drayer physical therapy, elite pt, tupelo pt, batson pt,...
TRANSCRIPT
Allen Thompson, MS, ATC, LAT, PES, CES, CSIWCP, CIEE, CAE
Director of Industrial Rehab, MSDrayer Physical Therapy, Elite PT, Tupelo PT,
Batson PT, Rehab at Work, Performance Rehab
The Good, The Bad, and the Ugly
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5What is a defensible FCE? Is that
possible?
The testing process is essential to objective measurements. We will evaluate the testing processes and the understanding the results
given by the therapist.
Should research be the final determination for the results of the test? We will evaluate the different
models of FCE reporting.
The Medical exam should match the medical history. The importance of the medical history should allow the therapist to distinguish self-limiting verses
appropriate or organic verses inorganic.
Explaining the FCE process and the importance of the type of FCE is performed may or may not be informative to the effectiveness of the results.
FCE Models Medical HX Testing Conclusions Defensible
The FCE process can be complex due to the multitudes of models within the
state and the country. We will look at some models to show the differences and their
benefits and potential hardships.
There are no current models that stipulate
purity in all forms.
All models have their benefits but also
their potential hardships.
The medical history can bring about some
misconceptions. Many doctors do not
understand the reason or importance
of the medical history.
However, many therapist do not understand the
importance of the history themselves.
History is the indicator for the
rationale for restrictions.
Testing processes differ between all FCE
models; however, there are parts of the
FCE which are consistent.
Understanding the process of the
evaluation and what determines PAIN or
SELF-LIMITING behaviors is essential for a successful FCE.
Should conclusions be based upon
computer model, human model, or mixture model?
Should conclusions be based upon active
research?
Determination of the restrictions and conclusions are essential for a
successful report.
The reliability and validity of the FCE is
essential for defensibility. Are
they peer reviewed or successfully
defended itself within a court setting?
Has it been evaluated for inter and intra
reliability?
I can say this, I have done some good
FCES, some bad FCEs, and some ugly FCEs.
• How can we stop ugly and bad FCEs from coming into the market?
• How can we make it efficient?
• How do we stop
The madness?
• Definitions• Reliability: “refers to the consistency of a measure” & “Reliability research
establishes the objectivity of the evaluation.” (Lechner, 1991)
• Interrater reliability: The ability to achieve similar scores on the evaluation when administered by different evaluators (Portney & Watkins, 1993)
• Intrarater reliability: Refers to the consistency of an evaluation performed by the same examiner at different points in time (Portney & Watkins, 1993)
• Validity: “refers to the accuracy of the evaluation (Portney & Watkins, 1993)
• Concurrent validity: “refers to the test’s ability to determine current abilities”
• Predictive validity: “refers to a test’s ability to determine future abilities” (Portney & Watkins, 1993)
• Objective: “objective means that measure is as free as possible from observer bias (Rothstein & Echternach, 1993)
FCE Models and their roles
• Understanding is knowledge!
• There are misunderstandings in those definitions!
• 1. Some clinicians confuse validity with the concept of sincerity of effort.
• 2. Clinicians believe validity is measured solely on consistency of effort.
• 3. Test validity is altered by the client’s cooperation.
• The validity and reliability of the test never changes but the intentions of the clients do! Thus, the test demonstrates what the client is willing to do.
• 4. Referral sources will continue to refer for reliability despite validity.
• 5. Waddell’s test proves self limitations only?
• A test should be performed neutral of bias. The examiner must remove personal beliefs and opinions from the report and testing process. • Good: Examiner relates truly upon objective facts of the
evaluation. Presenting organic evidence to substantiate the findings.
• Bad: Examiner leans consistently or partially to one party. The report in inconsistent of findings or objective and subjective reporting provides confusion.
• Ugly: The examiner performs a got-you report. Constantly looking for faults without evaluation causes. They are usually therapist who are hard left or right. These reports may also constantly report subjective evidences are true restrictions.
