Indications for the FCE

The rehabilitation community has many reasons for referring for an FCE. The list in Box 140-1 provides a comprehensive outline of FCE indications. Because of the varying nature of its purpose, the FCE takes on varying forms.

Classification of Work-Oriented Evaluations

The FCE goes by different names. The therapist should bear in mind that the names of the various classifications of work-oriented evaluations vary by geography and local convention. However, certain terms tend to have stable denotations as to purpose, although they will vary in format in different clinical settings. Box 140-2 lists many of the types of work-oriented evaluations.

For the purposes of this chapter, FCE refers to the evaluation as defined in Box 140-2 .

Recent legal developments have caused therapists who perform these evaluations to use care with evaluation terminology. When a therapist, per referral, performed a physical capacity evaluation (PCE) rather than a fit-for-duty evaluation, the outcomes resulted in a legal battle with the Americans With Disabilities Act (ADA) at the core. If the referral had been for a fit-for-duty evaluation, it would have eliminated the foundation for a legal dispute.

Pre-employment Screening

In accordance with the ADA, pre-employment screenings are no longer legal. However, once an employer makes an offer of employment, an employer can require a preplacement, postoffer, or fit-for-duty screening to assess the job applicant’s ability to perform the essential functions of the job. An employer may make a job offer conditioned on the successful completion of a medical examination if two conditions are met: (1) the examination must be applied uniformly to all entering employees in the same job category and (2) the medical information must be kept confidential. To ask for a fitness-for-duty examination of current employees, the employer must have a “reasonable belief, based on objective evidence” that (1) an employee’s ability to perform essential job functions will be impaired by a medical condition or (2) an employee will pose a direct threat due to a medical condition.

An employer may ask disability-related questions and mandate mandatory medical examinations if the inquiry is “job-related and consistent with business necessity.”

Upper limb specialists can perform job-specific FCEs to determine whether the person has the physical ability to perform the job. They can also perform tests such as nerve conduction velocity to screen for preexisting conditions that may place a worker at risk.

Reasonable Accommodation

Careful analysis and skillful intervention can often overcome barriers to employment or return to work. For years, federally mandated workers’ compensation has required employers to provide appropriate medical intervention after injury. The industrial community must bear in mind that the ADA now compels employers to provide reasonable accommodation (modification of or adjustment to a job, the work environment, or the way in which the job is usually performed that enables a qualified individual with a disability to enjoy an equal employment opportunity ) to allow a worker to return to work, unless the reasonable accommodation causes undue hardship. Undue hardship is any action that is unduly costly, extensive, substantial, or disruptive or would fundamentally alter the nature or operation of the business. Thus, the ADA has given significantly more weight to recommendations for adaptation and/or modification.

The Kinesiophysical Approach: Observation and Documentation to Predict Work Performance

Isernhagen coined the term kinesiophysical approach to describe the manner in which therapists are able to draw conclusions and make recommendations from limited information. Using the kinesiophysical approach, the evaluator bases the reason for difficulty with each task on musculoskeletal or physiologic observations. For example, a pinch limitation may be caused by weakened thenar eminence muscles or thumb basal joint arthritis. Inability to repetitively lift may be a result of shortness of breath.

Isernhagen describes the kinesiophysical approach to documentation and compares this with the psychophysical approach. In the psychophysical approach, subjects determine their own maximum levels. A statement such as “Patient said he could not lift 25 pounds from the floor because of pain” reflects the psychophysical approach and leaves the examiner and referral source at a loss as to what the actual level of patient function might be. Because of patient bias and inaccuracy in establishing true maximum physical abilities, the accuracy of the FCE performed under the psychophysical approach becomes suspect.

According to Isernhagen, the kinesiophysical approach involves observation of physical efforts from low to high levels of demand to determine maximum function. Because patient performance reaches a maximum gradually, the evaluator can observe early signs of fatigue, incoordination, and change in body mechanics. The evaluator classifies the physical changes into categories such as light, moderate, and heavy activity or slow, moderate, and rapid activity. These take into consideration physical changes that are observable as the level of work increases. Maximum function is defined as the greatest safe ability of a patient, either in repetitions or weight capacities.

Evaluators often describe an intuition about a worker’s ability, strength, or motivation. Although these evaluators may be incorporating observations of subtle aspects of body language, voice tone, or behavior, more often this intuition is based on the types of observations that Isernhagen describes as critical to the kinesiophysical approach. Thus, to achieve a high level of skill in performing FCEs, the evaluator must hone the ability to observe both gross and subtle worker behaviors and to document them.

The kinesiophysical approach allows the therapist to extrapolate from observation of the person for a relatively brief period to predict the level of function during an 8-hour workday. To provide the therapist with the needed information to make such a recommendation, the FCE techniques and methods must include monitoring of endurance factors, body mechanics, and heart and respiratory rates. Exertion scales have proven themselves valid in assessing the physiologic impact of activity on a worker. These scales help the evaluator match the worker’s reports of fatigue with actual fatigue. Kroemer and Grandjean review the literature about the relationship between exertion and various measures of physical exertion including heart rate, respiratory rate, and temperature. These measurements will help the evaluator determine the physiologic impact of the activity on the worker and will help predict worker function over a workday and workweek. A reevaluation of the patient on a second day of testing assesses the effects of the first and second days of testing. A follow-up contact after the second day of testing checks for sleep disturbance and increased use of medication. No formulas exist for projecting the patient’s tolerance over an 8-hour workday. Only careful documentation using the kinesiophysical approach, documentation of physiologic measures, and experience can generate this important information.

Who Performs the FCE?

