· 2020-05-19 · Table of Contents Chapter Page Chapter 1...

Functional Capacity Evaluation

The Procedure Manual

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OCCUPRO, LLC © 2020 www.occupro.net

Table of Contents

Chapter Page Chapter 1 Introduction………………………………………………………………….……1 Chapter 2 DOL Physical Demand Levels……………………………………………………4 Chapter 3 Consistency of Effort/Reliability of Pain……………………………………….10 Chapter 4 Pre Testing and Assessment Setup……………….……………………………...36 Chapter 5 Job Demands Analysis…………………………………………………………...47 Chapter 6 Musculoskeletal Testing…………………………………………………………58 Chapter 7 Upper Extremity Testing…………………………………………………………89 Chapter 8 Non-Material Handling………………………………………………………....108 Chapter 9 Occasional Material Handling………………………………………………….140 Chapter 10 Job Simulated Functional Abilities…………………………………….……….157 Chapter 11 Frequent Material Handling…………………………………………………….167 Chapter 12 Constant Material Handling…………………………………………………….180 Chapter 13 Sit – Stand – Climb….………………………………………………………….183

Chapter 14 Results and Recommendations…………………………………………………192 Chapter 15 Written Report………………………………………………………………….201 Appendix A Matheowitz age and gender norms……………………………………………..211 Appendix B Sources Cited………………………………………………………………...…216 Appendix C OccuPro Decision Charts……………………………………………………….227

OccuPro Functional Capacity Evaluation Introduction

OCCUPRO, LLC © 2020 www.occupro.net 1

Chapter 1

Introduction

Definition

Functional Capacity Evaluations (FCE’s) are performed to determine an individual’s functional abilities and limitations, in the context of safe, productive work tasks, in order to determine whether an individual has the physical abilities required to meet the physical demands of a job.1, 2

Functional Capacity Evaluations

OccuPro’s Functional Capacity Evaluation (FCE) uses a systematic process of assessing an individual's physical capacities and functional abilities. The FCE matches human performance levels to the physical demands of a specific job for a return to work FCE or to general work activity for baseline/general purpose FCE testing. The FCE is useful in determining job placement, job accommodation, or return to work after injury or illness.

OccuPro’s FCE can be used to gather objective, content valid and reliable functional levels of an individual’s capacity. Its precise data format provides information for use in various contexts. The FCE may be used:

To determine an individual's ability to safely return to work full time, part time or on modified duty

To determine if work restrictions, job modifications, or reasonable accommodations are necessary to prevent further injury and allow return to work.

To determine the extent to which impairments exist, or the degree of physical disability for compensation purposes

To predict the potential ability to perform work following acute rehabilitation or a work hardening/work conditioning program

As a baseline FCE to determine an individual’s ability or limitations in regards to disability

The functional capacity evaluation assesses the individual's flexibility, strength, balance, coordination, cardiovascular condition, lifting, carrying and push/pull abilities, positional tolerances and body mechanics. An effective return to work FCE determines whether



there is a match between the individual's functional capabilities and the physical demands of work. OccuPro’s Functional Capacity Evaluation was developed to do just that however it is also designed to determine baseline function for disability/ability purposes.

There are two types of FCE:

Baseline/General Pupose FCE -- An objective assessment of the individual's current physical abilities to perform a variety of tasks related to the physical demands of work

Job Specific FCE - An evaluation of the individual's physical abilities to function within the parameters of an identified job. The job specific FCE is based on critical physical demands of the essential functions of the job. Work simulation activities are an integral component of the evaluation.

OccuPro’s FCE testing protocol was originally designed as a “Job Specific FCE”. It was specifically developed to compare patient’s functional abilities directly to the physical demands of the job they will return to. A primary goal prior to performing any FCE is to obtain the physical demands of the job the client will be returning to or a job they previously held. This is completed in one of four ways with the best and most valid way being a Job Demands Analysis (this is discussed in detail later on). The three other ways to obtain the physical demands of the job, to compare this to the client’s functional abilities, are via a job description, through the Dictionary of Occupational Titles, or through the verbal report of the client being tested. In some situations, a combination of these four ways to collect this information may be used. Please note that the present Dictionary of Occupational Titles is an outdated reference and should be a last resort for collecting physical demands.

However, if the client being tested does not have a specific job to return to the FCE will calculate the specific Department of Labor physical demand level. This can be used for any of the following situations.

Permanent Partial Disability Rating from the physician Client is disabled and vocational placement is needed Documented functional abilities for a patient pursuing Social Security Disability

Income.

OccuPro’s FCE’s are done on an intensive one-to-one basis and range in length from 2 to 5 hours. The FCE may take place over two consecutive days if needed. All FCE’s are completed by licensed medical professionals from start to finish establishing reliability criteria.

Functional Capacity Evaluation practitioners have the unique combination of skills and abilities necessary to assess the physiological, psychophysical, and biomechanical function of the individual engaged in occupation. They also have the observational skills, training, and experience to perform complex task analysis and assessment of environmental factors affecting work performance.



There are certain general criteria that would suggest that a client is ready to have an FCE performed. These general criteria include:

Individual who has completed a course of therapy and is close to return to work. Individual who has achieved maximum medical improvement but continues to

have issues related to re-injury and return to work. Individual who needs quantification of their physical capacities for determination

of disability status. Individuals who need their function quantified prior to vocational job search

and/or return to work Individuals who require quantification of their physical function for medical legal

reasons.

