Functional Capacity Evaluation
Workers' compensation case managers often rely on a functional capacity
evaluation (FCE) performed by a physician, physical therapist, or occupational
therapist to assess an injured employee's impairment ratings and fitness for
work. But FCE's rely on the professional's visual estimation, or observation, of
movements that can vary greatly from one observer to another.
Kinematic analysis uses instrumentation combined with sophisticated computer
technology to turn FCE's from subjective observation to reproducible clinical
data.
Functional Capacity Assessment Applications
By Gideon Ariel, Ph.D.
Fifth Annual Scientific Sessions and Symposium
American Academy of Disability Evaluating Physicians
Ritz-Carlton Hotel, Kansas City, MO
November 14-16, 1991
The Ariel Performance Analysis System is a computer-based system for the
measurement and analysis of movement. The system models the human body as a
series of moving �links� upon which muscular, gravitational, inertial and
reaction forces are applied. The means of measuring human motion is based on the
processing of video recordings of a subject�s performance. The advantages of
such a system are that it is non-invasive, portable and the performing
environment need not be modified. This allows for greater flexibility in the
recording of an activity. The APAS has been applied for some time in areas
such as injury assessment, gait analysis and athletic performance.
Functional Capacity Assessments are a major application of the Ariel
Performance Analysis System. Such assessments are utilized for determining
whether or not someone is healthy enough to continue working or participating in
a certain activity (i.e.: athletics). An example of the use of this system is
for an injured baseball pitcher who claimed to feel ready to return to pitching
whereas his trainer and coach disagreed despite medical exams and strength
tests. Video pictures of the athlete before and after injury displayed the
change in function of the pitcher�s elbow indicating an insufficient post-injury
neuromuscular response under the dynamic conditions of pitching. Another example
is a longshoreman, who sustained a job-related injury, and his physician
contending that permanent disability and compensation ought to be awarded to the
worker whereas the employer disagreed. The employer requested that his employee
perform a number of sitting, standing, bending and light lifting maneuvers for
performance analysis. The evaluation showed inconsistent motion patterns and
changes in acceleration indicating that the worker was in fact exaggerating the
extent of his injury. Actual injury is represented by consistent acceleration
patterns, almost like a �signature�, that do not change in any significant
manner.
The value of applying the principles of biomechanics to the assessment of
functional capacity has been clearly demonstrated. Movement analysis provides
the means to quantify human activity and to provide insight into the mechanisms
that contribute either to superior or inferior levels of performance. Functional
capacity assessment is only the first step in the capacity of this technology.
Specific performance parameter measurements for various occupations, coupled
with actual performance analysis of individual disability, will allow better
rehabilitation programs to be established.
The System for Functional Restoration
By Earl F. Hoerner, M.D., Medical Director, Kinematic Consultants, Inc.
Abstract of �The System�
A Continuing Education Document
A Team Approach is instituted when a patient with Musculoskeletal injuries
does not respond to traditional care. Traditional care would be medication,
Physical and/or Occupational Therapy, Chiropractic care or alternative treatment
methods. After six weeks without improvement the patient may be identified as
failing to respond to his or her treatment plan. It is then that a Comprehensive
Medical Evaluation-Assessment is initiated which includes examination and
re-evaluation by a physician, trained in Occupational Medicine, or a
Physiatrist.
Assessment procedures would include the application of three-dimensional
motion analysis. A force-platform is used to evaluate/assess balance,
equilibrium and gait patterns. Muscle function, strength, endurance, power,
fatigue and rhythm are measured using surface electromyography. Motion analysis
would facilitate the identification of circumstances, which are present in the
patient�s failure to respond to traditional programs.
When appropriate, the Team, which consists of the �Gatekeeper�(physician),
treating personnel, Managed Care personnel, Rehabilitation Nurses and
specialists in the field of Evaluation/Assessment would establish an appropriate
treatment program to modify and correct the patient�s present treatment program.
The Treatment Program and the patient�s response to it would be recorded
objectively. Such documentation would include the rate of which treatment was
applied, patient active participation, resistance used and duration of
participation. This way outcome results will be identified and documented at the
initial six week re-assessment period, two to three weeks later and one month
after completion of the Treatment Program.
The goals of The System are to minimize time spent out of work, prevent or
postpone surgery, prevent recurrence of injury, increase the number of
individuals returning to work and decrease litigation. The System would be most
beneficial for Workers� Compensation injuries, Litigation-Tort related cases and
Managed Care Programs.
REPRINT: November 1996 vol.7 No.11 issue Case Management Advisor
Speed lost time in workers� comp with proactive case management
Aggressive approach pays off in workers� compensation
Kaiser Permanente Northwest Region in Portland, OR, reduced average loss time
per workers� compensation claim by $666. How did they do it? By setting up a
system of proactive case management that experts interviewed by Case Management
Advisor agree is the most effective way to prevent an injured employee from
remaining on the disability rolls.