Critical in the performance of this intensive evaluation are the characteristics of the evaluator. The FCE is truly the most demanding evaluation in the world of upper extremity rehabilitation. The clinician providing this service must have several years of experience in the field and an in-depth background in upper extremity acute care, including the following:

• •
  

  Knowledge of the pathologic conditions affecting the upper extremity

  
  
• •
  

  Appreciation of the range of recovery consistent with various pathologic conditions

  
  
• •
  

  Comprehensive upper extremity evaluation skills, including ROM, strength, sensation, pain, coordination, dexterity, provocative testing, and soft tissue evaluation

  
  
• •
  

  Ability to establish differential diagnoses and to use physician- and therapist-provided evaluation results to rule out pathologic conditions and to determine the most likely pathology

  
  
• •
  

  Knowledge of the physician- and therapist-offered interventions to be able to determine whether patient/worker has received appropriate treatment

  
  
• •
  

  Familiarity with resources in the area to be able to refer the worker to appropriate further intervention

  
  
• •
  

  Interview skills

  
  
• •
  

  Ability to work with a team

  
  
• •
  

  Ability to establish rapport with people

  
  
• •
  

  Excellent observation skills

  
  
• •
  

  Excellent documentation skills. The documentation must provide the needed information and communicate it clearly. In some cases, the documentation must hold up in court under the scrutiny of attorneys, a judge, and a jury.

  
  
• •
  

  Solid background in ergonomics

  
  
• •
  

  Ability to fabricate orthoses, supports, and protectors that might facilitate return to work

FCE administration is not for the novice therapist or the therapist new to upper extremity rehabilitation. Too often the clinic manager assigns the newest therapist to the work-oriented program. This is a mistake. The novice therapist will not possess the aforementioned characteristics. The professional performing the FCE needs to have the experience and judgment appropriate to the weight and significance that the FCE carries.

Resources for Getting Started

Interfacing with the world of work, be it the workers’ compensation system, industry, or unions as well as local, state, and federal regulatory bodies, requires sensitivity to others’ perspectives, knowledge of the law, and awareness of current trends. The novice work-oriented program coordinator must have the courage to begin and the wisdom to tread lightly until familiar and knowledgeable with all aspects of the process. Gathering adequate information about the industrial system in which he or she works, the therapist new to work programs promotes program quality and reputation.

To this end, attendance at national, state, and local organization meetings; participation at educational seminars; and networking with colleagues are absolutely essential. Accessing the many available publications such as those available from the organizations listed in Box 140-4 (online) will enhance knowledge and skills.

Preparing for the Evaluation

Before the evaluation, the therapist must clarify the evaluation objective with the referral source. Clear referral questions result in a well-designed FCE. Referrals made with heavy negative bias regarding motivation of the worker or with the intent to catch or trap the worker and prove fraud signal the clinician that the evaluation will be more complex and that communication problems already exist. According to Wright, “The FCE is too often used incorrectly—it is not a bludgeon or a witch hunt. It will help everyone if we can direct the FCE back to its original purpose—that of gaining insight into a person’s abilities and disabilities and trying to find ways to mitigate the disability in a cost-effective manner.” The therapist does not adopt an attitude of suspicion that the referral source conveys and remains unbiased throughout the evaluation. The worker will reveal himself or herself during the course of the FCE.

The referrer shares basic information about the patient during the referral phone call, such as diagnosis or primary functional problem, phone number, and address. When working with rehabilitation professionals and insurance companies (e.g., counselors, rehabilitation nurses, case managers), the clinic requests, but may not always receive, the following:

• •
  

  A letter of authorization

  
  
• •
  

  A referral form that includes important information about the patient, including billing information

  
  
• •
  

  Pertinent medical records

  
  
• •
  

  Vocational and psychiatric reports

  
  
• •
  

  A job analysis

When receiving a referral from a physician, the clinic requests the following:

• •
  

  A prescription

  
  
• •
  

  Medical records

  
  
• •
  

  Basic information about the patient

  
  
• •
  

  A copy of the job analysis if the physician has one

When the referrer does not forward the requested documents, the therapist and/or clinic faces a policy decision based on professional ethics and sound judgment. If the evaluator deems the missing documents to be critical to the appropriate and safe administration of the evaluation, the best option may be to delay evaluation or refuse the referral. However, such a decision may greatly inconvenience those participating in the worker’s care and could jeopardize the relationship with the referral source.

In many cases of background document problems, creative solutions can result in a “win-win” situation. In explaining the reason for requesting the documents to a referrer, the therapist has the opportunity to further show professional expertise. The lack of a job analysis may furnish the therapist with the chance to personally perform an on-site visit. Although the complexities of FCE coordination and performance demand a great deal from a therapist, one cannot miss the chance to make lemonade out of the inevitable lemons.

Often the physician’s office will authorize the evaluation with the insurance company before making the referral; however, the evaluating clinic must take responsibility for seeing to authorization. It is beyond the scope of this chapter to discuss the procedures involved in performing evaluations upon the referral of an attorney. Although many of the procedures for working with attorneys are the same as those with medical and vocational referrals, many differ. For example, the clinician will most likely participate in a deposition after the evaluation.

The IEP Process

After reviewing the job analysis, the therapist derives the initial IEP from the overall evaluation goal. The refined IEP evolves from information gathered during the intake interview and the subjective and physical evaluations. Modification of the IEP can occur at any time that the evaluator becomes aware that the patient’s endurance level, attitude, or other characteristics warrant an IEP change.

