Behind the Scenes of an FCE:

1. Behind the Scenes of an FCE: Understanding the Results

2. Welcome Tanya Kimball Vela Occupational Therapist for 20 years Worked in Industrial Rehab doing Work hardening/Conditioning, Onsite therapy and FCE�s for past 11 years. Certified FCE Evaluator Currently owner of Tanya K. Vela OT Services

3. Who are you? What is your FCE experience?

4. Course Objectives Overview of the tests used in the FCE Understand the implication of the results of these tools and impact on outcomes Ways to maximize benefit from the FCE

5. Why this Talk? Many people have asked me: This test is Valid? Are they faking it? Is this really what they can do? What does this really mean? I�d like to thank Suzy L who encouraged me to do this talk. I�d like to thank Suzy L who encouraged me to do this talk.

6. What is an FCE? A test to assist in determining an individual�s capacity for work. An FCE is a means to assist in case closure FCE�s are in many ways a behavior test Just a quick overview. Keep in the back of your mind� FCE are behavior test. Just a quick overview. Keep in the back of your mind� FCE are behavior test.

7. Validity and Reliability Validity: Measures what it is suppose to measure Reliability: Consistent measurement. Can be reproduced. Can be scary terms when talking about FCE�s. Can be scary terms when talking about FCE�s.

8. No Standard in the Industry There has not been one test/system that has been proven the most reliable/valid for FCE�s. Must rely on current studies/practices and literature and utilize the best battery of tests available to obtain a good outcome.

9. Goals of the FCE Answer the questions of the referral source: Can he work and at what level? Is there dysfunction/limitations? Can the worker return to a specific job? Was he trying his best?

10. FCE needs to address: Material handling including: Lifting from floor to overhead Push/pull Carry Non material handling/positional tolerances Sit, stand, walk Bend, stoop, kneel and squat

11. Please remember� The injured worker is put in position to decide if he or she wants to work. Thus the FCE becomes a behavioral test My job is to make some opinions based on those behaviors/tests.

12. Performance is the key How can I �force� an injured worker to push harder than they are willing. When we start the FCE, the worker is instructed to �stay safe, work up to the safe maximum ability� Thus we are looking at behavior and performance Putting validity and reliability aside, I believe performance is the key. What that injured worker deems as safe varies from worker to worker. Putting validity and reliability aside, I believe performance is the key. What that injured worker deems as safe varies from worker to worker.

13. I can�t say� Malinger Faker Symptom magnifier So when I go to write my FCE.. So when I go to write my FCE..

14. I can say� Acceptable effort Over guarding (fearful) May not represent true work capacity Can perform work at least at this level Will be safe to perform work at this level

15. How do I determine this? Going to look at a variety of items including: Pain levels pre, during and post test AROM pre and post test Heart Rate and Rate of Perceived Exertion Psychometric testing Coefficient of Variance Kinesiophysical Signs Lifting

16. Pain Scales See hand outs # 1-4 Five different examples that are used. There are others out there. Simply ask the client to report pain on the scale. If they report that pain is at 6 or above, but don�t want to take a break� At level 10 but still going strong? The scale I used mainly is handout number 1. Read over the descriptions. Hand out 1 and 4 give very detailed description of what function one should be able to do with this pain level. It also correlated with the line drawing on hand out 3. Pain level of 6 or above and no break is a red flag. �It is a 10 but I have a really high pain tolerance.� Try to educate them that a 10 is the worse, it can�t get any worse. The scale I used mainly is handout number 1. Read over the descriptions. Hand out 1 and 4 give very detailed description of what function one should be able to do with this pain level. It also correlated with the line drawing on hand out 3. Pain level of 6 or above and no break is a red flag. �It is a 10 but I have a really high pain tolerance.� Try to educate them that a 10 is the worse, it can�t get any worse.

17. Heart Rate and RPE See hand out #5 and 6 This is commonly called the BORG Ask client to rate exertion- �how much work hearts and lungs are doing� Compare to heart rate Must be aware of medications taking. Take pulse and ask them to rate I like on number 6 is the comparison to an activity. We are NOT talking about pain. Get volunteer. Have them run/step in place for 10 seconds. Take pulse and askTake pulse and ask them to rate I like on number 6 is the comparison to an activity. We are NOT talking about pain. Get volunteer. Have them run/step in place for 10 seconds. Take pulse and ask

18. Psychometric Tests See hand outs #7-11 Psychometric tests are self reporting pen and paper tests/questionnaires. They give the client an opportunity to rate/report their abilities and pain. What are psychometric tests? They are self reporting pen and paper tests. They give the IW an opportunity to rate their abilities and pain. What are psychometric tests? They are self reporting pen and paper tests. They give the IW an opportunity to rate their abilities and pain.

19. Psychometric Tests Modified Oswestry Low Back Questionnaire Rates for scores are a result of study by Blankenship: scores of 40-100% are considered high and indicate significant impairment or symptom magnification scores of 0-29% are considered low and indicate non symptom magnification scores of 30-39% indicate an equivocal result This test is used for low back injuries and pain. There are similar ones for knee and neck injuries as well.This test is used for low back injuries and pain. There are similar ones for knee and neck injuries as well.