�Our reporting system identifies workers who fall outside established
parameters for expected return to work,� says Betsy Kahnoski, RN, BSN, MS, COHN,
occupational health nurse case manager for Kaiser-on-the-job for the Kaiser
Permanente Northwest Region. �I receive reports every two weeks. Unresolved
cases come to my attention quickly and can also be referred directly to me. We
have established criteria thresholds that help identify excessive time loss or
extended time on modified duty. Review can begin on those cases to identify
problem areas.�
When an employee suffers from a soft-tissue injury, it�s sometimes difficult
to pinpoint the exact source of pain and prescribe a proper treatment plan, says
John M. Marshall, MD, a physiatrist with Appalachian Rehabilitation
Professionals in Kingsport, TN. �To avoid secondary gain factors, such as
psychological resistance to treatment and return-to-work, it helps when the time
between injury and aggressive treatment is minimized.�
Marshall suggests case managers be on the alert for the following
secondary gain issues that may cause an employee to malinger:
- Is the case in litigation?
- Has the employee applied for Social Security benefits?
- Is the employee going through a divorce?
- Does the employee have a history of substance abuse issues?
To track injuries and keep ahead of secondary gains, Eastman Chemical
Company in Kingsport, has a strict reporting policy for all workplace
injuries, says Stephen G. Jacobson, MD, assistant medical director of
Eastman Chemical in Kingsport and medical director for Eastman's Batesville,
AR, location. "All injuries are reported to the medical department, and the
information is put into a computer database and tracked from the first day
of injury," he says. "If an injury prevents an employee from performing
normal job duties, accommodations are often made to allow the employee to
remain safely on the job. By modifying work duties, many of our employees
remain safely on the job even when injured through a combination of work
accommodation, an aggressive return-to-work program, and proactive medical
management."
The key to keeping employees moving in a forward direction is to place
the focus of treatment on function and to help employees deal emotionally
and physically with issues in their lives that may affect recovery, says
Jacobson. For example, Eastman orders appropriate medical tests early on
rather than delaying them. "If a test is clinically indicated, we order it,
rather than take a wait-and-see approach in order to save short term costs,"
he says. "Even a negative test can be very reassuring to a scared patient
and helps speed return to work."
Early tests establish reference information
Ordering tests early also can establish reference baseline information for
use in future claims, adds Jacobson. "Electromyography [EMG], for example, done
early not only helps medically define an employee's condition in order to
diagnose and treat it properly, but it also establishes a baseline for the
future. If the results are negative, and two years later the employee complains
of back pain, and a second EMG is abnormal, we have proof that the back pain is
not related to the original injury"
However, if a physician orders a test for an injured employee, case managers
should insist that the test results, negative or positive, lead to an action,
says Marshall. "There are physicians who get test results and then sit on them.
The results may be negative. Yet, if the employee still complains of pain, the
physician will prescribe another three months of bed rest.
"If expensive tests are going to be ordered, case managers should emphasize
that the results be shared honestly and completely with the employee and lead to
a specific action. Physicians can actually create a situation where a person
languishes in pain and never returns to work. Order tests in a timely manner,
but don't waste the results," Marshall stresses. "Case managers should check in
with employees to make sure they have been informed about their current status,"
he adds.
A controversial diagnosis that often keeps employees on the disability
roles for months or even years is reflex sympathetic dystrophy (RSD). RSD is
characterized by pain out of proportion to the degree of injury and
autonomic nervous system malfunction. "The first step in keeping RSD cases
from getting out of control is for the case manager to begin considering the
possibility of RSD the minute an employee complains of pain of unknown
etiology," says Marshall.
New tool helps Identify fraud
A useful new tool in the case manager's arsenal against workers'
compensation fraud is a kinematic analysis. "We can clearly identify
abnormal body movement and mechanical-based pain," explains Robert W.
Wainwright, PT, physical therapy director, president, and chief executive
officer of Kinematic Consultants in Point Pleasant, NJ. (For further
discussion of kinematic evaluation, see the related story, �Article # 2�)
"With this information, we can recommend specific therapy to correct poor
biomechanics, which is often the cause of pain symptoms. The most effective
time for a kinematic analysis is four to six weeks post injury," notes
Wainwright. "That's the time when patients with soft-tissue injuries get
into trouble. If the patient isn't responding along normal rehabilitation
guidelines at that point, case managers should consider a functional
capacity evaluation (FCE), EMG, or kinematic analysis."