It is important to note that no specified format exists for the upper limb FCE. Although some evaluators have created structured and repeatable formats for the spine-oriented FCEs, the varied nature of upper limb job demands coupled with the widely variable impact of upper limb injury and disease necessitate that the clinician tailor each FCE addressing upper limb function specifically for a given worker. According to Pitts, “FCE systems rarely consider key and valuable points that are essential to allow injured workers to safely return to work. Most FCE programs use rote nonspecific tests that provide very little functional data.” “Branded” FCE systems typically will not address upper limb function in relation to a specific job. However, it is the critical demands of the client’s job that will most likely become determinants of their ability to return to work.

Klostermann describes how he investigated several of the worker health management packages and found that the WorkSTEPS program met his needs the best and answered the important questions. Clinicians interested in beginning or revising work-related programs may want to consider other offerings including WorkWell and People’s Injury Network. Of course, each therapist or therapy group will need to evaluate the available options individually for relevance and quality. Klostermann describes WorkSTEPS as the largest employment testing package in the United States. He has found that WorkSTEPS has proven itself valid and reliable in court cases and also at the appeal level of the worker compensation system (see Box 140-4 , online).

Wright prefers to use his own proprietary system that he has honed during his 15 years of experience in the field of work-related services including the workers’ compensation and legal arenas. Wright warns that many of the organizations that offered packages for work services in the past have ceased to exist, leaving purchasers without ongoing development and technical support. He also reported an experience when he testified in a case where therapists for the “other side” based their testimony on an evaluation system. These therapists failed to use terminology properly and did not know how to clearly interpret their own findings. Their testimony fell far short of what Wright was able to offer with his precise understanding of the worker compensation system, the evaluations that he had performed, and his highly developed observation skills and intuition regarding physical performance. Thus, using an evaluation system provides no guarantee of relevance or value. The evaluator still has the responsibility for understanding the gamut of upper limb function, observing well, documenting completely, and interpreting the results.

Referral Issues

The process of formulating the IEP involves clinical problem solving and the search for answers to the following questions:

• •
  

  What is the purpose of the referral?

  
  
• •
  

  What questions does the referral source have?

  
  
• •
  

  What specific issues does the referral source want addressed?

  
  
• •
  

  What are the patient’s areas of impairment?

Candidacy Screening

The evaluator must attempt to determine whether the evaluee (the injured worker) appears to be an appropriate candidate to participate in the FCE. When possible, the evaluator determines candidacy before the initial meeting with the client. However, the decision regarding candidacy may change after the initial session. The candidacy screening consists of four separate concerns: feasibility, cognitive, psychological, and medical issues. Each screening has key factors for consideration. Feasibility addresses the client’s demonstration of sufficient energy, symptom control, and ability to perform basic activities of daily living (ADL). To determine whether the client passes the cognitive screening, the therapist considers the client’s memory, attention span, and concentration. To meet the psychological factors criteria, the client must demonstrate appropriate mood, attitude, affect, self-expectations, and goals. The medical issues screening focuses on the adequacy of the time since injury or surgery, the appropriateness of the previous care rendered, and the overall health of the individual.

Content Determination

The referral questions or reason for the FCE will allow the evaluator to determine the actual format of the evaluation. Importantly, the preparatory problem solving will identify the critical physical work demands—those that the therapist anticipates will most likely produce symptoms that limit work performance —that will be included during testing. This in turn determines the types of evaluation devices used during the FCE. With the evaluation devices determined, the therapist can anticipate the client’s difficulties and identify potential modifications for trial during the evaluation.

Evaluation planning also includes structuring the order and gradation of activities. This structuring maximizes the evaluee’s ability to complete the evaluation without becoming subject to pain and fatigue. Planning allows observation of the hierarchy of skill, speed, and endurance within a specific physical demand. The evaluator should create a format structure to offer increasing complexity and to challenge endurance. This structure embodies the kinesiophysical approach and permits the greatest ability to observe important behavior, document clearly, and make the most accurate recommendations.

Time Required to Perform the FCE

The time required to perform the FCE will depend on the following: (1) the purpose of the referral, (2) the type of evaluation, (3) the evaluator’s familiarity with the client, and (4) the amount of time or service authorized. When the referral source focuses on issues of feasibility and wants to know whether a client will attend an appointment several days in a row, the evaluation must involve several whole or half days. If the question involves the ability to perform a specific task, the evaluation may be limited to 3 to 4 hours. In the author’s experience, an FCE will typically require 5 to 6 hours. Spreading the time over 2 consecutive days gives the evaluator the opportunity to compare volume, strength, symptom reports, and endurance levels between days. The evaluation duration will vary from clinic to clinic based on state laws, insurance reimbursement, referrers’ needs, and clinic logistics. When the evaluator has worked with a client before the FCE in an acute or work-hardening program, the evaluation may require less time because a good deal of data has already been collected. In contrast, if the evaluator is not familiar with the patient, the collection of medical data, etc., will increase the time for evaluation.

In the case in which the authorizing agent limits the time for an evaluation, the evaluator must design the evaluation to provide the maximum amount of information despite time restriction. When the authorizer fails to provide adequate time to answer the referral question, the individual evaluator and clinic must decide how to proceed. Some evaluators feel compelled to answer a referral question even when adequate time has not been authorized. They continue with the evaluation even when their facilities will not be reimbursed adequately for the service rendered. This deprives the authorizing agency of experiencing the “reality check” that it needs to provide “real-world” reimbursement of services rendered. Because therapists know the high value of the service that they provide, they are ideally suited to work with employers and insurers to set standards for appropriate authorization periods and fee schedules.

