An FCE is not an easy assessment to perform. The evaluator is assessing complex movement patterns that occur over a matter of seconds. Each task is evaluated for a brief period and then the patient’s abilities must be extrapolated to the 8-hour day. The secret to making those extrapolations accurately and performing a defensible FCE is using a system that is well-designed.
How do I unravel the secrets and find an FCE that is well-designed and evidence-based?
Features to look for…
Objectivity means that a measure is as free as possible from evaluator bias (Rothstein & Echternach, 1993). Too often objectivity is mistakenly associated exclusively with mathematical units of measurement. To be objective, measures do not have to be expressed in terms of inches, foot-pounds of force, joules, degrees, etc. Observation of movement also can be objective if a scoring system is used. Clinical judgment can never be removed from FCE - nor would you want to do so. However, Clinical judgement and be guided and standardized one can standardize so that each client receives a consistent, accurate, and unbiased evaluation.
Standardization ensures that the test is performed and scored the same way each time. The procedures for test’s administration and scoring must be documented and easily accessible. Some topics that may be covered include:
- Description of tasks
- Equipment and equipment set up
- Test administration procedures
- Standardized verbal instructions
- Systematic scoring system.
To ensure each task of the FCE is set up properly for each patient a detailed description of tasks and the set up should be followed. Procedures should be easily accessed through an online system. By including, standardized verbal instructions Scoring varies between FCE systems. Understanding and following a standardized scoring system is critical for reliability and validity of the test.
Feasibility/Practicality. A high quality, cost-effective functional assessment will make implementation practical. This includes features such as
- a comprehensive yet customizable system;
- efficient report writing;
- minimum equipment and space requirements.
Comprehensive: A well-designed FCE allows for testing all of the physical demands of work as described by the Department of Labor in the Dictionary of Occupational Titles (DOT- US Department of Labor). The client’s performance on tasks will need to be classified using the US DOL’s classification system.
Flexible: FCEs can be performed using therapist observation and scoring in a one-day, three to four-hour format. Although research indicates this is a valid scoring model, you will encounter referral sources who will insist on having a 2-day test. Rather than lose or risk alienating the referral source, a well-designed FCE may be adapted to perform 2-day testing.
Customization: While it is true that a well-designed FCE has a standardized scoring system, that does not mean it can’t be customized. In addition to the flexibility, a well-designed FCE can be customized to whatever length is needed, such as brief return to work screens or pre-hire/post-offer testing. In fact, ErgoScience encourages providers to do job-specific return to work screens and FCEs. Testing can range from a few minutes to several hours, depending on the test items selected.
Cost effective: One of the important features of an FCE is cost effectiveness. Having a user-friendly system that makes it easy for clinicians to administer and an efficient report-writing software makes implementing the service efficient and financially practical. If an FCE system require you to spend hours writing a report, this is not only, non-reimbursed time, but stress for your therapists. A well-designed FCE system should be easy to use and keep report writing to a minimum. Average report writing time with a well-designed FCE complimented with scoring and report-writing software should only take 15-20 minutes.
Safety Issues FCE carries with it certain inherent risks of injury. Patients with musculoskeletal dysfunction are lifting, carrying, pushing, pulling to their maximum abilities. They are assuming and maintain a variety of challenging positions (kneeling, squatting, crouching, reaching) and performing stressful repetitive movements (climbing, squatting, trunk rotation). The test should include methods that minimize the chance for injury and provide evidence that such precautions have occurred.
The PWPE protocol minimized injury by:
- Providing standardized instructions.
- Informing the patient that they always have a right to stop a task or the entire test.
- Not pressuring, cajoling, or encouraging the patient to continue if they really want to stop.
- Stopping the patient when the lifting technique begins to be unsafe or as soon as severe deviations identified.
- Having the patient wear a heart rate monitor throughout the test.
- Monitoring blood pressure and heart rate prior to testing.
- Taking a thorough patient history prior to testing.
- Avoiding static strengthen testing.
One ErgoScience provider shared a story about a patient who accused her of injuring him during the test by pressuring him to continues when he wanted to stop. When the provider showed the patient’s attorney the verbal instructions that were read to the patient and the consent form that the patient signed, the patient’s accusation was dropped.
Reliability refers to the consistency of a measure. If two evaluators conduct the test on the same client, will they get the same result (interrater reliability)? If the client does not change and takes the test twice, will they get the same results (intra-rater reliability)? Why is this important? Without reliability, the referral source could send the client to a different therapist and get an entirely different result. In a well-designed FCE, individual tasks of the FCE are often selected for job specific testing, the reliability of each individual task, as well as the reliability of the test as a whole, should be established by the research.
Validity refers to the accuracy of the evaluation. (Portney & Watkins, 1993). In an FCE, the validity question becomes: Can we accurately determine the level of work that an individual can perform safely? There are a variety of ways to demonstrate validity. Why is this important? Without validity, the client, therapist, referral source, and employer do not know if the test results are accurate. The APTA, the EEOC, ADAAA and the Supreme court also think reliability and validity are important in FCEs.
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