The cost of kinematic analysis and FCEs is more than justified when case
managers use the information to get employees back to work, says Jackie
Margadano, CCM, vice president of claims for Berkley Risk Managers, a workers'
compensation third-party administrator in Mays Landing, NJ. "As an added
incentive to employees to not only get well but to prevent future injury, we
also offer a three-month enrollment in a fitness plan when the employee
completes the prescribed physical therapy."
When an employee complains of long-term chronic pain past the time of expected
recovery, Kahnoski often suggests that the attending physician request a panel
review. �We call in appropriate team members depending on the case and the areas
of expertise needed,� she notes. �The review might include a physical exam of
the employee or a review of the medical records, or both.�
Marshall agrees that calling in a physician�s peers is a good approach for
case managers to try. �Case managers have to approach physicians carefully, if
they want quick results,� he notes. �Physicians are an egotistical bunch. They
will rear their backs up like a cat if a case manager pushes them too hard,� he
adds. �Calling in another physician to approach them at a peer level is much
more likely to understand and accept recommendations from another physician.
They�re also more likely to act quickly on those recommendations.�
Kinematic/kinetic testing increases
accuracy of FCEs
Technology turns the subjective into the objective
Workers' compensation case managers often rely on a functional capacity
evaluation (FCE) performed by a physician, physical therapist, or occupational
therapist to assess an injured employee's impairment ratings and fitness for
work. But FCEs rely on the professional's visual estimation, or observation, of
movements that can vary greatly from one observer to another.
Kinematic analysis uses instrumentation combined with sophisticated computer
technology to turn FCEs from subjective observation to reproducible clinical
data. The data has proved successful in resolving legal battles and improving
return-to-work outcomes in worker's compensation cases, say proponents of the
method.
"We use video technology, force plates, and electromyography (EMG) to
eliminate the need for subjective opinions and to mathematically quantify an
employee's injury, or lack of injury," says Robert W. Wainwright, PT, physical
therapy director, president, and chief executive officer of Kinematic
Consultants in Pt. Pleasant, NJ. "We can do a full analysis in about 90 minutes,
compared to several hours for a traditional FCE, and the cost is comparable," he
notes, adding that traditional FCE's usually run about $500, and a kinematic
evaluation costs between $500 and $700.
The value of the kinematic system is that the employee's injury can be
documented and measured, explains Wainwright. (See sample report last page.) "We
have a reliable measure of the employee's dysfunction and whether it is
repeatable. It also helps therapists develop a care plan to correct poor body
mechanics and makes for a more targeted, faster recovery."
Case managers who regularly refer injured employees to Kinematic Consultants
agree. "Kinematic Consultants has been instrumental in resolving some difficult
old files. In one case, the kinematic evaluation saved a second surgery on a
shoulder injury. I find the evaluations are an extremely fair assessment of the
individual employee's true clinical condition," says Jackie Margadano, CCM,
assistant vice president of claims for Berkley Risk Managers, a workers'
compensation third-party administrator in Mays Landing, NJ.
How It's done
Kinematic measurement uses three-dimensional force platforms, or scales, to
measure the various forces of human motion, explains Wainwright. The system
analyzes ground reaction forces and torques around geometric coordinates of x,
y, and z axes. The information gathered is used to calculate displacements,
velocities, and forces, he notes.
EMG is a common measure of normal and abnormal electrical response in
muscles. The motion specialist uses the EMG to measure activation of skeletal
muscles in timing response, frequency analysis, fatigue, and pain response
analysis. (For more discussion on the use of EMG for workers� compensation
cases, see cover story.) Kinematic Consultants uses EMG to correlate the
findings of kinematic measurements and to provide insight into possible
neuromuscular impairments, says Wainwright.
Kinematic Consultants uses the Ariel Performance Analysis System developed by
Gideon Ariel, a scientist and two-time Olympic athlete, who developed the system
to analyze the body mechanics of athletes and to help them enhance their
athletic performance. The system merges three-dimensional data gathered from
digitized video footage from up to nine cameras with data collected from force
plates and EMG.
While other facilities nationwide currently use the system to analyze and
enhance athletic performance, Kinematic Consultants is unaware of other
facilities who use the system for workers' compensation cases, Wainwright notes.
The final product is a comprehensive measurement and description of all
movements and forces used in the performance of a work task, says Wainwright.
Reflective markers are attached to employees, and the system measures the
displacements, velocities, and forces used while the employee performs various
work tasks, he explains.
"I wish I could send every injured employee to Kinematic, but not all
employees are willing to travel to the lab, and they have the right to refuse.
In some locations, we can also have Kinematic bring in portable equipment,"
notes Margadano. The analysis they provide is so much more sophisticated in
comparison to a traditional FCE. The report makes the injury appear almost
physical to you. It actually shows the true physical state of how a person is
doing,� she says.
See also