Functional Capacity Evaluations within Vocational Rehabilitation in Louisiana Workers Compensation
During the vocational rehabilitation process, the workers compensation insurance company will often have the injured employee undergo a Functional Capacity Evaluation (FCE), which is basically an examination by a physical therapist in order to determine the employee's physical ability to perform specific physical functions.
A Functional Capacity Evaluation (FCE) typically consists of a series of physical exercises administered over several hours, including:
- Lifting weights or other items;
- Carrying boxes or other items;
- Squeezing calipers;
- Pushing and pulling;
- Positional tolerance;
- Range-of-motion testing;
- Hand dexterity testing;
- Cognitive tests; and
- Other similar activities.
So, basically, a Functional Capacity Evaluation (FCE) will mainly measure the employee's strength, flexibility, and stamina, sometimes cognitive abilities.
The workers compensation insurance company will use the Functional Capacity Evaluation (FCE) to attempt to ascertain an employee's work capabilities and form the parameters of what type of work activity the employee is able to perform.
Injured Workers Must Beware of Functional Capacity Evaluations
The workers compensation insurance company pays for the Functional Capacity Evaluation, and often repeatedly works with the same therapists administering the functional capacity evaluation, in order to get the results that the insurance company wants.
The FCE therapist then uses the measurements from these activities to produce an FCE report that identifies the type and duration of physical labor that the injured employee can perform.
The workers compensation insurance company will then use this Functional Capacity Evaluation Report to claim that the employee can return to employment, and thus does not deserve lost wage benefits.
So unfortunately, the bottom line is that, like most of the actions taken by the workers compensation insurance companies, the purpose of a functional capacity evaluation (FCE) is to give the insurance company the ability to terminate the employee's indemnity (or lost wages) benefits.
Thus, a Functional Capacity Evaluation (FCE) is almost always used to the detriment of the employee, not the the benefit of the employee, because it is used to eliminate an employee's lost wages benefits.
Functional Capacity Examiners in Louisiana Workers Compensation
Generally, in Louisiana workers compensation claims, Functional Capacity Evaluations are performed by physician therapists known as Functional Capacity Examiners.
The Academy of Orthopedic Physical Therapy defines a Functional Capacity Examiner as "a physical therapist or occupational therapist licensed in the jurisdiction in which the services are performed, who is able to demonstrate evidence of education, training, and competencies specific to the design, administration, and interpretation of FCEs."
- According to the Academy of Orthopedic Physical Therapy, Functional Capacity Examiners are expected to:
- Utilize the best available evidence from clinically relevant research when designing and performing Functional Capacity Examinatio protocols;
- Utilize the best available evidence when forming conclusions about an individual's ability to safely participate in work and other major life activities;
- Use a client centered approach in which the examiner gathers information to understand what is currently important to the individual and to identify past work experiences that may assist in the understanding of the current issues; and
- Be able to demonstrate a post-professional level of knowledge and clinical expertise across a broad spectrum of medical, vocational, psychological, cognitive, and functional testing concepts.
Design of Functional Capacity Evaluations
Typically, Functional Capacity Examiners do not just administer Functional Capacity Evaluations, but also design the Functional Capacity Evaluations or choose to use established functional tests with or without personalized modifications.
Most established Functional Capacity Examination tests meet the following criteria:
- The Functional Capacity Evaluation tests should not lead to injury;
- The Functional Capacity Evaluation tests should produce consistent results;
- The Functional Capacity Evaluation tests measure what the tests were supposed to measure;
- The time and cost involved in the design, administration, interpretation and reporting of the FCE tests should be reasonable;
- The results in the Functional Capacity Evaluation report should be comprehensible to non-medical readers; and
- The results in the Functional Capacity Evaluation report should provide useful information.
Physicians as Functional Capacity Examiners
Typically, physicians or doctors do not perform Functional Capacity Evaluations, because they do not have the requisite skills and experience to do so.
In fact, physicians are much more adept, and their time much better utilized, when providing medical treatment to patients, rather than gathering data for a Functional Capacity Examination.
What to Actually Expect During a Functional Capacity Evaluation in Louisiana Workers Compensation
Most Functional Capacity Evaluations follow similar procedures or protocols.
First, the injured employee will meet with the Functional Capacity Examiner, who is the therapist trained and qualified to handle the Functional Capacity Evaluation. The examiner will likely have an intake procedure in which the examiner will take down the employee's general information, which includes the employee's demographics, work history, work injury history, medical history and social history.