FCE’s are performed in a structured and controlled environment that involves directly measuring and observing the work as he or she performs specific work and functional activities. Some of the places that an FCE can be performed at include: 3

Free standing facilities Industry (at the job site) Outpatient rehabilitation facilities Hospital rehabilitation departments

Sources Cited

1. Lechner DE, Roth D, Straaton K. Functional capacity evaluation in work disability. Work. 1991; 1: 37-47.

2. Isernhagen SJ. Work Injury Management and Prevention. Gaithsberg, Md: Aspen Publishers Inc; 1988.

3. Dahl R, Armstrong F, Ellexson M Larson B. Functional Capacity Evaluation. AOTA Consumer Info-Consumer Fact Sheets 1998

OccuPro Functional Capacity Evaluation Physical Demand Levels

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Chapter 2

Department of Labor Physical Demand Levels

Physical Demand Levels OccuPro’s Functional Capacity Evaluation breaks down a client’s ability in a couple of different ways. The primary tool to compare a client’s abilities to their job is to classify their abilities using the United States Department of Labor, Employment and Training Administrations, or the Dictionary of Occupational Titles. This tool is widely used by occupational analysts who perform job site analysis, ergonomics and functional capacity evaluations. OccuPro’s FCE classifies individual’s functional abilities using the physical demand levels. These physical demand levels take into account lifting, carrying, pushing, pulling, sitting, walking, and standing per the definitions. OccuPro’s FCE goes one step further while analyzing the other physical demands required in regard to gainful employment. This includes, grasping, pinching, fine motor coordination, gross motor coordination, walking, reaching, bending, squatting, kneeling, crawling, climbing, and balancing, as well as other non defined physical demand levels. Even though an individual may be classified within the strength rating of a heavy physical demand level does not always mean they can complete their job even if their job is classified within the heavy physical demand level. What if they need to bend constantly throughout their day? Can the client being tested perform bending activities constantly throughout their day? This is not addressed purely in the US Department of Labor Physical Demand Categories. OccuPro’s FCE testing protocol addresses this based on the percent of functional abilities as compared to the physical demands graph identified in the testing protocol. The Dictionary of Occupational Titles (DOT) was developed in response to the demand of an expanding public employment service for standardized occupational information to support job placement activities. The U.S. Employment Service recognized this need in the mid-1930's and initiated an occupational research program, utilizing analysts located in numerous field offices throughout the country, to collect the information required. The use of this information has expanded from job matching applications to various uses for employment counseling, occupational and career guidance, and labor market information services.


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In order to properly match jobs and workers, the public employment service system requires that a uniform occupational language be used in all of its local job service offices. Highly trained occupational analysts must go out and collect reliable data which is provided to job interviewers so they may systematically compare and match the specifications of employer job openings with the qualifications of applicants who are seeking jobs through its facilities. These analysts also use this information to establish the physical demands an injured client needs to achieve to return to full duty. PHYSICAL DEMANDS - STRENGTH RATING The Physical Demands Strength Rating reflects the estimated overall strength requirement of the job, expressed in terms of the letter corresponding to the particular strength rating. It represents the strength requirements which are considered to be important for average, successful work performance. The strength rating is expressed by one of five terms: Sedentary, Light, Medium, Heavy, and Very Heavy. In order to determine the overall rating, an evaluation is made of the worker's involvement in the following activities: a. Standing, Walking, Sitting

Standing - Remaining on one's feet in an upright position at a work station with-out moving about. Walking - Moving about on foot. Sitting - Remaining in a seated position.

b. Lifting, Carrying, Pushing, Pulling

Lifting - Raising or lowering an object from one level to another (includes upward pulling). Carrying - Transporting an object, usually holding it in the hands or arms, or on the shoulder. Pushing - Exerting force upon an object so that the object moves away from the force (includes slapping, striking, kicking, and treadle actions). Pulling - Exerting force upon an object so that the object moves toward the force (includes jerking). Lifting, pushing, and pulling are evaluated in terms of both intensity and duration.

Consideration is given to the weight handled, position of the worker's body, and the aid given by helpers or mechanical equipment. Carrying most often is evaluated in terms of duration, weight carried, and distance carried.

Estimating the Strength factor rating for an occupation requires the exercise of care on the part of occupational analysts in evaluating the force and physical effort a worker must exert. For instance, if the worker is in a crouching position, it may be much more difficult to push an object than if pushed at waist height. Also, if the worker is required to lift and carry constantly or push and pull objects over long distances, the worker may exert as much physical effort as is required to


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similarly move objects twice as heavy, but less frequently and/or over shorter distances.

c. Controls

Controls entail the use of one or both arms or hands (hand/arm) and/or one or both feet or legs (foot/leg) to move controls on machinery or equipment. Controls include but are not limited to buttons, knobs, pedals, levers, and cranks.

Following are descriptions of the five terms in which the Strength Factor is expressed: S-Sedentary Work - Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. L-Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible. M-Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work. H-Heavy Work - Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work. V-Very Heavy Work - Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force frequently, and/or in excess of 20 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Heavy Work. Determining the jobs Physical Demand Levels


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The primary tool in any job specific testing to determine the US Department of Labor physical demand levels is to go to the job and perform a Job Demands Analysis. This would entail analyzing all aspects of the job including the lifting, carrying, pushing and pulling. These four categories are primary categories for determining the physical demand levels. Other items will include sitting, standing, walking and foot controls. When analyzing a job, the highest vertical weight for lift and carry or the highest horizontal weight for push and pull would be used to classify a job within a physical demand level. For instance, if a job required 55 pounds of lifting, 45 pounds of carrying and 25 pounds of push/pull the job would be classified within the heavy physical demand level because of the 55-pound level. Other ways of classifying a jobs physical demand level for the purposes of functional testing include a job description, the Dictionary of Occupational Titles, or a verbal discussion with the client or employer. Determining the clients Physical Demand Level When performing Functional Capacity Evaluations one of the primary comparisons during a job specific FCE is to compare the client’s job physical demand level to the client’s physical demand level following the FCE completion. When performing a baseline FCE’s a tester should also classify a client within a physical demand level based on the lifting. This classification would occur based on the clients lifting, carrying, pushing and pulling abilities during testing. No research is available that would suggest what kind of lifting, carrying, pushing or pulling should be used however the generally accepted levels within the industry are two handed lifting from floor to waist level, two handed carrying and dynamic pushing and pulling. The previously outlined definitions may provide some insight but suggest carrying could be even carrying an object on your shoulder? There has been some discussion that floor to waist lifting is not common within work environments secondary to the onset of ergonomics. An argument can be made that would allow the lifting physical demand to go from floor to shoulder height and is more common these days. A main difference occurs with determining the clients physical demand level as compared to previously determining the jobs physical demand level. This difference is that when determining the client’s physical demand level, you are required to use the least common vertical or horizontal force exerted. Testers who classify someone within multiple categories are looked on as an FCE tester that cannot make a sound decision. For example, if a client on the other hand is able to lift 55 pounds, bilaterally carry 45 pounds and push and pull 25 horizontal force pounds they unfortunately would be placed within the medium physical demand level.


