities. Functional abilities are determined by an Examiner based on the results of an FCE. Functional capacity evaluation (FCE). A comprehensive performance-based medical assessment of an individual’s physical and/or cognitive abilities to safely participate in work and other major life activities. FCEs are designed, administered, and interpreted by Examiners. Functional Capacity Examiner (Examiner). A physical therapist or occupational therapist licensed in the jurisdiction in which the services are performed, who is able to demonstrate evidence of education, training, and competencies specific to the design, administration, and interpretation of FCEs. Functional impairment. The loss of functional ability to safely perform occupational and/or job specific activities. This term is sometimes but not always associated with the severity of anatomic/physiologic impairment obtained from an impairment evaluation. The severity of an individual’s functional impairment is determined by an Examiner based on the results of an FCE. Functional limitation. The inability to safely participate in work and/or other major life activities due to medically determinable impairment(s). Functional limitations are determined by an Examiner based on the results of an FCE. General educational development (GED). The formal and informal education which develops basic reasoning, ability to follow directions, math, and language skills. Experience and/or elf-study can develop GED. There are 3 categories of GED: Reasoning; Math; and Language. This worker characteristic is expressed as one of 6 levels: 1-3 Low; 4-5 Average; 6 High. GOE (Interest Areas). Guide for Occupational Exploration. A liking or preference for an activity. There are 12 interest factors used by the USES in job analysis: 1) Artistic; 2) Scientific; 3) Plants and Animals; 4) Protective; 5) Mechanical; 6) Industrial; 7) Business Detail; 8) Selling; 9) Accommodating; 10) Humanitarian; 11) Leading-Influencing; 12) Physical Performing. Grasping. Seizing, holding, grasping, turning, or otherwise working with hand or hands. Fingers are involved only to the extent that they are an extension of the hand, such as to turn a switch or shift automobile gears. Same as Handling.

171

Handling. Seizing, holding, grasping, turning, or otherwise working with hand or hands. Fingers are involved only to the extent that they are an extension of the hand, such as to turn a switch or shift automobile gears. Same as Grasping. Hearing. Perceiving the nature of sounds by ear. Heavy work. Exerting 51 to 100 pounds of force occasionally, or 26 to 50 pounds of force frequently, or 11 to 20 pounds of force constantly to move objects. Highly skilled work (levels 8-9). Work requiring over 4 years up to and including 10 years (level 8) or over 10 years (level 9) for the worker to learn the techniques, acquire the information, and develop the facility needed for average performance in a specific job-worker situation. Impairment. A significant deviation, loss, or loss of use of any body structure or function in an individual with a health condition, disorder, or disease. Impairment evaluation. A medical evaluation using a standard method (i.e. AMA Guides) to determine permanent anatomic or physiologic impairment associated with a physical or mental condition. Impairment rating. A consensus-derived percentage estimate of loss of activity reflecting severity for a given health condition, and the degree of associated limitations in terms of activities of daily living. This term is sometimes but not always associated with the severity of functional impairment. International Classification of Functioning, Disability and Health. The International Classification of Functioning, Disability and Health, known more commonly as ICF, is a classification of health and health-related domains. ICF is the WHO framework for measuring health and disability at both individual and population levels. Invalid performance. The individual’s test performance was not consistent with the severity of their medically determinable impairments based on biomechanical, physiological, and psychophysical factors. Job. A group of positions within an establishment which are identical with respect to their major or significant tasks and sufficiently alike to justify their being covered by a single analysis. There may be one or many persons employed in the same job. Job analysis. The process of quantifying the physical and cognitive demands of a job using a combination of techniques including interview, observation, and objective measurements. Job description. A written statement of job duties, responsibilities, and qualifications necessary to safely perform a job. Kinesiophobia. A term that describe people's fear of pain due to movement, a factor that hinders rehabilitation and prolongs disability and pain.

172

Kneeling. Bending legs at knees to come to rest on knee or knees. Lifting. Raising or lowering an object from one level to another (includes upward pulling). Light work. Exerting up to 20 pounds of force occasionally, or up to 10 pounds of force frequently, or a negligible amount of force constantly to move objects. A job should be rated Light work when it requires: (1). Walking or standing to a significant degree; or (2). Sitting most of the time but entails pushing or pulling of arm or leg controls; or (3). Working at a production rate pace entailing constant pushing or pulling of materials even though the weight of those materials is negligible. SSR 83-10 further defines the full range of Light work as requiring 6 or more hours of intermittent standing or walking in an 8-hour workday. Sitting may be required only intermittently and occasionally. Major life activities. Activities including, but are limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. A major life activity also includes the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. Malingering. The intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives. The motive for feigning a disorder may be to obtain financial compensation, drugs, avoid work, lessen a criminal sentence, escape incarceration, or to gain sympathy. The scope of a diagnosis of malingering is reserved to psychiatrists or qualified psychologists based on formal psychological testing. Marginal job function. The basic duties than an employee may perform, but they are not essential job functions. Maximum medical improvement. The point at which a patient’s medical condition has stabilized and is unlikely to change (improve or worsen) substantially in the next year, with or without treatment as determined by a physician. Maximum rehabilitation potential. The point at which a patient will no longer benefit from either physical rehabilitation as determined by a physical therapist or occupational therapist, or cognitive behavioral therapy interventions as determined by a psychologist. Medically determinable impairment. An impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medical evidence consisting of signs, symptoms, and diagnostic findings. A medically determinable impairment cannot be established in the absence of objective medical abnormalities. Medically stable. The medical condition is not significantly changing on a day to day basis. Medium work. Exerting 21 to 50 pounds of force occasionally, or 11 to 25 pounds of force frequently, or greater than negligible up to 10 pounds of force constantly to move objects. Near acuity. Clarity of vision at 20 inches or less.

173

Negligible weight/force. The weight or force is so small an amount that measurement is not meaningful (i.e. a pen, a few sheets of paper). Less than 1 pound. Noise intensity level. The noise intensity level to which the worker is exposed in the job environment. This factor is expressed by one of five levels. Non-exertional limitations. Functional limitations caused by an individual’s impairments and related symptoms, such as pain, that affect an individual’s ability to meet the demands of jobs other than the strength demands (i.e. reaching, handling, fingering, stooping, squatting, etc.). Non-repetitive activity. Performing the same task(s) less than 30 repetitions per hour, or less than 240 repetitions i an 8 hour work day. Use of keyboard less than 4 hours per day. Not present. The activity or condition does not exist. Observable. Able to be seen, heard, or otherwise perceived by a person other than the person performing the action. Occasional activity. The activity or condition exists up to 1/3 of the time, or up to 2 ½ hours in an 8 hour work day, or up to 12 repetitions per hour, or up to 100 repetitions in an 8 hour work day. Occupation. A group of jobs, found at more than one establishment, in which a common set of tasks are performed or are related in terms of similar objectives, methodologies, materials, products, worker actions, or worker characteristics. Pain. An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain behavior. Verbal and/or nonverbal manifestations of discomfort, and perhaps distress and suffering. The behavior or behaviors may be audible complaints – actions such as a grimace or other facial expression, abnormal posture, guarding, or rubbing a body part, a limp, or use of a walking aid, brace or other device – or inaction such as activity avoidance, even bedrest. Pain behaviors reflect the way persons think, feel, and act in response to their discomfort, and the way they communicate their symptoms to others. Participation. Involvement in a life situation. Participation restrictions. Problems an individual may experience in involvement in life situations. Perceptual. Relating to, or involving perception especially in relation to awareness of the elements of environment through physical sensation. Perceived disability. An individual’s perceptions about their own abilities and limitations with participating in major life activities.

174

https://www.merriam-webster.com/dictionary/perception

https://www.merriam-webster.com/dictionary/sensation

Perceived injustice. An individual’s cognitive appraisal comprising of elements of severity of loss, perceived irreparability of loss, a sense of unfairness and the external attribution of blame following a painful injury. Performance validity. The degree to which an individual’s test performance was consistent with objective medical evidence based on biomechanical, physiological, and psychophysical factors. Physical demands. The physical requirements made on the worker by the specific job-worker situation. There are 26 physical demands: 1) Standing; 2) Walking; 3) Sitting; 4) Lifting; 5) Carrying; 6) Pushing; 7) Pulling; 8) Climbing; 9) Balancing; 10) Stooping; 11) Kneeling; 12) Squatting (Crouching); 13) Crawling; 14) Reaching; 15) Handling; 16) Fingering; 17) Feeling; 18) Talking; 19) Hearing; 20) Tasting/Smelling; 21) Near Acuity; 22) Far Acuity; 23) Depth Perception; 24) Accommodation; 25) Color Vision; and 26) Field of Vision. Physiological limitation. Termination of a particular functional test by a Functional capacity examiner for safety purposes based on established physiological criteria including but not limited to heart rate, oxygen saturation, blood pressure, and respiratory rate. Preponderance of evidence. The greater weight of the evidence required in a civil (non-criminal) lawsuit for the trier of fact (jury or judge without a jury) to decide in favor of one side or the other. This preponderance is based on the more convincing evidence and its probable truth or accuracy, and not on the amount of evidence. Proximity to moving mechanical parts. Exposure to possible bodily injury from moving mechanical parts of equipment, tools, or machinery. Psycho-emotional. Describing any psychological interaction with the emotions. Psychometric. The psychological theory or technique of mental measurement Psychophysical limitation. Termination of a particular functional test by the individual being tested based on established subjective criteria including but not limited to the individual reporting the inability to safely perform or complete the activity. The Functional capacity examiner may also choose to terminate a particular functional test based on an individual’s uncooperative behaviors compromising safety. Psychosocial. Involving both psychological and social aspects Psychosomatic disorders. A group of disorders characterized by the presence of physical symptoms that are caused or exacerbated by psychological factors. Pulling. Exerting force upon an object so that the object moves toward the force (includes jerking). Pushing. Exerting force upon an object so that the object moves away from the force (includes slapping, striking, kicking, and treadle actions).

175

http://www.yourdictionary.com/psychological

http://www.yourdictionary.com/emotions

https://www.merriam-webster.com/dictionary/psychological

Reaching. Extending hand(s) and arm(s) in any direction. Reasonable accommodation. Any change in the work environment or in the way things are customarily done that enables an individual with a disability to enjoy equal employment opportunities. Regular and continuous basis. Being able to maintain a fulltime work schedule 8 hours per day for 5 days per week, or an equivalent work schedule. Repetitive activity. Performing the same task(s) 30 or more repetitions per hour, or 240 or more repetitions in an 8 hour work day. Use of a keyboard 4 or more hours per day. Residual functional capacity. Represents what an individual can still do despite functional limitations resulting from a medically determinable impairment(s) and impairment-related symptoms. Risk. Refers to the chance of harm to the individual, co-worker, or to the general public if the individual engages in specific work activities. Sedentary work. Exerting up to 10 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are Sedentary if walking and standing are required only occasionally and all other Sedentary criteria are met. SSR 83-10 further defines Sedentary work as requiring about 6 hours of sitting and no more than 2 hours of standing or walking in an 8-hour workday. Selection procedure. Any measure, combination of measures, or procedure used as a basis for any employment decision. Selection procedures include the full range of assessment techniques from traditional paper and pencil tests, performance tests, training programs, or probationary periods and physical, educational, and work experience requirements through informal or casual interviews and unscored application forms. Selection rate. The proportion of applicants or candidates who are hired, promoted, or otherwise selected. Self-Efficacy. Confidence in one's own ability to achieve intended results. Semi-skilled work (levels 3-4). Work requiring over 1 month up to an including 3 months (level 3) or over 3 months up to and including 6 months (level 4) for the worker to learn the techniques, acquire the information, and develop the facility needed for average performance in a specific job-worker situation. Sensation. A mental process resulting from the immediate external stimulation of a sense organ often as distinguished from a conscious awareness of the sensory process. Sitting. Remaining in a seated position. Skill. A present, observable competence to perform a learned psychomotor skill.

176

https://www.merriam-webster.com/dictionary/sense

https://www.merriam-webster.com/dictionary/sensory

Skilled work (levels 5-7). Work requiring over 6 months up to and including 1 year (level 5), over 1 year up to and including 2 years (level 6), or over 2 years up to and including 4 years (level 7) for the worker to learn the techniques, acquire the information, and develop the facility needed for average performance in a specific job-worker situation. Specific vocational preparation (SVP). The amount of lapsed time required by a typical worker to learn the techniques, acquire the information, and develop the facility needed for average performance in a specific job-worker situation. This training may be acquired in a school, work, military, institutional, or vocational environment. This worker characteristic is expressed as one of 9 levels: 1-2 Unskilled; 3-4 Semi-Skilled; 5-7 Skilled; 8-9 Highly Skilled. Squatting. Bending body downward and forward by bending legs and spine. Same as Crouching. Standing. Remaining on one’s feet in an upright position at a workstation without moving about. Stooping. Bending body downward and forward by bending spine at the waist, requiring full use of the lower extremities and back muscles. Substitution Pattern. The act, process, or result of substituting a biomechanical motion for another. Sustained posture. A posture that is maintained for a specified amount of time continuously without interruption. Talking. Expressing or exchanging ideas by means of the spoken word to impart oral information to clients or to the public and to convey detailed spoken instructions to other workers accurately, loudly, or quickly. Tasting/Smelling. Distinguishing with a degree of accuracy, differences or similarities in intensity or quality of flavors or odors, or recognizing particular flavors or odors, using tongue or nose. Temperaments. The adaptability requirements made on the worker by specific types of job situations. Temperaments relate to worker personality traits and can impact long term job retention. There are 11 different temperaments relative to work: 1) Directing, controlling, or planning activities of others; 2) Performing repetitive or short-cycle work; 3) Influencing people in their opinions, attitudes, and judgments; 4) Performing a variety of duties; 5) Expressing personal feelings; 6) Working alone or apart in physical isolation from others; 7) Performing effectively under stress; 8) Attaining precise set limits, tolerances, and standards; 9) Working under specific instructions; 10) Dealing with people; and 11) Making judgments and decisions. Tolerance. A psychophysical concept that refers to the level of work or activity an individual feels able to endure at a given time. Tolerance is impacted by an individual’s symptoms such as pain and fatigue.

177

https://www.merriam-webster.com/dictionary/substituting

Transferrable skills. Skills that an individual developed from past work that can be used in other similar work (transferability) based on worker traits to include specific vocational preparation, work fields, and materials used, products produced, and subject matter or services provided. Unskilled work (levels 1-2). Work requiring short demonstration only (level 1) or anything beyond short demonstration up to and including 1 month (level 2) for the worker to learn the techniques, acquire the information, and develop the facility needed for average performance in a specific job-worker situation. Valid performance. The individual’s test performance was consistent with the severity of their medically determinable impairments based on biomechanical, physiological, and psychophysical factors. Very heavy work. Exerting in excess of 100 pounds of force occasionally, or in excess of 50 pounds of force frequently, or in excess of 20 pounds of force constantly to move objects. Vibration. Exposure to a shaking object or surface. Visual accommodation. Adjustment of lens of eye to bring an object into sharp focus. This factor is required when doing near point at varying distances from the eye. Walking. Moving about on foot. Wet and/or humid. Contact with water or other liquids or exposure to non-weather-related humid conditions. Work: Labor or exertion, to make, construct, manufacture, form, fashion, or shape objects to organize, plan, or evaluate services or processes of living or governing; committed occupations that are performed with or without financial reward. Work behavior. An activity performed to achieve the objectives of the job. Work behaviors involve observable (physical) components and unobservable (mental) components. A work behavior consists of the performance of one or more tasks. Knowledges, skills, and abilities are not behaviors, although they may be applied in work behaviors. Work fields. Groupings of technologies and socioeconomic objectives that reflect how work gets done and what gets done as a result of the work activities of a job, or in other words, the purpose of the job. There are 96 work fields defined by USES. Worker characteristics. Worker attributes that contribute to successful job performance. Worker characteristics include: 1) General Educational Development (GED); 2) Specific Vocational Preparation (SVP); 3) Aptitudes; 4) Temperaments; 5) GOE (Interest Areas); 6) Physical Demands; and 7) Environmental Conditions. Working in high, exposed places. Exposure to possible bodily injury from falling. Working with explosives. Exposure to possible bodily injury from explosion.

178

OccuPro Functional Capacity Evaluation Consistency of Effort/Reliability of Pain

OCCUPRO, LLC © 2011 www.occupro.net 8

Chapter 3

Consistency of Effort/Reliability of Pain OccuPro’s functional capacity evaluation helps to determine if a client put forth full effort during testing and whether the pain reports the client reported during the evaluation can be used to determine the kinesiophysical endpoint. Some FCE testing procedures use the terms validity or sincerity of effort for the patient’s effort. OccuPro’s FCE relies on the terminology of consistency of effort. Some FCE testing procedures use the term symptom magnification syndrome or even malingering to determine if a clients effort was consistent, valid or sincere. OccuPro has broken these two things our separately and uses the terminology Reliability of Pain. When testing a client during OccuPro’s 100% kinesiophysical approach FCE and the client exhibits consistent behaviors and testing they can be considered to have put forth full effort. If during testing a client exhibits inconsistent behaviors or testing they will be considered to have exhibited self limiting behaviors. Consistency of Effort should be properly documented. During this testing procedure a client will be reporting pain levels after each test. Through testing procedures to be discussed soon if the clients report of pain is considered to be reliable then pain could be considered a limiting factor. If their pain report is considered to be unreliable then the tester should maintain the 100% kinesiophysical approach and focus strictly on the clients demonstrated mechanics. The decision on ability should then come down to mechanical changes and mechanical deficits.

Consistency of Effort

Consistency of Effort testing is performed throughout the FCE testing procedures. These can be classified as observational consistency of effort and researched test consistency of effort. Observational Consistency of Effort includes basic observation of the client being tested to determine if the things they are doing during the test make biomechanical and physiological sense. For example if a client during range of motion testing demonstrates 90 degrees of shoulder flexion but then during functional testing exhibits full shoulder flexion this would be an observational inconsistency and may suggest some self limiting behaviors during testing. When self limiting behaviors are noted the tester will attempt to do everything they can to minimize self limiting behaviors by focusing on a kinesiophysical approach an attempting to get the client to a biomechanical end point.

179



Observational Consistency of Effort This section of consistency of effort is based on the FCE tester’s knowledge of the diagnosis, biomechanics, and physiology and is an integral part of the overall test to determine a client’s consistency of effort. The items looked at by the FCE tester includes whether there were manual muscle testing or range of motion inconsistencies. These questions are simply answered with a yes or a no by the FCE tester.

1. Did this client demonstrate two or more functional testing range of motion inconsistencies as compared to range of motion testing?

2. Did this client demonstrate two or more functional strength inconsistencies as compared to manual muscle testing?

Occasional Material Handling Validity The occasional material handling validity section looks at the biomechanical differences between lifts and determines whether a client has put forth consistent effort. For instance, a client with a lumbar injury should be able to lift more weight in a power lifting position then in a full squat lifting position. The FCE looks at these differences and analyzes them. This section compares the following lifts. Is the power lifting weight greater then the squat lifting weight? Is the power lifting weight greater then the shoulder lifting weight? Is the power lifting weight greater then the overhead lifting weight? Is the power lifting weight greater then the bend/job specific weight? Is two handed carrying greater then unilateral carrying? These are all questions asked and a sample of this page is below. Hand Test Validity Hand testing validity criteria has been used in functional capacity evaluation for many years. It has been the staple of determining whether a client is putting forth full and consistent effort. It should be noted that many medical providers have used this criteria for determining if someone is valid and is putting forth consistent effort even if the diagnosis has nothing to do with the upper extremities. The procedures for OccuPro’s FCE would suggest that hand test validity really only applies to diagnoses related to the upper extremities. The main tool used in hand test validity includes the coefficient of variation for grip and pinch testing. This looks at the standard deviation of the grip or pinch test and then divides that by the mean. This calculation is the coefficient of variation. A positive test or sub-maximal effort is defined as 10% in males and 12% in females. M. Robinson defined 11% or greater as being sub-maximal effort. OccuPro Systems and Solutions’ FCE uses 11% or greater as their sub-maximal

180



effort cutoff. The following tests are looked at in regards to co-efficient of variation and sub-maximal effort.

Grip Coefficient of Variation (CV) on Right Grip Coefficient of Variation (CV) on Left Five Span position 2 versus Grip Strength CV on Right Five Span position 2 versus Grip Strength CV on Left Key Pinch CV on Right Key Pinch CV on Left Palmar Pinch CV on Right Palmar Pinch CV on Left Tip Pinch CV on Right Tip Pinch CV on Left

Five span grip strength testing tests a clients grip strength in all five positions of the Jamar hand dynamometer. This measurement should demonstrate a bell shaped curve with the peak of the curve being at position #2 or #3. H. Stokes found that maximal effort produces a bell shaped curve and sub-maximal effort produces a flat line curve. Further studies questioned the amount of a bell shaped curve that would suggest full effort and in the end “the shape of the curve is important – the flatter the curve the more likely sub-maximal effort is occurring”. OccuPro’s FCE provides the evaluator with a visually graphed curve in the software and the evaluator then makes a decision whether there is a bell shaped curve on the left and or the right. This is then automatically calculated into the validity/consistency of effort. Rapid grip exchange is also utilized as a measurement of hand validity. The literature varies greatly on this topic. Most literature is inconclusive in regards to whether someone who has a higher score during rapid grip as compared to static grip is actually giving sub-maximal effort. All of the studies completed in the literature were completed only looking at rapid grip exchange and not taking into account other hand tests and consistency of effort. With this said, OccuPro’s FCE looks at many different hand validity tests and does not rely solely on one test. With many hand validity tests and the overall validity needing to be below 85% for the test to be questionable and below 75% for the overall test to be invalid, it was determined to keep the rapid grip exchange in the FCE. The literature does say “Rapid exchange grip is useful when large variations occur”. Frequent Material Handling Validity The second set of validity criteria in this section includes the web based software taking a look at the difference between what the client was able to lift occasionally and then frequently. It would certainly raise some questions if the client was able to do more weight on a frequent basis during testing then what they were able to do occasionally. The software compares the following frequent to occasional weights.

Frequent Squat Lift vs. Occasional Squat Lift Frequent Power Lift vs. Occasional Squat Lift Frequent Shoulder Lift vs. Occasional Shoulder Lift

181



Frequent Two Handed Carry vs. Occasional Two Handed Carry Frequent Push vs. Occasional Push Frequent Pull vs. Occasional Pull Frequent Unilateral Lift vs. Occasional Unilateral Lift

Non-Material Handling Validity Criteria The last portion of validity criteria continues to take a look at a clients Rating of Perceived Exertion during tests that require a level of cardiovascular endurance. The same criteria are used as discussed above. The tests that are looked at are as follows:

Climbing RPE vs. Heart Rate Ladder Climbing RPE vs. Heart Rate

Reliability of Pain Ratings

OccuPro’s Online Assessment Application software helps to establish whether or not an individual was reliable in regards to the pain ratings they self reported. This is done utilizing a battery of questionnaires, the OccuPro Pain Intensity Scale TM and a rating of perceived exertion vs. pain report application in the online software. OccuPro Functional Pain Scale OccuPro has developed a pain scale in which the 0-10 Lickert pain levels have been defined to better describe pain as it relates to an individuals function. Since a traditional pain scale is highly subjective and the reliability of performing Functional Capacity Evaluations is always of concern a functional pain scale will help to increase the client’s pain reports objectively, will focus a client’s pain towards how it affects their function and increase the inter-rater and intra-rater reliability of the entire system. The functional pain scale as well helps to assist in determining a clients stopping point during functional testing. You will notice that a four on the pain scale definitions states “Pain that begins to cause limits in your present functional abilities”. This would be a level in which the client could be considered to be functional but that the pain may be starting to affect their functionality. Then, “You are unable to complete the current activity due to this pain” is part of the definition for a pain rating of a 5 on the 0-10 scale. This level would suggest that the client is unable to complete the functional testing you are performing and may suggest a need to stop the test and record the level that they are able to perform functionally. If the pain scale is used correctly and the patient understands the defined levels you should rarely have patients tell you that they are a 6 or greater. This pain scale should be presented to every patient you are testing and the patient should become very familiar with the definitions of each pain level. If during testing their pain levels and the definitions do not correlate then the scale should be reintroduced to the client and they should be asked to make sure that they pain they reported matches the definition.