During this time, or just beforehand, the employee will likely be asked to fill out questionnaires and pain diagrams.
The employee will also likely be asked to provide information for a Job Analysis, which involves:
- Describing the employee's job task requirements;
- Describing the employee's job environment in which the employee's job task requirements were performed;
- Describing the employee's physical requirements of the worker's job positions, including lifting, carrying, sitting, standing, walking driving, pushing, pulling, climbing, balancing, stooping, kneeling, crouching, crawling, twisting, reaching, handling, gripping, feeling, seeing, hearing, speaking, and walking on uneven surfaces; and
- Describing the employee's environmental factors, including chemical exposure, temperature extremes, heights, dust exposure, machinery, humidity exposure, loud noises, exposure to fumes, and vibrations.
Then, during the FCE Functional Capacity Evaluation tests, the employee will be asked to perform physical tasks, which will involve testing the employee's capacity with respect to lifting, pushing, pulling, standing, walking, flexibility, reaching, grasping, holding, bending, and balancing.
Throughout testing the Functional Capacity Examiner will typically monitor the injured employee's physiological, bio-mechanical, and psychophysical responses to activity.
Physiological monitoring includes regular monittoring of the employee's heart rate for safety reasons and also as a test of the employee's effort level during testing. If the employee's heart rate is affected by medication or other issues like a pacemaker, alternative monitoring may be used.
Bio-mechanical monitoring includes clinical observations of muscle movements, movement patterns, stance, balance, and counterbalancing.
The Functional Capacity Examiner will typically monitor the injured employee's psychophysical symptoms during the FCE in order to assess the employee's pain levels. However, it can be difficult for a Functional Capacity Examiner to assess how the employee's pain levels impact the employee's performance during the FCE testing. The examiner should use psychosocial screening, pain behavior assessment, and physiological assessment in order to accurately assess the employee's pain during FCE testing, since psychosocial factors do in fact influence performance.
Last, if the Functional Capacity Evaluation referral requests information about the employee's cognitive abilities, the Functional Capacity Examiner will typically administer cognitive functional testing, which oftentimes requires specialized skills and training.
Twelve Typical Test Components of Functional Capacity Evaluations in Louisiana Workers Compensation
Again, most Functional Capacity Evaluations follow similar procedures or protocols.
The following twelve test components typical appear in Functional Capacity Evaluations:
- Referral Review
- Medical Record Review
- Informed Consent
- Intake Interview
- Comprehensive Pain Assessment
- Physical Examination
- Cardiovascular Respiratory Abilities Testing
- Material Handling Testing
- Coordination, Flexibility, Postural Abilities Testing
- Cognitive Testing
- Other Work Simulation Testing
- Exit Interview and Instructions
#1. Referral Review in Functional Capacity Evaluations
The first step that occurs in a Functional Capacity Evaluation is the the Functional Capacity Examiner receives a referral for a Functional Capacity Evaluation.
Usually, the referral comes from either the workers compensation insurance company (through the vocational rehabilitation counselor) or the injured worker's treating physician.
This referral for the Functional Capacity Evaluation is important because it provides the reason for referral, which is key for both the worker and the Functional Capacity Examiner to understand, so as to maximize the usefulness of the Functional Capacity Evaluation.
#2. Medical Records Review in Functional Capacity Evaluations
Before meeting with the injured employee for the Functional Capacity Evaluation, the Functional Capacity Examiner will receive and review the employee's complete medical records.
These medical records will likely provide all information regarding the employee's medical history, the extent of the employee's injury, the treatment provided to the employee, and the employee's present condition.
Certainly, the Functional Capacity Examiner will be aware of all the details concerning any surgeries, diagnostic tests or other major treatments received by the employee.
Also, these medical records may include medical conditions directly related to the employee's work-related injury or illness, or unrelated to the employee's work-related injury or illness.
It is extremely important that the employee gather and review (preferably with the employee's workers compensation attorney) all of the employee's medical records, so the employee can be thoroughly prepared for the Functional Capacity Evaluation.
#3. Informed Consent in Functional Capacity Evaluations
Upon meeting with the injured employee for the Functional Capacity Evaluation, the Functional Capacity Examiner will required the informed consent - verbally and in writing - from the employee about the purpose, risks, and benefits of the Functional Capacity Evaluation.