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Interviewing the Client/Worker/Patient In many instances there is no job description and even if there is a good job description the information in that job description does not provide the physical demand data to the level required in a Functional Capacity Evaluation. You may not have time also or the employer/insurance may not let you go on-site to perform an actual job analysis. The job analysis would in the end provide the highest level of data to use within your FCE but is not always feasible. In many instances an evaluator needs to ask questions of the patient to determine what the physical demands are of their job. The patient can struggle in answering these questions and the way you ask these questions is critical. You cannot ask the question like this “Do you perform bending occasionally, frequently or constantly on your job?” The answer will be “constantly” not that the patient is overexagerating, it is that they do not understand the context of the questions. Here are the ways that OccuPro suggests you ask the questions to determine what a client needs to be able to perform for full duty return to work.

1. What is the total amount of time you need to be in a sitting position to perform you job over your work shift?

2. What is the amount of time at one time you need to be able to perform sitting until you are able to change positions on your job?

3. What is the total amount of time you need to be in a standing position to perform you job over your work shift?

4. What is the amount of time at one time you need to be able to perform standing until you are able to change positions on your job?

5. What is the heaviest weight you (lift, bilateral carry, push, pull, unilateral lift, and unilateral carry) on your job? [This question is to determine their occasional material handling physical demands]

6. Do you need to lift, carry, push, or pull 100 to 499 times during your shift? [this is for frequent material handling physical demands]

a. If yes then what heights, distances and one/two handed? b. If no then no frequent or continuous material handling

7. Do you need to lift, carry, push, or pull 500 times or more during your shift? [this is for constant material handling physical demands]

a. If yes then what heights, distances and one/two handed? 8. What percentage of your shift do you need to perform (simple grasping, firm

grasping, pinching, walking, forward reaching, above shoulder reaching, bending, squatting, sustained squatting, sustained kneeling, repetitive kneeling, crawling, stair climbing, ladder climbing

a. Pinching percentage equals fine motor coordination percentage b. Above shoulder reach percentage plus forward reach percentage equals

gross motor coordination percentage c. Climbing percentage needs to be used to determine static and dynamic

balance percentage.


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OccuPro has found that asking the physical demands questions in this format greatly assists in getting as accurate as possible information from the patient when needing to interview them in regard to their job.

OccuPro Functional Capacity Evaluation Consistency of Effort/Reliability of Pain

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Chapter 3

Consistency of Effort/Reliability of Pain OccuPro’s functional capacity evaluation helps to determine if a client put forth full effort during testing and whether the pain reports the client reported during the evaluation can be used to determine their functional levels. Some FCE testing procedures use the terms validity or sincerity of effort for the patient’s effort. OccuPro’s FCE relies on the terminology of consistency of effort. Some FCE testing procedures use the term symptom magnification syndrome or even malingering to determine if a client’s effort was consistent, valid or sincere. Some FCE systems never ask the client their pain report and some FCE systems ask pain after every test but use a subjective 0-10 pain scale. OccuPro’s testing methodology has split up methods and an evaluator can use the various methods during testing to determine if a client is putting forth full effort through the consistency of effort testing and whether their pain reports are reliable pain reports through the reliability of pain measures. When testing a client during OccuPro’s 100% kinesiophysical approach FCE and the client exhibits consistent behaviors the client can be considered to have put forth full effort. If during testing a client exhibits inconsistent behaviors, they will be considered to have exhibited self limiting behaviors or have put forth sub-maximal effort. Consistency of Effort should be properly documented. During this testing procedure a client will be reporting pain levels after each test but will be using a functionally based pain scale bound in definitions at each pain level. Through testing procedures if the client’s report of pain is considered to be reliable then pain could be considered a limiting factor during a particular test. This limiting factor may be a reason the patient/client is unable to perform at a certain functional level. If their pain report is considered to be unreliable then the tester should maintain the 100% kinesiophysical approach and focus strictly on the client’s demonstrated mechanics. The decision regarding functional ability should then come down to mechanical changes and mechanical deficits.

Consistency of Effort

Consistency of Effort testing is performed throughout the FCE testing procedures. These can be classified as observational consistency of effort and researched test consistency of effort. Observational Consistency of Effort includes basic observation of the client being tested to


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determine if the things they are doing during the test make biomechanical sense. For example, if a client during range of motion testing demonstrates 90 degrees of shoulder flexion but then during functional testing exhibits full shoulder flexion this would be an observational inconsistency and may suggest some self limiting/sub-maximal behaviors during testing. This may not mean they are purposefully self-limiting and should open up an opportunity to discuss the biomechanical discrepancies with the patient/client. If they client is able to explain the inconsistency, they evaluator may choose to mark is as consistent or give the client a chance to re-perform the individual test in question. When self limiting/sub-maximal behaviors are noted the tester will attempt to do everything they can to minimize these behaviors by focusing on a kinesiophysical approach and attempting to get the client to a biomechanical/kinesiophysical end point. Observational Consistency of Effort This section of consistency of effort is based on the FCE tester’s knowledge of the diagnosis, biomechanics, and physiology and is an integral part of the overall test to determine a client’s consistency of effort. The items looked at by the FCE tester includes whether there was manual muscle testing or range of motion inconsistencies. These questions are simply answered with a yes or a no by the FCE tester.

1. Did this client demonstrate Range of Motion inconsistencies during two or more functional testing as compared to range of motion testing?

2. Did this client demonstrate muscle testing inconsistencies during two or more functional tasks as compared to manual muscle testing?