182



Borg Rating of Perceived Exertion Formula The frequent material handling portion of OccuPro’s FCE is a section that takes into consideration a client cardiovascular endurance. During this section the client is asked to lift

183



weights in different positions at 5 repetitions per weight. If a client starts at 20 pounds and is able to frequently lift up to 50 pounds they were asked to lift 20, 30, 40 and 50 pounds 5 reps each weight. This would mean the client has performed 20 repetitions of lifting in a given lifting posture. The weight along with the repetition would require a level of exertion and the validity criteria in this section is based off of Borg’s Rating of Perceived Exertion formula. The Borg Rating of Perceived Exertion scale used is as follows:

Borg CR-20 Rating of Perceived Exertion Scale

Very, Very Light

Fairly Light Hard Very, Very Hard

Very Light Somewhat Hard Very Hard

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The formula utilized in this section is RPE*10-HR=. For instance if a client has a heart rate of 125 during testing and reports a rating of perceived exertion at 12 than this would be 12*10= 120. Then subtract the heart rate of 125 and the formula calculates out to -5. This would be considered an acceptable correlation. The breakdown occurs as follows. Acceptable Correlation (-15 to +20)

Large Negative Numbers ( <-15) Poor Cardiovascular fitness Underestimating Difficulty

Moderate Positive Numbers (21-49) Mild Exaggeration of Difficulty of Task Poor Musculoskeletal fitness Good CV Fit

Large Positive Numbers (≥+50) Symptom Exaggeration

If a client reports a rating of perceived exertion at hard or 15 and their heart rate is 85 beats per minute following frequent power lifting then the formula calculates out to 65. This would fall into large positive numbers and would suggest symptom exaggeration. Typically in this situation the client being tested has lifted minimal weight for a few repetitions and report significant exertion without an appreciable increase in heart rate. The client can even be told that the rating of perceived exertion is not pain related and pain should not be considered in their self report. OccuPro’s FCE considers this an invalid test when clients Rating of Perceived Exertion Formula calculates out to ≥ +50. This score would suggest symptom exaggeration and would add to the level of an overall invalid test. The tests that take a look at the Rating of Perceived Exertion Formula are as follows:

Frequent Squat Lift Frequent Power Lift Frequent Shoulder Lift

184



Frequent Two Handed Carry Frequent Push/Pull Frequent Unilateral Lift

Waddell Signs consist of a standardized assessment of non-organic physical signs for low back disorders. The testing consists of five non-organic physical signs of behavior and is combined to show the client’s response. Gordon Waddell developed this standardized assessment of physical signs to determine inappropriate responses to physical examination. The original purpose was to assist in clinical assessment to determine organic and non-organic physical signs, identify illness behavior, and reduce unnecessary medical procedures, diagnostic testing and or therapy. This testing was not originally developed for clinical use to identify malingerers or exaggerators. However it may provide clinical information of behavioral responses of appropriate or inappropriate signs that are elicited by the client. Using Waddell Testing, within OccuPro’s FCE, is meant to assist with the overall consistency of effort from the client with a low back disorder. OccuPro has implemented the use of Waddell signs to provide the evaluator with a glimpse of the client’s behavior and movement patterns. The validity of the Waddell’s test is only one component to the overall validity/consistency of effort of the client. This validity will be automatically calculated when noting whether each individual test was “positive” or “negative”. The evaluator will need to remain attentive for any inconsistencies or discrepancies the client may exhibit with physical signs of behavior during the rest of the evaluation. There are five tests that the evaluator must perform and note whether the client presents with a positive or negative response. It is considered a positive finding if three or more of these signs are positive which may suggest the client does not present with a straightforward medical condition, when referring to low back diagnoses. SUPERFICIAL TENDERNESS: This test is performed with light touch to the lumbar region. Typically tenderness is localized and physical back pain does not make the skin tender to light touch. The client is prone with his or her head straight down in the table headpiece, and the arms straight down and relaxed. The evaluator should ask: "Is that painful?" This test is considered positive if the client reports excessive pain to touch, over a wide area not consist with dermatome patterns, or excessive reaction to the light touch. Any response except a definite "no" is positive for impairment; "Just a little bit" is a positive response, according to Waddell. SIMULATION: This test has two components:

1. Axial Loading consists of applying pressure on the top of the head while the client is in standing position. This test should not cause low back pain. It is considered positive if the client reports low back pain post this test.

185



2. Simulated Rotation consists of passive rotation of the shoulders and pelvis in unison. When performing this test, the structures in the back are not stressed and considered positive if the client reports low back discomfort with this test.

If either of these tests is positive, then this entire simulation test is positive. DISTRACTION: Distraction test is performed with the client unaware of the test being performed, must include non-painful, non-emotional, and non-surprising behaviors by the client. This may be performed in a few ways. Typically the client is in seated position, attention distracted, and the straight leg raise is performed anytime the hip is flexed with the knee straight. Another version may be done when examining the foot with the client in seated position with one knee extended. Third variation is if the client uses the injured extremity when distracted. The client lies flat without a pillow, arms at his or her side, with hips and knees extended as fully as possible. Positive if: Sitting and supine tests are not consistent. Positive pain response when supine but no pain when sitting then this test is positive. REGIONAL DISTURBANCES: This test is performed for both sensory change and weakness of the client’s lower extremities. A positive response would consist of any numbness reported to an entire extremity, circumferential, or an entire side of the body that does not follow diagnosis or expected neurological pattern. For identifying weakness, a positive response by the client may consist with regional, sudden, or uneven weakness. The client demonstrating cogwheeling, giving away, or breakaway is a non-organic behavioral sign. OVERREACTION: This is the final test that identifies overreaction to all the tests performed. If the client presented with hypersensitivity to a specific area at one time during this testing and when tested a second time in the same location the client does not present with same response to palpation, is considered a positive response. Some overreaction signs may be disproportionate grimacing, tremoring, exaggerated verbalizations, profuse sweating, collapsing, sighing, guarding, bracing, rubbing, inconsistent on standing or changing positions, and questionable use of walking aids or assistive devices. COMMENTS: This section allows the evaluator to summarize the five non-organic physical signs that were tested. It should identify whether the client presented with “Waddell signs present” or “Waddell positive/negative” or “no Waddell signs present”. The evaluator should also be

186



attentive to the client’s heart rate and reported pain level during this section of the evaluation that will provide valuable input in the client’s overall physiological responses. The Ransford Pain Drawing

Purpose This is a useful tool to enable the patient to give the evaluator an idea of where they feel certain symptoms. This may be done in an informal way during the initial intake interview and the drawing will prompt dialogue between the two parties regarding symptoms, their frequency, behavior and when they occurred in relation to others. Alternatively, this may be done in a formal way utilizing the Ransford Pain Drawing (Ransford, et al, 1976). The Ransford Pain Drawing is used to assess the pain and psychodynamics in a patient with low-back pain. Administration Provide the patient with a body chart comprising anterior and posterior views of the body. If the informal version is used, ask the client to indicate on the chart where they feel symptoms using a key to describe different symptoms. The evaluator may ask the client to elaborate on each symptom during the process or at the end. The client may make notes on the chart to further describe symptoms. The Ransford Pain Drawing must be done on a specific body chart with four symptoms described above, namely stabbing, burning, pins and needles, and numbness. The instructions are at the top of the chart and read as follows: “Indicate where your pain is located and what type of pain you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain which are not related to your present condition.” Ransford showed that the drawings drawn by patients in the study correlated very well with the Hypochondria’s and Hysteria scores on an MMPI (Minnesota Mulitphasic Personality Inventory) taken at the same time. Scoring The evaluator should observe the drawing and determine if any of the criteria listed below feature in the drawing. The appropriate score is given and all scores are totaled at the end to reach a final score.

1. Unreal drawing (Poor anatomic localization, scores 2 unless indicated; bilateral pain not weighted unless indicated).

A. Total leg pain B. Lateral whole leg pain (trochanteric area and lateral thigh allowed) C. Circumferential thigh pain D. Bilateral anterior tibial area pain (unilateral allowed) E. Circumferential foot pain (scores 1)

187



F. Bilateral foot pain (scores 1) G. Use of all four modalities suggested in instructions (We feel patient is unlikely

to have “burning areas”, stabbing pain, pins-and-needles and numbness all together; scores 1)

2. Drawing showing expansion or magnification of pain. (May also represent

unrelated symptomology. Bilateral pain not weighted.)

A. Back pain radiating to iliac crest, groin or anterior perineum (each scores 1; coccygeal pain allowed)

B. Anterior knee pain (scores 1) C. Anterior ankle pain (scores 1) D. Pain drawing outside the outline; this is a particularly good indication of

magnification (scores 1 or 2 depending on extent).

3. “I particularly hurt here” indicators. Some patients need to make sure the evaluator is fully aware of the extent of symptoms (each category scores 1; multiple use of each category is not weighted).

A. Add explanatory notes B. Circle painful areas C. Draw lines to demarcate painful areas D. Use arrows E. Go to excessive trouble and detail in demonstrating the pain areas (using the

symbols suggested).

4. “Look how bad I am” indicators.

A. Additional painful areas in the trunk, head, neck or upper extremities drawn in. Tendency towards total body pain (scores 1 if limited to small areas, otherwise scores 2).

Interpretation A score of 3 or above indicates poor psychodynamics. The test is also useful as a distraction test to observe patient behavior while sitting or standing, depending what position he/she is in when doing the drawing. This test takes approximately 5 to 8 minutes to administer and approximately 5 minutes to score.

188



INSTRUCTIONS

Indicate where your pain is located and what type of pain you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain, which are not related to your present injury or condition. Key

/// Stabbing XXX Burning 000 Pins and Needles = = = Numbness

189



The McGill Pain Questionnaire

Purpose The McGill Pain Questionnaire (MPQ) (Melzack, 1983) provides a valid, reliable, rapid and consistent way of determining a patient’s subjective pain experience. Administration The patient is provided with a form comprising instructions and 20 word groups. The patient is instructed to read each word group and decide whether there is a work in the group which describes the pain he/she is experiencing there and then. The patient should circle one word in the group, which describes their pain. If there is no word in the group, which describes their pain, they are to move on to the next group until they have completed each of the 20 groups. Groups 1 to 10 are words used to describe sensory experience, groups 11 to 15 are affective words, 16 is evaluative and 17 to 20 are miscellaneous groups. Scoring Each word in the group has a rank value as follows:

WORD RANK WORD RANK #1 1 #4 4 #2 2 #5 5 #3 3 #6 6

Score each word group according to the word the patient circles and write the score alongside the group number. Add categories 1 to 10 and record this next to “sensory”. Add groups 11 to 15 and recorded this next to “affective”. Write the score for group 16 next to “evaluative”. Add scores for groups 17 to 20 and write this next to “miscellaneous”. Lastly, add all four categories, ie., groups 1 to 20, and write this next to “Total”. Interpretation A score of 30 or greater indicates poor psychodynamics. The test may also be used as an evaluative tool to assess pain before and after treatment techniques or medical procedures. It can also be useful for repeat testing in a work hardening program. The test takes approximately 5-10 minutes to complete (depending on the literacy and vocabulary of the patient) and takes approximately 3 minutes to score.

190



McGill Instructions

Some of the words below describe your present pain. Circle ONLY those words that best describe it. Leave out any category that is not suitable. Use only a single word in each appropriate category – the only one that applies best. 1. 2. 3. 4. Flickering Jumping Pricking Sharp Quivering Flashing Boring Cutting Pulsing Shooting Drilling Lacerating Throbbing Stabbing Beating Lancinating Pounding 5. 6. 7. 8. Pinching Tugging Hot Tingling Pressing Pulling Burning Itchy Gnawing Wrenching Scalding Smarting Cramping Searing Stinging 9. 10. 11. 12. Dull Tender Tiring Sickening Sore Taut Exhausting Suffocating Hurting Rasping Aching Splitting Heavy 13. 14. 15. 16. Fearful Punishing Wretched Annoying Frightful Grueling Blinding Troublesome Terrifying Cruel Miserable Vicious Intense Killing Unbearable 17. 18. 19. 20. Spreading Tight Cool Nagging Radiating Numb Cold Nauseating Penetrating Drawing Freezing Agonizing Piercing Squeezing Dreadful Tearing Torturing

191



The Oswestry Low Back Disability Questionnaire Purpose The Oswestry Low back Questionnaire (Fairbank et al, 1980) is a 10 item, self-report checklist that has been shown to be valid in assessing perceived disability. It is easy for the client to complete and easy for the evaluator to score. Administration Provide the client with the standard ten-item checklist. The client is instructed to read each of the six statements in each section and decide which statement best relates to them. They may only choose one statement in each section. The authors suggest that the form should be presented on pink paper since it is reported that patients find evaluation forms on colored paper more acceptable (Eastwood, 1940). Scoring Each section is scored for 0 to a maximum of 5 points depending on which statement is checked. If a section is not checked, the potential score of 5 is dropped from the final calculation. The first statement in each section scores 0, the second scores 1, the third 2 and so on. The scores for all answered sections are added together and divided by the total potential score, then multiplied by 100 to obtain a percentage. For Example, if only nine sections were answered and the total score was 21 (that is 21 out of a potential 45) then the final score is 21/45 x 100 = 47%. Interpretation of Disability Scores 0% - 20% Minimal Disability (This group can cope with most living activities. Usually no

treatment is indicated a part from advice on lifting, sitting posture, physical fitness, and diet. In this group some patients have particular difficulty sitting. This may be important if their new occupation is sedentary, e.g., a typist or lorry driver.)

20% - 40% Moderate Disability (This group experiences more pain and problems with sitting,

lifting and standing. Travel and social life are more difficult and they may be well off work. Personal care, sexual activity, and sleeping are not grossly affected and the back condition can usually be managed by conservative means.)

40% - 60% Severe Disability (Pain remains the main problem in this group of patients but travel,

personal care, social life, sexual activity, and sleep are also affected. These patients require detailed investigation.)

60% - 80% Crippled (Back pain impinges on all aspects of these patient’s lives both at home and at

work and positive intervention is required.)

This test is extremely useful as a comparison of the patient’s perception compared to their

demonstrated ability.

192



Date: _________________ Name: ________________________________ Address: _____________________ Date of Birth: _______________________ _____________________ Age: ___________ Occupation: _________________________ Hospital No. _______ How long have you had back pain? ________ Years ________ Months _______ Weeks How long have you had leg pain? _________ Years ________ Months _______ Weeks Please read: This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section, and mark in each section only the one box, which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box, which most closely describes your problem. Section 1 – Pain Intensity Section 3 - Standing □ I can tolerate the Pain I have without having to use □ I can stand as long as I want without extra

painkillers. □ The pain is bad but I manage with taking painkillers □ I can stand as long as I want but it gives me extra pain. □ Painkillers give complete relief from pain. □ Pain prevents me from standing for more than 1 hour. □ Painkillers give moderate relief from pain. □ Pain prevents me from standing for more than 30 minutes. □ Painkillers give very little relief from pain. □ Pain prevents me from standing for more than 10 minutes. □ Painkillers have no effect on the pain and I do not use □ Pain prevents me from standing at all. them. Section 2 –Personal Care (Washing, Dressing, etc.) Section 4 - Sleeping □ I can look after myself normally without causing extra pain. □ Pain does not prevent me from sleeping well □ I can look after myself normally but it causes extra pain. □ I can sleep well only by using tablets. □ It is painful to look after myself and I am slow and careful. □ Even when I take tablets I have less than six hours sleep. □ I need some help but manage most of my personal care. □ Even when I take tablets I have less that five hours sleep. □ I need help in every day in most aspects of self-care. □ Even when I take tablets I have less that two hours sleep. □ I do not get dressed, wash with difficulty and stay in bed. □ Pain prevents me from sleeping at all.

193



Section 5 – Lifting Section 8 –Sex Life □ I can lift heavy weights without extra pain. □ My sex life is normal and causes no extra □ I can lift heavy weights but it gives extra pain. □ My sex life is normal but causes some pain. □ Pain prevents me from lifting heavy weights off the □ My sex life is normal but it is very painful floor, but I can manage if they are conveniently positioned. □ Pain prevents me from lifting heavy weights if they are □ My sex life is severly restricted by pain. conveniently positioned. □ I can lift only very lightweights. □ My sex life is nearly absent because of pain. □ I cannot lift or carry anything at all. □ Pain prevents any sex life at all. Section 6 – Walking Section 9 – Social Life □ Pain does not prevent me from walking any distance. □ My social life is normal and gives me no extra pain. □ Pain prevents me from walking more than 1 mile. □ My social life is normal but increases the degree of pain. □ Pain prevents me from walking more that ½ mile. □ Pain has no significant effect on my social

life apart from limiting my more energetic interests, eg dancing, etc.

□ Pain prevents me from walking more than ¼ mile. □ Pain has restricted my social life and I do not go out as often. □ I can only walk using a stick or crutches. □ Pain has restricted my social life to my home. □ I am in bed most of the time and have to crawl to □ I have no social life because of pain. the toilet. Section 7 – Sitting Section 10- Traveling □ I can sit in any chair as long as I like. □ I can travel anywhere without extra pain. □ I can only sit in my favorite chair as long as I like. □ I can travel anywhere but it gives me extra

pain. □ Pain prevents me sitting more than 1 hour. □ Pain is bad but I can manage journeys over

two hours. □ Pain prevents me sitting more than ½ hour. □ Pain restricts me to journeys of less than 1

hour. □ Pain prevents me sitting more than ¼ hour. □ Pain restricts me to short necessary journeys

under 30 minutes. □ Pain prevents me from sitting at all. □ Pain prevents me from traveling except to

the doctor or hospital. Comments: ___________________________________________________________________________________________

Oswestry Neck Disability Index (NDI)

194



The Neck Disability Index is a revised form of the Oswestry Low Back Pain Questionnaire and is designed to measure the activities of daily living in adults with neck pain. It is useful in both clinical practice and in a research setting. Administration The Neck Disability Index is a paper and pencil exam, which takes 5 to 10 minutes to complete and approximately 5 minutes to score. Scoring Each section is scored on a five point ordinal scale. (See Oswestry scoring instruction for exact scoring mechanism.) The scores of each section are added together to achieve a total score. Interpretation A high score indicates that there is an extreme amount of functional disability caused by neck pain. Reliability In a study of 48 patients the Neck Disability Index is found to have a strong level of test-retest reliability. The correlation coefficient was computed at 0.89. The total index was found to have a high degree of internal consistency, with an alpha coefficient of 0.80. All of the individual subsets had an alpha coefficient larger that0.76 with the highest items including the sections of headaches, lifting, recreation, reading and driving. Validity Face validity was established based on feedback from a group of peers and patients. A moderate level of concurrent validity was established in a study of 48 subjects. The changes in the Neck Disability Index in pre- and post-treatment scores were compared with those of an improvement Visual Analog Scale. Reference Vernon H, Mior S. The Neck Disability Index: A study of Reliability and Validity. Journal of Manipulative and Physiological Therapeutics 1991; 14:409-415.

Neck Disability Index

195



Name ____________________________Date ________________ Evaluator _________________

This questionnaire has been designed to give your therapist information as to how your neck pain has affected you in your everyday life activities. Please answer each section; marking only ONE box which best describes your status today.

Section 1 – Pain Intensity □ I have no pain at the moment. □ The pain is very mild at the moment. □ The pain is moderate at the moment. □ The pain is fairly severe at the moment. □ The pain is very severe at the moment. □ The pain is the worst imaginable at the moment. Section 2 - Personal Care (Washing, dressing, etc.) □ I can look after myself normally without causing extra pain. □ I can look after myself normally but it causes me extra pain. □ It is painful to look after myself and I am slow and careful. □ I need some help but manage most of my personal care. □ I need help every day in most aspects of self-care. □ I do not get dressed, wash with difficulty and stay in bed. Section 3 – Lifting □ I can lift heavy weights without extra pain. □ I can lift heavy weights but it gives extra pain. □ Pain prevents me from lifting heavy weights off the floor, but I can manage if they

are conveniently positioned, for example on a table. □ Pain prevents me from lifting heavy weights but I can manage light to medium

weights if they are conveniently positioned. □ I can lift only very lightweights. □ I cannot lift or carry anything at all. Section 4 – Reading □ I can read as much as I want to with no pain in my neck. □ I can read as much as I want to with slight pain in my neck. □ I can read as much as I want with moderate pain in my neck. □ I can’t read as much as I want because of moderate pain in my neck. □ I can hardly read at all because of severe pain in my neck. □ I cannot read at all. Section 5 - Headache □ I have no headache at all. □ I have slight headaches, which come infrequently. □ I have moderate headaches, which come infrequently. □ I have moderate headaches, which come frequently. □ I have severe headaches, which come frequently.

196



□ I have headaches almost all the time. Section 6 – Concentration □ I can concentrate fully when I want to with no difficulty. □ I can concentrate fully when I want to with slight difficulty. □ I have a fair degree of difficulty in concentrating when I want to. □ I have a lot of difficulty in concentrating when I want to. □ I have a great deal of difficulty in concentrating when I want to. □ I cannot concentrate at all.

Section 7 – Work □ I can do as much as I want to. □ I can only do my usual work but no more. □ I can do most of my usual work, but no more. □ I cannot do my usual work. □ I can hardly do any work at all. □ I can’t do any work at all.

Section 8 – Driving □ I can drive my car without any neck pain. □ I can drive my car as long as I want with slight pain in my neck. □ I can drive my car as long as I want with moderate pain in my neck. □ I can’t drive my car as long as I want because of moderate pain in my neck. □ I can hardly drive at all because of severe pain in my neck. □ I can’t drive my car at all.

Section 9 – Sleeping □ I have no trouble sleeping. □ My sleep is slightly disturbed (less than 1 hour sleep loss). □ My sleep is mildly disturbed (1-2 hour sleep loss). □ My sleep is moderately disturbed (2-3 hour sleep loss). □ My sleep is greatly disturbed (3-5 hours sleep loss). □ My sleep is completely disturbed (5-7 hours sleep loss).

Section 10- Recreation □ I am able to engage in all my recreational activities with no neck pain at all. □ I am able to engage in all my recreational activities with some pain in my neck.

□ I am able to engage in most but not all of my usual recreational activities because of pain in my neck.

□ I am able to engage in a few of my usual recreational activities because of pain in my neck.

□ I can hardly do any recreational activities because of pain in my neck. □ I can’t do any recreational activities at all.

Comments:

197



Adapted and reprinted with permission. Vernon H, Mior S. The Neck Disability Index.: A Study of Reliability and Validity. Journal of Manipulative and Physiological Therapeutics 1991; 1 4(7):409-4 15. Conclusion Consistency of Effort and Reliability of Pain criteria are very important and are an aspect that physicians and insurance carriers tend to weight the value of an evaluation on. There are 40 Consistency of Effort and Reliability of Pain checks presently in the Online Assessment Application FCE. Not all checks are used in every evaluation. However, the test is considered Consistent Effort and Reliable Pain based on the outline below: Consistency of Effort

100% to 70% “During objective functional testing this client demonstrated a

consistency of effort of _____% which would suggest the

client put forth full and consistent effort during this

evaluation.”

69.9% to 60% “During objective functional testing this client demonstrated a


client presented with segmental inconsistencies during this

evaluation resulting in mild self limiting behaviors.”

59.9% and below “During objective functional testing this client demonstrated a


client presented with significant observational and evidenced

based contradictions resulting in consistency of effort

discrepancies and self limiting behaviors.”

Reliability of Pain

100% to 50% “During objective functional testing this client reported

reliable pain ratings _____% of the time which would suggest

that pain could have been considered a limiting factor during

testing.”

49.9% and below “During objective functional testing this client reported

reliable pain ratings _____% of the time which would suggest

that this client reported unreliable pain ratings. The

functional results obtained during this kinesiophysical test

were based on the demonstrated mechanics secondary to

these unreliable pain ratings.”

198



Sources Cited

Ashton, A. L. and Meyers, S. Serial grip strength testing – its role in assessment of wrist and hand disability. The Internet Journal of Surgery ISSN 1528-8242

Robinson, M. E., Geisser, M. E., Hanson, E. S., & O’Connor, P. D. (1993) Detecting sub-maximal efforts in grip strength testing with the coefficient of variation. Journal of Occupational Rehabilitation, 3, 45-50. Stokes, H. M., Landrieu, K. W., Domangue, B. and Kunen, S. (1995) Identification of low effort patients through dynamometry. Journal of Hand Surgery. 20A, 1047-1056. Waddell G, McCulloch JA, Kummel E, Venner, RM: Nonorganic Physical Signs in Low-Back Pain. Spine 5:117-125, 1980.