This informed consent will likely include:
- Discussion of the risk for injury, exacerbation of symptoms, or possibility of soreness in response to testing;
- Discussion of the exam procedures that will help to reduce that risk;
- Discussion concerning the release of Functional Capacity Evaluation information;
- A thorough description of the Functional Capacity Evaluation testing process; and
- An inquiry about the employee's questions and concerns.
#4. Intake Interview in Functional Capacity Evaluations
Next, the Functional Capacity Examiner will conduct an intake interview.
In this intake interview, the examiner will collect the employee's general information, including the employee's demographics, work history, work injury history, medical history and social history.
Also during this intake interview, the examiner interview may inquire about:
- Current, recent, and past levels of pain;
- Current, recent, and past levels of functioning; and
- The nature, severity, and irritability of the individual's condition.
#5. Comprehensive Pain Assessment in Functional Capacity Evaluations
Next, the Functional Capacity Examiner will conduct a comprehensive pain assessment.
The Functional Capacity Examiner will likely use psychometric/psychosocial pain questionnaires, and will monitor physiological responses associated with an acute increase in pain, despite the fact that physiological responses may be due to an increased pain stimulus, the anticipation of pain, or increased physical exertion.
In other words, when the employee reports an increase in pain during the Functional Capacity Evaluation, the Functional Capacity Examiner will look for physiological responses, such as:
- Increased heart rate;
- Increased blood pressure;
- Increased breathing rate;
- Diaphoresis; and
- Pupil dilatation.
Also, during the Functional Capacity Evaluation, the Functional Capacity Examiner will monitor pain symptoms, including:
- Facial expressions: Frowning, grimacing, distorted expression, or rapid blinking.
- Verbalizations/vocalizations: Sighing, moaning, calling out, or asking for help.
- Body movements: Rigid, tense, guarding, fidgeting, increased pacing/rocking, bio-mechanical changes such as motor restlessness.
- Changes in interpersonal interactions: Aggressive, resistive, disruptive, or withdrawn.
- Changes in activity patterns: Sudden cessation of common routines.
- Mental status change: Crying, increased confusion, irritability, or distress.
The Functional Capacity Examiner will likely use a pain scale with a functional pain scale during the comprehensive pain behavior assessment to provide further evidence in forming an opinion about how the individual's pain affected observed function during testing.
#6. Physical Examination in Functional Capacity Evaluations
Next, the Functional Capacity Examiner will conduct a physical examination off the injured worker.
The Functional Capacity Examiner will first likely look at cardiovascular status including resting heart rate and blood pressure, so that the examiner can ensure safe testing of particular physical functions.
Next, the Functional Capacity Examiner will usually conduct the actual physical examination, which includes:
- Range of motion testing;
- Strength testing;
- Girth measurements;
- Temperature measurements;
- Other diagnostic testing;
- Other musculoskeletal testing; and
- Other neuromuscular testing.
Many times the Functional Capacity Examiner will repeat measurements and average out the results in an attempt to achieve more reliable measurements or data.
#7. Aerobic Abilities Testing in Functional Capacity Evaluations
Next, the Functional Capacity Examiner will conduct aerobic abilities testing - also known as cardiovascular respiratory abilities testing.
Aerobic testing is important because it demonstrates an employee's capability of performing sustained work activity.
Usually aerobic testing in a Functional Capacity Evaluation takes the form of walking on a treadmill, riding a stationary bicycle, or climbing steps.
Typically, the Functional Capacity Examiner will consider the employee's job requirements and work history when deciding how to test an employee's aerobic function.
Or sometimes, in order to test an employee's aerobic function, the Functional Capacity Examiner will design specific activities to simulate the employee's job tasks, and then test those activities according various intensities, frequencies, and durations.
Last, the Functional Capacity Examiner will likely use heart rate measurements obtained during this testing to reliably determine the employee's ability to handle work-related activities over the course of an entire 8-hour work day.
#8. Material Handling Testing in Functional Capacity Evaluations
Next, the Functional Capacity Examiner will typically test the injured worker's ability to exert force to lift, push, pull, or carry objects - otherwise known as material handling testing.
Material handling testing frequently consists of:
- Lifting and lowering objects;
- Carrying objects;
- Pushing and pulling objects; and
- Grasping and pinching objects;
The ability of an injured worker to lift, push, pull, or carry objects is often an essential function of most job positions, and is almost always included in every Functional Capacity Evaluation.
The Functional Capacity Examiner will typically monitor the employee's heart rate and watch for perceived pain in the employee while conducting the material handling testing.
