Functional Capacity Evaluation
By Ron Smolarski, MA, CLCP, CEA, CRC, IPEC, LPC, CCM, CVE, CRV, CDEII.
As appears in The Journal of Forensic Vocational Analysis, Volume 23, Number 1, Summer 2023.
Since its inception, the functional capacity evaluation (FCE) has been a very suitable evaluation model for the rehabilitation community, specifically vocational rehabilitation counselors and vocational rehabilitation evaluators. By its own etiology and overall structure, this multi-component vocational functional test is not limited to direct service providers in rehabilitation (i.e., physiotherapists, occupational therapists), as assumed by many referral sources as well as rehabilitation literature reviews, rather it is best suited for graduate-level vocational rehabilitation practitioners.
There are several types of FCE models available for the evaluating practitioner. Some of these are used to establish functional baselines for setting therapy rehabilitation programs, some are used to assist physicians in identifying palatable restrictions for their patients prior to releasing them from care, and some models are used for determining functional losses and disrupted activities of daily living. The model that I prefer to use is the model endorsed by the National Association of Disability Evaluating Professionals, based upon the work and research conducted by Leonard Matheson, Ph.D. My evaluations only incorporate trait levels found in the U. S. Department of Labor Dictionary of Occupational Titles (DOT).
After 30 years of doing functional capacity evaluations, I have found that triangulation of multi-component evaluation functional tests with some profiling/pain indices has assisted me greatly in determining a person’s physical demand characteristic for work, work tolerances, as well as safe engagement in simulated work tasks. Some of the tests and indices I use have been very efficient in my functional evaluation goals and include hand and spinal function sorts, the evaluee’s pain evaluation, and DOT physical capacities, along with the McGill Pain Questionnaire and the Oswestry Disability Questionnaire, as well as the Functional Capacity Checklist. I will share with the reader just how my functional testing protocols are set, and which tests are used in a chronological order.
Step One: Engagement
I begin working with an evaluee by using the Hand Function Sort and Spinal Function Sort, both by Leonard N. Matheson and Mary L. Matheson. I administer these along with three other sheets: the anatomical pain figure (a figure on which the evaluee uses different color markers to indicate different types of pain) and two other sheets that list DOT physical capacities and ask the worker to indicate the degree of pain or discomfort associated with each task on a scale of 1 to 10. Then I ask evaluees to state in their own words how the discomfort affects them. After this, I ask them to complete two pain scales (the McGill Pain Questionnaire and the Oswestry Disability Questionnaire), and finally to fill out the Functional Capacity Checklist (FCC).
This initial evaluation gives me an excellent understanding of the evaluee’s problem list, and I compare my impressions to the medical diagnosis. I then discuss items on the sorts and the FCC with the evaluee if I feel the worker may be under-valuing or over-valuing his or her condition, based on the diagnosis. I listen to the responses and determine if the evaluee is over- or under-reacting based on the data they provided me and my knowledge of the disability, as well as its impact on each physical capacity worker trait factor.
At this point, the evaluee knows that the upper extremity and back sorts we have done provide me with feedback as to their effort in doing the functional capacity evaluation. I check the evaluee’s vitals at the beginning and at the end of the evaluation. I in turn know what kind of individual I am dealing with in terms of the almighty truth, and I have a clear understanding of how the disability has impacted the worker.
Step Two: Physical Testing
Then I use the Jamar Hand Grip Dynamometer to evaluate hand grip strength (3 times per hand for each of the 5 settings). I am looking here to see if the worker is giving me full effort through consistency (coefficients of variation and research-based profile across 5 handle positions). Prior to the evaluation and at the end of the evaluation, I take the individual’s blood pressure to make sure I am not working with a person who has an elevated diastolic pressure that could be detrimental to their health during testing.
Once I have determined that the diastolic pressure level is well below 115 mmHg, I perform timed upper extremity evaluations (manual dexterity, fine finger dexterity, motor coordination, tool usage) and compare the evaluee’s results to norms. I am looking for discrepancies: are the scores all over the place or are they consistent? Four of the five scores should be in line with each other, and one should be an outlier if the evaluee has displayed accurate/typical results.