Good, Bad, and Ugly Definitions
• Medical History means more to the FCE than most people give credit.• Establishes a baseline of injury and consistency of
related information• Remember Docs-You have seen them for months-Me=Today
• Gives progress and clinical observations• Unexplained reduction in ability may establish true objective
measurements.
• Denotes doctor’s professional opinions, in regards, to surgeries, MRI’s, NCS, and other related studies.
• Doctors have become much more specialized. If we only go off of studies, we may begin a miscommunication between the doctor and the therapist.
• Provides clarity to the desires of the physician.
Medical History and the Relevance
The Good The Bad The Ugly
The therapist was provided all relative medical information.
The therapist was able to review the material
due to the ability to expedite the medical
communication.
The therapist has a clear plan and
understanding of the injury and all
subsequent medical findings.
The therapist was provided some
medical information but many of the
studies were absent.
Other medical providers were not stated leaving large
gaps.
The medical information was
provided less than one week before the
test.
The therapist receive demographics to say
the least.
No studies were reported or provided. Maybe surgical notes was all to evaluation.
The medical information was provided the day
before or the day of the exam. Request for next day report was
made.
Medical History and the Relevance
• All movement patterns are relative to the test.• The physical exam is a PHYSICAL EXAM!
• Range of Motion, Strength Testing, Neurologic, and Mechanical Testing.
• The physical exam should be in correlation with the medical history.• There should be a measure of consistency with the
outcomes of the physician and the therapist.
• Objective findings should be the basis of all impairment ratings and restrictions!• Too many opinions are based upon subjective evidence
paraded as objective. The evidence must present to suggest objective findings consistent to the AMA regulations.
Physical Exam and the Rationale
• Benefits to a Physical Exam• Sets Restriction Parameters
• Allows Objective evidence to be presented efficiently to all parties
• Can allow outcome measures to be implemented
• Allows clarity to the therapist about potential hazards during the test
• May determine if any tests should be avoided during the examination
Physical Exam and the Rationale
The Good The Bad The Ugly
Physical Exam and the Rationale
Therapist performs an extensive physical
examination and denotes any organic or objective evidence of limitations.
The therapist is competent in their evaluation and has a history and professional
experience.
The report indicates all physical restrictions and compared to the FCE for
any inconsistencies.
The therapists performs a basic examination
indicating some of the parameters for a physical
examination. The therapist may indicate
some nonorganic factors as organic.
The therapist is competent but cannot
explain the process of the evaluation.
The report does not truly indicate inconsistencies.
The therapist performs no physical
examination other than the basic impairment
requirements.
The report presents with no indications of
inconsistencies between the physical exam and the physical abilities. The report is
scattered with nonorganic parameters
that effectively diminishes the FCE.
- This is important. What makes a FCE consistent? When the objective facts match the objective reflection of the patient. This means the patient’s radicular complaint is consistent to the location of the nerve root injury and demonstrates appropriate changes to the overall function or biomechanical function of the patient.
- The definition of self-limiting or inconsistent tasks indicate an undetermined reason or effort by the patient that presents without cause for the notion.
- Possible Reasons: Pain, fear of re-injury, anxiety, depression, poor understanding of instructions, or conscious or unconscious attempt to manipulate the results of the test.
Testing Miscalculations - Inconsistencies
• Possible Test Inconsistencies• Unexplainable improvement on endurance tasks
• There are possibilities of improvement. However, the improvement should be minor in nature or equal to the same quality as tested earlier.
• Comparing self-reported function to test performance• Inconsistent reporting during the testing process may help determine the true validity of
self-limitations. Ex. Radicular symptoms do not occur when lifting but increases with standing.
• Comparing test results to diagnosis or impairment• The individual has knee surgery but the back is the complaint during the test. You may
see increased carpal tunnel complaints despite little organic evidence.
• Comparing test performance to casual observations• Inconsistent cane use. Ex. Uses cane in the facility but walks normal outside of the
facility. The entire time is considered part of the testing process.
• Comparing subjective pain statements and pain behaviors/movement• Movement patterns should match pain score. The pain behavior or movements must be
in align to the nature of the injury itself.