199

Dual Inclinometric AMA guide to impairment ratings Cervical Range of Motion

Movement Description Range Calvarium angle

T1 ROM

Cervical flexion angle

± 10% or 5º Yes No

Maximum cervical flexion angle

Cervical Flexion

% impairment

Calvarium angle

T1 ROM

Cervical extension angle


Maximum cervical extension angle

Cervical Extension

% impairment

Position Cervical ankylosis in flexion/extension

% impairment

Excludes any impairment for abnormal flexion or extension

motion

Calvarium angle

T1 ROM

Cervical left flexion angle


Maximum cervical left lateral flexion angle

Cervical left lateral bending

% impairment

Calvarium angle

T1 ROM

Cervical right flexion angle


Maximum cervical right lateral flexion angle

Cervical right lateral bending

% impairment

Position Cervical ankylosis in lateral bending

% impairment

Excludes any impairment for abnormal lateral flexion or

extension motion

Cervical left rotation angle


Maximum cervical left rotation angle

Cervical left rotation

% impairment

Cervical right rotation angle


Maximum cervical right rotation angle

Cervical right rotation

% impairment

Cervical ankylosis in rotation

Excludes any impairment for abnormal rotation

Total cervical range of motion and ankylosis impairment______________% Total cervical range of motion=% impairments of flexion + extension + left lateral bend + right lateral bend + left rotation + right rotation

200

Dual Inclinometric AMA guide to impairment ratings Thoracic Range of Motion

Movement Description Range

T1 reading xxxxx xxxxx xxxxx xxxxx xxxxx

T 12 reading xxxxx xxxxx xxxxx xxxxx xxxxx

Angle of minimum kyphosis xxxxx xxxxx xxxxx xxxxx xxxxx

Angle of Minimum Kyphosis (thoracic ankylosis in extension)

% impairment due to thoracic ankylosis Use larger of either ankylosis or flexion impairment

T1 ROM

T12 ROM

Thoracic Flexion angle


Maximum thoracic flexion angle

Thoracic Flexion

% impairment

T1 ROM

T12 ROM

Thoracic left rotation angle


Maximum thoracic left rotation angle

Thoracic left rotation

% impairment

T1 ROM

T12 ROM

Thoracic right rotation angle


Maximum thoracic left rotation angle

Thoracic right rotation

% impairment

Position Thoracic ankylosis in rotation

% impairment

Total thoracic range of motion and ankylosis impairment______________%

201

Dual Inclinometric AMA guide to impairment ratings Lumbar Range of Motion

Movement Description Range

T12 ROM

Sacral ROM

True Lumbar Flexion angle


Maximum true lumbar flexion angle

Lumbar Flexion

% impairment

T12 ROM

Sacral ROM

True Lumbar extension angle


Maximum true lumbar extension angle Add sacral flexion and extension ROM and compare to tightest SLR angle

Lumbar Extension

% impairment

Left SLR


Straight Leg raising Left

Maximum SLR Left

If tightest SLR ROM exceeds sum of sacral flexion and extension by more than 15% lumbar ROM test is invalid

Right SLR


Straight Leg raising Right

Maximum SLR Right

If tightest SLR ROM exceeds sum of sacral flexion and extension by more than 15% lumbar ROM test is invalid

T12 ROM

Sacral ROM

True left lateral bending angle


Maximum true left lateral bend angle

Lumbar left lateral bending

% impairment

T12 ROM

Sacral ROM

True right lateral bending angle


Maximum true right lateral bend angle

Lumbar right lateral bending

% impairment

Position Lumbar ankylosis in lateral bending

% impairment

Total lumbar range of motion and ankylosis impairment______________%

202

OccuPro Functional Capacity Evaluation Upper Extremity Testing


Chapter 7

Upper Extremity Testing

HAND STRENGTH Hand strength is an activity that each and every client must have to complete the tasks needed throughout their daily life, work and throughout this test. Numerous tests throughout this evaluation require the client to have functional hand strength. Without functional hand strength the client would struggle with all of the material handling tests. Simple and firm grasping needs to be observed during this test and correlated to the results of formal grip and pinch strength testing. A client’s hand strength is measured using a standard hand and pinch strength dynamometer and the results are compared to Mathiowetz age and gender norms. The Functional Capacity Evaluation allows for documentation of the clients grip and pinch numbers, the norms and ranges per the Mathiowetz age and gender norms are automatically populated within the sotware, and the coefficient of variation between the three trials is calculated. *Please note that in functional testing per, the Americans with Disabilities Act, comparing someone’s ability to norms CANNOT be used to determine if someone can or cannot perform a job. In OccuPro’s FCE we use Matheowitz age and gender norms to assist in determining if someone can perform grasping and pinching on an occasional, frequent or continuous basis. We also use the other functional tests performed during testing to make our overall decision.

Grip Testing Grip Strength Grip strength is assessed using the hand strength dynamometer- Jamar, and three separate tests are performed on both the right and left upper extremity. The highest score noted in these tests are used to help determine a client’s abilities. Typically when performing this testing the mean or average grip strength is compared to the Mathiowetz age and gender norms and more importantly the ranges. The goal of grip strength is for the client to be within the Mathiowetz age and gender ranges that are provided in appendix A and in the grip strength tables in the FCE software. Being within these ranges would suggest that the client has the ability to perform simple work related grasping activities on a continuous basis during an average work shift and firm grasping on an occasional to frequent basis. However, the mean will not be the route in which these levels are determined from. It will be the highest score from position two of the dynamometer based on the three separate tests performed. If the physical demands of the job require firm grasping frequently to continuously during an average shift, then the clients grip strength ability achieved in any of the three tests would

203



need to exceed Mathiowetz’s age and gender mean. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a grip strength test and you will hold the grip strength dynamometer at you side with your elbow at 90 degrees.” “Please squeeze the dynamometer as hard as you can.” “You will be performing three separate tests on each hand and we will then determine your maximum grasping strength.” After each test you will document right and left next to trial 1, 2, and 3. Throughout testing the peak grasping strength will be compared to the range and mean per the Mathiowetz age and gender norms. These are gathered from appendix A in the procedure manual or within the software. The comparison of the client’s highest score from three trial grip, five span grip position 2 or rapid grip exchange to the range and mean will establish whether the client can perform occasional, frequent, or continuous firm and simple grasping throughout an average shift. The next item is the consistency of effort criteria! The coefficient of variation between each trial should be calculated and reported on. If the coefficient of variation is greater than or equal to 15% then the three trial grip test is considered to be inconsistent. Secondly, the software will calculate the clients grip strength and compare it to the second position on five span grip strength testing. This will help to establish a client’s consistency of effort between multiple tests in that the client needs to perform within 15% of each other for a consistent test. If the coefficient of variation between the three trial grip strength and the second position during 5 span grip strength testing is greater than or equal to 15% then the test is considered to be inconsistent. Five Span Grip Strength Testing Five span grip strength testing helps to establish consistency of effort and whether the client put forth full effort during three trial grip strength testing. The clients grip strength is tested in all five positions on the grip strength dynamometer starting in the first position or the position where the handle is closest to the bar. The client should be instructed that they will only get one opportunity to exert full effort with each hand in each position and that they need to put forth their fullest effort. The client should be instructed, “The next test you will perform is called the five span grip strength test and what I would like you to do is again squeeze the dynamometer as hard as you can.” We are going to place the dynamometer into the five different positions starting in this first position.” “You will first start on the right and then we will place the dynamometer into your left hand and again you will squeeze as hard as you can.” We will continue until all five positions have been tested.” Following each trial the scores should be documented. The results of this test are to produce a bell shaped or modified bell shaped curve. If one of these is not obtained then this clients grip testing will be considered to be inconsistent. The above graph demonstrates a bell shaped curve on the right and left. The Online Assessment

204



Application software will calculate whether a bell shaped curve is achieved based on the research performed by Stokes in 1983. Much research has been done since this time that does not support Stokes findings in regards to Five Span Grip Strength Testing. OccuPro’s FCE allows a modified to flattened bell shaped curve which allows a consistent test. A non-bell shaped curve would suggest the client was inconsistent in regards to their effort. Rapid Exchange Grip Strength Test Rapid exchange grip strength testing helps to establish consistency of effort and whether the client put forth full effort during grip strength testing. The handle of the dynamometer should first be placed in the 2nd position. The evaluator holds the dynamometer with one hand grabbing at the back of the dial and the other hand supporting the bottom. The client is asked to sit with both arms at their side and their elbows at 90 degrees. The dynamometer should then be placed into one of the hands and the client should be instructed to squeeze with maximum effort for a split second. After the split second, the dynamometer is removed from the first hand and placed instantly into the second hand. The dynamometer should then be moved back and forth between the two hands for split seconds and up to 8 grips per hand. The entire test should take no more than 8 – 9 seconds. The evaluator should monitor the dynamometer gauge throughout testing and determine the client’s peak forces for both hands between repetition 5 and repetition 8. The first four repetitions should be disregarded in regards to the numerical values achieved. These peak forces should then be compared to the peck force during three trial grip testing and postion number two during five span testing. The client should be instructed, “The next test you will perform is the rapid exchange grip strength test and what I would like you to do is again squeeze the dynamometer as hard as you can but now each squeeze will be a fraction of a second and I will alternate between both of your hands 8 times.” “ Please sit with your elbows at 90 degrees and both of your hands ready to accept the dynamometer” “I will first start on your right, you will squeeze for less than a second, and then we will place the dynamometer into your left hand and again you will squeeze as hard as you can for less than a second.” “We will continue until we have reached 8 trials on each hand”. The peak scores noted on the right and left between repetition 5 through repetition 8 should then be compared to the three trials on the right and left during three trial grip strength testing and position number 2 during 5 span grip testing. If either of these peaks was greater than any of the three trials on that same side than that would suggest inconsistency. The most important part of this test is to determine if the client can perform simple and firm grasping on an occasional, frequent, or continuous basis throughout an average day. Both simple and firm grasping needs to be determined based on their abilities when performing three trial grip strength, five span grip strength and rapid exchange grip testing. The following table is provided to assist in this determination but it should be recognized that there is no cookie cutter answer. The hints provided under the occasional, frequent, and continuous columns would suggest that the client is at that level regarding their functional abilities. One, some, or all of the suggestions are appropriate to determine the physical demand level a patient is at. To document the level of avoid the client needs to demonstrate a zero in regards to grasping and/or pinching strength.

205



206



Pinch Testing Key/Lateral Pinch Strength Key or Lateral pinch strength is assessed using the pinch strength dynamometer and three separate tests are performed on both the right and left upper extremity. The highest demonstrated ability during pinch testing is then used to calculate the client’s lateral pinch strength abilities and used as a comparison to the Matheowitz age and gender norms. The goal of lateral pinch strength is for the client to be within the Matheowitz age and gender ranges that are provided in appendix A or in the table provided in the software. Being within these ranges would suggest that the client has the ability to perform simple work related pinching activities on a continuous basis during an average work shift. If the physical demands of the job require firm pinching frequently too continuously during an average shift, then an ergonomic consultation needs to be performed secondary to the likelihood of ergonomic related risk factors. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a pinching test and you will hold the pinch strength dynamometer at you side with your elbow at 90 degrees.” “Please squeeze the dynamometer as hard as you can in a fashion in which you would be holding a key.” “You will be performing three separate

207



tests on each hand and we will then calculate the average pinch strength.” After each test you will document the right and left pinch strength abilities next to trial 1, 2, and 3. The comparison of the client’s average to the range and mean will establish whether the client can perform occasional, frequent, or continuous firm and simple pinching throughout an average shift. The next item is the consistency of effort criteria! The coefficient of variation between each trial is calculated. If the average percent difference is greater than or equal to 15% then the test is considered to be inconsistent. Palmar Pinch Strength Palmar pinch strength (three chuck jaw/three point pinch) is assessed using the pinch strength dynamometer and three separate tests are performed on both the right and left upper extremity. The highest score of these three tests are then used to calculate the client’s palmar pinch strength abilities and then used as a comparison to the Matheowitz age and gender norms. The goal of palmar pinch strength is for the client to be within the Matheowitz age and gender ranges that are provided in appendix A or in the software. Being within these ranges would suggest that the client has the ability to perform simple work related palmar pinching activities on a continuous basis during an average work shift. If the physical demands of the job require firm pinching frequently too continuously during an average shift, then an ergonomic consultation needs to be performed secondary to the likelihood of ergonomic related risk factors. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a pinching test and you will hold the pinch strength dynamometer at your side with your elbow at 90 degrees.” “Please squeeze the dynamometer as hard as you can in a fashion in which you would be pinching using your pointer and middle finger and pinching with your thumb.” “You will be performing three separate tests on each hand and we will then calculate the average pinch strength.” After each test you will document the right and left palmar pinch ability next to trial 1, 2, and 3. The results of the highest pinch would then be compared to the range and mean per the Matheowitz age and gender norms. These are gathered from appendix A or in the software. The comparison of the client’s average to the range and mean will establish whether the client can perform palmar pinching on an occasional, frequent, or continuous basis throughout an average shift. Tip Pinch Strength Tip pinch strength is assessed using the pinch strength dynamometer and three separate tests are performed on both the right and left upper extremity. The highest achieved score is used to calculate the client’s tip pinch strength abilities and then used as a comparison to the Matheowitz age and gender norms. The goal of tip pinch strength is for the client to be within the Matheowitz age and gender ranges that are provided in appendix A or within the software. Being within these ranges would suggest that the client has the ability to perform simple work related tip pinching activities on a continuous basis during

208



an average work shift. If the physical demands of the job require firm pinching frequently too continuously during an average shift, then an ergonomic consultation needs to be performed secondary to the likelihood of ergonomic related risk factors. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a pinching test and you will hold the pinch strength dynamometer at your side with your elbow at 90 degrees.” “Please squeeze the dynamometer as hard as you can in a fashion in with your index finger on top and your thumb on the bottom.” “You will be performing three separate tests on each hand and we will then calculate the average pinch strength.” After each test you will document the right and left tip pinch results next to trial 1, 2, and 3. The highest achieved pinch strength is then compared to the Matheowitz age and gender norms. The comparison of the client’s highest level compared to the range and mean will help to establish whether the client can perform occasional, frequent, or continuous simple pinching throughout an average shift. The next item is the consistency of effort criteria! If the coefficient of variation is greater than or equal to 15% then the test is considered to be inconsistent.

Fine Motor Coordination Fine motor coordination may be used in a variety of occupations and employment settings. This may consist of using or manipulating small electrical wires, small mechanical parts/objects, hand tools, or manipulating various objects. Assessing fine motor coordination and finger dexterity may be demonstrated in 2 different standardized tests. Ultimately any fine motor test can be used as long as it is research based and has some type of scoring mechanism. Secondly, if a job requires

209



pinching then the job also requires fine motor coordination. If the client has a sensation deficit, these tests will assist in determining the client’s functional limitations and may be able to correlate to the client’s sensation limitations. Purdue Pegboard The standard test used for coordinational testing is the Purdue Pegboard however; many of the standardized coordinational tests can be used to supplement the Purdue Pegboard. When performing the Purdue Pegboard test the subject should be comfortably seated at the testing table directly in front of the Purdue Pegboard. The far right and far left cups should have 25 pins in each to equal a total of 50 pins. For right-handed subjects, the cup to the right of center should have 20 collars and the cup to the left of center should have 40 washers. If the subject is left handed, the collar and washer locations should be on the reverse side of center. The following directions are for single subject testing.

4 TESTS: “This is a test to see how quickly and accurately you can work with your hands. Before you begin each battery of the test, you will be told what to do and then you will have an opportunity to practice. Be sure you understand exactly what to do.” Right Hand (30 seconds) Begin by saying and demonstrating: “Pick up one pin at a time with your right hand from the right-handed cup. Starting with the top hole, place each pin in the right-hand row. Now you may insert a few pins for practice. If during the testing time you drop a pin, do not stop to pick it up. Simply continue by picking another pin out of the cup.” “Stop. Now take out the practice pins, and put them back into the right hand cup”. “When I say ‘Begin,’ place as many pins as possible in the right-hand row, starting with the top hole. Work as rapidly as you can until I say ‘Stop.’” “Are you ready? Begin.” At the end of the exactly 30 seconds, say: “Stop.” Left Hand (30 seconds) “Pick up one pin at a time with your left hand from the left-handed cup. Starting with the top hole, place each pin in the left-hand row. Now you may insert a few pins for practice.” Same as above for the right hand. Both Hands (30 seconds) “For this part of the test, you will use both hands at the same time. Pick up a pin from the right-hand cup with your right hand, and at the same time pick up a pin from the left-hand cup with your left hand. Then place the pins down the rows. Begin with the top hole of both rows. (Demonstrate. Then replaced the pins used for demonstration.) Now you may insert a few pins with both hands for practice”. “Stop. Take out the practice pins, and put them back in the proper cups.”

210



Then say: “When I say ‘Begin,’ place as many pins as possible with both hands, starting with the top hole of both rows. Work as rapidly as you can, until I say ‘Stop.’” “Are you read? Begin.” Start timing when you “Begin.” Assembly (1 minute): “Pick up one pin from the right-hand cup with your right hand. While you are placing it in the top hole in the right hand row, pick up a washer with your left hand. As soon as the pin has been placed, drop the washer over the pin. While the washer is being placed over the pin with your left hand, pick up a collar with your right hand. While the collar is being dropped over the pin, pick up another washer with your left hand and drop it over the collar. This completes the first ‘assembly,’ consisting of a pin, a washer, a collar, and a washer. While the final washer for the first assembly is being placed with your left hand, start the second assembly immediately by picking up another pin with your right hand. Place it in the next hole, drop a washer over it with your left hand, and so on, completing another assembly. Now, take a moment to try a few practice assemblies.” “Stop. Now return the pins, collars, and washers to their proper cups.” Then say: “When I say ‘Begin,’ make as many assemblies as possible, beginning with the top hole. Work quickly until I say ‘Stop.’” Emphasize that both hands should be operating at all times: one picking up a pin, one a washer, one a collar, and so on. The client should be allowed to make four or five complete assemblies before the test is begun to make certain they fully understand the “alternating” procedure. The client must keep both hands moving at the same time. If he or she fails to do this, the evaluator should give further instructions. Note: If the client is left-handed, the washer and collar locations in the cups are switched. The client begins by picking up the pin with his/her left hand, the washer with his/her right hand, the collar with his/her left hand, another washer with his/her right hand and so on through all assemblies. Count the number of parts assembled and record the number of parts assembled in the pieces section. Beyond completed assemblies, if there are additional parts properly placed at the end of the minute, they are also added to the Assembly score. For example, if there is another pin and first washer, in addition to those 2 parts, the score is 32 + 2, or 34. After you record the score, the subject should return the pins, collars, and washers to the proper cups. The worker is classified as poor fine motor skills (0-23 parts), low speed assembly (24-29 parts), high-speed trainable (30-39 parts) and high-speed assembly (greater than 40 parts). The overall goal of coordinational testing with an FCE is to meet or exceed 30 parts, which would suggest that the client is at a high-speed trainable level. If the client is unable to meet or exceed this level it does not in and of itself mean the client cannot perform coordinational activities. The client’s ability to perform in a coordinational fashion must be observed along with the number of parts assembled. Figure 2C Male & Female Production Work (n=454)

211



Right Hand

Poor Low Avg. Average High Avg. Excellent 12 13 14 15 16 17 18 19 20 21 2 2 23 24 11.85 13.88 15.91 17.94 19.97 22.00 24.03 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Left Hand

Poor Low Avg. Average High Avg. Excellent 12 13 14 15 16 17 18 19 20 21 11.85 13.47 15.14 16.81 18.48 20.15 21.82 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Both Hands

Poor Low Avg. Average High Avg. Excellent 10 11 12 13 14 15 16 17 18 9.60 11.10 12.60 14.10 15.60 17.10 18.60 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Assembly

Poor Low Avg. Average High Avg. Excellent 20-27 28-33 34-40 43 44- 50 5 1-60 20.60 27.29 33.98 40.67 47.36 54.05 60.74 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Moberg’s Pick up Test Moberg’s test was designed for discriminative sensibility testing. This will involve assessing the client’s motor function, sensation, and may assist with identifying median nerve injuries rather than ulnar or radial nerve deficits. This is due to the median nerve innervates the digits that are required for grasping and precision pinching. This test will assess the client’s fine motor coordination/prehension with each hand when using basic household and everyday objects. Included in the box are 12 standard objects: wing nut, screw, key, nail, large nut, nickel, dime, washer, safety pin, paper clip, small hex nut, and small square nut. The evaluator will instruct the client and perform the following:

1. Tape small and ring digits to palm to prevent use. With the client using vision,

have the client pick up and place objects in a box as quickly as possible. Time the performance on two trials.

212



2. Response: Client picks up each object and deposits it in the box as quickly as

possible.

Measure the time to pick up and place all 12 objects into the box. The evaluator will input these trials in the boxes provided in the input page of the FCE. The average speed the client should be performing these tasks at are listed below, eyes open for trials 1 and 2.

Trial 1=10 to19 seconds

Trial 2= 9 to 16 seconds

The evaluator will then instruct the client to close their eyes and perform the same task in the same fashion.

3. Then occlude vision, place one object at a time between three-point pinch in random order and measure response; do two trials with each object.

4. Response: Client manipulates the object

and names it as quickly as possible. Measure the time to recognize each object on each of two trials (up to a maximum of 30 seconds).

Trial 1= 2 seconds per object Trial 2= 2 seconds per object.

The evaluator will need to identify the limiting factors and determine the frequency of the client’s ability to perform at “occasional, frequent, or continuous”. Then document in the comment section regarding the client’s ability and performance during this test. The evaluator should, also note any compensatory techniques, mechanical changes/deficits and/or limiting factors during this testing.

213



Gross Motor Coordination Gross motor coordination is part of every tasks as well as part of every occupation for essential functional tasks. Assessing gross motor coordination (manual dexterity) is different than fine motor coordination-which was discussed above. There are many gross motor tests on the market and any gross motor test can be used in this testing as long as it is research based and the client is able to be scored against a scoring system. The following test was initially developed to measure manual dexterity with people whom had severe coordination deficits or physical disabilities. Box and Block test allow the evaluator to assess each upper extremity dexterity, skillful abilities, and eye/hand coordination when handling large objects. This test will also give the evaluator the ability to assess the client’s endurance dynamically of the upper extremity due to this is a light repetitive activity. Box and Block The test box is placed lengthwise along the edge of a standard height table. Seat the client in a standard height chair facing the box. The 150 cubes are in the compartment of the test box to the dominant side of the client. The evaluator sits facing the client to monitor the blocks being transported. The following instructions are given: “I want to see how quickly you can pick up one block at a time with your right [left] hand (the evaluator points to the hand). Carry it to the other side of the box and drop it. Make sure your fingertips cross the partition. Watch me while I show you how.” The evaluator transports three blocks over the partition in the same direction the client is to move

214



them. After the demonstration the evaluator says: “If you pick up two blocks at the same time, they will count as one. If you drop one on the floor or table after you have carried it across, it will still be counted, so don’t waste time picking it up. If you toss the blocks without your fingertips crossing the partition, they will not be counted. Before you start you will have a chance to practice for 15 seconds. Do you have any questions? Place your hands on the sides of the box. When it is time to start, I will say “Ready” and then “Go”. Perform the 15-second practice. Start the stopwatch and when the 15 seconds have elapsed, say, “stop”. If mistakes are made during the practice period correct them before the actual testing period begins. On completion of the practice period return the transported blocks to the starting compartment. Mix the blocks to assure random distribution. Continue with the following instructions. “This will be the actual test. The instructions are the same. Work as quickly as you can. Ready. Go. [After 1 minute] “Stop”. Count the number of blocks transported and record. If the client transported more than one block at a time, or their fingertips did not cross the partition, this is noted by the evaluator and subtracted from the total. Turn the box so all blocks are in the same side as the next hand to be tested.

“Now you are to do the same thing with your left (right) hand. First you can practice. Put your hands on the sides of the box, as before. Pick up one block at a time with your hand and drop it on the other side of the box. Ready.” The evaluator waits 3 seconds. “Go”. (After 15 seconds). “Stop”. The score is the number of blocks carried from one compartment to the other in 1 minute subtracting from the total those transported 1 at a time. The evaluator will need to input the total number of blocks transported for each right hand and left hand. After the evaluator has completed the test, record the number in the data page of the software. Then document any of compensatory techniques utilized by the client, observed pain behaviors, reported pain during the task (quality of pain, location, and intermittent or constant), and identify any deficits with prehension.

215




For all of the hand tests, there are various consistency of effort tests being performed. They include basic observational consistency, coefficient of variation during three trial grip, five span grip testing, coefficient of variation between 5 span and three trial, rapid exchange grip testing, and coefficient of variation between pinch testing. This is summarized under the Validity Profile module for your review. The software, as described above, will automatically calculate whether the client is presenting with consistency of effort concerns or not. A sample is listed below and will also be described in the Consistency of Effort/Reliability of Pain chapter earlier in this manual.

Sources Citied Mathiowetz V., Volland G., Kashman N., Weber K.: Adult Norms for Box and Block Test of Manual Dexterity. Am J Occup Ther 39386-391, 1985. Mathiowetz V., Volland G., Kashman N., Weber K., Dowe, M., & Rogers, S. (1985). Grip and pinch strength: Normative data for adults. Archives of Physical Medicine and Rehabilitation, 66 (2), 69-74. Mathiowetz V., Volland G., Kashman N., Weber K. (1984). Reliability and validity of grip and pinch strength evaluation. Hand Surgery, 9A(2), 222-226.

216



Moberg, Eric: Objective Methods for Determining the Functional Value of Sensibility in the Hand. J. Bone Joint Surg. 40B:454, 1958. Stokes, HM. The Seriously uninjured hand – weakness of grip, Journal of Occupational Medicine, 1983; 25: 683-684 Tiffin, J. (1968). Purdue Pegboard: Examiner Manual. Chicago: Science Research Associates.

217

OccuPro Functional Capacity Evaluation Non-Material Handling


111

Chapter 8

Non-Material Handling

Walking Fast Paced Walking The Functional Capacity Evaluation is organized in a way that allows a client to warm up general areas of their body prior to performing weighted material handling testing. The first positional tolerance/repetitive functional test that is performed is the client’s ability to perform fast paced walking. The client in question may also need to perform prolonged walking testing as well if the client’s job requires continuous walking or you are performing a baseline FCE. The client is instructed that they are about to begin the next test involving the client walking 100 yards at his or her fastest possible walking pace. The United States Army regulation time for 100 yards suggests that an average individual will be able to complete this distance in 66 seconds. During this test the client’s gait pattern is observed and the amount of time it takes to complete the 100 yards is documented. The client is instructed, “You will now be performing a walking test on a level carpeted surface. You will be walking 100 yards without stopping. Please perform this test in the fastest possible walking pace that you feel you can tolerate. I will be timing you to see how fast you can perform this 100 yard walking test”. During the test there are certain things you need to observe and questions you need to answer. Did the client use an assistive device? Did the client require a cane to complete the test? Was the client wearing any splints? Was the client holding a body part or otherwise guarding during ambulation? Did the client exhibit a non-antalgic gait pattern on their right or left lower extremities? The evaluator may identify the client’s gait or any deficits with the stance phase or the swing phase. Was their speed considered a fast, slow, or average pace? Finally, was the client’s stride length equal? Any of these limiting factors may decrease the client’s ability to perform walking on a continuous, frequent, or even an occasional basis throughout an average shift.