Initial (Intake) Interview

The initial interview has multiple purposes. It presents the chance for the therapist to establish rapport with the client before the challenge of evaluation. During the interview, the therapist familiarizes the client with the procedure sequence and purpose of the evaluation. The therapist then cross-checks the information gleaned from the pre-evaluation records review with the client to check for consistency. Finally, the therapist closely observes the client to further screen for feasibility, cognitive, psychological, and medical issues. On completion of this interview, the therapist may deem it appropriate to revise the evaluation plan.

Usually, the therapist has reviewed the client’s vocational and medical records before the evaluation and has excerpted relevant information onto an intake form. Using a form like this, the therapist can ask the evaluee the same questions and look for consistency. In this author’s experience, this procedure has revealed important errors and inconsistencies that have significant bearing on the structure and interpretation of the evaluation. For example, several clients have revealed that they were left-handed from birth but forced to learn to write with the right hand and so are considered right-handed when in fact they are left dominant. An error in the recording of evaluee’s age can change the nature of various aspects of the client’s behavior, including physical status and client attitude. An older client may have less resilient musculoskeletal tissues or may have issues of retirement clouding the rehabilitation efforts.

Other important cross-checks include occupation at the time of injury and the amount of time since the client’s last medical procedure. Importantly, the therapist reviews the type of medical treatment, both invasive and conservative, provided to the client. The therapist may find that the client never received the generally accepted standard of care for his or her particular diagnosis. Finally, the client’s recollection of return-to-work efforts can sometimes reveal hidden motivations regarding the evaluation. A client may choose not to share with the therapist that he or she returned to work for long periods of time before this most recent period of disability. With the cross-checks of history complete, the evaluator can move on to current issues.

During the initial evaluation, the therapist documents the client’s timeliness, mode of transportation to evaluation, dress and grooming, demeanor or temperament, and hand posture or position while he or she sits in the waiting area and during the initial interview. It is important to use nonpejorative terms when documenting these client attributes. Each of these factors can provide valuable information to the evaluator. The therapist must carefully observe the client from the first instant of meeting. A hand offered casually to shake hands in greeting or lift a purse may not be voluntarily used again during the entire evaluation.

The evaluator should ask the client about his or her entire life medical history including current general health and previous work-related and nonwork-related injuries. The information gained can be compared with and/or added to the information obtained before the evaluation. A general review of body systems can reveal such important diagnoses as high blood pressure, rheumatoid arthritis, diabetes, and a cardiac or pulmonary condition. The therapist checks into problems with vision and hearing as well as any history of substance abuse. Documentation of all the medications that the client takes is a necessary part of this section. The recording of a thorough medical history helps with interpretation of client behavior and helps to ensure client safety during the evaluation.

Finally, the therapist attempts to elicit the evaluee’s major concern and his or her current life goals. Without prompting any answers, the therapist asks the evaluee to identify what he or she deems most problematic about the upper extremity and then records the response. To complete the initial interview, the therapist asks the evaluee to identify his or her vocational goal. With some frequency, this goal will differ from the one that the vocational counselor or employer offers. Such goal discrepancies can foretell complications such as poor cooperation and often symptom magnification.

Subjective Evaluation

The next component of the evaluation, the subjective evaluation, consists mostly of an interview. This interview offers the evaluator the opportunity to learn about the client’s subjective experience of the injury or illness and about the client’s view of the impact the injury or illness on his or her life. The therapist will want to consider three major areas: (1) pain, (2) impact on ADL, and (3) impact of limb cosmesis.

Physical (Musculoskeletal) Evaluation

The musculoskeletal evaluation is a crucial part of the upper extremity FCE. Attempts to “focus on function” without a sound appreciation for ROM, strength, sensation, volume, and soft tissue status will confound the findings. The physical evaluation for an FCE looks a great deal like that for an acute injury. Often, it is even more comprehensive.

The focus of the FCE musculoskeletal evaluation differs from that of an acute patient. It provides the foundation for understanding the client’s behavior during the activity evaluation. The physical evaluation reveals the critical aspects for emphasis during the activity evaluation. It may clue the therapist to symptom magnification and it may reveal a previously unidentified impairment or diagnosis. The information gathered during the physical evaluation may change the IEP. Finally, it may suggest types of modifications to offer the client during the activity portion of the evaluation. The therapist must carefully document all aspects of the physical evaluation.

The advent of computerized evaluation systems has given the therapist a new tool for capturing, manipulating, and analyzing data from the physical evaluation ( Fig. 140-1 ). The strength modules, especially those of sustained grip ( Fig. 140-2 ), allow the therapist to view muscle action over time. This provides an opportunity to look at consistency as well as quality of effort. Graph functions allow powerful visual representation of changes and consistency on test–retest ( Figs. 140-3 and 140-4 ).

JTech Computerized Evaluation system. Computerized evaluation systems such as the JTech system provide the therapist with tools for capturing, manipulating, and analyzing data from the physical evaluation and importing it into the functional capacity evaluation system.

(JTech Medical Industries, Salt Lake City, Utah.)

Greenleaf EVAL sustained grip evaluation. The computerized strength modules, especially that of sustained grip (this sample from the Greenleaf EVAL system), allow the therapist to view muscle action over time. This provides an opportunity to look at consistency as well as quality of effort.

JTech grip strength evaluation: test-retest. Worker grip strength can be tested on more than one occasion on the same day and compared with previous tests for consistency or to reveal fatigue. L, left; R, right.

(JTech Medical Industries, Salt Lake City, Utah.)

The computerized sensory evaluation modules, such as those from the JTech system, provide a means of representing sensory data in a clear and powerfully graphic manner.