Lifting and lowering will usually be tested progressively beginning with minimal weights and progressing to heavy weights, while allowing the maximum opportunity for control.
Carrying will also be tested progressively beginning with minimal weights and progressing to heavy weights, while allowing the maximum opportunity for control. Carrying can be tested unilaterally or bimanually - meaning with one hand or with two hands.
Pushing and pulling are typical work-related demands that will be tested progressively starting with the need for relatively little force and ending at maximum safe ability. An employee's ability to push and pull is most often reported in pounds of force.
Grasping and pinching - which are often required to work in many job positions - are typically measured in pounds of force.
#9. Coordination, Flexibility, Postural Abilities Testing in Functional Capacity Evaluations
Next, the Functional Capacity Examiner will typically test the injured worker's coordination, flexibility, and postural abilities.
Basically, this testing involves measures work-related tasks such as:
- Twisting; and
- Reaching out with your body, arms, or legs.
The Functional Capacity Examiner will seek to determine of the injured worker can maintain these activities occasionally, frequently, or constantly.
Also, the Functional Capacity Examiner will typically test the injured worker both unilaterally or bimanually - meaning with one or with two hands, arms, legs, etc.
#10. Cognitive Testing in Functional Capacity Evaluations
Sometimes the Functional Capacity Examiner will administer cognitive testing, but many times the Functional Capacity Examiner will not.
Really the decision whether to administer cognitive testing will be based on the injured worker's symptoms or diagnosis, and almost certainly on the Functional Capacity Evaluation referral request.
If the Functional Capacity Examiner does administer cognitive testing, he or she will test the injured worker for:
- Cognitive factors;
- Perceptual/sensory factors;
- Communicative factors;
- Behavioral factors; and
- Psycho-emotional factors.
#11. Other Work Simulation Testing in Functional Capacity Evaluations
Work simulation testing is another form of testing that may be provided by the Functional Capacity Examiner.
Work simulation testing is simply when the Functional Capacity Examiner provides excersies or tests that simulate the work experiences of the injured employee.
For example, if a worker's job is to lift 40 pound boxes, then it makes sense that the Functional Capacity Examiner would have a test where the worker is supposed to repeated lift 40 pound boxes if he is able.
Such testing would likely start off with lighter boxes and then progress to heavy boxes, until the worker could lift the 40 pound boxes.
Last, sometimes work simulation testing needs to be performed in the field or with equipment specifically provided by the employer.
#12. Exit Interview and Instructions in Functional Capacity Evaluations
Finally, the Functional Capacity Examiner will conduct an exit interview with the injured worker, where the Functional Capacity Examiner will answer any questions of the worker, and provide instructions to the worker if appropriate.
In this exit interview, the Functional Capacity Examiner will likely review to make sure that the testing has not had an unexpected or adverse effect on the employee. If the testing did have an unexpected or adverse effect on the employee, the Functional Capacity Examiner would likely further documents and assess the situation to see if further action or testing is necessary.
During the exit interview, the Functional Capacity Examiner will also assess any perceived changes in location and intensity of the employee's pain, tightness or soreness pain.
The Functional Capacity Examiner will also document and received changes to the employee regarding tingling, numbness, stiffness, weakness, instability, swelling and spasm.
Last, the Functional Capacity Examiner will provide exit instructions to the employee. Usually, these exit instructions will inform the employee of his or her rights to access to the FCE test results, and when results will be available.
Functional Capacity Evaluation Detailed Reports in Louisiana Workers Compensation
Following the Functional Capacity Evaluation meeting, the Functional Capacity Evaluator Weill prepare and submit a Functional Capacity Evaluation Report.
The Examiner's name and field(s) of expertise will be plainly listed, and the report pages will be numbered.
Usually, the Functional Capacity Evaluation Report will include a summary of findings, which will often be presented towards the front of beginning of the report, before the detailed report data.
This summary of findings in a Functional Capacity Evaluation Report will frequently identify:
- An analysis of the validity of the injured employee's effort
- The injured employee's functional abilities;
- The injured employee's functional limitations; and
- The injured employee's ability to return to work
Typically, a Functional Capacity Evaluation Report should be prepared in a clear enough manner, so that it can be read and understood by non-legal and non-medical people, such as the injured employee.
This simply means that the Functional Capacity Evaluation Report should avoid highly technical terms and legal or medical jargon, and instead just use plain English whenever possible.
