Vocational Assessment and Training for Patients with Chronic Occupational Musculoskeletal Disorders

1. Safety: When used properly, the test must not be expected to lead to injury

2. Reliability: The test score must be dependable across evaluators, evaluees, and the date or time of test administration

3. Validity: The test score must measure what is intended to be measured and must predict or reflect performance in a target task

4. Practicality: The direct and indirect costs of the test procedure must be reasonable

5. Utility: The test procedure must meet the needs of the evaluee, referrer, and payer

The US Department of Labor (DOL) in the Revised Handbook for Analyzing Jobs (US Department of Labor, 1991c) provides Physical Demand Factors that are important attributes to measure in the performance of work. The Physical Demand Factors include strength (classified as sedentary, light, medium, heavy, and very heavy), lifting, carrying, pushing, pulling, and the following positions/postures: sitting, standing, walking, climbing, balancing, stooping, reaching, kneeling, crouching, crawling, handling, and fingering. The strength classification levels are described in the Physical Demand Classification for Work chart. Please refer to Table 25.2 for specific details.

Table 25.2

Department of Labor Physical Demand Level table (Matheson et al., 1995)

Physical demand level	Occasional	Frequent	Constant	Typical energy required
Physical demand level	0.33 % of the workday	34–66 % of the workday	67–100 % of the workday	Typical energy required
Sedentary	10 lb	Negligible	Negligible	1.5–2.1 METS
Light	20 lb	10 lb and/or walk/stand/push/pull of arm/leg controls	Negligible and/or push/pull of arm/leg controls while seated	2.2–3.5 METS
Medium	20–50 lb	10–25 lb	10 Ib	3.6–6.3 METS
Heavy	50–100 lb	25–50 lb	10–20 lb	6.4–7.5 METS
Very heavy	Over 100 lb	Over 50 lb	Over 20 lb	Over 7.5 METS

Additionally, the US Department of Labor provides frequency classification guidelines for manual material handling and postural tolerances. The DOL frequency guidelines referenced in Table 25.3 are considered to be the “gold standard” for frequency classification. The DOT Physical Demand Factors and frequency classification guidelines are used to classify the physical demands of jobs/occupations and to report the required physical capacities of workers. Because the same factors are utilized to classify jobs and measure a worker’s physical capacity, an easy comparison of job/occupation requirements can be made to an individual’s measured functional capacities (Feuerstein, Menz, Zastowny, & Barron, 1994; Lechner, Jackson, Roth, & Straaton, 1994). Utilizing these guidelines during testing and presenting FCE results in the context of these guidelines allows for an easy comparison of functional data to occupational demands.

Table 25.3

Department of Labor Frequency guidelines (US Department of Labor, 1991b)

Occasional	>0–33 %	Of the work day
Frequent	34–66 %	Of the work day
Constant	67–100 %	Of the work day

Department of Labor. Dictionary of occupational Titles, 4th Edition, Revised (1991b)

FCEs should include the following six evaluation components: a structured-intake interview, condition-specific screening measures, manual material-handling testing, functional activity testing, interpretation of test results, and report generation. In the structured-intake interview, the clinician will obtain self-reported information regarding the worker’s medical history, mechanism of injury and diagnosis, response to treatment, current self-reported abilities for activities of daily living, and functional tolerances. Additionally, the clinician will likely administer one or more self-report measures to identify the worker’s perception of disability and screen for potential performance issues (pain behaviors and depression). A health history questionnaire is also completed. FCEs are most useful (with regard to return to same job or occupation) when the details of the job can be compared to the injured worker’s functional abilities (Feuerstein, Menz, Zastowny, & Barron, 1994; Lechner, Jackson, Roth, & Straaton, 1994). Therefore, the clinician should request a detailed description of the worker’s job demands prior to the scheduled FCE appointment and then spend time during the structured-intake interview to review the job demands with the worker. Lastly, the clinician will review the FCE process, establish goals and expectation of testing, and review the referral questions to be answered in the FCE. Once the structure intake interview is complete, the clinician will obtain vitals (resting heart rate and blood pressure) to ensure the worker is safe to commence functional testing.