218



112

The client’s reported pain rating on the zero to ten functional pain rating scale and their heart rate is then documented. The key with the pain rating scale is to determine the client’s self reported pain rating while performing the activity. It should also be noted that, as the evaluator, you are making a decision that a client can tolerate walking on a continuous basis during the course of an average shift and their job requires continuous walking then the client should be tested on prolonged walking to make a full walking decision. Example: Client demonstrates the ability to complete the 100 yards of walking in 68 seconds and reports no increases in pain, with an antalgic gait pattern. The client would be at a level that would allow him to walk on an occasional basis throughout an average shift. As a medical professional you would be hard pressed to recommend frequent or continuous walking when a client exhibits a deviation in gait and is unable to complete 100 yards of walking within 66 seconds. Prolonged Walking

Following the client’s demonstration of the 100 yard walking ability it is determined if the client needs to perform continuous walking and/or if the client demonstrated mechanical changes or not during the fast paced walking. If the evaluator determines that yes the client needs to perform continuous walking and the client did not demonstrate any mechanical changes or deficits during fast paced walking then prolonged walking testing should be performed. The evaluator should set up the treadmill for and explain how to safely get on and off the treadmill to the client. The evaluator should instruct the client by “I want to test your ability to walk at one time for as long as you are able to tolerate up to 15 minutes, using the treadmill. We will start out at a slow pace for a few seconds and increase as you can tolerate up to 3.0 mph or faster”. The speed should start at a comfortable walking pace for the client between 2.0 and 3.0 mph or what is similar to the pace the client would normally walk. The treadmill speed should then be increased up to 3.0mph or faster secondary. This is done to simulate a walking pace that is greater than a normal walking pace to make sure that the client is able to tolerate greater stresses to their body in regards to higher walking activities.

For example, the client may be a meter reader and walks all day long reading meters. This would be considered continuous walking and as the evaluator, this should be tested to determine the client’s continuous walking ability. The following table is provided to assist in whether the client can perform walking on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The hints provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities.

219



113

Start at the right column and the client needs to pass each category to be scored at that level.

Walking Comments

The most important portion is answering the question client can tolerate walking within the following frequency? The answer is one of the following: avoid, occasional, frequent, or continuous basis throughout an average day. There is a text box for both fast-paced walking and prolonged walking in order to thoroughly document the client’s abilities and deficits for each area. Since these tasks focus on different aspects of the client’s abilities it is important to identify any changes in gait pattern, areas if discomfort reported by the client, overall cardiovascular condition, and any other limiting factors identified.

Forward Reaching It would be safe to say that all jobs and during daily activities of living require forward reaching. This is a reaching evaluation to determine a client’s functional ability to perform forward reaching activities. There are three separate tests that are performed with forward reaching. The first test is a one time forward reach, the second test is forward reaching for 10 repetitions, and the third test is forward reaching for 10 repetitions in the fastest possible pace the client can tolerate. Prior to this specific test,

220



114

asks the following question. Does the client have a history of neck or shoulder injuries? This question will help to establish the client’s consistency of effort in this area. If the client does not have a history of neck or shoulder injuries and they are unable to achieve a continuous level than there is a concern regarding consistency of effort at this time.

One Time Forward Reach The client is asked to start with their hands at their side and then forward reach to a fully extended position at roughly shoulder height one time. “The next test you will perform is forward reaching and I would like for you to start with your hands at your side and then reach out in front of you one time and back down to your side.” The percent of forward reach is documented and then the limiting factors that were reported or observed. These include the clients speed, movement pattern in regards to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not you reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s heart rate and reported functional pain level. Following this documentation it is determined if the client can perform the 10 repetition test next. A reason the client would not be able to proceed was an inability to perform one repetition secondary to biomechanical limitations or a significant increase in self reported functional pain symptoms. Forward Reach Times 10 Repetitions The client is asked to start with their hands at their side and then forward reach to a fully extended position at roughly shoulder height ten times at a comfortable pace. “The next test you will perform is forward reaching and I would like for you to start with your hands at your side, then reach out in front of you as many times as you can up to 10 repetitions at a comfortable pace while returning your hands to your side after each repetition.” The percent of forward reach is documented and the limiting factors that were reported or observed. These include the clients speed, movement pattern in regards to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not you reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s heart rate and reported pain level. During this test the client should be palpated for crepitus. This is a non-documented validity test. Non-documented means that the test does not account for this however, if a client has an inability to complete the 10 repetitions and reports increase in pain

221



115

symptoms it would be safe to say that you would palpate an increase or a significant level of crepitus or possibly other biomechanical changes. Following this documentation it is determined if the client can perform the 10 repetition test at a fast pace which is next. Some reasons they may not be able to proceed is an inability to complete the 10 repetitions secondary to biomechanical limitations or an increase in self reported pain symptoms. Forward Reach Times 10 Repetitions in a Fast Pace The client is asked to start with their hands at their side and then forward reach to a fully extended position at roughly shoulder height ten times at the fastest possible pace they can tolerate. “The next test you will perform is forward reaching and I would like for you to start with your hands at your side, then reach out in front of you as many times as you can up to 10 at a the fastest possible pace you can tolerate while returning your hands to your side after each repetition.” The percent of forward reach is documented along with the limiting factors that were reported or observed. These include the clients speed, movement pattern in regards to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not you reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s heart rate and reported pain level. During this test the client should be palpated for crepitus. If the client is able to complete the 10 repetitions at a fast pace and exhibits a faster pace than the previous test without any documentable limiting factors then it would be safe to say that the client is able to forward reach on a continuous basis throughout an average shift. The following table is provided to assist in whether the client can perform forward reaching on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The levels provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

222



116

Example: Client demonstrates the ability to complete the 10 repetitions of reaching with noted crepitus and the client reporting a mild increase in pain symptoms. Client is asked to perform the 10 repetitions at a fast pace and they are able to complete this but report higher pain symptoms to a 5 and their overall speed did not change from the first set of 10 reps. This would suggest that the client is at a level that would allow frequent forward reaching abilities. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regards to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Above Shoulder Reaching Again, it would be safe to say that all jobs require forward reaching however, not all jobs require above shoulder reaching, if performing a job specific FCE. If the FCE is assessing overall functional abilities, then above shoulder reaching should be tested. This is a reaching evaluation to determine a client’s functional ability to perform reaching activities above the level of their shoulder. There are three separate tests that are performed with above shoulder reaching. The first test is a one time above shoulder reach, the second test is reaching above their shoulder level for 10 repetitions, and the third test is above shoulder reaching for 10 repetitions in the fastest possible pace the patient can tolerate. Prior to this specific test, ask the following question. Does the client

223



117

have a history of neck or shoulder injuries? This question will help to establish the client’s consistency in this area. If the client does not have a history of neck or shoulder injuries and they are unable to achieve a continuous level than there is a mild concern regarding consistency of effort at this time. One Time Above Shoulder Reach The client is asked to start with their hands at their side and then reach over the level of their shoulder to a fully extended position one time. “The next test you will perform is above shoulder reaching and I would like for you to start with your hands at your side and then reach over the level of your shoulder one time and back down to your side.” The percent of above shoulder reach is documented with the limiting factors that were reported or observed. These include the clients speed, movement pattern in regards to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not you reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s heart rate and reported pain level. During this test the client should be palpated for crepitus. Following this documentation it is determined if the client can perform the 10 repetition test next. Some reasons they may not be able to proceed is an inability to perform one repetition secondary to biomechanical limitations or a significant increase in self reported pain symptoms. Above Shoulder Reach Times 10 Repetitions The client is asked to start with their hands at their side and then reach over the level of their shoulder to a fully extended position ten times at a comfortable pace. “The next test you will perform is above shoulder reaching and I would like for you to start with your hands at your side, then reach over the level of your shoulder as many times as you can up to 10 at a comfortable pace while returning your hands to your side after each repetition.” The percent of above shoulder reach is documented regarding the limiting factors that were reported or observed. These include the client’s speed, movement pattern in regards to scapulohumeral rhythm, whether the movement pattern correlated with the pain reported. During this test the client should be palpated for crepitus. This is a non-documented validity test. Non-documented means that the test does not account for this however, if a client has an inability to complete the 10 repetitions and reports increase in pain symptoms it would be safe to say that you would palpate an increase or a significant level of crepitus with certain diagnosis. Following this documentation it is determined if the client can perform the 10 repetition test at a fast pace which is next. Again, a few reasons they would not be able to proceed is an inability to complete the 10 repetitions secondary to biomechanical limitations or an increase in self reported pain symptoms.

224



118

Above Shoulder Reach Times 10 Repetitions in a Fast Pace The client is asked to start with their hands at their side and then reach to a fully extended position over the level of their shoulder ten times at the fastest possible pace they can tolerate. “The next test you will perform is above shoulder reaching and I would like for you to start with your hands at your side, then reach over the level of your shoulder as many times as you can up to 10. I would like for you to perform this at the fastest possible pace you can tolerate while returning your hands to your side after each repetition.” The percent of above shoulder reach is documented with the limiting factors that were reported or observed. These include the clients speed, movement pattern in regards to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not you reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s heart rate and reported pain level. During this test the client should be palpated for crepitus. If the client is able to complete the 10 repetitions at a fast pace and exhibits a faster pace than the previous test without any documentable limiting factors then it would be safe to say that the client is able to above shoulder reach on a continuous basis throughout an average shift. The following table is provided to assist in whether the client can perform above shoulder reaching on an avoid, occasional, frequent, or continuous basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

225



119

Example: Client demonstrates the ability to complete the 10 repetitions of above shoulder reaching with audible and palpable crepitus noted. The client also exhibits biomechanical changes secondary to “a hitch” in his scapulohumeral rhythm. Client is not asked to perform above shoulder reaching times 10 reps at a fast past secondary to the biomechanical changes doing 10 reps at a comfortable pace. The question is now, is the client at the level that would allow occasional or frequent above shoulder reaching? Other factors need to be documented such as the client’s self reported ability and the reported pain. If the client reports no increase in pain and they report they don’t feel they have any deficits then the client is at an occasional level secondary to the mechanical changes. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regards to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Bending The bending test is the first test that primarily tests the client’s ability to perform activities that involve the low back. This is an activity that a client should be able to attempt or it is questionable if they are ready for a functional capacity evaluation. As medical professionals we have a primary goal related to teaching an injured client how to perform correct body mechanics while performing the essential functions of their job.

226



120

This focus on correct body mechanics would suggest that the client should refrain from bending as much as possible, especially if they are being treated for a low back injury. Biomechanical studies however have shown bending and lifting an object is better than squatting when the object lifted is wider than the lifters stance. When the object being lifted is a wide or a large object, studies have shown that there is less compressive force on the lumbar discs when bending and lifting compared to squatting, reaching forward to get to the box, and lifting. When the object to be lifted is a wide object and the lifter needs to reach out in front of them to grasp the object, because they cannot get close to the object, they are increasing the lever arm with their lumbar region being the fulcrum. Thus, bending and grasping the object keeps the object closer to the body and decreases this lever arm. Also, it needs to be recognized that clients in general will get into situations were they will need to bend or will forget the correct body mechanics. Because of these two points a bending test needs to be performed to determine the client’s bending abilities. The bending test consists of three separate tests with the evaluator asking the client to perform one repetition, as many bends as they can up to 10 repetitions, and thirdly, as many bends as they can up to 10 repetitions at the fastest possible pace they can tolerate. The bends should be to a height that allows them to stay comfortable and return to an erect position. During the instruction of this test the client needs to be instructed that they should bend to a height as close to their toes as possible but that they should go to a height that they can safely return to a full erect position without losing their balance or without causing undue biomechanical stress. Bending Times One Repetition The client is asked to start with their hands at their side and then bend to as close to their toes as they can for one repetition. “The next test you will perform is bending and I would like for you to start with your hands at your side, feet shoulder width apart, and then bend to as close to your toes as you can one time. The key to this bend is that I would like you to bend to a height off of the floor where you can return to an erect position without loss of balance and without a significant increase in pain.” The percent of full bend is documented with touching their toes being 100%, bending to mid calf being 75%, bending to their knee height being 50% and bending to their mid thigh being 25% of a full functional bend. The next section to be identified is in regards to the limiting factors that were reported or observed. These include the client’s speed, movement pattern in regards to bending mechanics, whether the movement pattern correlated with the pain reported, and regarding pain symptoms in comparison to the client’s ability. Following this documentation it is determined if the client can perform the 10 repetition test next. Some reasons they would not be able to proceed was an inability to perform one repetition secondary to biomechanical limitations or a significant increase in self reported pain symptoms.

227



121

Bending Times Ten Repetitions The client is asked to start with their hands at their side and then bend to as close to their toes as they can ten times at a comfortable pace. “The next test you will perform is bending and I would like for you to start with your hands at your side and then bend to as close to your toes as you can for as many repetitions as possible up to 10 reps. The key to this bend again is that I would like you to bend to a height off of the floor where you can return to an erect position without loss of balance and without a significant increase in pain.” The percent of full bend is documented with touching their toes being 100%, bending to mid calf being 75%, bending to their knee height being 50% and bending to their mid thigh being 25% of a full functional bend. The next section to be identified filled out is in regards to the limiting factors that were reported or observed. These include the client’s speed, movement pattern in regards to bending mechanics, whether the movement pattern correlated with the pain reported, and whether or not you observed an overreaction regarding pain symptoms in comparison to the client’s ability. Following this documentation it is determined if the client can perform the 10 repetition at a fast pace next. Some reasons they would not be able to proceed was an inability to perform the ten repetitions secondary to biomechanical limitations or a significant increase in self reported pain symptoms. Bending Times Ten Repetitions at a Fast Pace The client is asked to start with their hands at their side and then bend to as close to their toes as they can ten times at the fastest possible pace they can tolerate. “The next test you will perform is bending at the fastest possible pace that you can perform. I would like for you to start with your hands at your side and then bend to as close to your toes as you can for as many repetitions as possible up to 10 reps. The key to this bend again is that I would like you to bend to a height off of the floor where you can return to an erect position without loss of balance and without a significant increase in pain while performing these ten reps as fast as you feel you can.” The percent of full bend is documented with touching their toes being 100%, bending to mid calf being 75%, bending to their knee height being 50% and bending to their mid thigh being 25% of a full functional bend. Next, is identifying the limiting factors that were reported or observed. These include the client’s speed, movement pattern in regards to bending mechanics, whether the movement pattern correlated with the pain reported, and regarding pain symptoms in comparison to the client’s ability and diagnosis.

228



122

The following table is provided to assist in whether the client can perform bending on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

Example: Client demonstrates the ability to complete the 10 repetitions of bending and reports increased pain symptoms to a 3.5. The client also exhibits a decrease in rhythm from the first rep to the tenth rep. Client is not asked to perform bending times 10 reps at a fast past secondary to the increase in pain and the decrease in pace towards the end of the bending. The question is now, is the client at the level that would allow occasional or frequent bending? Other factors need to be documented such as the client’s self reported ability and the reported pain. If the client reports that they don’t feel they have any deficits in regards to bending then the client is at a frequent level and it would make sense to attempt the bending times 10 at a fast pace. If the client reports an increase in pain symptoms and that they continue to have difficulty regarding day-to-day bending then the client would be better off at the occasional level. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regards to the reasoning behind the physical demand

229



123

level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Squatting Squatting ability is usually an important aspect of most jobs. This is your first opportunity to observe the client’s ability to perform correct body mechanics prior to lifting. The squatting test is the second test that primarily tests the client’s ability to perform activities that involve the low back and or the lower extremities. This is an activity that a client should be able to attempt. If not it is questionable how they perform functional tasks at work and home and will need to identify compensatory techniques with functional activities. Squatting testing involves repetitive squatting and sustained squatting. These two tests are described below Repetitive Squatting Unlike the tests up to this point, the repetitive squatting test consists of two separate tests with the evaluator asking the client to perform one repetition and as many squats as they can up to 10 repetitions. The client is not asked to perform 10 repetitions of squatting at a fast pace because it is very rare that a client you are testing would need to perform continuous squatting throughout their day. If the client does need to perform continuous squatting during their shift, you would be better off testing this in the job simulation section of this evaluation and potentially coming back to this section and choosing a physical demand level if you would like. The squats should be to a height that allows them to stay comfortable. During the instruction of this test the client needs to be instructed that they should squat to a height as close to the floor as possible but that they should go to a height that they can safely return to a full erect position without losing their balance or without causing undue biomechanical stress. Squatting Times One Repetition The client is asked to start with their hands at their side and then squat to as close to the floor as they can for one repetition. “The next test you will perform is squatting and I would like for you to start with your hands at your side and then squat to as close to the floor as you can one time. The key to this squat is that I would like you to squat to a height off of the floor where you can return to an erect position without loss of balance, struggle, and without a significant increase in pain.” The percent of full squat is documented with touching the floor being 100%, squatting to mid calf being 75%, squatting to their knee height being 50% and squatting to their mid thigh being 25% of a full functional squat. The next section to be filled out is the yellow section in regards to the limiting factors that were reported or observed. These include

230



124

the clients speed, movement pattern in regards to squatting mechanics, whether the movement pattern correlated with the pain reported, and whether or not you observed an overreaction regarding pain symptoms in comparison to the client’s ability. A typical change in regards to biomechanics during squatting is the client not being able to weight bear evenly on their lower extremities. This would be considered a significant change in biomechanics. Following this documentation it is determined if the client can perform the 10 repetition test next. Some reasons they would not be able to proceed was an inability to perform one repetition secondary to biomechanical limitations or a significant increase in self reported pain symptoms. Squatting Times Ten Repetitions The client is asked to start with their hands at their side and then squat to as close to the floor as they can ten times at a comfortable pace. “The next test you will perform is ten reps of squatting and I would like for you to start with your hands at your side and then squat to as close to the floor as you can for as many repetitions as possible up to 10 reps. The key to this squat again is that I would like you to squat to a height off of the floor where you can return to an erect position without loss of balance, struggle, and without a significant increase in pain.” The percent of full squat is documented with touching of the floor being 100%, squatting to mid calf being 75%, squatting to their knee height being 50% and squatting to their mid thigh being 25% of a full functional squat. The next section to be filled out is the yellow section in regards to the limiting factors that were reported or observed. These include the clients speed, movement pattern in regards to squatting mechanics, whether the movement pattern correlated with the pain reported, and whether or not you observed an overreaction regarding pain symptoms in comparison to the client’s ability. The following table is provided to assist in whether the client can perform repetitive squatting on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

231



125

Example: Client demonstrates a significant struggle to complete the one repetition of squatting, exhibits unequal weight bearing, and reports increased pain symptoms. Client is not asked to perform squatting times 10 reps secondary to the above-mentioned items. The client is at a level where they should avoid all squatting activities.

Sustained Squatting Sustained squatting testing is performed on the rare occasion that the job specific FCE you are performing requires sustained squatting to perform the job. This testing should always be performed in job simulation testing fashion. This will not only improve the overall validity of your testing but sustained squatting is never performed without some need to perform sustained squatting to complete a job specific task. For example, a finish carpenter needs to be able to perform sustained squatting while using their nail gun to attach base boards. Well this is not straight sustained squatting and may involve some kneeling and some walking in a squatting position. Most importantly the finish carpenter will also be holding and carrying their nail gun. The more job simulation you can perform with this task the better off your test will be. The first aspect will be to create and document the job simulated sustained squatting test you will be performing. This should include the activity you will be simulating, a description of the tools you will be using for simulation, the weights of these tools, the duration of the simulation, the mechanics required for successful completion and the

232



126

overall expectation. Secondly, the amount of time requested should be entered into the appropriate text box. Following the completion of the job simulated activity the amount of time the client was able to complete should be entered, as well as movement pattern, pain correlation, compensatory techniques, and equal weight bearing. Then the overall heart rate and pain level should be documented. Other items requiring documentation may include pain behaviors, overall mechanics, location of pain, types of compensatory techniques, and inconsistencies. The following table is provided to assist in whether the client can perform sustained squatting on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regards to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Kneeling Client’s performing kneeling activities at work generally perform one or both of the following when it comes to kneeling. They may perform frequent or continuous kneeling which would involve them getting into a kneeling position on numerous occasions during their shift but not maintaining that position for a period of time and the opposite where the client gets into a kneeling position and maintains that position for a length of time.

233



127

Both areas of kneeling may need to be tested. This is an observational test to see if the client can tolerate 10 repetitions of kneeling which will help to establish frequent or continuous kneeling or 2 minutes of prolonged kneeling which will help to establish the client’s ability to perform occasional kneeling. Sustained Kneeling The sustained kneeling test involves the client ascending into a tall kneeling position and they are asked to maintain the tall kneeling position for as long as they can up to two minutes. This test is best performed with an item in front of the client that would allow them the safety of grabbing this item and pushing off of it to stand back up if needed. The best item to use in a clinic setting is a plinth. This item should only be used if necessary and should be avoided if the client is able. The client is instructed to “The next test you are going to perform is a prolonged kneeling test”. “I would like you to get into a tall kneeling position for as long as you can up to two minutes”. “Go ahead and use the table in front of you only if you need it for safety reasons when getting into the kneeling position or standing up”. The client may need a demonstration of what a tall kneeling position is or they will sit down on their legs during this kneeling test. Some of the items you are observing is the client’s ability to demonstrate equal weight bearing, can they tolerate the two minutes, and pain symptoms. The documentation of whether the movement pattern was normal or abnormal, did the movement correlate with the pain reported, did the client present with equal weight bearing, did the client require upper extremity assistance, noted crepitus, input heart rate and reported pain level, and was the client demonstrating compensatory techniques during sustained kneeling. The following table is provided to assist in whether the client can perform sustained squatting on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

234



128

Repetitive Kneeling The repetitive kneeling test looks at a client’s ability to descend to a kneeling position and ascend out of a kneeling position for as many repetitions as possible up to 10. This should be done in the same area as the sustained kneeling test so the client with safety concerns has the opportunity to use the object for upper extremity assistance. The client should be instructed that they should not use the plinth, table, or other object and that they should only use it if they are unable to stand or feel that they are feeling unsafe during the repetitions. This is to help determine if the client is at a level that they can perform frequent or continuous repetitive kneeling activities. If the client is able to complete the 10 repetitions of kneeling without the assistance of the table or plinth in front of them then they are able to perform kneeling frequently. If they require the use of the plinth or table to complete the 10 reps then they are at a level that they can perform occasional kneeling. Few jobs require continuous kneeling. One job that may require continuous kneeling for instance is a carpet layer. The client should be asked to ascend and descend for as many repetitions as they can up to 10 without using anything to hold on to unless they need to. The client should be instructed “Now you are going to perform a repetitive kneeling test and I would like you to kneel and stand up as many times as you can up to ten”. “I do not want you to

235



129

use the table unless you need to for safety reasons or if you are unable to get down or back up from the kneeling position”. The FCE allows for documentation of the percent of full kneel, whether the speed was slow, normal, or fast, whether the movement pattern was normal or abnormal, did the pain correlate with the movement pattern and diagnosis, upper extremity assistance used, and was there crepitus noted. The evaluator will need to input heart rate and reported pain level post this task. The following table is provided to assist in whether the client can perform sustained squatting on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

Example: Client demonstrates a struggle to complete the two minutes of kneeling, exhibits unequal weight bearing, and reports increased pain symptoms. Client is not asked to perform kneeling times 10 reps secondary to the above-mentioned items. The client is at a level where they should avoid all kneeling activities. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regards to the reasoning behind the physical demand

236



130

level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Crawling The test of crawling is functional and job specific. This task should be tested when assessing a client for disability reasons or if it pertains to the client’s specific job tasks. Crawling may be performed in a variety of jobs for instance: fire fighters, HVAC, carpenters, carpet layers, concrete finishers, housekeepers-industrial/hotel/residential, electricians, plumbers, mechanics, landscapers, etc., which involves the entire body to perform this task. Crawling is assessed in both forward and backward mobility. The evaluator will instruct the client to: “The next test you are going to perform is the crawling test”. “I would like you to get into a crawling position and crawl forwards for 30 seconds and then backwards for 30 seconds for a total of 1 minute”. “Go ahead and use the table in front of you only if you need it for safety reasons when getting into the crawling position or when standing up”. The client may need a demonstration of what a crawling forwards and backwards is. Crawling testing is job simulated in nature. There are no researched crawling tests on the open market so crawling needs to be demonstrated in minutes per hour in regards to occasional, frequent or continuous. Some of the areas you may observe are the client’s ability to demonstrate equal weight bearing, can they tolerate the one minute of crawling, can they ambulate both in a forwards and backwards direction, and pain symptoms. The documentation of whether the movement pattern was normal or abnormal- focusing on spine positioning, scapulohumeral rhythm, and hand/wrist positioning. Other questions may be did the movement correlate with the pain reported, did the client present with equal weight bearing on upper and lower extremities, did the client require upper extremity assistance to ascend or descend into position, noted crepitus, input heart rate and reported pain level, and was the client demonstrating compensatory techniques during crawling. The following table is provided to assist in whether the client can perform sustained squatting on an avoid, occasional, frequent or continuous basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and continuous columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

237



131

Example: Client completes the one minute of crawling without any mechanical deficits. The client is at a level in which they can perform crawling on an occasional basis. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regards to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Off of the Ground Balance Static and dynamic balancing are activities that are usually taken for granted in regards to the client’s occupation. For instance, an ironworker needs to be able to perform frequent dynamic balance and even a painter needs frequent static balance when performing ladder or scaffold work. Balance of the client, following a lower extremity injury, is highly important and overall balance deficits may be recognized during this functional test. This may require a referral to a vestibular and balance specialist. Static Balance When testing the ability of the client for static balance, there are several different tests that may be performed. They are listed below in the order of most basic too most difficult of balancing tasks. Romberg’s Test:

238



132

Instructions: “Stand with feet together and arms folded across chest and hold for 30 seconds”. The evaluator should note the client’s sway pattern and if the client presents with a loss of balance while attempting to maintain the narrow stance. Keep in mind the client’s heart rate or reported pain level with observed pain behaviors (facial grimacing, holding breath, shortness of breath, holding affected body part, etc). Sharpen Romberg’s Test: Instructions: “Stand with one foot in front of the other; arms are folded across chest, and hold for 30 seconds”. This test if formally tested with either foot in test position. It may be tested in 2 trials, first with right foot in front and second with right foot in back, and the client is only able to have 2 attempts per trial. It should be noted if there is a difference, loss of balance, or reported pain during either test. Keep in mind the client’s heart rate or reported pain level with observed pain behaviors (facial grimacing, holding breath, shortness of breath, holding affected body part, etc). If the client presents with the ability to perform these two tests without a safety concern, then continue to test the client in single leg stance and functional reach assessment. The Functional Reach Assessment is to assess how far the client is able to balance outside their center base of support. This assessment has normative data to assist with categorizing the client within the frequency. During this test, the evaluator may identify weight-bearing strategies with sway patterns, any compensatory techniques observed, and safety concerns with noted loss of balance. In the comment section, be sure to document identify reported pain, observed pain behaviors, and safety concerns of the client. Functional Reach Assessment: Instructions:

Positioning of the client: Align acromion process with yardstick. Flex arm to 90° with elbow extended and measure the end of their fingertips. Instruct the client to: “Lean forward as far as able without your feet moving”. After this is performed, measure the distance from start position to end position and calculate the difference between 1st and 2nd measurement. This number is then inputted into the box (norms are listed below). The evaluator must document any problems areas or deficits with this task in the balance comment section. A loss of balance is noted by taking a step with either foot or holding on to the wall/evaluator.