(JTech Medical Industries, Salt Lake City, Utah.)

Physical Demand (Activity) Testing

The physical demand or activity phase of the evaluation is the nucleus of the evaluation because during this FCE component, the therapist has the opportunity to observe the client using the involved part and the whole body in specific tasks. Physical demand testing has two components: standardized tests and nonstandardized tests or structured activities. The standardized tests always have associated norms, whereas structured activities do not. In addition, the evaluator administers a standardized test in a consistent manner, whereas the evaluator grades and tailors the structured activities to the individual FCE and worker.

Before starting the physical demand testing, a frank and supportive discussion with the worker helps establish expectations, boundaries, and the importance of cooperation. Brenda Dean has honed this presentation, and, with her permission, it is provided here. She begins “I know you have pain with activity and this is normal for you. It is also normal to have increased symptoms following a functional assessment. I would like you to do each functional test to your maximum ability. Part of the testing will determine whether you have given your full effort and this will be part of the report.”

Dean explains that she does not expect the client to participate to the point of causing unreasonable symptoms. She emphasizes the importance of safety and that the client must always feel safe with testing. She states that she may encourage the worker to test further if she believes that he or she is safe, but the worker is free to refuse. Dean gives the client control of the endpoints, except for one situation. She will stop the test if she observes that the worker is using unsafe techniques for the injured part or for other body parts. She stresses that she will not allow the client to sustain an injury during the assessment, although it is likely that the worker’s pain level will increase.

She goes on to instruct the worker to continue each test until reaching one of the following three stopping points:

• 1
  

  You have reached your maximum physical strength. For example, you are unable to lift any heavier weight because of your strength.

  
  
• 2
  

  Your symptoms become unreasonable during the test, or you think they will become unreasonable later if you continue.

  
  
• 3
  

  You feel that what is being asked is not safe for you.

She then concludes “The most objective testing will occur if we both agree on the final end points. I take this assessment and report very seriously, as it will influence your life/work direction from this point forward. It is, therefore, very important that we are both as transparent and objective as possible.”

The therapist may revise this content to fit his or her style and the needs and characteristics of the client to be evaluated. However, all involved with the evaluation will benefit if the issues are discussed. Some workers do not have problems with pain, but rather with lack of sensation, coordination, or strength. In these cases, the focus on pain will change to focus on function and ability.

Examples of Standardized Tests of Upper Extremity Function

Standardized tests commonly administered as part of an upper extremity FCE include the following: Purdue Pegboard, Minnesota Rate of Manipulation, Crawford Small Parts Dexterity Test ( Fig. 140-5 ), Bennett Hand Tool Dexterity Test ( Fig. 140-6 ), Rosenbusch Test of Finger Dexterity ( Fig. 140-7 ), and the Jebsen’s Hand Function Test. In addition to these, some manufacturers have developed standardized testing systems such as Valpar ( Fig. 140-8 ).

Crawford Small Parts Dexterity Test. This test has two components using tweezers and a small screwdriver. In part 1, the tweezers are used to place pins into holes within the assembly plate and to place the collars over the pins. In part 2, the screws are placed in threaded holes and secured into the hole with the small screw driver.

Bennett Hand Tool Dexterity Test. This test provides the opportunity to observe the client using standard hand tools to assemble and disassemble nut and bolt assemblies.

Rosenbusch Test of Finger Dexterity. This test is the only standardized test that focuses on the ability to simultaneously hold, manipulate, and place small objects.

Valpar Standardized Work Sample. The Valpar system offers multiple workstations that evaluate a wide variety of physical and cognitive work abilities and behaviors. The Valpar system also includes motion-time standards.

The Purdue Pegboard test has multiple tests available within it. Generally, it tests the ability to pick up, manipulate, and then place small pegs in consecutive holes rapidly and accurately. The Minnesota Rate of Manipulation Test also contains multiple tests. It looks at the ability to repetitively reach, pick up, manipulate, and place medium-size (double checker) objects with speed and accuracy. The literature review of Yancosek and Howell about this test found good evidence of its validity and reliability, with even greater reliability with the three-trial administration.

The Crawford Small Parts Dexterity Test (see Fig. 140-5 ) has two components: pins and collars, and screws. The pins and collars component examines the ability to use a small hand tool (tweezers) to pick up and place small objects. The screws portion examines the ability to use a small hand tool (a screwdriver) to set small screws into prethreaded holes. The patient also must pick up, manipulate, and place a small screw. According to Yancosek and Howell, the literature is void of studies establishing solid validity and reliability for this test. One study questioned the ability to use the original reference values because changes had been made in the testing materials, but normative values remain the same.

The Bennett Hand-Tool Dexterity Test (see Fig. 140-6 ) provides the opportunity to observe the client using standard hand tools (a screwdriver, a large and a small box end wrench, and an adjustable wrench) to assemble and disassemble nut and bolt assemblies. The Rosenbusch Test of Finger Dexterity (see Fig. 140-7 ) is the only standardized test that focuses on the ability to simultaneously hold, manipulate, and place small objects. It includes motion-time standards (MTSs) (see subsequent discussion) to score the client’s performance. Stein and Yerxa established the reliability and validity of this test.

The Jebsen’s Hand Function Test addresses hand function related to ADL. The evaluator reports the normative data from the Jebsen as a mean with standard deviations. The evaluator designates, via standard deviation, how far above or below the mean the worker performed. Yancosek and Howell identified a study that established reliability, validity, and reference values based on age. A second study established criterion validity with traumatic spinal cord–injured patients. The Valpar (see Fig. 140-8 ) system offers multiple workstations that evaluate a wide range of physical and cognitive work abilities and behaviors. Popular among evaluators, each workstation has high face validity in that it looks like “real work” and has norms associated with it. The Valpar system also includes MTSs (see subsequent discussion).

