Looking Beyond the Test Result

Physicians need a tool that can provide an accurate assessment of the functional status of a claimant who has been injured at work. This assessment can be used to determine impairment and current employability. This type of measure is typically recorded during a functional capacity evaluation (FCE). Here is what you need to know in order to make an FCE work for you.

Assessment Options

The comprehensive nature of an FCE should outline specific limitations and capabilities of the injured individual and allow the medical provider to make decisions based on clinical data. These decisions include, but are not limited to, employability, potential physical restrictions, and claims management.

FCEs must be based on valid measurements of effort or contribution by the participant. Since the concept of validity testing was included as a part of FCEs, various methods and protocols have been used. Unfortunately, a large number of methodologies have produced a wide variety of results regarding validity of effort. The readers of such reports receive mixed messages regarding the quality of measure. There are also occasional workers compensation cases that involve two FCEs on the same individual with conflicting validity of effort results. These situations can increase the time to close claims and disrupt the decision-making process of key individuals.

It is important to accurately measure an injury claimant’s function because this information will influence claims spend. When individuals demonstrate the inability to achieve their normal job demands the cost of indemnity, including partial permanent disability (PPD), can outweigh the cost of therapy or FCE testing.

Behavioral factors can also interfere with the ability to accurately measure the claimant’s function. These factors can be related to secondary gain, kinesiophobia, fear of re-injury, low self-efficacy, and pain-focused behavior. In situations where the individual doesn’t have the ability to lift greater than 10-12 pounds safely, a potential permanent or total disability claim may be the outcome. In addition, the indemnity spend would be significant.

Therefore, inquiries should be made to ensure that the demonstrated maximal safe capability is a true representation of the claimant’s function. This is where validity-of-effort testing is of value. If a sub-maximal effort is accurately identified and legally defensible, it can significantly change the claim’s outcome. The additional benefit of this testing is having a means of obtaining a measure of function closer to an employable threshold (hypothetically, 20-30 pounds of safe lifting capacity). Accurate test results can significantly reduce the indemnity spend.

Accurate Assessment of Effort

Claims professionals typically do not have the time for a full or comprehensive investigation regarding the accuracy of the FCEs they review. Instead, they trust the FCE provider to give an accurate and legally defensible measure of function. If the reports indicate less-than-sedentary capabilities or significant limitations, then the claims professional may be left questioning not only the low measure of function, but also if the money allocated to the FCEs was well spent. Identifying accurate and legally defensible methods for assessing an individual’s effort during testing begins when the claims professional understands how an FCE works. The claims professional will want to know how the following components relate to assessing effort, subjective pain complaints, medical diagnosis, objectivity, and confounding variables.

Subjective Versus Fact

Reports of pain from an individual participating in an FCE are subjective. Individuals have a perceived level of pain based on numerous individual factors including, but not limited to, personality, past experiences, fear, and more.

In addition, pain reports are not always associated with the severity of injury or extent of pathology. If measures of effort during FCEs are reliant on verbal reports or expressions of pain, then the results can be as varied as the individuals being tested. Individuals who are expressive with pain complaints and symptoms may be identified as symptom magnifiers, while individuals with a more stoic presentation may be identified as symptom minimizers. It is possible to minimize symptoms but give a sub-maximal effort, and vice versa. Reports of pain and levels of effort during functional testing should be considered as two different measures—each worthy of reporting and measuring, but not directly influencing the test results of one another.

The presence or lack of presence of significant medical finds or a severity medical diagnosis is also an independent measure opposed to having a direct influence on effort during FCEs. Clinicians may inaccurately assume that the presence of pathology determines limitations are organic in nature, but this perception is erroneous on multiple levels. There have been a few occasions in which pathology or injury was missed during diagnostic testing. If evaluators let the presence of identified pathology influence their assessments of effort, individuals presenting with significant limitations may be incorrectly identified as giving a sub-maximal effort. The same is true if a clinician assumes any presented limitation is from a maximal effort secondary to the presence of significant medical findings.

Objective Measurements

Objective measurements eliminate the personal opinions and perceptions from the evaluator. Any measures that involve a clinician’s interpretation of results can allow for subjective components to influence the outcome.

For instance, in the 2018 a paper, “Current Concepts in Functional Capacity Evaluation: A Best Practice Guideline,” the authors noted examiner bias is a limitation of FCEs. To limit examiner bias or subjective decision-making, the criteria used to determine the assessment of effort should be declared and free from individual interpretation. This goes beyond using a numerical measures.

For example, the 0-10 pain scale is subjective in nature secondary to an individual’s perception of pain associated with a given number not being universal. Unbiased criteria should involve a calculation to determine results as opposed to clinician interpretation. Criteria considered unavailable or secretive in nature prevents the reader from being able to determine if the assessment of effort was objective.

Using unbiased criteria to determine maximal or sub-maximal effort would ideally be published and subject to the peer-review process. This allows for anonymous reviewers to determine if the criteria was developed though standard scientific methods. This process also allows for the identification of any confounding variables or factors that influence the measure that are unrelated to the effort being tested identified. An example of a confounding variable affecting a measure can be seen using a physiologic measure such as heart rate. Science tells us that there is a relationship between heart rate and the level of physical exertion. However, science also tells us that there are many factors unrelated to effort that can affect heart rate, including nervousness, fear, substance ingestion (such as caffeine or nicotine), fitness levels, and hydration status. These variables can interrupt the intended measurement of the level of effort.

Claims professionals will have confidence in FCEs when the assessment of effort is determined to be specific to the functional measures as opposed to a diagnosis or reported pain. By asking specific questions of the evaluator prior to scheduling the FCE and requesting peer-reviewed published research, a claims professional can allocate dollars to tests that produce accurate, legally defensible results.

Furthermore, FCE clinicians should be willing to assist the claims professional in determining the quality of the FCE they perform. Through a collaborative effort, the value of FCEs will support the claims professional in factual decisions and reduce indemnity costs.