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Hand Test Consistency of Effort Hand testing consistency of effort criteria has been used in functional capacity evaluation for many years. It has been the staple of determining whether a client is putting forth full and consistent effort. It should be noted that many medical providers have used this criteria for determining if someone is valid and is putting forth consistent effort even if the diagnosis has nothing to do with the upper extremities. The procedures for OccuPro’s FCE would suggest taking into account whether that hand testing consistency of effort should only applies to diagnoses related to the upper extremities and testers should take this into account when testing a diagnosis that does not include the upper extremity and more importantly the distal upper extremity. The main tool used in hand test consistency of effort includes the coefficient of variation for grip and pinch testing. This looks at the standard deviation of the grip or pinch test and then divides that by the mean. This calculation is the coefficient of variation. A positive test or sub-maximal effort is defined as 10% in males and 12% in females. M. Robinson defined 11% or greater as being sub-maximal effort. Many other researched based cut points use the 15% level of Coefficient of Variation as the level to determine consistent or inconsistent effort. OccuPro’s FCE uses 15% or greater as their sub-maximal effort cutoff. The following tests are looked at in regard to co-efficient of variation and sub-maximal effort.

Grip Coefficient of Variation (CV) on Right Grip Coefficient of Variation (CV) on Left Five Span position 2 versus Grip Strength CV on Right Five Span position 2 versus Grip Strength CV on Left


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Key Pinch CV on Right Key Pinch CV on Left Palmar Pinch CV on Right Palmar Pinch CV on Left Tip Pinch CV on Right Tip Pinch CV on Left

More recent research has noted that the coefficient of variation and its use in determining self limiting behaviors/sub-maximal effort has some flaws especially with a client that has a diagnosed distal upper extremity weakness. The general nature of the Coefficient of Variation calculation may produce a false negative when a client has a diagnosed distal upper extremity weakness. For example, a client that has full upper extremity strength may score 100, 90, and 80 pounds when performing grip strength testing. The coefficient of variance for this spread is 11.11 which would be considered to be a consistent effort with 15 being the cut point. However, if a client presents with upper extremity weakness and just scores lower numbers because of the upper extremity weakness and for instance scores 50, 60, 70 their coefficient of variation calculation is 16.67 and this person would be classified as being inconsistent and a self limiter. As noted in this example the difference in the spread of the numbers in both examples are the same and thus with a distal upper extremity weakness we may not be able to classify the second example as being a self limiter due to the characteristics of the calculation of coefficient of variation. This challenge is handled within the software. In the Upper Extremity Testing module there is a question that asks for both the right and left upper extremity and says “Does this client present with diagnosed distal upper extremity weakness? If yes, the software does not consider a score that would come back as being above 15% due to the possibility of this being a false negative. Five span grip strength testing tests a client’s grip strength in all five positions of the Jamar hand dynamometer. This measurement should demonstrate a bell-shaped curve with the peak of the curve being at position #2 or #3. H. Stokes found that maximal effort produces a bell-shaped curve and sub-maximal effort produces a flat line curve. Further studies questioned the amount of a bell-shaped curve that would suggest full effort and, in the end, “the shape of the curve is important – the flatter the curve the more likely sub-maximal effort is occurring”. OccuPro’s FCE provides the evaluator with a visually graphed curve in the software and the evaluator then makes a decision whether there is a bell-shaped curve on the left and or the right. This is then automatically calculated into the consistency of effort criteria based on Stokes protocol Rapid grip exchange is also utilized as a measurement of hand consistency of effort. The literature suggests a strong relationship when comparing rapid grip scores to position number 2 during 5 span grip testing and a decent relationship when comparing to three trial grips. Something that is consistent throughout all literature in regarding using hand testing for consistency of effort testing is that you should never use just one test to determine if a client is inconsistent/consistent in the overall test. With this said OccuPro’s FCE looks at many consistency of effort tests and does not rely solely on one test. With 38 total consistency of


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effort tests and the clinicians ability to create their own custom consistency of effort tests and the overall consistency of effort needing to be below 70% for the test to be show segmental inconsistencies suggesting mild self limiting behaviors and below 60% for the overall test to be inconsistent and suggesting consistency of effort discrepancies and self limiting behaviors, it was determined to keep all hand testing consistency of effort testing within the testing procedures. It is not whether you should or should not use this testing it is the proper interpretation of this testing by the evaluator that is important.

Occasional Material Handling Consistency of Effort The occasional material handling consistency of effort section looks at the biomechanical differences between lifts and determines whether a client has put forth consistent effort. For instance, a client with a lumbar injury should be able to lift more weight in a power lifting position then in a full squat lifting position. The FCE looks at these differences and analyzes them. This section compares the following lifts. Is the power lifting weight greater than or equal to the squat lifting weight? Is the power lifting weight greater than or equal to the shoulder lifting weight? Is the power lifting weight greater than or equal to the overhead lifting weight? Is the power lifting weight greater than or equal to the bend/job specific weight? Is the power lifting weight greater than or equal to the unilateral lifting weight? Is two handed carrying greater than unilateral carrying?


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These are all questions asked and a sample of this page is below.

Frequent Material Handling Consistency of Effort The second set of material handling consistency of effort criteria in this section includes the FCE software taking a look at the difference between what the client was able to lift occasionally and comparing to what they were able to lift/carry/push/pull frequently. It would certainly raise some questions if the client was able to do more weight on a frequent basis during testing then what they were able to do occasionally. The software compares the following frequent to occasional weights.

Frequent Squat Lift vs. Occasional Squat Lift Frequent Power Lift vs. Occasional Squat Lift Frequent Shoulder Lift vs. Occasional Shoulder Lift Frequent Overhead lift vs. Occasional Overhead lift Frequent Bilateral Carry vs. Occasional Bilateral Carry Frequent Two Handed Carry vs. Occasional Two Handed Carry Frequent Push vs. Occasional Push Frequent Pull vs. Occasional Pull Frequent Unilateral Lift vs. Occasional Unilateral Lift


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Frequent Unilateral Carry vs. Occasional Unilateral Carry

Custom Consistency of Effort There are other consistency of effort test out on the open market. Users of OccuPro’s FCE testing method may create their own custom consistency of effort tests. We will not discuss those other tests here but below is a screen shot looking at where you can put in your own custom consistency of effort tests.