Nonstandardized Tests of Hand Function

The clinic that offers FCEs should have structured activities representing each of the physical demand categories described in Box 140-3 . In addition, the strength requirement of each physical demand category should vary from sedentary to very heavy ( Box 140-6 ). The IEP determines the choice of physical demands and strength levels tested. Most frequently, the critical demands of the target job—those that the therapist anticipates will most likely produce symptoms that limit work performance —are the ones chosen for the activity evaluation. Just as one tends not to measure ROM of uninvolved joints, one tends not to evaluate a physical demand that the client can easily perform. However, the effect of deconditioning cannot be underestimated. Even though a joint or muscle group may not be specifically involved in the pathologic condition, the long-term effects of not working or functioning at the preinjury level may take its toll on the entire person. While focusing on critical demands, the clinician must note general endurance and function.

Box 140-6

Physical Demands

Degrees of Strength: Lifting/Carrying/Pushing/Pulling

• 
  

  Sedentary:lift 10 pounds maximum and occasionally carry small objects

  
  
• 
  

  Light:lift 20 pounds maximum and frequently lift/carry up to 10 pounds

  
  
• 
  

  Medium:lift 50 pounds maximum and frequently lift/carry up to 25 pounds

  
  
• 
  

  Heavy:lift 100 pounds and frequently lift/carry up to 50 pounds

  
  
• 
  

  Very heavy:lift in excess of 100 pounds and frequently lift/carry up to 50 pounds

Data from U.S. Department of Labor: Handbook for Analyzing Jobs . Menomonie, WI: 1991; Materials Development Center, University of Wisconsin–Stout.

Both Emerson and Wright described the value of heart rate monitoring during the FCE. Checking heart rate throughout the evaluation has clear safety implications, especially during the higher cardiovascular demand components of the evaluation including lifting, carrying, overhead reaching, pushing, and pulling. Emerson documents heart rate throughout the FCE but especially when a worker describes extreme pain. She states that “one might expect to see a heart rate increase, in men, with high levels of pain.” In their 2005 study, Tousignant-Laflamme and colleagues found that heart rate did increase in response to exposure to noxious stimuli. They state that the clinical implications need to be further evaluated with patients before clinicians can use heart rate as a complementary tool in pain assessment.

However, recent legal actions make the use of tests that are not “job-related and consistent with business necessity” questionable. The evaluator must use testing appropriately for the purpose and format. For example, physical evaluation is permitted during an FCE; however, without meeting the “job-related and consistent with business necessity” test, the law might not allow a medical test such as heart rate to be included in a fit-for-duty evaluation.

However, beyond this, both of these experienced evaluators have postulated that a correlation might exist between reports of significantly increased pain and heart rate. One would expect heart rate to spike if an evaluee made a sudden exclamation of pain. It appears that no research on this correlation currently exists; however, therapists might consider using this as one of many pieces of evidence from which to draw conclusions.

Clinics can avail themselves both of commercially available structured activities and of custom-made ones ( Figs. 140-9 through 140-14 ). Structured activities do not need to be computerized and do not need to have a polished look. Indeed, the more the activity testing area resembles the workshops and warehouses of industry, the more valid the FCE will be. Advertisement in professional publications and exhibits at conferences are sources for identifying and trying out commercially available work samples. Custom work samples run the gamut of one’s imagination. The guidelines described in Chapter 141 along with a sound budget will help the clinic designer select relevant and effective work samples.

Lawnmower engine activity. Disassembly and reassembly of a lawnmower engine assesses the use of tools, fingering, handling, and reaching.

Electrical assembly activity. Assembly of computer boards assesses fine coordination, pinch, and safety around hot objects.

Putty in work simulation. Therapy putty has many uses in work simulation. This worker was a sushi chef at the time of his injury and uses putty to simulate the motions of sushi making.

West IV torquing simulation. This simulation provides resistance to assess the ability to generate torque force. It provides the ability to vary task height, tool orientation, tool type, and tool handle shape.

When the object to be lifted has stationary handles, wrist deviation often becomes extreme, even when the load is moved through a short arc. This test provides the opportunity to assess the worker’s tolerance of loaded wrist deviation.

Lifting evaluation. Many types of equipment for testing lifting are available. An apparatus with adjustable shelves such as this unit from JTech offers face validity, versatility, and space economy.

(JTech Medical Industries, Salt Lake City, Utah.)

As the client performs the structured activities, the evaluator documents clearly and objectively, often with the aid of worksheets to structure and organize observations. However, these observations must transcend mere description and will need to correlate functional limitation with physical findings.

Computerized Variable Resistance Tests

Although not a necessary part of the evaluation, computerized, variable-resistance tests provide another opportunity for the evaluator to observe and document worker behavior and physical tolerances. Most of the equipment tests function in both dynamic and static modes. Static modes offer the opportunity to compute coefficients of variation (refer to the section Submaximum Voluntary Effort, below), whereas dynamic tests have greater validity because they more closely simulate actual work. These devices often require high levels of force generation or high levels of endurance. To ensure that the client will be able to complete all portions of the evaluation, the therapist probably will have the client perform these tests near the end of the evaluation. According to Lankhorst and colleagues neither static nor dynamic torque production of muscles has been shown to be a good predictor of functional capacity. The computerized devices have the advantage of offering versatility in structured task design and computer analysis of performance. However, they lack the high face validity that work stations and work simulations provide. These tests do offer another opportunity to challenge the worker in a specific way and to observe and document performance.