Norms: Young male 18-35=17 inches Young female 18-35=15 inches Middle age male 35-55=15 inches Middle age female 35-55= 14 inches Elderly male 55+ = 13 inches Elderly female 55+ = 10 inches

239



133

The next tests for static balance are: Single Leg Stance - eyes open (SLS EO) Single Leg Stance - eyes closed (SLS EC) Both SLS are testing for strength of the lower extremities and proprioception. Static balance testing is performed with the client performing some basic balancing tasks. Each of the tasks is 30 seconds in duration. Single leg Stance is tested with the client independently balancing on their right leg and left leg for up to 30 seconds. The client is asked to “I would like you to balance on your left and right leg for as long as you can up to 30 seconds, with your arms folded across your chest, and you can start with whichever leg you would like to since we will be attempting this on both legs”. If the client demonstrates the ability to balance for the 30 seconds bilaterally they would be considered to have average functional static balance. The client has the opportunity to attempt 2 trials of each extremity. If they are unable to complete the 30 seconds, it needs to be determined if the balance deficit was vestibular in nature, due to pain, orthopedic in nature, or muscular weakness while noting sway pattern- compensatory strategies, ability to recover or a loss of balance occurred. Single leg stance with eyes closed is a higher level balancing and proprioceptive task. The client is instructed the following: “I would like you to balance on your left and right leg for as long as you can up to 30 seconds, with your eyes closed and arms folded across your chest, and you can start with whichever leg you would like to since we will be attempting this on both legs”. the 30-second test on each leg with their eyes closed. If vestibular in nature, a referral to a vestibular specialist would be highly beneficial for a client that requires static balance in their occupation. If the balance is pain related then a goal needs to be set and as pain decreases throughout the program balance needs to be retested for improvement documentation. When the balance deficits are due to muscular strength, then the work hardening program job simulation, functional activities and general strengthening must be incorporated. Example: The client was able to demonstrate Romberg’s test and Sharpen Romberg’s test for 30 seconds without a loss of balance, reported pain and was within the normative range for the functional reach assessment. The client was then able to demonstrate 30 seconds of SLS-EO bilaterally however unable to demonstrate SLS-EC for more than 15 seconds at which time the client demonstrated a loss of balance. This client was placed on a frequent basis for static balancing abilities. The following is provided to assist in the determination of the level of frequency based on the balancing evaluation, but it should be recognized that there is no cookie cutter answer.

240



134

Dynamic Balance The following is the testing that will consist of identifying the client’s dynamic balance abilities. In the software, the evaluator will need to identify if the client passes or fails the individual test. The following is a progression of the most basic ambulation task to the most difficult. During all the above dynamic balancing tasks if the client does not meet the criteria listed in “pass” column, the client “fails” that task. Gait on level surface Instructions: “Walk at your normal speed from here to the next mark (6 m (20 ft)).”

Pass – Walks 6 m (20 ft) in less than 5.5 seconds, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside of the 30.48 – cm (12-in) walkway width.

Change in Gait speed Instructions: “Begin walking at your normal pace (for 1.5 m [5 ft]). When I tell you “go,” walk as fast as you can for (1.5 m [5 ft]). When I tell you “slow,” walk as slowly as you can for (1.5 m [5 ft]).”

Pass – Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. Deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.

Gait with horizontal head turns

Instructions: “Walk from here to the next mark 6 m (20 ft) away. Begin walking at your normal pace. Keep walking straight; after 3 steps, turn your head to the right and keep walking straight while looking to the right.

241



135

After 3 more steps, turn your head to the left and keep walking straight while looking left. Continue alternating looking right and left every 3 steps until you have completed 2 repetitions in each direction.”

Pass – Performs head turns smoothly with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.

Gait with vertical head turns

Instructions: “Walk from here to the next mark (6 m [20 ft]). Begin walking at your normal pace. Keep walking straight; after 3 steps, tip your head up and keep walking straight while looking up. After 3 more steps, tip your head down, keep walking straight while looking down. Continue alternating looking up and down every 3 steps until you have completed 2 repetitions in each direction.” Pass – Performs head turns with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.

Gait with pivot/turns

Instructions: “Begin with walking at your normal pace. When I tell you, “turn & stop,” turn as quickly as you can to face the opposite direction and stop.”

Pass – Pivot turns safely within 3 seconds and stops quickly with no loss of balance

Step over obstacle

Instructions: “Begin walking at your normal speed. When you come to the shoe box, step over it, not around it, and keep walking.”

Pass – Is able to step over 2 stacked shoe boxes taped together (22.86 cm [9 in] total height) without changing gait speed; no evidence of imbalance.

Gait with narrow base of support

Instructions: “Walk on the floor with arms folded across the chest, feet aligned heel to toe in tandem for a distance of 3.6 m [12 ft]. The number of steps taken, in a straight line, is counted for a maximum of 10 steps.”

Pass – Is able to ambulate for 10 steps heel to toe with not staggering.

Gait with eyes closed

Instructions: “Walk at your normal speed from here to the next mark (6 m [20 ft]) with your eyes closed.”

Pass – Walks 6 m (20 ft), no assistive devices, good speed, no evidence of imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. Ambulates 6 m (20 ft) in less than 7 seconds.

Ambulating backwards Instructions: “Walk backwards until I tell you to stop”.

Pass – Walks 6 m (20 ft), no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.

242



136

Sources Cited

Duncan PW, Weiner DK, Chandler J, Studenski S. Functional Reach: A new clinical measure of balance. J Gerontol. 1990. 45: M192-M197, 1990. Romberg, M.H. Tabes Dorsalis. Berlin, 1846;vol. 1 p795.

243

OccuPro Functional Capacity Evaluation Occasional Material Handling


Chapter 9

Occasional Material Handling

Material Handling

This is the primary section that most insurance carriers and physicians are concerned about when it comes to return to work and/or establishing the physical demand level. When a physician is prescribing return to work, whether it is regular duty or modified duty, the client is given weight restrictions. The FCE establishes the client’s present weight restrictions and will help to determine if the client can return to work on modified duty or full duty work. The first part of this section is for the evaluator to establish the client’s heart rate and level of pain following the repetitive functional activities. This will help to establish their cardiovascular abilities because their heart rate would most likely have decreased to a resting heart rate similar to the first time it was checked in the beginning. The client’s pain rating can be cross referenced with what they reported in the beginning to establish whether or not their resting pain level has increased or remained the same at this juncture of the evaluation.

Job-Specific/Bend Lift This is the first of five lifts that will be performed and is considered the lift that is specific to a client’s job or is a lift that is performed in a forward bending fashion. This particular lift is not always performed in the FCE. It is tested if the client performs bending and lifting or if a specific type of lift is performed during the course of a normal shift. A primary goal of injured client rehabilitation is to teach proper body mechanics in order to assist in the healing process or to decrease the likelihood of a future injury. Even though our focus is proper body mechanics there may still be situations that a client will be required to lift in a bending fashion based on situations at their job. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf of the lifting station should be positioned at or slightly higher than the client’s waist. The client should be asked to lift the box that has an opening and closing lid and they should use the top handles of the box with the box starting off to the side of the lifting stations. The client should perform a 90 degree turn when placing the box on the shelf and a 90 degree turn when placing the box back on the floor. This is important in that you want to make sure

244



the client is fully facing the way they are lifting or placing to decrease the likelihood of an injury. The client should be instructed to perform this lift in a forward bending fashion. The box itself weighs 15-pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform a job specific lift”. “I would like you to perform a lift in which you are forward bending to the top handles, lift the box, turn and place the box on this shelf, and then return the box to the floor in the same position it started”. When instructing the client on the procedure you should demonstrate what you mean by a job specific lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete, mechanical deficits, with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds at a safer level. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are there to use as a tool for later reference when documenting in the comments section for limiting factors and overall mechanics. The last item that needs to be documented is the client’s self reported functional pain symptoms.

Squat Lift

This is the second of five lifts that will be performed and is considered the lift that the first set of mechanics is observed. One of the primary goals of injured worker

245



rehabilitation is to teach proper body mechanics to assist in the healing process or to decrease the likelihood of future injury. This lift requires documentation in regards to these body mechanics and in certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf of the lifting station should be positioned so the bottom handles of the lifting box are at waist height and then the shelf should stay at this level for the rest of the lifting testing. The worker should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting off to the side of the lifting stations. The client should perform a 90 degree turn when placing the box on the shelf and a 90 degree turn when placing the box back on the floor. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The client should be instructed to perform this lift in a full squatting fashion. The box itself weighs 15-pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform a full squat lift”. “I would like you to perform a lift in which you are squatting to the bottom handles, lift the box, turn and place the box on this shelf, and then return the box to the floor in the same position it started”. When instructing the client on the procedure you need to demonstrate what you mean by a full squat lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete, mechanical deficits, with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on you observation? The client may have demonstrated the ability to perform 45 pounds at a safer level. This would be the safe occasional weight and the weight that the report will

246



generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. The boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported functional pain symptoms.

Power Lift This is the third of five lifts that will be performed and is considered the lift that is the primary lift to observe the client’s body mechanics. A primary goal of injured client rehabilitation is to teach proper body mechanics, which will assist in the healing, process or decrease the likelihood of a future injury. The power lift is the lift that many rehabilitation professionals teach in regards to proper body mechanics. The clients overall body mechanic performance should be documented. In certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf of the lifting station should be positioned as adjusted during squat lifting. They should be asked to lift the box that has an opening and closing lid and they should use the top handles of the box with the box starting off to the side of the lifting stations. The client should perform a half squat, they should lift the box, perform a 90 degree turn when placing the box on the shelf, and a 90 degree turn when placing the box back on the floor in the same half squat fashion. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The client should be instructed to perform this lift in this half squatting/power lifting fashion. The box itself weighs 15-pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift.

247



The client should be instructed to “I am now going to evaluate your ability to perform a power lift”. “I would like you to perform a lift in which you are squatting to the top handles, lift the box, turn, and place the box on this shelf, and then return the box to the floor in the same fashion and position it started”. When instructing the client on the procedure you need to demonstrate what you mean by a power lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete, mechanical deficits, with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds at a safer level. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported functional pain symptoms.

Shoulder Lift This is the fourth of the five lifts that are performed and is considered the lift that focuses on the client’s ability to lift items from their waist to their shoulder height. This lift is usually performed with all FCE’s but may be avoided if a Job Demands Analysis reveals that the client does not need to lift to shoulder height. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf should still be in the same position from squat lifting and the top shelf should be placed at level in which the hands are placed on the bottom handles and lift to shoulder height. The client should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting on the bottom shelf. They should grasp the bottom handles and lift the box to the top shelf with no weight in the box. The box should not be let go of and then placed back on to the bottom shelf. The box itself weighs 15-pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation then the client can stop the lift

248



when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform a shoulder lift”. “I would like you to grasp the bottom handles, lift the box from waist level height to the top shelf, place the box on this shelf, and then return the box to the same position it started”. When instructing the client on the procedure you need to demonstrate what you mean by a shoulder lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds at a safer level. This would be the safe occasional weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These check boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the clients self reported functional pain symptoms.

Overhead Lift This is the last of the five lifts that are performed and is considered the lift that focuses on the client’s ability to lift items overhead. This lift again is only performed if the client needs to perform overhead lifting as part of their job or daily life. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf should still be at the height from the squat lift test and the client will be lifting to the top of the Hausmann lifting station. The client should be asked to lift the box that has an opening and closing lid and they can lift the box in any fashion they would like from the bottom shelf. The client should grasp the box in any fashion they would like to keep them as safe as possible when lifting overhead. In the real work environment the client would perform such a lift in the safest fashion and this should be adhered to in this evaluation. The client should lift the box to the top of the lifting station initially with no weight in the box. The box can be let go of and then it should be placed back on to the bottom shelf. The box itself weighs 15-pounds empty and based on the client’s ability following the empty box lift you can add

249



10 pounds or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform an overhead lift”. “I would like you to grasp the box in any fashion that is most comfortable for you, lift the box from waist level height to the top of the lifting station, place the box on the top, and then return the box to the same position it started”. When instructing the client on the procedure you may need to demonstrate what you mean by an overhead lift if possible. Do not put yourself at risk if this is too difficult for you. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45-pouns at a safer level. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms.

Lifting Comments This is an important area and requires careful documentation of the client’s abilities and limitations in regards to overall lifting. If there is ever any question regarding a client’s lifting abilities, this is the section that should answer those questions. The comments section should be a summary of the five lifting tests. This summary should include the amount of weight lifted in a safe and occasional manner, the observed behaviors, pain levels reported, mechanical changes, mechanical deficits and most importantly, the limiting factor in regards to the amount of weight tolerated.

250



Unilateral Lift This is a specific upper extremity lift that is performed in regards to upper extremity strength. This test will also provide a comparison of upper extremity strength between dominant/non-dominant and between affected and un-affected extremity. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf of the lifting station should be positioned as noted in squat lifting. The position could certainly be changed however to make the test a more job specific test based on the heights a client needs to unilaterally lift on their job. The client will be asked to start with a five pound ankle weight/dumbbell/or disc weight and lift this weight from the top of the closed lid box to the shelf at waist height for 1 repetition. The weight is then transferred to the other side of the body to test the opposite arm. The client should perform a 90 degree turn when placing the ankle weight/dumbbell or disc weight on the shelf and a 90 degree turn when placing the weigh on the shelf. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The test is then raised by 5 pounds up to a 10-pound ankle weight/dumbbell/or disc weight and performed utilizing the right and left upper extremity. The next level up is the 15-pound box and the smaller of the two, handled Hausmann lifting box is utilized. This box begins at 15 pounds empty and again is manipulated from the floor to the shelf at waist height. The box is increased by 5-pound increments until a safe maximum level is reached. This is completed on both upper extremities until a peak weight level is achieved on both the right and left upper extremity. In a kinesiophysical approach test this peak weight would be the weight in which the client demonstrated a kinesiophysical endpoint. The occasional weight would then be documented the weight which was at a level that was the safe unilateral lift weight. If the weight is different on both upper extremities then the lower weight should be the one placed in the occasional weight category. If a psychophysical approach test is being performed like in a work hardening evaluation and the client discontinues a test secondary to psychophysical reasons then as a professional you need to agree with the patient that you also feel the client has reached their baseline maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. This occasional weight is then considered the weight the client could perform on an occasional basis throughout an average shift from knee to waist. It should be noted that per a Job Demands Analysis or a detailed job description, this client might need to perform unilateral lifting up to and exceeding the level of their shoulder based on their job. This test then needs to be modified to allow testing that is related to the essential physical demands of their job and the heights associated with their job. The client should be instructed to “I am now going to evaluate your ability to perform lifting using your left and right arm”. “I would like you to perform a lift in which you are squatting to this ankle weight/dumbbell/disc weight on the top of this box, lift the

251



weight, turn and place the ankle weight on this shelf, and then return the weight to the box.” “I am going to ask you to perform this one time with your right arm and then you will perform the same thing with your left arm.” “Depending how you do we will then increase the weight as appropriate.” When instructing the client on the procedure you need to demonstrate what you mean by this type of lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The safe occasional weight needs to be the lowest weight the client performed regardless of the extremity. For instance, if the client tolerated 25 pounds maximum on the right upper extremity and only 15 pounds on the left, then the safe occasional weight the client could tolerate in an employment setting would be the 15-pound weight. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These check boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported functional pain symptoms.

Bilateral Carry The client’s ability to carry items is also an important material handling task since it should be within the same ballpark as their ability to perform power lifting. Carrying is also an important material handling activity that determines the physical demand level the client is able to perform within. Carrying uses the same two handled, open and closed lid box, as the lifting evaluations used. The box should be placed on the bottom shelf that is still in the same position as when lifting was performed, the client should grasp the bottom handles, carry the box for 25 feet, turn around and return to the lifting station. The box itself weighs 15-pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift.

252



This test allows for mild variations in the carrying distance. For instance, if a client performs up to 100-pound carrying throughout their normal shift, they may not need to carry this much weight for 50-feet. In this situation the client should carry the weight the job specific distance and this should be properly documented in the carrying comments section. The client should be instructed, “The test you will now perform is the carrying test”. “I would like for you to grasp the box using the bottom handles and then carry the box for 25 feet and then turn around and bring the box back to the lower shelf”. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to carry. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may carry 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds and they may have demonstrated safer overall mechanics. This would be the safe occasional weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms. The comments section is available to summarize the client’s abilities during bilateral carrying. If there is ever any question regarding a client’s carrying abilities, this is the section that should answer those questions. The comments section should be a summary of the carrying test. This summary should include the amount of weight carried in a safe and occasional fashion, the observed behaviors, pain levels reported, biomechanical abilities and most importantly, the limiting factor in regards to the amount of weight tolerated.

Unilateral Carry The client’s ability to carry items unilaterally is important to test whether it’s related to function or job specific. The evaluator may test this with the smaller box with the tool bar handle or dumbbell/disc weight; which ever best resembles the job. However, if the evaluator used an object other than the box, it should be clearly documented. This test allows for mild variations in the carrying distance. For instance, if a client performs up to 50-pound toolbox from their truck to work site during their normal shift,

253



but may not need to carry this much weight for their hand tools. In this situation the client should carry the weight the job specific distance and this should be properly documented in the carrying comments section. The client should be instructed, “The test you will now perform is the unilateral carrying test”. “I would like for you to grasp the box using the top handle and then carry the box for 25 feet and then turn around and bring the box back to the lower shelf”. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to carry. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may carry 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds and they may have demonstrated safer overall mechanics. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms.

Pushing and Pulling The push and pulling evaluation utilizes the push pull cart and is also an important task in regards to material handling. The push pull test can be measured in regards to weight pushed or pulled in two different fashions. It can be measured in terms of the amount of weight in the push pull sled or it can be measured by the amount of force required to push and pull which is termed horizontal force pounds. These two measurements are important because someone pushing 500 pounds on a cart with great wheels really does not apply 500 pounds of force to push or pull that cart. They may be exerting only 50 pounds of force. The opposite may occur when a client is pushing and pulling an item with 50 pounds in it and it may require 100 horizontal force pounds to move the cart because of poor wheels or the type of floor it is pushed on. Thus we need a constant scale to use because it is impossible to get a cart and put 500 pounds on it in a therapy clinic. This is where the push pull cart comes into play while taking into account the friction factor of the floor and horizontal force pounds this generates. The best way to determine the amount of horizontal force pounds required to push and pull your cart with weight in it is to load up the cart, attach a force gauge, and give the cart a whirl. On a normal carpeted floor the push pull cart requires 20 horizontal force pounds (hfp) to operate it. Typically, then as you add 15 pounds of weight it adds 5 hfp to push and pull the cart. The client should be instructed, “The test you will now perform is the push/pull test”. “I would like for you to grasp any handle of the sled and then push the sled for 25 feet and then pull the sled for 25 feet”.

254



The cart begins empty and the client is instructed to push the cart for 25 feet and then pull it back to the start. The cart itself weights 20 horizontal force pounds empty or requires 20 pounds of force to push and pull. Based on the clients ability following the cart push and pull you can add 15 pounds, which increases the hfp by 5 pounds. This should be done based off of the effort they exhibited and/or the pain they reported. This push and pull evaluation should be performed until the client reports they have reached their maximum one time ability to push and pull. As a professional you need to agree with the client that you also feel they reached their maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. This maximum push and pull is then considered the weight the client could perform on an occasional basis throughout an average shift. The FCE allows for documentation that includes the peak weight, the safe occasional horizontal force pound push and pull weight, and the heart rate. The peak weight is the maximum weight the client was able to push or pull. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may push and pull 50 horizontal force pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 horizontal force pounds and it was a safer level. This would be the safe occasional weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self reported pain symptoms. The comments section is available to summarize the client’s abilities during pushing and pulling. If there is ever any question regarding a client’s abilities, this is the section that should answer those questions. The comments section should be a summary of the both pushing and pulling. This summary should include the amount of weight pushed and pulled in a safe and occasional fashion, the observed behaviors, pain levels reported, biomechanical abilities, and most importantly, the limiting factor in regards to the amount of weight tolerated.


255



OccuPro’s FCE uses biomechanical consistency of effort criteria during material handling testing. When clients are lifting the box with the closing lid they are asked to lift this box in 5 different positions. Each position requires different biomechanical movements. Some of these movements are easier than others. For instance, the lift from knee to waist should biomechanically be easier and less physically exerting than the overhead lift. This would suggest the client would lift more weight during the power lift from knee to waist in comparison to the overhead lift. The FCE automatically checks validity criteria as the test proceeds and calculates this in the end of the evaluation. Please see the chapter that discusses the overall validity criteria for more details. There are three separate biomechanical validity criteria automatically checked during the FCE. The first is whether the power lift weight is greater than the full squat lifting weight. Biomechanically, a client should lift more weight when lifting from knees to waist then from floor to waist. There is more muscle recruitment and less end range of the knees. The second internal biomechanical validity check is the weight difference between power lift and the shoulder lift. Again a client should be able to lift more weight from knees to waist then from waist to shoulder height. The third biomechanical validity check was mentioned above and is the power lift as compared to the overhead lift. A client should be able to lift more weight from knees to waist then from waist to overhead. These are checked and documented in the end of the report under the section of validity profile and then help to establish the tests overall validity in the end of the report. The percentage of valid functional tests graph in the end of the report incorporates these biomechanical validity criteria.

256

OccuPro Functional Capacity Evaluation Frequent Material Handling


Chapter 11

Frequent Material Handling

This is an important section that many insurance carriers and physicians are concerned about when it comes to return to work and/or establishing the physical demand level. Occasional material handling and the physical demand level that is generated from that section should co-inside with this section and generally should be somewhere around half of what the occasional material handling is. Research would suggest that frequent material handling should be 50% to 70% of occasional material handling abilities. When a physician is prescribing return to work, whether it is regular duty or modified duty, the client is given weight restrictions. The FCE establishes the client’s present weight restrictions and will help to determine if the client can return to work on modified duty or full duty work. This section will help to establish what the client is able to perform on a frequent basis during an average shift. Multiple tests are performed in this section and are performed in the same biomechanical manner as in occasional material handling. They are frequent squat, power, shoulder and unilateral lifting. Frequent bilateral carrying and push/pull are also tested in this section. Any lifting activity can be performed using this kinesiophysical lifting technique. When performing frequent lifting in this section the lifts are performed for five repetitions. When performing frequent material handling testing and performing a kinesiophysical approach there are three criteria that would stop a client while performing the 5 repetitions at each weight level.

1. Exceeding their aerobic limiting factor (220-age *.85) 2. Mechanical Change 3. A decrease in within repetition pace or cadence (suggests a decrease in muscle

endurance) If performing in a psychophysical approach like during a baseline work hardening evaluation the same three criteria will be used but the client may also stop a test based on their psychophysical feelings.