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Reliability of Pain Ratings

OccuPro’s Functional Capacity Evaluation testing protocol has been designed to help establish whether or not an individual was reliable regarding the pain ratings they self report. This is done utilizing a battery of psychometric questionnaires, the OccuPro Pain Intensity Scale, a rating of perceived exertion vs. pain report application, whether movement patterns correlated with pain and a client physiological response to pain. Observational Reliability of Pain When performing Functional Capacity Evaluations, the research supports and the American Physical Therapy Association FCE guidelines support that when a client reports increased pain there should be at least one of the following evidence-based things to occur.

1. A physiological response. This includes blood pressure and respiratory rate increase however this is challenging to check during an FCE. There is also research to support an increase in heart rate by 8 bpm within 8 to 12 seconds after the pain stimulus. It should be noted that this research has some flaws which includes the researchers not being sure if the increase in heart rate was due to the pain stimulus or the anticipation of the pain stimulus in an experimental setting

2. A mechanical change. It is common that if a client reports that they have an increase in pain we should be able to observe a change in the mechanics at that joint or area where the pain has increased

3. A pain behavior. The research is pretty straight forward with this one. If a client reports increased pain, we should be able to see a pain behavior associated with this increase in pain. The pain behavior could be facial grimacing, verbal expressions, wincing, holding


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of the body part, change in body posturing, mechanical change and to the extreme crying and sweating. The research also states that a client is able to fake pain behaviors, but the research also supports that evaluators are able to determine whether a pain behavior is a true pain behavior or a faked pain behavior.

Following each functional test, the evaluator should ask the following question. Did the client report an increase in pain symptoms as compared to the previous functional test?

- If the answer is no, then the tester can move on to the next test. - If the answer is yes, then one of the following three things need to occur for the pain

repot to be a reliable pain report o Client exhibited an increase in heart rate by 8 bpm within 8 to 12 seconds of the

increase in pain report o Client exhibits a true pain behavior o Client exhibits an associated mechanical change or deficit at the joint or area with

increased pain.

Further observational reliability of pain occurs during objective functional testing and using the OccuPro functional pain scale. This would include whether or not the client follows the valid and reliable functional pain scale used by OccuPro. The question the evaluator needs to ask is whether the client had three or more instances where their pain report did not match up to the definitions on the pain scale even after questioning their pain and re-showing them the pain scale? OccuPro Functional Pain Scale OccuPro has developed a pain scale based on a widely used functionally based pain scale in which the 0-10 Lickert pain levels have been defined to better describe pain as it relates to an individual’s function. Since a traditional pain scale is highly subjective and performing Functional Capacity Evaluations is always of concern regarding subjective pain reports, a functional pain scale will help to increase the objectivity of a client’s pain reports and will focus a client’s pain towards how it affects their function. The functional pain scale as well helps to assist in determining a client stopping point during functional testing. You will notice that a four on the pain scale definitions states “Pain that


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begins to cause limits in your present functional abilities”. This would be a level in which the client could be considered to be functional but that the pain may be starting to affect their functionality. Then, “You are unable to complete the current activity due to this pain” is part of the definition for a pain rating of a 5 on the 0-10 scale. This level would suggest that the client is unable to complete the functional testing you are performing and may suggest a need to stop the individual test and record the level that they are able to perform functionally. If the pain scale is used correctly and the patient understands the defined levels, you should rarely have patients tell you that they are a 6 or greater. This pain scale should be presented to every patient you are testing, and the patient should become very familiar with the definitions of each pain level. If during testing their pain levels and the definitions do not correlate, then the scale should be reintroduced to the client and they should be asked to make sure that they pain they reported matches the definition.

Waddell Signs and Reliability of Pain Waddell Signs consist of a standardized assessment of non-organic physical signs for low back disorders. The testing consists of five non-organic physical signs of behavior and is combined to show the client’s response. Gordon Waddell developed this standardized assessment of physical signs to determine inappropriate responses to physical examination.


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The original purpose was to assist in clinical assessment to determine organic and non-organic physical signs, identify illness behavior, and reduce unnecessary medical procedures, diagnostic testing and or therapy. This testing was not originally developed for clinical use to identify malingerers or exaggerators. However, it may provide clinical information of behavioral responses of appropriate or inappropriate signs that are elicited by the client. The research on Waddell Signs shows some significant concern regarding the inter-rater reliability of performing Waddell Signs. However, the validity of Waddell Signs in relationship to function and pain is pretty strong. Using Waddell testing, within OccuPro’s FCE, is meant to assist with the overall reliability of pain determination when you are testing a client with a low back disorder. OccuPro has implemented the use of Waddell signs to provide the evaluator with a glimpse of the client’s behavior and movement patterns. It should be noted that if you use Waddell signs as a test to help determine if this clients pain reports are reliable or unreliable that Waddell Signs should be one of the last reliability of pain tests you use secondary to some of the inter-rater reliability questions with this test. There are five tests that the evaluator must perform and note whether the client presents with a positive or negative response. It is considered a positive Waddell sign if three or more of these signs are positive which may suggest the client does not present with a straightforward medical condition, when referring to low back diagnoses. SUPERFICIAL TENDERNESS: This test is performed with light touch to the lumbar region. Typically, tenderness is localized, and physical back pain does not make the skin tender to light touch. The client is prone with his or her head straight down in the table headpiece, and the arms straight down and relaxed. The evaluator should ask: "Is that painful?" This test is considered positive if the client reports excessive pain to touch, over a wide area not consistent with dermatome patterns, or excessive reaction to the light touch. Any response except a definite "no" is positive for impairment; "Just a little bit" is a positive response, according to Waddell. SIMULATION: This test has two components:

1. Axial Loading consists of applying pressure on the top of the head while the client is in standing position. This test should not cause low back pain. It is considered positive if the client reports low back pain post this test.