Lifting and Carrying (Manual Materials Handling) Evaluation

Because employment often revolves around the issue of lifting and carrying, also known as manual materials handling, these physical demands require special attention. Lifting evaluations fall into two general categories: job specific and general or baseline evaluations. The job-specific evaluation simulates the characteristics of the actual lifting task or tasks that the client must perform on the job. Thus, if the client lifts a 50-pound sack of concrete at work, the job-specific evaluation will require the client to lift a sack weighing 50 pounds containing either concrete or a material similar in density, center of gravity, and so on. Testing this worker with a 40-pound box will not provide the needed information about work ability and is not a valid test of return to work.

The baseline evaluation usually involves a specific protocol and set of equipment. Several such evaluations exist. This type of evaluation takes the subject through a hierarchy of weights, repetitions, prehension patterns, and arcs of lift. The evaluation seeks to establish a quantification of the client’s lifting capacity, usually for comparison with future performance or with general job requirements. Over the years, equipment for evaluation of lifting capacity has diversified and multiplied. Each equipment manufacturer has a recommended protocol for the evaluation of lifting capacity. Evaluators also have derived their own evaluation techniques (see Fig. 140-14 ).

Within the framework of the general evaluation, the therapist can choose between several other options. Will the client perform a static or dynamic lift? Will the client lift a given weight one time only or repetitively? Will the task require the use of one or two hands? Will the evaluator consider only the amount of resistance successfully encountered or will the rate of lift and arc of motion be taken into account? Static or isometric testing has been a part of both the medical and the engineering models for many years. Some clinicians have attempted to establish rate and ROM coupled with resistance encountered as multiple criteria for evaluation of manual material handling. Others have questioned the validity of static testing because lifting is, by nature, dynamic.

One lifting evaluation option, the repetitiveness of the lift, warrants special attention. At this time, many clinicians use mostly intuition to determine the amount of weight that a subject will lift repetitively. Although no firmly established guidelines exist, the literature does provide some direction in this determination. With respect to the physiologic model, Snook and Irvin recommend not exceeding 33% of an individual’s maximum aerobic capacity. Using psychophysics, Snook identified 50% of the maximum load lifted as the maximum weight that a person can lift repetitively. Thus, for a repetitive lifting evaluation, the therapist might consider using a weight between 33% and 50% of the subject’s maximum lift.

Gross and Battie examined the interrater and test–retest reliability of determinations of maximum safe lifting during kinesiophysical FCEs in a sample of people who were off work and receiving workers’ compensation. Twenty-eight subjects with low back pain who had plateaued in treatment participated in the study. Five occupational therapists (OTs), trained and experienced in kinesiophysical methods, conducted testing. Raters tested subjects simultaneously yet independently. The OTs rated the subjects on two occasions, separated by 2 to 4 days. The intraclass correlation coefficients for interrater reliability ranged from 0.95 to 0.98. Test–retest values ranged from 0.78 to 0.94. Gross and Battie concluded that inconsistencies in subjects’ performance across sessions were the greatest source of FCE measurement variability. Their findings support good test–retest reliability and excellent interrater reliability.

The evaluator should be familiar with the widely used the National Institute of Occupational Safety and Health (NIOSH) lifting guidelines and equation for establishing the safety of a manual materials handling task. The determination of safe lifting requires no special equipment This guideline evaluates two-handed lifting or lowering only, assumes that the worker’s work space is not restricted, and does not apply to workers who sit or kneel.

The equation requires the following data: the horizontal distance from the load to the low back; the vertical location of load at the beginning and end of the lift; degrees from the midline at which the load is located at beginning and end of the lift; the frequency of lifting in “lifts per minute”; the duration of the task; the quality (or lack of) handles or hand holds; and the load weight. The equation generates a recommended weight limit. However, the upper limb–focused therapist will want to keep in mind that the NIOSH lifting guide focuses on the risk of lifting to the low back and not the upper limb.

Changing Demands of the Wrist and Hands

To assess the interaction between lifting and prehension patterns, evaluators use lifting equipment with varied shapes and with different types of handles or hand–object interfaces. As the height of the lift changes, the prehension pattern and ROM at each upper limb joint also change. The impact of wrist deviation during lifting will not become apparent unless the handle attaches statically to the container (see Fig. 140-13 ). Lifting loads the wrist in unique ways and will cause the unstable or mechanically impaired wrist to become symptomatic. A person with scaphoid dysfunction will often demonstrate the ability to lift significant loads of 50 pounds or more with the wrist in neutral. However, the instant the wrist deviates, the person will lose the ability to sustain the lift. The handle configuration, the shape of the object, and the joint ROM all interact to produce either a fluid lift or one that reflects the many issues that can impair the ability to lift and carry.

Body Mechanics, Safety, and Liability

Because the body performs lifting as a whole unit, lifting evaluation protocols should consider addressing comprehensive body mechanics. Even when the evaluee has no documented back, neck, or lower extremity involvement, the use of poor body mechanics during the assessment creates the potential for injury. The therapist should consider instructing the client in appropriate body mechanics for the lifting task. Some therapists will not initiate or continue an evaluation if the client cannot consistently demonstrate safe body mechanics. It is this author’s opinion that allowing a worker to participate in a lifting task in the absence of safe body mechanics is simply too risky both for the evaluee and the evaluator and should not be permitted.