257



Frequent Squat Lift This is the first frequent lift test that will be performed and is considered the lift that the first set of mechanics is observed in regards to frequent lifting. One of the primary goals of injured client rehabilitation is to teach proper body mechanics to assist in the healing process or to decrease the likelihood of future injury. This is a lift that these body mechanics can be documented and in certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf of the lifting station should be positioned so the clients hands lift using the bottom handle and end up at waist height. The client should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting off to the side of the lifting stations. They will perform each weight for five repetitions to establish frequency. The client should perform a 90 degree turn when placing the box on the shelf and a 90 degree turn when placing the box back on the floor. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The client should be instructed to perform this lift in a full squatting position. The box itself weighs 15 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics or the pain they reported. When performing this lift in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regards to frequent lifting. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift from floor to waist. The first part of this section is to obtain the client’s heart rate and document this. This helps to establish a resting heart rate and can be compared to the client’s heart rate following exertion. The client should be instructed to “I am now going to evaluate your ability to perform frequent full squat lifting”. “I would like you to perform a lift in which you are squatting to the bottom handles, lift the box, turn and place the box on this shelf, and then return the box to the floor in the same position it started” “I would like you to perform each weight for five repetitions.” “If you need to stop during this test for safety reasons feel free to.” When instructing the client on the procedure you

258



may need to demonstrate what you mean by a full squat lift however the client should have already performed this lift during occasional material handling testing. The FCE allows for documentation that includes the peak frequent weight, the occasional frequent weight, the heart rate and exertion level. The peak frequent weight is the maximum weight the client was able to lift for five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may lift 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms. The frequent lifting utilizes a rating of perceived exertion formula to calculate the client’s self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, reliability of pain or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 50-70%. This depicts the client’s ability of their material handling ability and should be close or within this range.

Frequent Power Lift

This is the second frequent lifting test that will be performed and is considered the lift that is the primary lift to observe the clients body mechanics. One of the primary goals of injured client rehabilitation is to teach proper body mechanics to assist in the healing process or to decrease the likelihood of future injury. This is a lift that many rehabilitation professionals teach and these body mechanics can be documented. In certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf of the lifting station should be positioned based on the frequent squat lift. The client should be asked to lift the box that has an opening and closing lid and they should use the top handles of the box with the box starting off to the side of the lifting stations. The client should perform a half squat, they should lift the box, perform a 90 degree turn when placing the box on the shelf, and a 90 degree turn when placing the box back on the floor in the same half squat position. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. This lift as

259



well is performed for five repetitions at each weight to establish that the client can perform frequent lifting. The client should be instructed to perform this lift in this half squatting/power lifting position. The box itself weighs 15 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics or the pain they reported. When performing this lift in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regards to frequent lifting. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift from floor to waist. The client should be instructed to “I am now going to evaluate your ability to perform frequent power lifting”. “I would like you to perform a lift in which you are squatting to the top handles, lift the box, turn, and place the box on this shelf, and then return the box to the floor in the same position and position it started”. “I would like you to perform each weight for as many repetitions as you can up to five repetitions.” When instructing the client on the procedure you may need to demonstrate what you mean by a power lift however you did just perform occasional power lifting. The FCE allows for documentation that includes the pre-lift heart rate, the peak frequent weight, the safe frequent weight, the heart rate and the exertion level. The peak frequent weight is the maximum weight the client was able to lift for five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may lift 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the client’s self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is

260



underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 50-70%. This depicts the client’s ability of their material handling ability and should be close or within this range.

Frequent Shoulder Lift

This is the third frequent lift test that is performed and is considered the lift that focuses on the client’s ability to lift items to their shoulder height. This lift is only performed if a Job Demands Analysis, job description or client reveals that the client needs to lift frequently to shoulder height at their job. This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf should be positioned as adjusted in squat lifting. The client should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting on the bottom shelf. They should grasp the bottom handles and lift the box to the top shelf with no weight in the box for up to five repetitions at each weight level. The box should not be let go of in between each repetition and then placed back on to the bottom shelf after the fifth repetition. The box itself weighs 15 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds or 5 pounds based on their mechanics or the pain they reported. When performing this lift in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regards to frequent lifting. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift from floor to waist. The client should be instructed to “I am now going to evaluate your ability to perform frequent shoulder lifting”. “I would like you to grasp the bottom handles, lift the box from waist level height to the top shelf, place the box on this shelf, and then return the

261



box to the same position it started”. Please do not let go of the box and I would like you to perform as many repetitions as you can up to five repetitions.” When instructing the client on the procedure you may need to demonstrate what you mean by a shoulder lift however you did recently perform shoulder lifting in occasional material handling. The FCE allows for documentation that includes the pre-lift heart rate, the peak frequent weight, the safe frequent weight, the heart rate and the exertion level. The peak frequent weight is the maximum weight the client was able to lift for five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may lift 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.

Frequent Bilateral Carrying

Carrying uses the same two handled, open and closed lid box, as the lifting evaluations used. The box should be placed on the bottom shelf that is still in the same position as when lifting was performed, the client should grasp the bottom handles, carry the box for 25 feet, turn around and return to the lifting station. The box itself weighs 15 pounds empty and based on the client’s ability following the empty box carry you can add 10 pounds or 5 pounds based on their mechanics or the pain they reported. When performing this carry in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regards to frequent carrying. There may also be

262



times when the client wants to continue and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift for carrying. This test allows for mild variations in the carrying distance. For instance, if a client performs up to 100-pound carrying throughout their normal shift, they may not need to carry this much weight for 50-feet. In this situation the client should carry the weight the job specific distance and this should be properly documented in the carrying comments section. The client should be instructed, “The test you will now perform is the carrying test”. “I would like for you to grasp the box using the bottom handles and then carry the box for 25 feet and then turn around and bring the box back to the lower shelf”. “Please do not let go of the box and I would like you to perform as many repetitions as you can up to five repetitions.” The FCE allows for documentation that includes the peak weight, the safe occasional weight, the heart rate and the exertion level. The peak frequent weight is the maximum weight the client was able to carry for five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may carry 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms.

Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.

Frequent Pushing and Pulling

263



The pushing and pulling evaluation utilizes the push/pull sled and is also an important task in regards to material handling. The push/pull test can be measured in regards to weight pushed or pulled in two different fashions. It can be measured in terms of the amount of weight in the push pull sled or it can be measured by the amount of force required to push and pull which is termed horizontal force pounds. These two measurements are important because someone pushing 500 pounds on a cart with great wheels really does not apply 500 pounds of force to push or pull that cart. They may be exerting only 50 pounds of force. The opposite may occur when a client is pushing and pulling an item with 50 pounds in it and it may require 100 horizontal force pounds to move the cart because of poor wheels or the type of floor it is pushed on. Thus we need a constant scale to use because it is impossible to get a cart and put 500 pounds on it in a therapy clinic. This is where the push pull cart comes into play while taking into account the friction factor of the floor and horizontal force pounds this generates. The best way to determine the amount of horizontal force pounds required to push and pull your cart with weight in it is to load up the cart, attach a force gauge, and give the cart a whirl. On a normal carpeted floor the push pull cart requires 20 horizontal force pounds (hfp) to operate it. Typically, then as you add 15 pounds of weight it adds 5 hfp to push and pull the cart. The client should be instructed, “The test you will now perform is the push/pull test”. “I would like for you to grasp any handle of the sled and then push the sled for 25 feet and then pull the sled for 25 feet”. “I would like you to perform as many repetitions as you can up to five repetitions.” The sled begins empty and the client is instructed to push the sled for 25 feet and then pull it back to the start. The sled itself may weigh 20 horizontal force pounds empty or requires 20 pounds of force to push and pull. Based on the client’s ability following the sled push and pull you can add 15 pounds, which may increase the HFP by 5 pounds based on your coefficient of friction. *Please Note: the force the sled takes to push/pull empty should be calculated with the carpet or surface in your particular clinic by using a Chatillon Gauge. This should be done based off of the effort they exhibited and/or the pain they reported. This push and pull evaluation should be performed until the client reaches their kinesiophysical endpoint. If performing in a psychophysical approach then as a professional you need to agree with the client that you also feel they reached their maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. This maximum push and pull is then considered the weight the client could perform on an occasional basis throughout an average shift. The FCE allows for documentation that includes the peak weight, the safe occasional horizontal force pound push and pull weight, and the

264



heart rate. The peak weight is the maximum weight the client was able to push or pull. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may push and pull 50 horizontal force pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 horizontal force pounds and it was a safer level. This would be the safe occasional weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. The last item that needs to be documented is the client’s self reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the client’s self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests.

Frequent Unilateral Lift

This lift is performed using the Hausmann Work Well Systems lifting station. The bottom shelf of the lifting station should be positioned at or slightly higher than the client’s waist. The client will be asked to start with a five pound ankle weight/dumbbell/or disc weight and lift this weight from the top of the closed lid box to the shelf at waist height for 1 repetition. The weight is then transferred to the other side of the body to test the opposite arm. The client should perform a 90 degree turn when placing the ankle weight/dumbbell or disc weight on the shelf and a 90 degree turn when placing the weigh on the shelf. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The test is then raised by 5 pounds up to a 10-pound ankle weight/dumbbell/or disc weight and performed utilizing the right and left upper extremity. The next level up is the 15-pound box and the smaller of the two, handled Hausmann lifting box is utilized. This box begins at 15 pounds empty and again is manipulated from the floor to the shelf at waist height. The box is increased by 5-pound increments until a safe maximum level is reached. This is completed on both upper extremities until a maximum safe level is achieved on both the right and left upper extremity. As a professional you need to agree with the patient that you also feel the client has reached their maximum. There may also be times when the client wants to continue and you feel that they have reached their safe maximum as well. This maximum weight is then considered the weight the client could perform on an occasional basis throughout an average shift from knee to waist.

265



It should be noted that per a Job Demands Analysis or a detailed job description, this client might need to perform unilateral lifting up to and exceeding the level of their shoulder based on their job. This test then needs to be modified to allow testing that is related to the essential physical demands of their job. The client should be instructed to “I am now going to evaluate your ability to perform lifting using your left and right arm. I would like you to perform a lift in which you are squatting to this ankle weight/dumbbell/disc weight on the top of this box, lift the weight, turn and place the ankle weight on this shelf, and then return the weight to the box. I would like you to perform as many repetitions as you can up to five repetitions. Depending how you do we will then increase the weight as appropriate.” When instructing the client on the procedure you may need to demonstrate what you mean by this type of lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The safe occasional weight needs to be the lowest weight the client performed regardless of the extremity. For instance, if the client tolerated 25 pounds maximum on the right upper extremity and only 15 pounds on the left, then the safe occasional weight the client could tolerate in an employment setting would be the 15-pound weight. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These check boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.

Comments

In the comments section, the evaluator will need to identify and classify the client’s overall lifting body mechanics. The categories are the following: poor, fair, and excellent. A few suggestions on how body mechanics may be classified. In order to classify excellent mechanics, the client does not require or would require body mechanics education or retraining, any verbal cues, or repeated visual demonstrations on how to perform the lift safely. For fair body mechanics, the client may need a verbal cue or redirection with a visual demonstration for proper technique on 1 lift but not all of the lifts- able to generalize the principle of body mechanics, however unable to maintain

266



proper body mechanics as weight increases. For poor body mechanics, the client requires frequent verbal and visual redirection, would recommend body mechanics training/education in recommendations, and the evaluator does not feel safe while the client is lifting or needs “hands on” during the lift. There are pre-populated statements that will be produced however if the evaluator needs to clarify or add pertinent information this should be added in this section. RATING OF PERCIEVED EXERTION FORMULA Following each of the three frequent tests the client’s heart rate is recorded. The client is then asked to rate their perceived exertion using the Borg Rating of Perceived Exertion scale. Borg demonstrated a correlation between a client’s heart rate during an activity involving fatigue of large muscle groups and their rating of perceived exertion. In essence a client reporting significant exertion during frequent lifting testing should have a correlated increase in their heart rate. If the client does not have a correlated increase in heart rate there are questions of symptom exaggeration that should be raised. This formula also allows for cardiovascular fitness documentation. If a client lifts minimal weight for only four repetitions but exhibits a significant increase in heart rate than cardiovascular concerns are present. The Borg scale used is as follows:

Borg CR-20 Rating of Perceived Exertion Scale

Very, Very Light

Fairly Light Hard Very, Very Hard

Very Light Somewhat Hard Very Hard 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

The formula utilized in this section is RPE*10-HR=. For instance if a client has a heart rate of 125 during testing and reports a rating of perceived exertion at 12 than this would be 12*10= 120. Then subtract the heart rate of 125 and the formula calculates out to -5. This would be considered an acceptable correlation. The breakdown occurs as follows. Acceptable Correlation (-15 to +20)

Large Negative Numbers ( <-15) Poor Cardiovascular fitness Underestimating Difficulty

Moderate Positive Numbers (21-49) Mild Exaggeration of Difficulty of Task Poor Musculoskeletal fitness Good CV

Fit Large Positive Numbers (≥+50)

Symptom Exaggeration

267



If a client reports a rating of perceived exertion at hard or 15 and their heart rate is 85 beats per minute following frequent power lifting then the formula calculates out to 65. This would fall into large positive numbers and would suggest symptom exaggeration. Typically in this situation the client being tested has lifted minimal weight for a few repetitions and report significant exertion without an appreciable increase in heart rate. The client can even be told that the rating of perceived exertion is not pain related and pain should not be considered in their report.

Sources Cited

Borg. Perceived exertion is how hard you feel your body is working. It is based on the physical sensations a person experiences during physical activity, including increased heart rate, increased respiration or breathing rate, increased sweating, and muscle fatigue. Although this is a subjective measure, a person's exertion rating may provide a fairly good estimate of the actual heart rate during physical activity* (Borg, 1998). Borg RPE scale © Gunnar Borg, 1970, 1985, 1994, 1998

Research (Journal of Sports Sciences, 2002,20,873-899) found that there is a correlation between an athlete's rate of perceived exertion (RPE) and their heart rate, lacate levels, % VO2 max, and breathing rate.

268

OccuPro Functional Capacity Evaluation Sit – Stand – Climb


Chapter 12

Sit – Stand – Climb

Climbing Stair Climbing Stair climbing is a functional task that may be assessed for either a baseline FCE or job specific FCE. Stair climbing is usually an important aspect in most of the client’s home situation. This is an activity that a client should be able to attempt. If not it is questionable how they perform functional tasks at work or home and will need to identify compensatory techniques with functional activities. This task is used with the 6” rise on the step or a formal staircase in the clinic. The client is requested to ascend the stairs using a reciprocal gait pattern and using the handrails for only safety reasons. If a client requires the use of a gait belt while ambulating, at the evaluator’s discretion may not test stair climbing due to safety concerns. In this case, the client may use the 4” steps to determine the actual deficit the client has whether it is negotiate stairs, balance, or lower extremity strength which will assist in the streamlining of the client’s plan of care for therapy. This may be tested if the client lives independently and is required to negotiate stairs in the home environment. Stair climbing 36 steps The first set of stair climbing consists of 1-36 steps. The evaluator should request the client to perform stating: “I want you to climb up the stair case and come back down without using the handrails- unless you need them for safety for a total of 36 steps”. After the task is completed the evaluator will need to obtain the client’s heart rate, reported functional pain level, and the client’s perceived rate of exertion using the Borg Scale. Stair climbing 72 steps The second set of stair climbing consists of 36-72 steps. The evaluator should request the client to perform stating: “I want you to climb up the stair case and come back down without using the handrails- unless you need them for safety for a total of 36 steps”. After the task is completed the evaluator will need to obtain the client’s heart rate,

269



reported functional pain level, and the client’s perceived rate of exertion using the Borg Scale. Stair climbing 108 steps The third set of stair climbing consists of 71-108 steps. The evaluator should request the client to perform stating: “I want you to climb up the stair case and come back down without using the handrails- unless you need them for safety for a total of36 steps”. After the task is completed the evaluator will need to obtain the client’s heart rate, reported pain level, and the client’s perceived rate of exertion using the Borg Scale. The overall amount of stairs that the client was able to perform may assist the evaluator in classifying the frequency level the client is able to perform. Listed below is only an example that may assist in classifying the frequency.

For Example: If the client’s job requires continuous stair climbing, the evaluator may want to test the client greater than 108 steps and combine this task with a particular material-handling task depending on the job. For instance: the client’s occupation is of a residential realtor, which requires stair climbing when showing various homes. The client may show a 2-story home and 2 per hour, which may result to stair climbing 120 steps per hour. The client should then be tested for the ability to negotiate stairs of 120 steps within an hour to fully document the client’s ability to perform the essential functions of the job. Comment Section

270



The evaluator will need to identify the frequency the client is able to perform this task at via the radial button. The software will pre-populate the frequency in the comment section. The evaluator should also identify any compensatory techniques used, gait pattern, weight bearing deficits, balance deficits, client reports of increased pain/discomfort and any physical pain behaviors observed. Ladder Climbing Ladder climbing is a functional task that may be performed for daily activities or job specific activities. Some jobs that may require ladder climbing consists of: roofer, fire fighter, carpenter, painter, warehouse laborer, tanker driver, department of public works employees, trimming trees, etc. The task of ladder climbing is typically tested when performing a job simulated FCE or combined with a job simulation task. However, the evaluator may test this task separately to ensure the client’ ability prior to pairing with multiple tasks. The clinic should have at least a 6-foot ladder to use for this testing. If the client demonstrated ladder climbing using a different size ladder, the evaluator should identify the height difference in the comment section. Please note: If the client demonstrates balance deficits, the evaluator may decide this task should not be tested at this time and defer testing to a later date. The evaluator will need to document any and all safety concerns presented. This task may then be placed on an avoid basis. Ladder climbing times 5 repetitions The evaluator will instruct the client “I want you to climb up this ladder to the fourth rung for 5 repetitions, alternating your step with both feet touching the top fourth rung and then both feet touching the floor”. The first is ladder climbing for a total of 5 repetitions. The evaluator will need to obtain the client’s heart rate, rate of perceived exertion and the client’s pain level. The evaluator will need to determine whether the client is able to continue or not. The evaluator will need to use the drop down boxes for determining or identifying the limiting factors that occurred during this task. Ladder climbing times 10 repetitions (5-15) for total of 15 The second section of ladder climbing is to request the client to climb for a total of 15 repetitions. “I want you to climb up this ladder to the fourth rung for 10 repetitions, alternating your step with both feet touching the top fourth rung and then both feet touching the floor”. The evaluator will need to obtain the client’s heart rate, rate of perceived exertion and the client’s pain level. The evaluator will need to use the drop down boxes for determining or identifying the limiting factors that occurred during this task. Ladder climbing times 10 repetitions (16-25) for total of 25

271



The last section is having the client perform ladder climbing for a total of 25 repetitions up to the 4 rungs. “I want you to climb up this ladder to the fourth rung for 10 repetitions, alternating your step with both feet touching the top fourth rung and then both feet touching the floor”. The evaluator will need to obtain the client’s heart rate, rate of perceived exertion and the client’s pain level. The evaluator will need to use the drop down boxes for determining or identifying the limiting factors that occurred during this task. Comment Section The evaluator will need to identify the frequency the client is able to perform this task at via the radial button. It should also be noted to identify all the limiting factors that the client demonstrated or exhibited during this task via using the drop down boxes and the software will automatically put into the comment box. The software will pre-populate the frequency in the comment section. The evaluator should also identify any compensatory techniques used, gait pattern, weight bearing deficits, balance deficits, client reports of increased pain/discomfort and any physical pain behaviors observed.

Reliability of Pain Criteria In the COE/ROP mdodule under the tab for climbing there is a calculation that looks at the rating of perceived exertion of climbing activities and whether the pain reports were reliable pain reports for each level of climbing.

272



Sitting and Standing When performing both sitting and standing testing throughout an FCE the question always is whether the client can perform the amount of sitting and standing the job requires. Different FCE’s calculate this ability in different ways. OccuPro’s methodology decided that we are going to calculate hours of sit and stand tolerance up against the actual hours that a job requires. This raises a second question in regards to how do you calculate someone’s ability to sit for 8 hours or stand for 8 hours if your test is only a 4 hour test. We have handled this through a strategy of observing the client sit and stand during your FCE and asking a bunch of subjective questions to extract from your client how much sitting and standing they plan to do after or before your test. The purpose of these questions and observations is in an attempt to capture what this person is able to perform within the 24 hour period of you performing this test. The questions that are asked and the observed level of sitting and standing along with the amount of time th client is in a lying down position should equal up to 24 hours within a 24 hour day. Sitting This evaluation assesses both a client’s self-reported and demonstrated ability of performing prolonged one time sitting and sitting throughout an average shift. During the evaluation the client will demonstrate a total amount of sitting time and an amount of sitting at one time they can tolerate. Then various sitting questions will be asked to determine their sitting before the test and what they perceive their ability will be after the test.

1. Within the last week, in a 24 hour period how many hours are you in a laying down position?

a. This is to determine the amount of time this client is not in a sitting or standing position and is used within the 24 hour calculation

2. How long were you sitting prior to coming to this evaluation? a. Looks at the amount of sitting performed prior to the test not to include

driving to the test and is calculated into the 24 hour calculation 3. How long did it take you to drive to this evaluation?

a. Should not include the sitting time before the test and is used within the 24 hour calculation

4. How many hours do you anticipate being in a sitting position after this evaluation?

a. Looks at their self perceived number of hours they will be sitting after the evaluation and is used to calculate the total of 24 hours

5. How many hours total did the client sit during this evaluation? a. The total time sitting during your test and is used in the 24 hour

calculation 6. How many hours total could you sit during the course of a day?

a. Is a self perceived question in regards to the number of hours the client feels they could totally sit during a 24 hour period

273



7. What was the longest this client sat at one time during this evaluation? a. Is your calculation of observed sitting at one time during the test

8. How many hours at once could you tolerate sitting before needing to change positions?

a. Is the same as question 7 but is the clients perceived amount of sitting at one time before needing to change positions

Body mechanics, sitting posture, and changing of positions should be observed and noted, as this is an important aspect of an individual that may perform prolonged sitting throughout their shift. The software will automatically calculate the final totals for the report of the sitting abilities of the client based on the numbers that were entered- using the drop down boxes. Sitting ability should be documented in the recommendation section of this evaluation with a frequency of ability based on what the client was able to demonstrate. For instance, a client who is a rural mail carrier, their job requires them to perform 4 hours of sitting and they have sustained a lumbar injury. Their job simulation may be to perform 4 hours of sitting while twisting to place simulated mail into mailboxes. The client was a quarry worker who drove a dump truck around the quarry for up to 12 hours and they needed to demonstrate the ability to sit for up to 10 of those hours prior to discharge. This may seem excessive but it was in the client’s best interest. The doctor could not make the call if the client could work for 12 hours bouncing in a dump truck and needed to have documentation that stated whether or not the client could perform this for return to work. Standing This evaluation assesses both a client’s self-reported standing abilities of what the client is able to perform throughout an average shift over a 24 hour day and what the client was able to perform during the evaluation. Before asking any question you will want to have an idea of how many hours are left in a 24 hour day? You will want to add up the total sitting they did and self reported they are doing, the amount of time in a lying down position and use the remaining amount to make sure you are extracting as close to 24 hours as possible. During the evaluation, the evaluator will ask a series of questions to the client in regards to what their present standing ability is throughout a 24-hour day and at one time. The client should be asked

1. How many hours were you in a standing position prior to coming to this evaluation?

a. The clients report of the number of hours standing before the test and is calculated within the 24 hour time

2. How many hours total did the client stand during this evaluation?

274



a. Your calculation of the number of hours they stood total during your test and is calculated within the 24 hour calculation.

3. How many hours do you anticipate being in a standing position after this evaluation?

a. The clients self perceived ability to be in a standing position after the test and is calculated within the 24 hour total calculation

4. How many hours total could you stand during the course of a day? a. The clients perception of how many total hours they could stand in a 24

hour period and can be compared to the calculated amount above 5. What was the longest this client stood at one time during this evaluation?

a. Your calculation of the longest one time the client was able to maintain a standing position during your test

6. How many hours at once could you tolerate standing before needing to change positions?

a. The clients self perceived amount of standing they feel they can do at one time and can be compared to what they actually did during the test and the higher of the two could be used in your report as their ability

Posture/Body mechanics is also noted, as this is an important aspect of an individual that may perform any amount of standing throughout their shift. The software will automatically calculate the final totals for the report of the standing abilities of the client based on the numbers that were entered- using the drop down boxes. Examples:

1. An individual may need to stand in an 8 foot by 4-foot work cell and work on 2 different machines. He would be walking between the separate machines but only taking a few steps and a pivot/turn. You may need to document what the client demonstrated during job simulation activities that would correlate to this standing tolerance physical demand.

2. A client may be a cashier at a grocery store. This would consist of standing for

several hours at a time and may be paired with another task in the job simulation section. The client should be assessed during this evaluation for standing ability/tolerance in order to determine if the client is able to return to work in regards to standing. When identifying the client’s ability to stand at one time, the evaluator should consider what limiting factors the client has, equal weight distribution to their lower extremities, leaning on a table/wall, etc. since this would decrease the overall client’s ability.

Standing frequency should be documented in the recommendation section of this evaluation with a frequency of ability based on what the client was able to demonstrate.

275

APPENDIX A

Average Performance of Normal Subjects on GRIP STRENGTH

* The above mean scores for older subjects may be slightly lower (0-10 pounds lower than they should be) due to instrument error detected after study.