2. Simulated Rotation consists of passive rotation of the shoulders and pelvis in unison. When performing this test, the structures in the back are not stressed and considered positive if the client reports low back discomfort with this test.

If either of these tests is positive, then this entire simulation test is positive. DISTRACTION:


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Distraction test is performed with the client unaware of the test being performed, must include non-painful, non-emotional, and non-surprising behaviors by the client. This may be performed in a few ways. Typically, the client is in seated position, attention distracted, and the straight leg raise is performed anytime the hip is flexed with the knee straight. Another version may be done when examining the foot with the client in seated position with one knee extended. Third variation is if the client uses the injured extremity when distracted. The client lies flat without a pillow, arms at his or her side, with hips and knees extended as fully as possible. Positive if: Sitting and supine tests are not consistent. Positive pain response when supine but no pain when sitting then this test is positive. REGIONAL DISTURBANCES: This test is performed for both sensory change and weakness of the client’s lower extremities. A positive response would consist of any numbness reported to an entire extremity, circumferential, or an entire side of the body that does not follow diagnosis or expected neurological pattern. For identifying weakness, a positive response by the client may consist with regional, sudden, or uneven weakness. The client demonstrating cogwheeling, giving away, or breakaway is a non-organic behavioral sign. OVERREACTION: This is the final test that identifies overreaction to all the tests performed. If the client presented with hypersensitivity to a specific area at one time during this testing and when tested a second time in the same location the client does not present with same response to palpation, is considered a positive response. Some overreaction signs may be disproportionate grimacing, tremoring, exaggerated verbalizations, profuse sweating, collapsing, sighing, guarding, bracing, rubbing, inconsistent on standing or changing positions, and questionable use of walking aids or assistive devices.


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COMMENTS: This section allows the evaluator to summarize the five non-organic physical signs that were tested. It should identify whether the client presented with “Waddell signs present” or “Waddell positive/negative” or “no Waddell signs present”. The evaluator should also be attentive to the client’s heart rate and reported pain level during this section of the evaluation that will provide valuable input in the client’s overall physiological responses. Psychometric Testing and Reliability of Pain The McGill Pain Questionnaire

Purpose The McGill Pain Questionnaire (MPQ) (Melzack, 1983) provides a valid, reliable, rapid and consistent way of determining a patient’s subjective pain experience. Administration The patient is provided with a form comprising instructions and 20 word groups. The patient is instructed to read each word group and decide whether there is a work in the group which describes the pain he/she is experiencing there and then. The patient should circle one word in the group, which describes their pain. If there is no word in the group, which describes their pain, they are to move on to the next group until they have completed each of the 20 groups.


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Groups 1 to 10 are words used to describe sensory experience, groups 11 to 15 are affective words, 16 is evaluative and 17 to 20 are miscellaneous groups. Scoring Each word in the group has a rank value as follows:

WORD RANK WORD RANK #1 1 #4 4 #2 2 #5 5 #3 3 #6 6

Score each word group according to the word the patient circles and write the score alongside the group number. Add categories 1 to 10 and record this next to “sensory”. Add groups 11 to 15 and recorded this next to “affective”. Write the score for group 16 next to “evaluative”. Add scores for groups 17 to 20 and write this next to “miscellaneous”. Lastly, add all four categories, i.e., groups 1 to 20, and write this next to “Total”. Interpretation A score of 30 or greater indicates poor psychodynamics. The test may also be used as an evaluative tool to assess pain before and after treatment techniques or medical procedures. It can also be useful for repeat testing in a work hardening program. The test takes approximately 5-10 minutes to complete (depending on the literacy and vocabulary of the patient) and takes approximately 3 minutes to score.


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McGill Instructions

Some of the words below describe your present pain. Circle ONLY those words that best describe it. Leave out any category that is not suitable. Use only a single word in each appropriate category – the only one that applies best. 1. 2. 3. 4. Flickering Jumping Pricking Sharp Quivering Flashing Boring Cutting Pulsing Shooting Drilling Lacerating Throbbing Stabbing Beating Lancinating Pounding 5. 6. 7. 8. Pinching Tugging Hot Tingling Pressing Pulling Burning Itchy Gnawing Wrenching Scalding Smarting Cramping Searing Stinging 9. 10. 11. 12. Dull Tender Tiring Sickening Sore Taut Exhausting Suffocating Hurting Rasping Aching Splitting Heavy 13. 14. 15. 16. Fearful Punishing Wretched Annoying Frightful Grueling Blinding Troublesome Terrifying Cruel Miserable Vicious Intense Killing Unbearable 17. 18. 19. 20. Spreading Tight Cool Nagging Radiating Numb Cold Nauseating Penetrating Drawing Freezing Agonizing Piercing Squeezing Dreadful Tearing Torturing


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The Ransford Pain Drawing

Purpose This is a useful tool to enable the patient to give the evaluator an idea of where they feel certain symptoms. This may be done in an informal way during the initial intake interview and the drawing will prompt dialogue between the two parties regarding symptoms, their frequency, and behavior and when they occurred in relation to others. Alternatively, this may be done in a formal way utilizing the Ransford Pain Drawing (Ransford, et al, 1976). The Ransford Pain Drawing is used to assess the pain and psychodynamics in a patient with low-back pain. Administration Provide the patient with a body chart comprising anterior and posterior views of the body. If the informal version is used, ask the client to indicate on the chart where they feel symptoms using a key to describe different symptoms. The evaluator may ask the client to elaborate on each symptom during the process or at the end. The client may make notes on the chart to further describe symptoms. The Ransford Pain Drawing must be done on a specific body chart with four symptoms described above, namely stabbing, burning, pins and needles, and numbness. The instructions are at the top of the chart and read as follows: “Indicate where your pain is located and what type of pain you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain which are not related to your present condition.” Ransford showed that the drawings drawn by patients in the study correlated very well with the Hypochondria’s and Hysteria scores on an MMPI (Minnesota Mulitphasic Personality Inventory) taken at the same time. Scoring


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The evaluator should observe the drawing and determine if any of the criteria listed below feature in the drawing. The appropriate score is given, and all scores are totaled at the end to reach a final score.