Condition-specific screening measures are an essential component of the FCE. Reflecting back to the test hierarchy that was presented above, safety is the foundation of the FCE. Therefore, a formal neuromuscular evaluation measuring active range of motion, strength, and sensation of the injured body part is essential. Because a worker’s whole body returns to work or purposeful activity, the FCE must measure whole body functions (Isernhagen, 1988). A screen of active motion, strength, and sensation for the whole body (not just the injured body area) should be administered. In the event that the worker has a brain injury, a cognitive evaluation screen will assess memory, comprehension, ability to follow multistep directions, and attention to task. Condition-specific screening measures will assist the clinician to select appropriate assessments in the FCE and to make necessary recommendations to appropriate referral sources for further assessment and treatment. Once the intake interview is completed and appropriate condition-specific screening measures and the neuromuscular evaluation are complete, then manual material-handling testing can begin. Strength and material-handling testing includes lifting, carrying, pushing, and pulling. Lifting, carrying, pushing, and pulling should be assessed generically, prior to job-specific testing, so that a safe baseline of functional abilities can be established. This is achieved by utilizing a standardized dynamic protocol and beginning with a low weight that is increased incrementally (to ensure safety during the testing process). An example of a dynamic and incremental test of lift capacity is the EPIC Lift Capacity Test (Matheson et al., 1995). Push and pull testing is often measured isometrically via a Chatillon force gauge (or similar) due to space constraints in rehabilitation facilities and the industry’s lack of standardized test of dynamic push and pull ability.

The assessment of functional abilities builds upon the generic manual material-handling test results. Physical job analyses that provide information specific to the weight, force, height, coupling, and displacement required on the job should be utilized. Sensitivity to the items lifted, carried, pushed, and pulled and setting up the job-specific tests to match the physical job demands is essential for determining if an injured worker can return to work safely. It is easy to understand that a box of product or bag of concrete is lifted much differently than a 5-gallon bucket of paint. Therefore, utilizing actual work samples, such as 2 × 4s, sheets of dry wall, bags of sand or concrete, and boxes or cases of product, is preferred when possible. Several computerized functional testing systems exist in the marketplace that allow the therapist to customize job-specific tests to meet the exact parameters of the work site. Unlike the generic manual material-handling testing, job-specific testing should test a worker to the level documented in the job analysis, but not above the job demands requirements or to maximal abilities. If a job description is not provided, occupational references, such as the Dictionary of Occupational Titles, fourth Edition (US Department of Labor, 1991a) or O*NET (O*NET), can provide the clinician with useful information as to the generic material-handling requirements, postural demands, and common job tasks.

After the FCE is complete, the clinician analyzes the test data utilizing clinical reasoning skills and then generates a comprehensive report of the findings. The ability to interpret test results in the context of the worker’s injury, clinical presentation, and job distinguishes a professional evaluator from a technician or test administrator (Smith, 1994; Isernhagen & Hart, 1999). “Test results that are provided without the interpretation of the evaluator often are meaningless and can be misleading. The results of the FCE become an integral part of the return-to-work process. It forms a basis for return-to-work conclusions which allow appropriate productivity, with the possibility of identifying physically contraindicated work activities that can be modified to make the activities safe in spite of impairment” (Hart, Isernhagen, & Matheson, 1993). The FCE report should document the objective functional work capacities of the injured worker and support the clinician’s clinical reasoning. Clinical reasoning is the clinician’s ability to pull all components of the FCE together into an overall statement of performance. The clinician does this by analyzing all available information and specifically the following test components: condition-specific screening results, neuromuscular evaluation results, formal test results, HR analysis and response, quality of movement, subjective reports, self-report measures, pain reports, pain response to activity, and validity-specific test components. Utility of an FCE is achieved when the reliability of the selected test measures determine the validity of the worker’s performance resulting in an accurate report of maximum functional abilities.

