1. WorkWell Prevention & Care
WorkWell’s FCE V.2
WorkWell Prevention & Care

2. Objectives Participants will understand
Sections included in reports and importance of each.
Policies each facility should have in place
Using quantitative and qualitative scoring criteria and correlating test activities
Answers to your questions

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

4. Evaluation Functional Capacity Evaluation Professional responsibility
A thorough history and physical examination prior to testing.
Identify contraindications / precautions for testing
Client safety

5. Clinic Policies and Procedure
Contraindications to testing
Blood pressure
Heart rate
Safety (lifting, postural, pacing/control)
Observers
Videotaping
Medical Records

6. Contraindications Professional responsibility to keep client safe
Identify if there are absolute contraindications to testing
Identify if certain tests are contraindicated
Any contraindication or restriction must be documented

7. Blood Pressure / HR Determine clinic guidelines for testing
What is the maximum
What is the time frame for BP or HR to return to below the maximum
Physiologic response in an activity may be the limiting factor

8. Safety Safe test environment and test procedures
Safe testing is not necessarily picture perfect body mechanics
Observe compensatory muscle recruitment or changes in body mechanics
Modifications required for safe testing
Not safe to proceed with test

9. Observation / Video taping
Observation of testing may influence the client’s performance
Adhere to your written policy
Others are welcome to sit in waiting room but can not be in testing area

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

11. Spend time up front Client consent form Explain process to client
Safe testing protocol
Feedback from client
Max. effort with/without physical limitations
Pain acknowledged but safe maximum is established on each test based on objective scoring criteria

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

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

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

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

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

17. Disability FCE Most referrers do not want
Any return to work or work recommendations
Recommendations for further medical care
Recommendations to test activities (FCE Grid)

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

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

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

21. FCE Summary: Abilities and Limitations
Write a paragraph explaining
Tests that demonstrate “abilities/strengths”
Tests with limitations
Explain the limitations in a paragraph
What test was limited and why

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

23. Scoring Criteria
2 parts to determining score
Quantitative
Qualitative

24. Quantitative
Amount of weight
Distance
Time

25. Qualitative
Observations of problems or limitations during the test activity
Postures
Movement patterns
Muscle recruitment
Physiologic response

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

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

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

29. 6 Minute Walk Test Quantitative (age related distances) Qualitative
Rare (below 328 yds.) – MUST have dx. to support this low a distance.
Factors that reduce distance in manual
Qualitative
Antalgic gait / use of assistive device

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

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

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

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

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

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

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

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

38. Flexibility in testing
Therapist’s clinical decisions
Additional tests in physical exam
Add functional tests based on
Referral source questions
Need to determine continuous
Job specific testing

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

40. Frequently asked Questions

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

42. Testing for Continuous
Standing, Sitting or Walking required on a continuous basis.
Continuous is % of workday (5 hr. 15 min. to 8 hours)
In a job description standing, sitting and walking cannot all be required continuously (by definition)
Testing options
Expand test time based on job demand
Perform job specific testing and do job match

43. US DOL PDL US Department of Labor – Physical Demand Level
Occasional0-33%
Frequent
34-66%
Constant
67-100%
Sedentary
10 lbs
Negligible
Sit most of day
Light
lbs
Walk/Stand
Medium
lbs
10 – 25 lbs.
10 lbs.
Heavy
50 – 100 lbs
25 – 50 lbs
20 lbs.
Very Heavy
Over 100 lbs
Over 50 lbs.
Over 20 lbs.

44. Explaining PDL
Test results: Lifts 45 max. (waist to floor) Carries 50 max. Lifts 15 max. (waist to crown) Standing – frequent Walking – occasional

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

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

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

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

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

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

51. Scenario #2 Insurer requesting additional information / testing
Important to know prior to FCE
Insurer forms – results consistent with FCE. Alter the referral source forms as needed.

52. Scenario #3 Client observed in parking lot, hallway, waiting room
Ability during testing inconsistent with observation outside testing area
Document inconsistency
Do not include observations made outside of professional setting

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

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

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

56. Specific Questions Submitted by Providers

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

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

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

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

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

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

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

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

65. Webinar conclusion Thank you for participating!