1. Unreal drawing (Poor anatomic localization, scores 2 unless indicated; bilateral pain not weighted unless indicated).

A. Total leg pain B. Lateral whole leg pain (trochanteric area and lateral thigh allowed) C. Circumferential thigh pain D. Bilateral anterior tibial area pain (unilateral allowed) E. Circumferential foot pain (scores 1) F. Bilateral foot pain (scores 1) G. Use of all four modalities suggested in instructions (We feel patient is unlikely to

have “burning areas”, stabbing pain, pins-and-needles and numbness all together; scores 1)

2. Drawing showing expansion or magnification of pain. (May also represent

unrelated symptomology. Bilateral pain not weighted.)

A. Back pain radiating to iliac crest, groin or anterior perineum (each scores 1; coccygeal pain allowed)

B. Anterior knee pain (scores 1) C. Anterior ankle pain (scores 1) D. Pain drawing outside the outline; this is a particularly good indication of

magnification (scores 1 or 2 depending on extent).

3. “I particularly hurt here” indicators. Some patients need to make sure the evaluator is fully aware of the extent of symptoms (each category scores 1; multiple use of each category is not weighted).

A. Add explanatory notes B. Circle painful areas C. Draw lines to demarcate painful areas D. Use arrows E. Go to excessive trouble and detail in demonstrating the pain areas (using the

symbols suggested).

4. “Look how bad I am” indicators.

A. Additional painful areas in the trunk, head, neck or upper extremities drawn in. Tendency towards total body pain (scores 1 if limited to small areas, otherwise scores 2).

Interpretation A score of 3 or above indicates poor psychodynamics.


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The test is also useful as a distraction test to observe patient behavior while sitting or standing, depending what position he/she is in when doing the drawing. This test takes approximately 5 to 8 minutes to administer and approximately 5 minutes to score.


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INSTRUCTIONS

Indicate where your pain is located and what type of pain you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain, which are not related to your present injury or condition. Key

/// Stabbing XXX Burning 000 Pins and Needles = = = Numbness


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The Oswestry Low Back Disability Questionnaire Purpose The Oswestry Low back Questionnaire (Fairbank et al, 1980) is a 10 item, self-report checklist that has been shown to be valid in assessing perceived disability. It is easy for the client to complete and easy for the evaluator to score. Administration Provide the client with the standard ten-item checklist. The client is instructed to read each of the six statements in each section and decide which statement best relates to them. They may only choose one statement in each section. The authors suggest that the form should be presented on pink paper since it is reported that patients find evaluation forms on colored paper more acceptable (Eastwood, 1940). Scoring Each section is scored for 0 to a maximum of 5 points depending on which statement is checked. If a section is not checked, the potential score of 5 is dropped from the final calculation. The first statement in each section scores 0, the second scores 1, the third 2 and so on. The scores for all answered sections are added together and divided by the total potential score, then multiplied by 100 to obtain a percentage. For Example, if only nine sections were answered, and the total score was 21 (that is 21 out of a potential 45) then the final score is 21/45 x 100 = 47%. Interpretation of Disability Scores 0% - 20% Minimal Disability (This group can cope with most living activities. Usually no treatment

is indicated a part from advice on lifting, sitting posture, physical fitness, and diet. In this group some patients have particular difficulty sitting. This may be important if their new occupation is sedentary, e.g., a typist or lorry driver.)


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20% - 40% Moderate Disability (This group experiences more pain and problems with sitting, lifting

and standing. Travel and social life are more difficult, and they may be well off work. Personal care, sexual activity, and sleeping are not grossly affected, and the back condition can usually be managed by conservative means.)

40% - 60% Severe Disability (Pain remains the main problem in this group of patients, but travel,

personal care, social life, sexual activity, and sleep are also affected. These patients require detailed investigation.)

60% - 80% Crippled (Back pain impinges on all aspects of these patient’s lives both at home and at

work and positive intervention is required.)

This test is extremely useful as a comparison of the patient’s perception compared to their

demonstrated ability. Date: _________________ Name: ________________________________ Address: _____________________ Date of Birth: _______________________ _____________________ Age: ___________ Occupation: _________________________ Hospital No. _______ How long have you had back pain? ________ Years ________ Months _______ Weeks How long have you had leg pain? _________ Years ________ Months _______ Weeks


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Please read: This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section, and mark in each section only the one box, which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box, which most closely describes your problem. Section 1 – Pain Intensity Section 3 - Standing □ I can tolerate the Pain I have without having to use □ I can stand as long as I want without extra

painkillers. □ The pain is bad, but I manage with taking painkillers □ I can stand as long as I want but it gives me extra pain. □ Painkillers give complete relief from pain. □ Pain prevents me from standing for more than 1 hour. □ Painkillers give moderate relief from pain. □ Pain prevents me from standing for more than 30 minutes. □ Painkillers give very little relief from pain. □ Pain prevents me from standing for more than 10 minutes. □ Painkillers have no effect on the pain, and I do not use □ Pain prevents me from standing at all. them. Section 2 –Personal Care (Washing, Dressing, etc.) Section 4 - Sleeping □ I can look after myself normally without causing extra pain. □ Pain does not prevent me from sleeping well □ I can look after myself normally, but it causes extra pain. □ I can sleep well only by using tablets. □ It is painful to look after myself and I am slow and careful. □ Even when I take tablets I have less than six hours sleep. □ I need some help but manage most of my personal care. □ Even when I take tablets I have less than five hours sleep. □ I need help in every day in most aspects of self-care. □ Even when I take tablets I have less than two hours sleep. □ I do not get dressed, wash with difficulty and stay in bed. □ Pain prevents me from sleeping at all. Section 5 – Lifting Section 8 –Sex Life □ I can lift heavy weights without extra pain. □ My sex life is normal and causes no extra □ I can lift heavy weights, but it gives extra pain. □ My sex life is normal but causes some pain. □ Pain prevents me from lifting heavy weights off the □ My sex life is normal, but it is very painful floor, but I can manage if they are conveniently positioned. □ Pain prevents me from lifting heavy weights if they are □ My sex life is severely restricted by pain. conveniently positioned. □ I can lift only very lightweights. □ My sex life is nearly absent because of pain. □ I cannot lift or carry anything at all. □ Pain prevents any sex life at all.