As discussed above, FCEs are most useful with regard to return to same job or occupation when the details of the job can be compared to the injured worker’s functional abilities. In the event that an injured worker does not have a job or occupation to return to, or his or her injuries are so significant that the individual cannot return to work in the same job or occupation, the FCE can still be a useful tool. Because FCEs measure multiple abilities of an individual, the FCE can easily and accurately report general abilities of an injured worker. A general FCE report can be used to compare a worker’s abilities to other jobs in the worker’s department or employer. In the event that a match is made, the worker can transition to a new job for the same employer. In the event that the injury or disability is too significant for return to work in the same job or for the same employer, a comparison can be made to other similar occupations. In this context, general ability FCEs can act as starting point for vocational exploration. Therefore, the FCE is not only a useful clinical tool but also a baseline for ADA accommodations and/or formal vocational exploration and placement programs that aid to transition a worker from injury to supported employment.

Post-offer of Employment Testing

A useful tool for employers to prevent disability in the workplace is a Post-Offer of Employment Test (POET). Under the ADA guidelines, employers are prohibited to ask questions regarding disability during the interview process. However, following a conditional offer of employment, an employer can request a POET to assess the candidate’s ability to safely perform the physical demands of a job. The primary reference for the implementation of a POET program is the Uniform Guidelines on Employee Selection Procedures, issued by the Equal Employment Opportunity Commission in 1978 (EEOC, Uniform guidelines on employee selection procedures, 1978). The US Equal Opportunity Commission is “responsible for enforcing federal laws that make it illegal to discriminate against a job applicant or an employee because of the person’s race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information” (EEOC, US Equal Employment Opportunity Commission, 2012). The models to validate a POET program were originally drafted by the American Psychological Association standards for validating educational and psychological tests (American Psychological Association, 1999). An employer who seeks to implement any type of selection procedure, physical or psychological in nature, must be prepared to justify the methods of the program. The Uniform Guidelines reference three types of validity to be considered: content validity, criterion-related validity, and construct validity. Content validity means that the test components reflect the physical requirement in the job. Criterion-related validity can be defined as two separate types, such as a test component’s ability to predict a current capability, or concurrent validity, and a protocol’s ability to select candidates who can safely perform the work and reduce an employer’s workplace injuries, or predictive validity. Construct validity references the statistical means of establishing the relationship of the test components within a protocol and to one or multiple requirements for job performance (Hogdon & Jackson, 2000).

The physical demands job analysis should be the cornerstone of any POET program. Establishing the essential functions with associated physical demands is coupled with an understanding of the hiring and job placement practices of the employer to set up test protocol(s). Test protocols themselves should follow the same functional testing hierarchy referenced with performing FCEs: safety, reliability, validity, practicality, and utility (Matheson et al., 1995). A best practice in POET protocol design and safe test administration is to follow a progressive loading principle. This consideration of test sequence allows the candidate to maximize performance in lower to higher physical demands requirements. The progressive loading test sequence will also improve the reliability of the data for construct validity analysis. The Uniform Guidelines provide the employer with a reference when validating a POET program, but several key issues must be considered during the setting of cut scores. The primary consideration is adverse impact which occurs when the selection of a group is less than 80 % of the highest selected group, also known as the 4/5ths rule (EEOC, Uniform guidelines on employee selection procedures, 1978). Adverse impact can be justifiable when the physical demands have been validated by on-site job analysis and it is deemed to be a business necessity. Other factors for an employer to consider include workforce demographics, productivity, and injury rates. Ensuring there is a match between the physical requirements of a job and a worker’s functional ability is beneficial to both the individual and the employer. The candidate who does not meet the requirements avoids injury and potential loss of future income. The employer does not incur the financial pitfalls related to workplace injuries and maintains productivity with a healthy and capable workforce. A thorough validation study report, including on-site objective job analysis, should be completed and available in response to any potential EEOC inquiries. Given the time elapse that can occur between the onset of a program and any challenge, programs that maintain concurrent validation studies with performance data on all job candidates to date will strengthen defensibility of the program.

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