(pounds) MALES FEMALES

Age Hand Mean* SD Range Mean* SD Range 20-24 R 121.0 20.6 91-167 70.4 14.5 46-95

L 104.5 21.8 71-150 61.0 13.1 33-88

25-29 R 120.8 23.0 78-158 74.5 13.9 48-97 L 110.5 16.2 77-139 63.5 12.2 48-97

30-34 R 121.8 22.4 70-170 78.7 19.2 46-137 L 110.4 21.7 64-145 68.0 17.7 36-115

35-39 R 119.7 24.0 76-176 74.1 10.8 50-99 L 112.9 21.7 73-157 66.3 11.7 49-91

40-44 R 116.8 20.7 84-165 70.4 13.5 38-103 L 112.8 18.7 73-157 62.3 13.8 35-94

45-49 R 109.9 23.0 65-155 62.2 15.1 39-100 L 100.8 22.8 58-160 56.0 12.7 37-83

50-54 R 113.6 18.1 79-151 65.8 11.6 38-87 L 101.9 17.0 70-143 57.3 10.7 35-76

55-59 R 101.1 26.7 59-131 57.3 12.5 33-86 L 83.2 23.4 43-117 47.3 11.9 31-76

60-64 R 89.7 20.4 51-137 55.1 10.1 37-77 L 76.8 20.3 26-116 45.7 10.1 29-66

65-69 R 91.1 20.6 56-131 49.6 9.7 35-74 L 76.8 19.8 43-117 41.0 8.2 29-63

70-74 R 75.3 21.5 32-108 49.6 11.7 33-78 L 64.8 18.1 32-93 41.5 10.2 23-67

75+ R 65.7 21.0 40-135 42.6 11.0 25-65 L 55.0 17.0 31-119 37.6 8.9 24-61

All Age R 104.3 28.3 32-176 62.8 17.0 25-137 Groups L 93.1 27.6 27-160 53.9 15.7 23-115

207 276

208

Average Performance of Normal Subjects on KEY PINCH (pounds)

MALES FEMALES Age Hand Mean SD Range Mean SD Range

20-24 R 26.0 3.5 21-34 17.6 2.0 14-23 L 24.8 3.4 19-31 16.2 2.1 13-23

25-29 R 26.7 4.9 19-41 17.7 2.1 14-22 L 25.0 4.4 19-39 16.6 2.1 13-22

30-34 R 26.4 4.8 20-36 18.7 3.0 13-25 L 26.2 5.1 17-36 17.8 3.6 12-26

35-39 R 26.1 3.2 21-32 16.6 2.0 12-21 L 25.6 3.9 18-32 16.0 2.7 12-22

40-44 R 25.6 2.6 21-31 16.7 3.1 10-24 L 24.8 4.0 19-31 15.8 3.1 8-22

45-49 R 25.8 3.9 19-35 17.6 3.2 13-24 L 24.8 4.4 18-42 16.6 2.9 12-24

50-54 R 26.7 4.4 20-34 16.7 2.5 12-22 L 26.1 4.2 20-37 16.1 2.7 12-22

55-59 R 24.2 4.2 18-34 15.7 2.5 11-21 L 23.0 4.7 13-31 14.7 2.2 12-19

60-64 R 23.2 5.4 14-37 15.5 2.7 10-20 L 22.2 4.1 16-33 14.1 2.5 10-19

65-69 R 23.4 3.9 17-32 15.0 2.6 10-21 L 22.0 3.6 17-28 14.3 2.8 10-20

70-74 R 19.3 2.4 16-25 14.5 2.9 8-22 L 19.2 3.0 13-28 13.8 3.0 9-22

75+ R 20.5 4.6 9-31 12.6 2.3 8-17 L 19.1 3.0 13-24 11.4 2.6 7-16

All Age R 24.5 4.6 9-41 16.2 3.0 8-25 Groups L 23.6 4.6 11-42 15.3 3.1 7-26

277

209

Average Performance of Normal Subjects on PALMER PINCH


Age Hand Mean SD Range Mean SD Range 20-24 R 26.6 5.5 18-45 17.2 2.3 14-23

L 25.7 5.8 15-42 16.3 2.8 11-24

25-29 R 26.0 4.3 19-35 17.7 3.2 13-29 L 25.1 4.2 19-36 17.0 3.0 13-26

30-34 R 24.7 4.7 16-34 19.3 5.0 12-34 L 25.4 5.7 15-37 18.1 4.8 12-32

35-39 R 26.2 4.1 19-36 17.5 4.2 13-29 L 25.9 5.4 14-40 17.1 3.4 12-24

40-44 R 24.5 4.3 17-37 17.0 3.1 10-23 L 24.8 4.9 15-37 16.6 3.5 10-25

45-49 R 24.0 3.3 19-33 17.9 3.0 12-27 L 23.7 3.8 18-33 17.5 2.8 12-24

50-54 R 23.8 5.4 15-36 17.3 3.1 12-33 L 24.0 5.8 16-34 16.4 2.9 12-22

55-59 R 23.7 4.8 16-34 16.0 3.1 11-26 L 21.3 4.5 12-28 15.4 3.0 11-21

60-64 R 21.8 3.3 16-28 14.8 3.1 10-20 L 21.2 3.2 15-27 14.3 2.7 10-20

65-69 R 21.4 3.0 15-25 14.2 3.1 8-20 L 21.2 4.1 14-30 13.7 3.4 8-22

70-74 R 18.1 3.4 14-27 14.4 2.6 9-19 L 18.8 3.3 13-27 14.0 1.9 10-17

75+ R 18.7 4.2 9-26 12.0 2.6 8-17 L 18.3 3.8 10-26 11.5 2.6 6-16

All Age R 23.4 5.0 9-45 16.3 3.8 8-34 Groups L 23.0 5.3 10-42 15.7 3.6 6-32

278

210

Average Performance of Normal Subjects on TIP PINCH



L 17.0 2.3 12-33 10.5 1.7 8-14

25-29 R 18.3 4.4 10-34 11.9 1.8 8-16 L 17.5 5.2 12-36 11.3 1.8 9-18

30-34 R 17.6 6.7 12-25 12.6 3.0 8-20 L 17.6 4.8 10-27 11.7 2.8 7-17

35-39 R 18.0 3.6 12-27 11.6 2.5 8-19 L 17.7 3.8 10-24 11.9 2.4 8-16

40-44 R 17.8 4.0 11-25 11.5 2.7 5-15 L 17.7 3.5 12-25 11.1 3.0 6-17

45-49 R 18.7 4.9 12-30 13.2 3.0 9-19 L 17.6 4.1 12-28 12.1 2.7 7-18

50-54 R 18.3 4.0 11-24 12.5 2.2 9-18 L 17.8 3.9 12-26 11.4 2.4 7-16

55-59 R 16.6 3.3 11-24 11.7 1.7 9-16 L 15.0 3.7 10-26 10.4 1.4 8-13

60-64 R 15.8 3.9 9-22 10.1 2.1 7-17 L 15.3 3.7 9-23 9.9 2.0 6-15

65-69 R 17.0 4.2 11-27 10.6 2.0 7-15 L 15.4 2.9 10-27 10.5 2.4 7-17

70-74 R 13.8 2.6 11-21 10.1 2.6 7-15 L 13.3 2.6 10-21 9.8 2.3 6-17

75+ R 14.0 3.4 7-21 9.6 2.8 4-16 L 13.9 3.7 8-25 9.3 2.4 4-13

All Age R 17.0 4.1 7-34 11.3 2.6 4-20 Groups L 16.4 4.0 8-36 10.8 2.4 4-18

279

Purdue Pegboard norms

Right Hand

Poor Low Avg.

Average High Avg. Excellent

12 13 14 15 16 17 18 19 20 21 2 2 23 24 11.85 13.88 15.91 17.94 19.97 22.00 24.03 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Left Hand

Poor Low Avg.


12 13 14 15 16 17 18 19 20 21 11.85 13.47 15.14 16.81 18.48 20.15 21.82 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Both Hands

Poor Low Avg.

Average High Avg.

Excellent Poor

10 11

12 13 14 15 16 17 18

9.60 11.10 12.60 14.10 15.60 17.10 18.60 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Assembly

Poor Low Avg.


20-27 28-33 34-40 43 44-

50 5 1-60

20.60 27.29 33.98 40.67 47.36 54.05 60.74 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Moberg’s Pick up Test Moberg’s test was designed for discriminative sensibility testing. This will involve assessing the client’s motor function, sensation, and may assist with identifying median nerve injuries rather than ulnar or radial nerve deficits. This is due to the median nerve innervates the digits that are required for grasping and precision pinching. This test will assess the client’s fine motor coordination/prehension with each hand when using basic household and everyday objects. Included in the box are 12 standard objects: wing nut, screw, key, nail, large nut, nickel, dime, washer, safety pin, paper clip, small hex nut, and small square nut. The evaluator will instruct the client and

211 280

perform the following:

1. Tape small and ring digits to palm to prevent use. With the client using vision, have the client pick up and place objects in a box as quickly as possible. Time the performance on two trials.

2. Response: Client picks up each object and deposits it in the box as

quickly as possible.

Measure the time to pick up and place all 12 objects into the box. The evaluator will input these trials in the boxes provided in the input page of the FCE. The average speed the client should be performing these tasks at are listed below, eyes open for trials 1 and 2.

Trial 1=10 to19 seconds

Trial 2= 9 to 16 seconds

The evaluator will then instruct the client to close their eyes and perform the same task in the same fashion.

3. Then occlude vision, place one object at a time between three-point pinch in random order and measure response; do two trials with each object.

4. Response: Client manipulates the object

and names it as quickly as possible. Measure the time to recognize each object on each of two trials (up to a maximum of 30 seconds).

Trial 1= 2 seconds per object Trial 2= 2 seconds per object.

212 281

213

Average Performance of Normal Subjects on the Box and Block Test

(blocks transferred in one minute) MALES FEMALES


L 86.4 8.5 70-102 83.4 7.9 66-99

25-29 R 85.0 7.5 71-95 86.0 7.4 53-96 L 84.1 7.1 69-100 80.9 6.4 53-93

30-34 R 81.9 9.0 68-95 85.2 7.4 75-101 L 81.3 8.1 69-99 80.2 5.6 66-92

35-39 R 81.9 9.5 64-104 84.8 5.1 71-95 L 79.8 9.7 56-97 93.5 6.1 72-97

40-44 R 83.0 8.1 69-101 81.1 8.2 60-97 L 80.0 8.8 59-93 79.7 8.8 57-97

45-49 R 76.9 9.2 51-93 82.1 7.5 63-99 L 75.8 7.8 50-88 78.3 7.5 59-91

50-54 R 79.7 9.7 62-106 77.7 10.7 57-91 L 77.0 9.2 50-97 74.8 9.9 53-93

55-59 R 75.2 11.9 45-97 74.7 8.9 56-94 L 73.8 10.5 43-94 73.6 7.8 54-85

60-64 R 71.3 8.8 52-64 75.1 6.9 53-95 L 70.5 8.7 47-82 73.6 6.4 52-85

65-69 R 68.4 7.1 55-80 72.0 6.2 50-82 L 67.4 7.2 48-86 71.3 7.7 51-79

70-74 R 66.3 9.2 50-85 53.6 7.0 55-87 L 64.3 9.8 45-84 58.3 7.0 53-89

75+ R 53.0 7.2 47-75 65.0 7.1 52-79 L 51.3 8.4 46-74 63.6 7.4 51-81

All Age R 17.0 4.1 7-34 11.3 2.6 4-20 Groups L 16.4 4.0 8-36 10.8 2.4 4-18

282

OCCUPRO Functional Capacity Evaluation Appendix B

218


APPENDIX B – Functional Capacity Evaluation Research

General

Orthopedic Section of the American Physical Therapy Association (2011). Occupational Health Physical Therapy: Evaluating Functional capacity Guidelines. Accessed 11/30/11 from http://www.orthopt.org/sig_oh_guidlines.php

American Physical Therapy Association (2011). Defensible Documentation: Setting Specific Considerations in Documentation. Accessed 11/30/11 from http://www.apta.org/documentation/defensibledocumentation/specificconsiderations/

OWind, H., Gouttebarge, V., Kuijer, P., Sluiter, J. and Frings-Dresen, M. (2009) “Complementary value of functional capacity evaluation for physicians in assessing the physical work ability of workers with musculoskeletal disorders” International Archive Occupational and Environmental Health (82) 435-443

Mitchell, T. (2008) “Utilization of the functional capacity evaluation in vocational rehabilitation” Journal of Vocational Rehabilitation (28) 21-28

Soer, R., Geertzen, J. Reneman, M, Groothoff, J., and van der Schans, C (2008) “Towards consensus in operational definitions in functional capacity evaluation: a delphi survey” Journal of Occupational Rehabilitation (18) 389-400

Innes, EV and Straker, L (1999). “Validity of work related assessments”. Work 13: 125-152

Innes, EV and Straker, L (1999). “Reliability of work related assessments”. Work 13: 107-124

Innes, E (2006) “Reliability and validity of functional capacity evaluations: an update” International Journal of Disability Management Research (1)1 135-148

Simons, G. (2006). “Credibility Crisis in FCE’s”. Ptproductsonline.com

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996). “Evidence based medicine: what it is and what it isn’t”. BMJ 312: 71-2.

Matheson, L (2003) “The functional capacity evaluation”. Disability Evaluation 2nd edition G. Anderson & S. Detmer & G. Smith. Mosby Yearbook, Chicago, IL.

James, C. Mackenzie, L. and Higginbotham, N. (2007) “Health professionals attitudes and practices in relation to functional capacity evaluations” Work (29) 81-87

283


219


Job Demands Analysis Lysaght, R. (2004) “ Approaches to worker rehabilitation by occupational and

physical therapists in the United States: Factors impacting practice” Work 23: 139-146

Lindstrom, I., Ohlund, C., Nachemson, A. (1994) “Validity of Patient Reporting and Predictive Value of Industrial Physical Work Demands” Spine Vol. 19, No. 8: 888-893

Musculoskeletal Testing Jones T. and Kumar, S. (2002) “Functional capacity evaluation of manual

material handlers: a review”. Disability and Rehabilitation 25 (4-5): 179-191

Fishbain, D., Cutler, R., Rosomoff, H. and Rosomoff, R. (1999) “Chronic pain disability exaggeration/malingering and sub-maximal effort research”. The Clinical Journal of Pain 15: 244-274

Lechner, D., Bradbury, S., and Bradley, L. (1998) “Detecting Sincerity of Effort: A Summary of Methods and Approaches”. Physical Therapy (78)8 867-888

Sensation

Reliability of Pain Chan, C., Goldman, S., Iistrup, D., Kunselman, A. and O’Neil, P. (1993) “The

pain drawing and Waddell’s non-organic physical signs of chronic low back pain”. Spine 18(13): 1717-1722

Reneman, M., Jorritsma, W., Dijkstra, S. and Dijkstra, P. (2003) “Relationship between kinesiophobia and performance in a functional capacity evaluation”. Journal of Occupational Rehabilitation 13(4): 277-285

Psychometric Testing Fairbank, J., Davies, J., Couper, J., O’Brien, J. (1980) “The Oswestry Low Back

Pain Questionnaire” Physiotherapy Vol. 66, No 8: 271-273

Melzack, R. (1975) “The McGill Pain Questionnaire: Major Properties and Scoring Methods”. Pain 1: 277-299

Vernon, H. and Mior, S. (1991) “The Neck Disability Index: A Study of Reliability and Validity”. Journal of Manipulative and Physiological Therapeutics. 14(7): 409-415

Ransford, A.O., Cairns, D., Mooney, V. (1976) “The Pain Drawing as an Aid to the Psychologic Evaluation of Patients With Low-Back Pain”. Spine Vol. 1, No 2: 127-134

284


220


Pain, Heart Rate, Blood Pressure, Respiratory Rate Coghill, R., Talbot, J., Evans, A., Meyer, E., Gjedde, A., Bushnell, M. and

Duncan, G. (1994) Distributed processing of pain and vibration by the human brain”. The Journal of Neuroscience 14(7): 4095-4108

Kregel, K., Seals, D. and Callister, R. (1992) “Sympathetic nervous system activity during skin cooling in humans: relationship to stimulus intensity and pain sensation”. Journal of Physiology 454: 359-371

Keefe, F., Wilkins, R. and Cook, W (1984) “direct observation of pain behavior in low back pain patients during physical examination”. Pain 20: 59-68

Jensen, I., Bradley, L. and Linton, S. (1989) “Validation of an observation method of pain assessment in non-chronic back pain”. Pain 39: 267-274

Dirks, J., Wunder, J., Kinsman, R., McElhinny, J. and Jones, N (1993) “A pain rating scale and a pain behavior checklist for clinical use: development, norms and the consistency score”. Psychotherapy Psychosomatic 59: 41-49


Moltner, A., Holzl, R. and Strian, F (1990) “Heart rate changes as an autonomic component of the pain response” Pain 43: 81-89

Keefe, F. and Hill, R. (1985) “An Objective Approach to Quantifying Pain Behavior and Gait Patterns in Low Back Pain Patients” Pain, 21: 153-161

Matheson, L. (1996) “Relationships Among Age, Body Weight, Resting Heart Rate, and Performance in a New Test of Lift Capacity” Journal of Occupational Medicine, Vol 6 No.4: 225-237

Brouwer, S., Dijkstra, P., Stewart, R., Goeken, L., Groothoff, J., Geertzen, J., (2005) “Comparing self-report, clinical examination and functional testing in the assessment of work-related limitations in patients with chronic low back pain”. Disability and Rehabilitation, Vol 27(17): 999-1005

Coghill, R., Talbot, J., Evans, A., Meyer, E., gjedde, A., Bushnell, M.C., Duncan, G. (1994) “Distributed Processing of Pain and Vibration by the Human Brain” The Journal of Neuroscience 14(7): 4095-4108

Kregel, K., Seals, D., Callister, R. (1992) “Sympathetic Nervous System Activity During Skin Cooling in Humans: Relationship to Stimulus Intensity and Pain Sensation” Journal of Physiology 454: 359-371

Keefe, F., Wilkins, R., Cook, W. (1984) “Direct Observation of Pain Behavior in Low Back Pain Patients during Physical Examination”. Pain 20: 59-68

Jensen, I., Bradley, L., Linton, S (1989) “Validation of an observation method of pain assessment in non-chronic back pain” Pain 39: 267-274

Dirks, J., Wunder, J., Kinsman, R., McElhinny, J., Jones, N. (1993) “A Pain Rating Scale and a Pain Behavior Checklist for Clinical Use: Development, Norms, and the Consistency Score” Psychother Psychosom 59: 41-49

285


221


Lechner, D., Bradbury, S., Bradley, L. (1998) “Detecting Sincerity of Effort: A Summary of Methods and Approaches”. Physical Therapy Volume 78, No 8: 867-888

Moltner, A., Holza, R., Strian, F. (1990) “Heart rate changes as an autonomic component of the pain response”. Pain 43: 81-89

Waddell Signs Fishbain, D., Cole, B., Cutler, R., Lewis, J., Rosomoff, H. and Rosomoff, R.

(2003) “A structured evidence based review of the meaning of nonorganic physical signs: Waddell signs”. Pain Medicine 4(2): 141-181

Bradish, C., Lloyd, G., Aldam, C., Albert, J., Dyson, P., Doxey, N and Mitson, L. (1988) “Do nonorganic signs help to predict the return to activity of patients with low back pain”. Spine 13(5): 557-560

Pransky, G. and Dempsey, P. (2004) “Practical aspects of functional capacity evaluations”. Journal of Occupational Medicine 14(3): 217-229

Waddell, G., McCulloch, J., Kummel, E. and Venner, R. (1980) “Nonorganic physical signs in low back pain”. Spine 5(2): 117-125

Lehmann, T., Russell, D. and Spratt, K (1983) “The impact of patients with non-organic physical finding on a controlled trial of transcutaneous electrical nerve stimulation and electroacupuncture”. Spine 8(6): 625-634

Lechner, D. (2004) “Functional capacity evaluation: an evidence based approach” Pre Training required reading from the internet



Waddell, G., Main, C., Morris, E., Paola, M., Gray, I. (1983) “Chronic Low-Back Oain, Psychologic Distress, and Illness Behavior”. Illness Behavior: 209-211

Gallagher, R. (2003) “Waddell Signs: Objectifying Pain and the Limits of Medial Altruism”. Pain Medicine Volume 4, No.2: 113-115

Karas, R., McIntosh, G., Hall, H., Wilson, L., Melles, T. (1997) “The Relationship Between Nonorganic Signs and Centralization of Symptoms in the Prediction of Return to Work for Patients With Low Back Pain”. Physical Therapy Volume 77, No.4: 354-360

Scalzitti, D. (1997) “Screening for Psychological Factors in Patients With Low Back Problems: Waddell’s Nonorganic Signs” Physical Therapy Volume 77, No. 3: 306-312

Spratt, K., Lehmann, T., Weinstein, J., Sayre, H. (1990) “A New Approach to the Low-Back Physical Examination”. Spine Volume 15, No. 2

286


222


Fishbain, D., Cutler, R., Rosomoff, H., Rosomoff, R., Steele (2004) “Is There a Relationship Between Nonorganic Physical Findings (Waddell Signs) and Secondary Gain/Malingering?”. Clin J Pain Volume 20 (6): 399-408

Keefe, F., Crisson, J., Maltbie, A., Bradley, L., Gil, K. (1986) “Illness Behavior as a Predictor of Pain and Overt Behavior Patterns in Chronic Low Back Pain Patients”. Journal of Psychosomatic Research Vol. 30, No. 5: 543-551

Feinberg, S., Kirz, Joshua. And Mackey, S. (2005) “Symptom magnification & Waddell behavior signs” www.cwce.com/feinbergarticles

Gaines, W. and Hegmann, K. (1999) “Effectiveness of Waddell’s nonorganic signs in predicting a delayed return to regular work in patients experiencing acute occupational low back pain”. Spine 24(4): 396-401

Consistency of Effort Lechner, D., Bradbury, S., and Bradley, L. (1998) “Detecting Sincerity of Effort:

A Summary of Methods and Approaches”. Physical Therapy (78)8 867-888

Saunders, R. (1999) “Letters and responses: sincerity of effort”. Physical Therapy 79(1): 94-96

Matheson, L. (1988) “How do you know that he tried his best?” – The Reliability Crisis in Industrial Rehabilitation” Industrial Rehabilitation Quarterly Vol.1, No 1:1-3

Lemstra, M. Olszynski, W. and Enright, W (2004) “The sensitivity and specificity of functional capacity evaluations in determining maximal effort: a randomized trial”. Spine 29: 953-959

Kaplan, G., Wurtele, S. and Gillis, D. (1996) “Maximal effort during functional capacity evaluations: and examination of psychological factors”. Archives of Physical Medicine and Rehabilitation 77: 161-164

Grip/Pinch Testing King, P (1998) “Analysis of approaches to detection of sincerity of effort through

grip strength measurements”. Work 10: 9-13(23) Joughin, K., Gulati, P., Mackinnon, S.,

McCabe, S., Murray, J., Griffiths, S. and Richards, R. (1993) “An evaluation of rapid exchange and simultaneous grip tests”. The Journal of Hand Surgery 18A(2): 245-252

Hildreth, D., Breidenbach, W., Lister, G. and Hodges, A (1989) “Detection of sub-maximal effort by use of the rapid exchange grip”. The Journal of Hand Surgery 14A(4): 742-745

Matheson, L., Isernhagen, S. and Hart, D (2002) “Relationship among lifting ability, grip force, and return to work”. Physical Therapy 82(3): 249-256

287


223


King, J and Berryhill, B (1991) “Assessing maximum effort in upper extremity functional testing”. Work 1(3): 65-76

Taylor, C and Shechtman, O (2000) “The use of the rapid exchange grip test in detecting sincerity of effort, part I: administration of the test” Journal of Hand Surgery 13: 195-202

Taylor, C and Shechtman, O (2000) “The use of the rapid exchange grip test in detecting sincerity of effort, part II: validity of the test” Journal of Hand Surgery 13: 203-210

Shechtman, O., Gutierrez, Z. and Kokendofer, E. (2005) “Analysis of the statistical methods used to detect sub-maximal effort with the five-rung grip strength test”. Journal of Hand Therapy 18: 10-18

Goldman, S., Cahalan, T. and An, K. (1991) “The injured upper extremity and the jamar five handle position grip test”. American Journal of Physical Medicine and Rehabilitation 70(6): 306-308

Matheson, L (1998) “Use of maximum voluntary effort testing to identify symptom magnification syndrome”. Employment Potential Improvement Corporation http://www.epicrehab.com/abstracts

Matheson, L and Dakos (2000) “Re-visiting “how do you know he tried his best”… the coefficient of variation as a determinant of consistent effort” Employment Potential Improvement Corporation http://www.epicrehab.com/abstracts

Shechtman, O. (2001) “The coefficient of variation as a measure of sincerity of effort of grip strength, part I: the statistical principle”. Journal of Hand Therapy 14: 180-187

Shechtman, O. (2001) “The coefficient of variation as a measure of sincerity of effort of grip strength, part II: sensitivity and specificity”. Journal of Hand Therapy 14: 188-194



Gutierres, Z. and Shechtman, O. (2003) “Effectiveness of the five handle position grip strength test in detecting sincerity of effort in man and women”. American Journal of Physical Medicine and Rehabilitation 82(11): 847-855

Westbrook, A.P., Tredgett, M.W., Davis, T.R.C., Oni, J.A. (2002) “The Rapid Exchange Grip Strength Test and the Detection of Submaximal Grip Effort”. The Journal of Hand Surgery 27A: 329-333

Hamilton, A.., Balnave, R., Adams, R. (1994) “ Grip Strength Testing Reliability”. J Hand Ther 7: 163-170

288


224


Agre, J., Magness, J., Hull, S., Wright, K., Baxter, T., Patterson, R., Stradel, L. (1987) “Strength Testing with a Portable Dynamometer: Reliability for Upper and Lower Extremities”. Arch Phys Med Rehabilitation Vol. 68: 454-458