Documenting Client Lifting Performance

Central to the ability to document the client’s performance is the ability to biomechanically analyze the lifting task. Chaffin and Andersson group the factors that define the manual materials handling task or system as follows:

• •
  

  Worker characteristics

  
  
• •
  

  Material/container characteristics

  
  
• •
  

  Task characteristics

  
  
• •
  

  Work practices

These categories assist the evaluator in structuring a report of the many complex and interrelated aspects of the client’s lifting performance. A form helps organize the necessary data from a job-site lifting analysis.

The interaction between the following factors determines the body’s response to the work demand placed on it :

• •
  

  Muscle contraction

  
  
• •
  

  Tendon excursion

  
  
• •
  

  Joint flexibility

  
  
• •
  

  Joint stability

  
  
• •
  

  Skin tolerance to pressure, texture, temperature, or shear

  
  
• •
  

  Physiologic status to support effort (e.g., circulatory or respiratory sufficiency)

  
  
• •
  

  Sensation

  
  
• •
  

  Proprioception

  
  
• •
  

  Joint or soft tissue status outside of the upper extremity

  
  
• •
  

  Pain experience

The therapist systematically documents this response.

These factors have been used successfully during FCEs to document the important components of and observation during a lifting task. In addition to the amount of weight lifted, the therapist should note the quality of the task performance. The speed, control, and smoothness of the lift can reveal a great deal about the evaluee. With this information, the therapist determines several other crucial task characteristics. What muscle groups engage the load? What is the duration of the lift? What percentage of maximum voluntary contraction of a given muscle group does the lifter use during the lift? Which joints require flexibility? Which require stability? How do these designations change as the lift progresses and the load moves from one height to another?

With all the aforementioned factors noted, the therapist then adds an all-important variable to the equation—the client’s disability. Hand therapists “differ from other types of testers in their detailed understanding of pathological anatomy and kinesiology, their understanding of ergonomic factors in task analysis, and their ability to examine the hand.” This comprehensive background enables the hand therapist to fully appreciate the impact of pathology on function.

When a worker has difficulty performing a lifting task, the therapist must identify the reason. Often this consists of recognizing the weak link in the system, which could be any one or a combination of the factors listed previously. A client’s ability or inability to problem solve and spontaneously adapt significantly affects the accomplishment of physically challenging tasks.

On-Site Evaluation

When performing an on-site FCE, the therapist evaluates the worker in the workplace rather than in a clinic setting. Usually, this takes place at the site of last employment for the injured worker and often where the injury occurred. However, it may occur at a new proposed worksite or an alternative area of the preinjury workplace. The entire structure of the FCE remains essentially the same, with the exception that the nonstandardized physical demand component of the evaluation takes place at the workplace and thus incorporates the environment, equipment, and physical demands of the actual work. Performing the FCE at the work site rather than at the clinic boasts many advantages. The validity increases substantially as does the ability to describe relevant physical capacity. On-site evaluation provides the opportunity to identify options for modifications that can enable return to work. NIOSH’s consistent focus in the area of safety and injury prevention demonstrates that implementation of safe work practices decreases the incidence of injury leading to decreased productivity and workplace attendance. The disadvantages of this approach to FCE include additional time for the therapist to travel and the possibility that helpful or necessary clinic equipment and supplies will be unavailable at the job site.

The portions of the evaluation preceding the physical demand evaluation—initial interview, subjective evaluation, neuromusculoskeletal evaluation, and standardized testing—may take place in the clinic, or the employer may designate a location at the work site for these evaluation components. When these occur at the work site, the evaluator must prepare well and bring the necessary equipment for each segment including, but not limited to, worksheets, neuromusculoskeletal evaluation tools, and standardized tests. Preparation also includes becoming familiar with the work and physical plant. The therapist accomplishes this via either review of a written job analysis or video, a visit to the job site, an interview with the employer/supervisor, an interview with the worker, or any combination of these options.

The on-site evaluation occurs with the consent and authorization of the employer and insurance carrier. With signed permission from the employer and any other employees who might be involved, the therapist can take photos or video of the workplace and the worker performing in it. This invaluable documentation often communicates in a way that written reports cannot. Before arriving at the job site, the therapist needs to consider all health and safety issues and must comply with dress codes, which may include hair kept back, closed-toe shoes, hard hat, and eye and ear protection. The on-site visit requires that the therapist becomes familiar with the world of work. Thoughtful preparation, coupled with pre-evaluation contact with responsible parties to the case and a well-designed but flexible IEP, helps ensure success.

Reevaluation and Postevaluation Follow-up

In the final component of the FCE, the therapist reevaluates the worker’s physical status to screen for problems related to activity. This generally includes observation and palpation of the upper extremity for redness, swelling, lumps, and triggering or crepitation with tendon motion. Measurement of temperature and limb volume may help document these findings. If the client reveals altered sensory status or change in reported pain level, the therapist documents these changes via repeat sensibility testing and/or pain analog scale administration. However, as stated previously, the repeated use of pain scales will focus the worker on pain, therefore the therapist should administer judiciously. In this author’s opinion, the onset of pain exceeding a level 4 on a scale of 10 that does not subside within an hour, redness, triggering, and a volume increase that exceeds 1% of pre-activity limb volume constitute unreasonable tissue reactivity and indicate that the evaluation exceeded the worker’s tissue tolerance.

Follow-up contact with the client a day or more after the evaluation is crucial because problems may not appear until several hours after the evaluation. The questions should address how the patient felt within the following 24 hour period. Questions should address discomfort, sleep schedule, or any other changes in activity. The client may answer the questions by phone or may fill out a questionnaire and return it by mail, fax, or email.