20. Work Recovery Expectations Questionnaire Look at question 3. If the client marks a 5 on this, I ask them if this is what they really believe. This could be the biggest indicator of success of return to work for this client. If the client marks a 5 on this, I ask them if this is what they really believe. This could be the biggest indicator of success of return to work for this client.

21. McGill Pain Questionnaire Another opportunity to understand where this client is This is form the research of Melzack back in 1975. It has been researched further. Explain test. This is form the research of Melzack back in 1975. It has been researched further. Explain test.

22. Modified Somatic Perception Questionnaire Another chance to see where this client is Need to ask about medication-side effects could be the cause Score over a 6 is high. Score over a 6 is high.

23. Ransford Pain Drawing Again, another look at how this person perceives pain Sometimes do pre and post drawings Look for pictures that have exaggerated markings, Score of 3 is highLook for pictures that have exaggerated markings, Score of 3 is high

24. Pain Drawing Score 0

25. Pain Drawing Score 4

26. Additional Questionnaires DASH SPADI Pain Disability Index Dallas KOOS Michigan Hand Outcomes FAAM Here is a list of several others you may come across. Here is a list of several others you may come across.

27. Psychometric test warning These tests can not stand alone. They must be used in conjunction with each other and the rest of the test I can not make a decision on ability based solely on these tests. I can not make a decision on ability based solely on these tests.

28. Waddell�s Panel for Non Organic Signs A group of observations taken during specific tasks These point to the presence of nonorganic factors causing back pain. Must have three of five groups to be considered positive This must be done without any suggestion that the activity may cause pain. Demonstration This must be done without any suggestion that the activity may cause pain. Demonstration

29. Movement Measure range of motion at beginning Why would it be better or worse at the end of the test? Better if need to �loosen up� Worse if in pain. What if better, but more pain? Measure at beginning and at end. Measure at beginning and at end.

30. Coefficient of Variance Static Strength testing Grip testing ROM I have an excel program that figures it for me. Used to determine consistency of effortI have an excel program that figures it for me. Used to determine consistency of effort

31. Grip Testing Bell shaped curved Rapid Exchange Test Great tool. Very easy to do. But be careful with hand injuries. If bell shaped curve is missing, need to figure out why. Some hand/wrist injuries will cause some differences. Get volunteer and demoGreat tool. Very easy to do. But be careful with hand injuries. If bell shaped curve is missing, need to figure out why. Some hand/wrist injuries will cause some differences. Get volunteer and demo

32. Kinesiophysical Signs Base of support Hand grips Muscle recruitment Counter balance My FCE�s will state The IW displayed Kinesiophysical Changes during the FCE. These are the things I am looking for. Get volunteer and demo My FCE�s will state The IW displayed Kinesiophysical Changes during the FCE. These are the things I am looking for. Get volunteer and demo

33. Kinesiophysical effort Light Effort: no accessory muscles, natural stance, easy movement patterns Moderate Effort: Involuntary recruitment of accessory muscles, stable base, beginning of counter balance, smooth movements, lift takes longer Heavy effort: Obvious recruitment of neck muscles, arm muscles; wider solid base; counter balance is obvious and used This comes from the work of Isernhagen. This comes from the work of Isernhagen.

34. Inconsistent Lifting PILE results correlates with Occasional lift test This is another test used to ensure max effort is being used. Basically comparing one lift test to another. This is another test used to ensure max effort is being used. Basically comparing one lift test to another.

35. Full effort Test can be used to determine work restrictions with confidence

36. Over Guarding�. Will you really ever get more out them? Maybe the best thing is to recommend work category at their level and they will be safe. Also consider Pain issues, can they be better controlled, What about fear? Ex: Does not control pain with medications, exercise or anything�. Jo example Had not moved in a year. Recommended therapy, was able to improve Example 2: really does not want to work. Also consider Pain issues, can they be better controlled, What about fear? Ex: Does not control pain with medications, exercise or anything�. Jo example Had not moved in a year. Recommended therapy, was able to improve Example 2: really does not want to work.

37. Add�m up and get the Results Have to look at the big picture Looking for patterns Consistency in effort vs. non effort Like I mentioned earlier with the psychometric tests, all factors have to be considered. Like I mentioned earlier with the psychometric tests, all factors have to be considered.

38. Obviously not trying Talks with Doctor, Employer, Case manager, etc. This is where it gets complicated and all involved must assist in getting case closure Look at why this Injured Worker is not performing as expected. Once this is determined, then can move forward. Ex: Needs to stay home as care giver. Look at why this Injured Worker is not performing as expected. Once this is determined, then can move forward. Ex: Needs to stay home as care giver.

39. Maximize the results FCE type JA available? What do you expect from the FCE? The best way to get the best results is to have a discussion with the evaluator prior to the test. I want to know what you are looking for? JA? Can I have it? Will zone in on the essential job functions in the FCE.The best way to get the best results is to have a discussion with the evaluator prior to the test. I want to know what you are looking for? JA? Can I have it? Will zone in on the essential job functions in the FCE.

40. Questions? Comments?

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