Stokes, H., Landrieu, K., Doinangue, B., Kunen, S. (1995) “Identification of Low-effort Patients Through Dynamometry”. J Hand Surg 20A: 1047-1056

Joughin, K., Gulati, P., Mackinnon, S., McCabe, S., Murray, J., Richards, R. (1993) “An evaluation of rapid exchange and simultaneous grip tests”. J Hand Surg 18A: 245-252

Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., Rogers, S. (1985) “Grip and Pinch Strength: Normative Data for Adults”. Arch Phys Med Rehabil 66: 69-72

Ashton, L.A., Myers, S. (2004) “Serial Grip Strength Testing-Its Role in Assessment of Wrist and Hand Disability”. The Internet Journal of Surgery Volume 5 Number 2

Niebuhr, B. and Marion, R. (1990) “Voluntary Control of Submaximal Grip Strength”. American Journal of Physical Medicine & Rehabilitation Vol. 69, No 2: 96-91

Stokes, H. (1983) “The Seriously uninjured Hand-Weakness of Grip” Journal of Occupational Medicine Vol 25, No 9:683-684

Niebuhr, B., Marion, R. (1987) “Detecting Sincerity of Effort when Measuring Grip Strength” American Journal of Physical Medicine Vol. 66, No 1: 16-23

Coordination King, P, Tuckwell, N. and Barrett, T (1998) “A critical review of functional

capacity evaluations”. Physical Therapy 78(8): 852-866

DesRosiers, J., Hebert, R., Bravo, G., Dutil, E. (1995) “The Purdue Pegboard Test: normative data for people aged 60 and over”. Disability and Rehabilitation Vol. 17, No. 5: 217-224

Non Material Handling

Walking Keefe, F and Hill, R (1985) “An Objective Approach to Quantifying Pain Behavior

and Gait Patterns in Low Back Pain Patients” Pain 21: 153-161

Balance Testing Wrisley, D., Marchetti, G., Kuharsky, D., Whitney, S. (2004) “Reliability,

Internal Consistency, and Validity Obtained With the Functional Gait Assessment”. Physical Therapy Volume 84, No. 10:

289


225


Materials Handling Soer, R. Poels, B., Geertzen, J., and Reneman, M. (2006) “A comparison of two

lifting assessment approaches in patients with chronic low back pain” Journal of Occupational Rehabilitation (16) 639-646

Isernhagen, S., Hart, D. and Matheson, L. (1999) “Reliability of independent observer judgments of level of lift effort in a kinesiophysical functional capacity evaluation”. Work 12: 145-150

King, P, Tuckwell, N. and Barrett, T (1998) “A critical review of functional capacity evaluations”. Physical Therapy 78(8): 852-866

Jay, M., Lamb, J., Watson, R., Young, I., Fearon, F., Alday, J., and Tindall, A. (2000) “Sensitivity and Specificity of the indicators of sincere effort of the EPIC lift capacity test on a previously injured population”. Spine 25(11): 1405-1412

Gardener, L. and McKenna, K. (1999) “Reliability of occupational therapists in determining safe, maximal lifting capacity”. Australian Occupational Therapy Journal 46: 110-119

Reneman, M., Jaegers, S., Westmaas, M., Goeken, L. (2002) “The reliability of determining effort level of lifting and carrying in a functional capacity evaluation”. Work 18: 23-27

Matheson, L., Mooney., Grant, J., Affleck, M., Hall, H., Melles, T., Lichter, R., McIntosh, G. (1995) “ A Test to Measure Lift Capacity of Physically Impaired Adults –Part 1 - Development and Reliability Testing” Spine Volume 20, No. 19: 2119-2129

Reneman, M., Fokkens, A., Dijkstra, P., Geertzen, J., Groothoff, J. (2005) “ Testing Lifting Capacity: Validity of Determining Effort Level by Means of Observation” Spine Volume 30(2): E40-E46

Snook, S and Ciriello, V. (1991) “The design of manual handling tasks: revised tables of maximum acceptable weights and forces”. The design of manual handling tasks: 1197-1213

Matheson, L. ( 1996) “Relationships Among Age, Body Wight, Resting Heart Rate, and Performance in a New Test of Lift Capacity”. Journal of Occupational Rehabilitation, Vol.6, No. 4: 225-237

Matheson, L., Mooney, V., Holmes, D., Leggett, S., Grant, J., Negri, S., Holmes, B. (1995) “A Test to Measure Lift Capacity of Physically Impaired Adults- Part 2 Reactivity in a Patient Sample”. Spine Volume 20, No. 19: 2130-2134

Smith, R. (1994) “Therapists’ Ability to Identify Safe Maximum Lifting in Low Back Pain Patients During Functional Capacity Evaluation” JOSPT Volume 19, No. 5: 277-281

Gross, D and Battie, M. (2002) “Reliability of Safe Maximum Lifting Determinations of a Functional Capacity Evaluation”. Physical Therapy Volume 2, No.4: 364-370

290


226


Saunders, R., Beissner, K., McManis, B. (1997) “Estimates of Weight That Subjects Can Lift Frequently in Functional Capacity Evaluations”. Physical Therapy, Volume 77: 1717-1728

Mayer, T., Barnes, D., Kishino, N. Nichols, G., Gatchel, R., Mayer, H. and Mooney, V. (1988) “Progressive isoinertial lifting evaluation I. a standardized protocol and normative database”. Spine 13(9): 993-996

Job Simulated Testing Sit –Stand - Climb

291


Non Material Handling/

Positional Tolerance Decision Charts Avoid Occasional Frequent Constant

S I

M P L E

G R A S P I N G

Ability Client is unable to generate

any poundage on dynamometer

Client able to generate some poundage on dynamometer

Client able to achieve grip strength that is within normal age and gender ranges per Matheowitz

norms

Male clients are able to achieve grip strength that is

within 21 points of their mean and female clients are

within 12 points of their mean or greater per


Mechanics

Client demonstrates mechanical deficits to include but not limited to significant loss of distal upper extremity

range of motion.

Client demonstrates mechanical changes to

include but not limited to distal upper extremity range

of motion.

Client demonstrates no loss of distal upper extremity

mechanics


mechanics

Functional Pain

Client understands and appropriately uses the

OccuPro pain intensity scale, has minimal to no reliability

of pain issues and reports increases in pain symptoms to

a 6 or higher specifically associated with the distal

upper extremity.

Client understands and appropriately uses the OccuPro pain intensity

scale, has minimal to no reliability of pain issues, and reports pain at a 5 or

less specifically associated with the distal upper

extremity.


scale, has minimal to no reliability of pain issues and

reports pain at a 4 or less specifically associated with

ility of pain issues, and r



of pain issues and reports pain symptoms at a 2.5 or less specifically associated

with the distal upper extremity.

Pain Behaviors

Client exhibits significant facial grimacing, verbal grunting, holding, and/or

requires a break following this test and is specifically associated with pain in the

distal upper extremity.

Client exhibits mild pain behaviors including but not limited to facial grimacing

and is specifically associated with pain in the


Client exhibits no pain behaviors specifically

associated with pain in the distal upper extremity.



Functional Demonstration

Client exhibits an inability to perform material handling

activities secondary to functional grip strength

Client exhibited the ability to perform occasional

material handling activities at low weight levels

Client exhibited the ability to perform all occasional

and frequent material handling activities at low

weight levels

Client exhibited the ability to perform all material handling

activities without deficit

292


Avoid Occasional Frequent Constant

F I R M

G R A S P I N G

Ability

Client is unable to generate grip strength poundage that is within normal ranges per Matheowitz age and gender

norms

Client able to achieve grip strength that is within normal

age and gender ranges per Matheowitz norms

Male clients are able to achieve grip strength that is

within 21 points of their mean and female clients are

within 12 points of their mean or greater per


Client able to achieve grip strength that is greater than the mean per Matheowitz

age and gender norms

Mechanics

Client demonstrates mechanical changes and/or

mechanical deficits to include but not limited to significant loss of distal upper extremity range of

motion


mechanics


mechanics


mechanics

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with the distal

upper extremity.


OccuPro pain intensity scale, has minimal to no reliability of pain issues, and reports

pain at a 5 or less specifically associated with the distal upper extremity.


scale, has minimal to no reliability of pain issues and reports pain at a 2.5 or less specifically associated with the distal upper extremity.





Pain Behaviors





and is specifically associated with pain in the distal upper

extremity.






Client exhibited an inability to perform maximal

occasional material handling testing

Client exhibited the ability to perform occasional maximal

material handling testing without deficit

Client exhibited the ability to perform frequent

maximal material handling activities without deficit

Client exhibited the ability to perform all frequent

maximal lifting material handling activities without

deficit

293



S I

M P L E

P I N C H I N G

Ability Client is unable to generate

any poundage on pinch dynamometer

Client able to generate some poundage on pinch

dynamometer

Client able to achieve pinch strength that is within normal age and gender ranges per Matheowitz

norms

Male clients are able to achieve pinch strength that is within 4 points of their mean and female clients are within

3 points of their mean or greater per Matheowitz age

and gender norms

Mechanics

Client demonstrates mechanical deficits to

include but not limited to significant loss of distal upper extremity range of

motion


include but not limited to distal upper extremity range

of motion


mechanics


mechanics

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with distal upper

extremity.



pain at a 5 or less specifically associated with








of pain issues and reports pain symptoms at a 2.5 or less specifically associated with distal upper extremity.

Pain Behaviors






extremity.






Client exhibited an inability to perform fine motor testing

secondary to functional pinch strength

Client exhibited the ability to perform some fine motor activities without deficit

Client exhibited the ability to perform most fine motor


Client exhibited the ability to perform all fine motor


294



F I N E

M O T O R

C O O R D I N A T I O N

Ability Client is unable to complete any of the fine motor testing

Client able to perform fine motor testing and generate

some results

Client able to perform fine motor testing and generates

results in which at least 50% of the tests are able to be scored within the tests

scoring system

Client able to perform all fine motor testing and all

results are able to be scored within the tests scoring

system

Mechanics


include but not limited to significant loss of distal UE ROM, hand eye coordination

and/or median nerve sensation


include but not limited to distal UE ROM, mild hand

eye coordination and/or mild median nerve sensation

deficits

Client demonstrates no loss of distal UE mechanics, hand eye coordination and/or median nerve

sensation

Client demonstrates no loss of distal UE mechanics, hand

eye coordination and/or median nerve sensation

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with the distal

upper extremity.



pain at a 5 or less specifically associated with the distal upper extremity.



reports pain at a 4 or less specifically associated with the distal upper extremity.





Pain Behaviors






extremity.






Client exhibits an inability to perform pinching testing

Client exhibits an ability to perform pinching on an

occasional level.

Client exhibits an ability to perform pinching on a

frequent level.

Client exhibits an ability to perform pinching on a

constant level.


G R O S S

M O T O R

C O O R D I N A T I O N

Ability Client is unable to complete

any of the gross motor testing

Client able to perform gross motor testing and generate

some results

Client able to perform gross motor testing and generates

results in which at least 50% of the tests are able to be scored within the tests

scoring system

Client able to perform all gross motor testing and all results are able to be scored

within the tests scoring system

Mechanics


include but not limited to significant loss of upper

extremity range of motion, hand eye coordination and/or

sensation


include but not limited to upper extremity range of motion, mild hand eye

coordination, and/or mild sensation deficits

Client demonstrates no loss of upper extremity

mechanics, hand eye coordination and/or

sensation

Client demonstrates no loss of upper extremity

mechanics, hand eye coordination and/or

sensation

Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with the upper

extremity.




the upper extremity.




the upper extremity.



of pain issues and reports pain symptoms at a 2.5 or less specifically associated with the upper extremity.

Pain Behaviors



upper extremity.


and is specifically associated with pain in the upper

extremity.


associated with pain in the upper extremity.


associated with pain in the upper extremity.


Client exhibits an inability to perform forward reaching

and above shoulder reaching

Client may be able to perform forward reaching

and/or above shoulder reaching on an occasional

basis.


and/or above shoulder reaching on a frequent

basis.


and/or above shoulder reaching on a constant basis.

295



W A L K I N G


100 yards of walking. Client able to complete the

100-yard walk. Client able to complete the

100-yard walk.

Client able to complete the 100 yard walk and 15 minutes of prolonged walking at 3.0 mph or

greater on the treadmill

Time Client exceeds 2 minutes

during demonstration of 100 yard walk.

Client completes 100 yards in greater than 66 seconds

due to slow pace.

Client completes the 100 yards in 66 seconds or less.

Client completes the 100 yards in 66 seconds or less

and completes 15 minutes of prolonged walking at 3.0

mph or greater

Mechanics

Client exhibits mechanical deficits including but not limited to unequal stride,

splinting, and/or an antalgic gait pattern.

Client exhibits mechanical changes including but not

limited to the use of a cane, unequal stride, splinting,

and/or antalgic gain.

Client exhibits no changes in regards to walking

mechanics.

Client exhibits no changes in regards to walking

mechanics.

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically

associated with the back and/or lower extremities.




the back and/or lower extremities.




back and/or lower extremities.



of pain issues and reports pain symptoms at a 2.5 or less specifically associated with the back and/or lower

extremities.

Pain Behaviors


requires a break following this test and is specifically

associated with pain in back and/or lower extremities.


and is specifically associated with pain in the back and/or

lower extremities.


associated with pain in the back and/or lower

extremities.


associated with pain in the back and/or lower

extremities.


Client exhibits an inability to perform walking throughout

this evaluation or re-assessment

Client demonstrates the ability to walk during this

evaluation or re-assessment

Client demonstrates the ability to perform walking

with no difficulty throughout this functional

test

Client demonstrates the ability to perform walking

with no difficulty throughout this functional test

296



F O R W A R D

R E A C H I N G


one repetition of forward reaching.

Client able to complete one repetition of forward

reaching.

Client able to complete 10 reps of forward reaching at

a comfortable pace.

Client able to complete 10 reps of forward reaching

while exhibiting a faster pace than the 10 reps at a comfortable pace.

Time No specific time involved Client completes the one rep

within roughly 3 seconds

Client completes the 10 repetitions within a

reasonable time

Client completes the 10 reps at a faster pace than 10 reps

at a comfortable pace

Mechanics

Client exhibits mechanical deficits including but not limited to scapulohumeral rhythm, shoulder hiking, compensation and painful

crepitus.

Client exhibits mechanical changes including but not limited to scapulohumeral

rhythm, hiking, compensation and

palpable/audible crepitus

Client exhibits no changes in mechanics with normal

crepitus.


crepitus.

Functional Pain




associated with the shoulder.




the shoulder.




the shoulder.




with the shoulder.

Pain Behaviors



shoulder.


and is specifically associated with pain in the shoulder.


associated with pain in the shoulder.




Client exhibits an inability to perform gross motor

activities during this test

Client is able to perform gross motor activities during

this functional test

Client is able to perform gross motor activities throughout this entire

functional test.


functional test.


A B O V E

S H O U L D E R

R E A C H I N G


one repetition of above shoulder reaching.

Client able to complete one repetition of above shoulder

reaching.

Client able to complete 10 reps of above shoulder

reaching at a comfortable pace.

Client able to complete 10 reps of above shoulder

reaching while exhibiting a faster pace than the 10 reps

at a comfortable pace.




reasonable time



Mechanics

Client exhibits mechanical deficits including but not limited to scapulohumeral rhythm, shoulder hiking, compensation and painful

crepitus.

Client exhibits mechanical changes including but not limited to scapulohumeral

rhythm, hiking, compensation and

palpable/audible crepitus


crepitus.


crepitus.

Functional Pain




associated with the shoulder.




the shoulder.




the shoulder.




with the shoulder.

Pain Behaviors



shoulder.


and is specifically associated with pain in the shoulder.






Client exhibits an inability to perform gross motor

activities during this test

Client is able to perform gross motor activities during

this functional test


functional test.


functional test.

297



B E N D I N G

Ability Client is unable to complete one repetition of bending at 25% of a full bend or more.

Client able to complete one repetition of bending at 25%

of a full bend or more.

Client able to complete 10 reps of bending at 25% of a

full bend or more at a comfortable pace.

Client able to complete 10 reps of bending while

exhibiting a faster pace than 10 reps at a comfortable pace

and is able to perform at 50% or more of a full bend.




reasonable time



Mechanics

Client exhibits mechanical deficits including but not

limited to range of motion, equal weight bearing,

compensation, and single plane lumbar flexion.

Client exhibits mechanical changes including but not limited to range of motion,

equal weight bearing, compensation, and single

plane lumbar flexion.

Client exhibits no changes in mechanics.


Functional Pain




associated with the low back.




the low back.




the low back.




with the low back.

Pain Behaviors



low back.


and is specifically associated with pain in the low back.


associated with pain in the low back.


associated with pain in the low back.


Client exhibits an inability to perform the Bend Lift

Client is able to perform the Bend Lift if performed

Client is able to perform bending within 66% of this

test

Client is able to perform bending within 99% of this

test


S Q U A T T I N G

Ability Client is unable to complete one repetition of squatting to 50% of a full squat or more.

Client able to complete one repetition of squatting to

50% of a full squat or more.

Client able to complete 10 reps of squatting at a

comfortable pace while demonstrating a squat at

50% of a full squat or more.

Client demonstrates the ability to perform job

simulated squatting for 41 to 60 minutes




reasonable time

41 to 60 minutes of job simulated repetitive

squatting

Mechanics


limited to decreased weight bearing on one side, single plane movement pattern,

and/or compensation.






Functional Pain




associated with the low back and lower extremities.




the low back and lower extremities.








with the low back and lower extremities.

Pain Behaviors



low back and lower extremities.


and is specifically associated with pain in the low back

and lower extremities.


associated with pain in the low back and lower

extremities.



extremities.


Client exhibits an inability to the squat lift during this test

Client is able to perform occasional squat lifting

Client is able to perform frequent squat lifting

Client is able to perform squatting activities within

99% of this test 298



S U S T A I N E D

K N E E L I N G


the tall kneeling. Client able to complete the

tall kneeling for one minute.

Client able to complete the tall kneeling for two

minute.

Client able to complete the tall kneeling for greater than

41 to 60 minutes in a job simulated test.

Time Unable to complete one

minute

Client completes the sustained kneeling and achieves one minute

Client completes the sustained kneeling and achieves two minutes

Client completes the sustained kneeling and

achieves greater than 41 minutes in a job simulated

test

Mechanics

Client exhibits mechanical deficits including decreased weight bearing on one side, compensation, single plane movement pattern and/or requires significant upper

extremity assistance.

Client exhibits mechanical changes including decreased

weight bearing, compensation, single plane movement pattern and/or requires upper extremity

assistance.



Functional Pain

















Pain Behaviors









extremities.



extremities.


S U S T A I N E D

S Q U A T T I N G


any sustained squatting. Client is able to complete

sustained squatting Client is able to complete

sustained squatting Client is able to complete

sustained squatting

Time 0 Minutes 1 – 20 minutes of sustained

squatting simulation

21 – 40 minutes of sustained squatting

simulation

41 - 60 minutes of sustained squatting simulation

Mechanics



compensation, and/or requires significant upper

extremity assistance.






Functional Pain

















Pain Behaviors









extremities.



extremities.

299



R E P E T I T I V E

K N E E L

Ability

Client was placed on avoid for tall kneeling or is unable to complete one repetition of

repetitive kneel

Client able to complete the tall kneeling and/or one

repetition of repetitive kneel.

Client able to complete 10 reps of repetitive kneeling

with minimal upper extremity assistance

Client able to complete 10 reps of repetitive kneeling in

a faster fashion than repetitive kneeling at a

comfortable pace or perform in a job sim.

Time No time achieved Client completes one minute of prolonged kneeling or one repetition within 8 seconds


reasonable time

Client completes the 10 reps at a faster pace than the previous test or 41 to 60 minutes of job simulated

repetitive kneeling

Mechanics


limited to decreased weight bearing on one side,

significant upper extremity assistance, compensatory techniques and/or single plane movement pattern.


limited to decreased weight bearing, upper extremity assistance, compensation

and/or single plane movement pattern.



Functional Pain

















Pain Behaviors









extremities.



extremities.


C R A W L I N G

Ability Client is unable to get into 4-point position and perform 1

minute of crawling.

Client able to complete the 1 to 20 minutes of crawling

forward and backward.

Client able to complete crawling, forward and

backward mobility, with intermittent rest breaks.

Client able to complete consecutive crawling both

forward and backward mobility

Time Unable to complete one

minute Client completes 1 to 20

minute of crawling Client completes the 21 to

40 minutes of crawling Client completes the 41 to 60

minutes of crawling

Mechanics


limited to decreased weight bearing on one side,

compensatory techniques and significant upper extremity assistance.


limited to decreased weight bearing, compensatory techniques and upper extremity assistance.



Functional Pain




associated with the low back, lower extremities and/or

upper extremities




the low back, lower extremities and/or upper

extremities.




the low back, lower extremities, and/or upper

extremities



of pain issues and reports pain symptoms at a 2.5 or less specifically associated with the low back, lower extremities, and/or upper

extremities.

Pain Behaviors



low back, lower extremities, and/or upper extremities.


and is specifically associated with pain in the low back, lower extremities, and/or

upper extremities.


associated with pain in the low back, lower

extremities, and/or upper extremities.


associated with pain in the low back, lower extremities,

and/or upper extremities.

300



S T A T I C

B A L A N C E

Ability

The client is unable to complete Romberg’s test,

Sharpen Romberg’s test and Functional Reach

Assessment

The client is able to perform Romberg’s and Sharpen

Romberg’s without a loss of balance and the Functional Reach Assessment is within

normative ranges.

The client is able to perform Single Leg Stance with eyes open with no loss

of balance bilaterally.

The client is able to perform Single Leg Stance with eyes closed and no loss of balance

bilaterally.

Time/ ability demonstration

No time achieved

Client completes Romberg’s/ Sharpened Romberg’s for 30

seconds and Functional Reach per procedure manual

norms

Client completes 30 seconds of Single Leg

Stance eyes open bilaterally

Client completes 30 seconds of Single Leg Stance eyes

closed bilaterally

Mechanics

Client exhibits mechanical deficits including but not limited to lower extremity weakness, decreased range

and/or significant compensatory techniques to

maintain balance.

Client exhibits mechanical changes including but not limited to lower extremity weakness, decreased range

and/or minimal compensatory techniques with no safety concerns.

Client exhibits no changes in mechanics with minimal

compensatory strategies noted with ability to

demonstrate safe recovery patterns.

Client exhibits no changes in mechanics with minimal compensatory strategies

noted with ability to demonstrate safe recovery

patterns.

Functional Pain

















Pain Behaviors









extremities.



extremities.


D Y N A M I C

B A L A N C E

Ability

The client fails gait on level surface, change in gait speed,

gait with horizontal and vertical head turns

The client passes gait on level surface, change in gait speed, gait with horizontal

and vertical head turns

The client passes gait and pivot turn and step over

obstacle bilaterally

The client passes gait with narrow base of support, gait

with eyes closed, and ambulating backwards.

Time/ ability demonstration

Time/ability and pass/fail as defined in procedure manual

Time/ability and pass/fail as defined in procedure

manual

Time/ability and pass/fail as defined in procedure manual

Mechanics Mechanics as outlined in

procedure manual Mechanics as outlined in

procedure manualMechanics as outlined in

procedure manual Mechanics as outlined in

procedure manual

Functional Pain

















Pain Behaviors









extremities.



extremities.

301



S T A I R

C L I

M B I N G


36 steps of negotiation Client able to complete the 36 steps of stair climbing

Client able to complete 72 steps of stair climbing

Client able to complete 108 steps of stair climbing

Mechanics

Client exhibits mechanical deficits, which include but are not limited to use of an assistive device, unequal

stride, splinting, and/or an antalgic gait pattern.

Significant safety or balance concerns while ascending/

descending stairs.

Client exhibits mechanical changes, which include but are not limited to use of an assistive device, unequal




Dynamic Balance

Client was placed on an avoid for dynamic balance

Client is able to perform dynamic balancing on an

occasional basis

Client is able to perform dynamic balancing on a

frequent basis

Client is able to perform dynamic balance on a

constant basis

Functional Pain

















Pain Behaviors



low back/lower extremities.






extremities.



extremities.


L A D D E R

C L I

M B I N G


1 rung of negotiation

Client able to complete the 4 rungs at 5 repetitions of

ladder climbing (20 ladder rungs total)

Client able to complete 4 rungs 15 repetitions of

ladder climbing (60 ladder rungs total)

Client able to complete the 4 rungs 25 repetitions of ladder climbing (100 ladder rungs

total)

Mechanics

Client exhibits mechanical deficits, which include but are not limited to use of an assistive device, unequal


Significant safety or balance concerns while ascending/

descending the ladder.

Client exhibits mechanical changes, which include but are not limited to use of an assistive device, unequal




Static/Dynamic Balance

Client was placed on an avoid for dynamic balance

and/or avoid for static balance if ladder climbing requires static balancing

Client was placed on an occasional level for dynamic balance and/or an occasional

level for static balance if ladder climbing requires

static balancing

Client was placed on a frequent level for dynamic balance and/or a frequent level for static balance if ladder climbing requires

static balancing

Client was placed on a constant level for dynamic balance and/or a constant level for static balance if ladder climbing requires

static balancing

Functional Pain

















Pain Behaviors









extremities.



extremities.

302

cover for fce course compendium software user · 2020-04-09 · 4 functional capacity evaluation...

Documents