Testing Miscalculations - Inconsistencies
• What’s the big deal? • Inconsistencies brings inconsistent results!• Too many self-limitations without Objective
evidence have been made permanent work restrictions without merit.
• Full ROM at doctor-Limited at FCE=Restrictions without merit.
• Inconsistencies are not comparable to self-limitations in nature, but you will see one side-by-side with the other
• Inconsistencies are present and can be due to self-limitations; but also FEAR! Thus, inconsistencies should be based on a comparative evaluation during the FCE process and not during one particular test.
• Can alter the testing process• Could affect the impairment score and may diminish
the patient’s overall Department of Labor score.
Testing Miscalculations - Inconsistencies
The Good The Bad The Ugly
The therapist would appropriately
distinguish Objective factors of
inconsistency and the relationship to the
outcome of the test.
The inconsistencies would discourage
inappropriate restrictions based on
non-conclusive evidence of organic factors; but rather,
Subjective.
The therapist recognizes that the patient presents
with inappropriate behaviors but cannot relate
if all actions are inconsistencies.
The FCE model may detect some irregularities but
some do not.
States or maybe mentions differences but still allows
the changes to become restrictions due to
misunderstandings.
The therapist administers the test
and reports self-limitations but does
not report inconsistencies.
They rely solely on the test parameters
to determine inconsistencies.
Relating the inconsistencies is not
the standard to computer reports.
Medical History and the Relevance
- All restrictions must be based upon objective and organic risk factors.
- American Medical Association, A Physician’s Guide to Return to Work (2nd ed.) and American Medical Association, Guides to the Evaluation of Permanent Impairment (6th ed.)
- The lack of understandings in the regards to restrictions have diminished the effectiveness of physicians. However, the physicians have the means in providing appropriate recommendations.
- Poor recommendations may lead to adverse reactions upon the patient or the company. The restrictions may hinder their ability to return to work or hinder their ability to find future work.
- Risk should be the basis of restrictions. AMA states risk, “chance of harm to the patient, or to the general public, if the patient engages in specific work activities.”
- Substantial Harm indicates, “objectively verifiable worsening in the patient-examinee’s condition, and not merely an increase in previously present symptoms, like pain or fatigue.”
Testing gives appropriate Restrictions
The Good The Bad The Ugly
The therapist will determine the
conclusions based upon reasonable, reliable, and valid
research.
The information will not report personal opinions; but rather,
factual objective evidence related to
specific and non-biased research.
The therapist will utilized the
conclusions made by their respective FCE
process.
There may be some indications within the
report on potential conflicts; however,
there is a lack of true evidence to support
their findings. May be biased to one side or
may present with some manners of
personal opinions.
The report will be a primarily the
interpretation of the respective FCE
process and the therapist will offer nothing more than
their signature.
Validation of test results or conclusions will be subjective and
based upon the physician.
Testing gives appropriate Restrictions
• FCEs• Only as Valid as the evidence and
the experience of the therapist.
• Only as Reliable as the information between the FCE and the physician and the judges. • The information must be evaluated
and delineated appropriately restrictions
• Interpreting with unbiased opinions the self limiting factions of the FCE
Conclusions and Reporting
The Good The Bad The Ugly
The FCE is performed without bias and represents true
objective evidence of risk for the patient to
participant in work activities.
The FCE is compared to the functional job description to rule
out risked participation.
Great communication!
The FCE is performed without a bias lean
but does not present objective evidence or
subjective/self-limiting potential
affects the outcome and the restriction
requirements.
No comparison to functional job
descriptions/doctor signs report without
noting objective restrictions.
The FCE could be biased and has little objective evidence but is riddles with
subjective outcome models.
The doctor signs the report “Per FCE” and the self-limitations are not addressed
and deemed permanent restrictions.
Medical History and the Relevance
• FCEs• Only as Valid as the evidence and
the experience of the therapist.
• Only as Reliable as the information between the FCE and the physician the physician. • The information must be evaluated
and delineated appropriately restrictions
• Interpreting with unbiased opinions the self limiting factions of the FCE
Conclusions