After each segment (finger dexterity, manual dexterity, motor coordination, tool usage, disassembly), and after each 10-pound incremental increase to lifting, I note whether the evaluee’s pain levels are going up, going up and down, or staying the same.
I perform the lifting portion of the evaluation with the Simulated Work Environment Ability Test (SWEAT) instrument, developed by Claude Peacock, a CARF accreditation evaluator and vocational evaluator, to objectively measure the worker’s capacities related to specific work function. He designed the SWEAT to profile functions related to the DOT and physical demand characteristics (finger dexterity, manual dexterity, motor coordination, strength, reaching/ handling, pushing, and pulling, standing, balancing, endurance, feeling, crouching). Dr. McCroskey developed the norms for the SWEAT machine.
Vocational evaluators (IPEC and CVE) can meet legal criteria by assessing the relevant strength and limitations of evaluees using the SWEAT test because it interfaces directly with the job profiling and job description and the General Aptitude test battery utilized by the Department of Labor. It provides validity and reliability by measuring specifically the worker traits as defined by the U.S. Dept. of Labor federal regulations in determining disability.
I compare the SWEAT trait levels/percentage results to job titles in the United States economy that are in the DOT, which is the Department of Labor standard. The worker’s strength classification is determined by weight/force, position, and pace criteria, which indicate what the worker can be expected to do now and in the future.
The SWEAT measures isotonic lifting (contraction of muscle under resistance – for example, lifting weights from the floor to overhead at full extension) and upper extremity aptitudes. The isotonic lifting is measured within the sagittal plane, since physical measurements specific to lifting have been provided by the Department of Labor within the same classification. This measures the range of motion from 6” to 72”. The upper extremity aptitude measures are standardized to the Department of Labor and Dictionary of Occupational Titles worker traits (motor coordination, manual dexterity, and finger dexterity). These worker traits are related to real work activity. The measurement is taken using a stopwatch to see how much time an evaluee takes to complete a task in each test. The results provide the vocational evaluator with a foundation to assist in assessing vocational disability, vocational placement, and rehabilitation.
The norms are based on the general working population (adult workers ages 16-70). Various tasks have been categorized according to the levels of strength associated with them: sedentary, light, medium, heavy, and very heavy. The research backing the SWEAT derived from a sample of 337 workers from the general worker population and related to the DOT and percentages of occupations that fall within the above strength levels.
I conduct the SWEAT going from 36” to 6” and 36” to 72,” at 6” intervals (for example, 36” to 30” to 24,” etc.). I stop the evaluation when I see that the evaluee’s pain level is moving too high—99.9% of the time I eventually stop when pain increases while lifting with the upper extremities, but I try to finish the test even with increased pain. I make my decision to stop if the feedback from the evaluee is that the pain level is between 8 and 9 or if the pain increases after a steady feedback of pain level (as an example, if 4s for previous test move up to 5) because it is at this point that I determine that the worker must stop now, or I will cause harm. The previous points (pain levels 1 to about 7 or 8) provide me with a good understanding of how the worker deals with the pain. The actual physical testing portion provides me with a good understanding of whether the worker can continue working at a competitive and a sustained rate (two especially important variables).
Step Three: Review and Confirmation
After completing the physical testing, I review the medical reports and compare them to my evaluation data to determine if there are any discrepancies. I also consult with the treating physician, physiatrist or expert physician and share my findings. I also receive the physician’s agreement to my findings. During my 30 years of experience assessing functional capacity, I have found that the FCE provides me with a good, grounded knowledge of what the worker can do realistically over time, because I am basing my determinations on a particularly good sample. I follow up on clients the day after the evaluation to determine if there are any pain/discomfort issues, how they slept, and whether there has been a change in their use of pain medications.
The above methodology is based on my training with Dr. Matheson, Dr. May, Dr. Stein, Claude Peacock, M.A., Dr. McCroskey, and training through the University of Michigan Industrial Engineering Department with the 3 Dimensional Man software program that provides a safe lifting analysis. I encourage the reader to explore the literature further to learn more about this testing methodology made for vocational evaluators and counselors.