Functional Capacity Evaluation Report Sections
This Functional Capacity Evaluation Report will likely contain the following components:
- Introduction. This section will identify the employee, provide the reason for the FCE (from the FCE referral), and identify the type of FCE that was performed.
- Employee's background information. This section will include the employee's personal data (such as age, sex, height, weight), diagnosis, occupation, hand dominance, and identification of any assistive medical devices (splints, braces, crutches or other assistive devices) worn during the FCE.
- List and summary of employee's medical records.
- Summary of information from the employee interview.
- Summary of information from employee questionnaires.
- Clinical examination findings.
- Results of the functional tests and examinations. This section will include the functional test results and end amounts, as well as other physiological, biomechanical, and psychophysical results.
- Analysis of the validity of the employee's performance level (including effort and consistency), and pain reaction, tolerance and behaviors.
- Summary of the employee's functional abilities and limitations. This section will also attempt to identify possible work modifications or accommodations that could affect the employee's functional limitations.
- Comparison of the employee's abilities with the employee's physical job demands. This section will be only likely be included if there is a request for a job or occupation specific FCE.
- Recommendations. If appropriate and requested, this section will include work recommendations, treatment recommendations, and, if requested, a statement identifying the employee's functional limitations as temporary or permanent. If the employee's functional limitations are temporary, then functional re-testing may be performed at a later date so as to reassess the employee's safe work tolerances, functional limitations, and work restrictions. If the employee's functional limitations are permanent, then the FCE results should be considered applicable for up to 6 months.
Functional Capacity Evaluation Report Submission
This Functional Capacity Evaluation Report will likely be submitted or provided to:
- The injured employee or the injured employee's representatives;
- The employer or its representatives; or
- The workers compensation insurance company or its representatives; and
- The injured employee's treating physician.
This Functional Capacity Evaluation Report will almost definitely be submitted or provided to the employee's treating physician. In fact, it is typically the treating physician who actually orders the Functional Capacity Evaluation.
Likely, the treating physician will use the Functional Capacity Evaluation Report to decide whether the employee should continue to be on work restriction or not.
Also, since the Functional Capacity Evaluation is often ordered after the injured worker reaches Maximum Medical Improvement, the treating physician may use the Functional Capacity Evaluation Report to decide whether the employee should be placed on permanent activity restrictions.
Many treating physician will generally agree with the FCE findings, and some treating physicians will modify or add restrictions at their discretion.
Functional Capacity Evaluation Report Validity Testing Concerns
One issue that all injured employee needs to be aware of in Functional Capacity Evaluation Reports is "validity testing."
Almost all Functional Capacity Evaluation Reports will prominently list an assessment of the validity of the injured employee's effort during the Functional Capacity Evaluation.
In fact, built into all Functional Capacity Evaluations are exercises and tests that are specifically included for the purpose of measuring whether the injured employee is giving a sincere effort. These exercises and tests are known as validity testing.
Examples of Validity Testing
One example of a common validity test performed in Functional Capacity Evaluations is grip testing. Functional Capacity Evaluations Reports often claim that the "data" in the Functional Capacity Evaluation showed that the employee gave inconsistent, subpar or invalid efforts during grip testing.
Another example of a common validity test performed in Functional Capacity Evaluations is heart-rate monitoring. The employee's heart-rate will be monitored throughout the Functional Capacity Evaluation.
If employee's heart rate fails to reach a certain threshold (usually 80% of employee's maximum heart-rate) following certain exercises or tests, then this heart-rate is interpreted as self-limiting behavior and the entire Functional Capacity Evaluation may be deemed invalid.
Consequences of Validity Testing
Again, every injured employee needs to understand that the results of "validity testing" and an analysis of the injured employee's effort will be listed and featured prominently in all Functional Capacity Evaluation Reports.
Functional Capacity Evaluation reports can impact an injured employee's workers compensation claim if the report claims that the employee cannot believed - and thus is not credible - because of the employee's efforts in the Functional Capacity Evaluation process.
Such assertions in Functional Capacity Evaluation reports - that the employee acted in bad faith - are common, and can affect not only the employee's credibility as far as the Functional Capacity Evaluation, but can also call into question the employee's credibility as to other aspects of the injured employee's workers compensation claim.
On the flip side, if the Functional Capacity Evaluation Report shows consistent efforts and the testing shows validity in the efforts, the Functional Capacity Evaluation Report will bolster the employee's credibility and believability when it comes to other issues in the workers compensation claim, such as impairment or disability.