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Section 6 – Walking Section 9 – Social Life □ Pain does not prevent me from walking any distance. □ My social life is normal and gives me no extra pain. □ Pain prevents me from walking more than 1 mile. □ My social life is normal but increases the degree of pain. □ Pain prevents me from walking more that ½ mile. □ Pain has no significant effect on my social

life apart from limiting my more energetic interests, e.g. dancing, etc.

□ Pain prevents me from walking more than ¼ mile. □ Pain has restricted my social life and I do not go out as often. □ I can only walk using a stick or crutches. □ Pain has restricted my social life to my home. □ I am in bed most of the time and have to crawl to □ I have no social life because of pain. the toilet. Section 7 – Sitting Section 10- Traveling □ I can sit in any chair as long as I like. □ I can travel anywhere without extra pain. □ I can only sit in my favorite chair as long as I like. □ I can travel anywhere but it gives me extra

pain. □ Pain prevents me sitting more than 1 hour. □ Pain is bad, but I can manage journeys over

two hours. □ Pain prevents me sitting more than ½ hour. □ Pain restricts me to journeys of less than 1

hour. □ Pain prevents me sitting more than ¼ hour. □ Pain restricts me to short necessary journeys

under 30 minutes. □ Pain prevents me from sitting at all. □ Pain prevents me from traveling except to

the doctor or hospital. Comments: ___________________________________________________________________________________________


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Oswestry Neck Disability Index (NDI)

The Neck Disability Index is a revised form of the Oswestry Low Back Pain Questionnaire and is designed to measure the activities of daily living in adults with neck pain. It is useful in both clinical practice and in a research setting. Administration The Neck Disability Index is a paper and pencil exam, which takes 5 to 10 minutes to complete and approximately 5 minutes to score. Scoring Each section is scored on a five point ordinal scale. (See Oswestry scoring instruction for exact scoring mechanism.) The scores of each section are added together to achieve a total score. Interpretation A high score indicates that there is an extreme amount of functional disability caused by neck pain. Reliability In a study of 48 patients the Neck Disability Index is found to have a strong level of test-retest reliability. The correlation coefficient was computed at 0.89. The total index was found to have a high degree of internal consistency, with an alpha coefficient of 0.80. All of the individual subsets had an alpha coefficient larger that0.76 with the highest items including the sections of headaches, lifting, recreation, reading and driving. Validity Face validity was established based on feedback from a group of peers and patients. A moderate level of concurrent validity was established in a study of 48 subjects. The changes in the Neck Disability Index in pre- and post-treatment scores were compared with those of an improvement Visual Analog Scale. Reference Vernon H, Mior S. The Neck Disability Index: A study of Reliability and Validity. Journal of Manipulative and Physiological Therapeutics 1991; 14:409-415.


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Neck Disability Index Name ____________________________Date ________________ Evaluator ______________

This questionnaire has been designed to give your therapist information as to how your neck pain has affected you in your everyday life activities. Please answer each section; marking only ONE box which best describes your status today.

Section 1 – Pain Intensity □ I have no pain at the moment. □ The pain is very mild at the moment. □ The pain is moderate at the moment. □ The pain is fairly severe at the moment. □ The pain is very severe at the moment. □ The pain is the worst imaginable at the moment. Section 2 - Personal Care (Washing, dressing, etc.) □ I can look after myself normally without causing extra pain. □ I can look after myself normally, but it causes me extra pain. □ It is painful to look after myself and I am slow and careful. □ I need some help but manage most of my personal care. □ I need help every day in most aspects of self-care. □ I do not get dressed, wash with difficulty and stay in bed. Section 3 – Lifting □ I can lift heavy weights without extra pain. □ I can lift heavy weights, but it gives extra pain. □ Pain prevents me from lifting heavy weights off the floor, but I can manage if they

are conveniently positioned, for example on a table. □ Pain prevents me from lifting heavy weights, but I can manage light to medium

weights if they are conveniently positioned. □ I can lift only very lightweights. □ I cannot lift or carry anything at all. Section 4 – Reading □ I can read as much as I want to with no pain in my neck. □ I can read as much as I want to with slight pain in my neck. □ I can read as much as I want with moderate pain in my neck. □ I can’t read as much as I want because of moderate pain in my neck. □ I can hardly read at all because of severe pain in my neck. □ I cannot read at all. Section 5 - Headache □ I have no headache at all. □ I have slight headaches, which come infrequently. □ I have moderate headaches, which come infrequently. □ I have moderate headaches, which come frequently. □ I have severe headaches, which come frequently.


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□ I have headaches almost all the time. Section 6 – Concentration □ I can concentrate fully when I want to with no difficulty. □ I can concentrate fully when I want to with slight difficulty. □ I have a fair degree of difficulty in concentrating when I want to. □ I have a lot of difficulty in concentrating when I want to. □ I have a great deal of difficulty in concentrating when I want to. □ I cannot concentrate at all.

Section 7 – Work □ I can do as much as I want to. □ I can only do my usual work but no more. □ I can do most of my usual work, but no more. □ I cannot do my usual work. □ I can hardly do any work at all. □ I can’t do any work at all.

Section 8 – Driving □ I can drive my car without any neck pain. □ I can drive my car as long as I want with slight pain in my neck. □ I can drive my car as long as I want with moderate pain in my neck. □ I can’t drive my car as long as I want because of moderate pain in my neck. □ I can hardly drive at all because of severe pain in my neck. □ I can’t drive my car at all.

Section 9 – Sleeping □ I have no trouble sleeping. □ My sleep is slightly disturbed (less than 1 hour sleep loss). □ My sleep is mildly disturbed (1-2 hour sleep loss). □ My sleep is moderately disturbed (2-3 hour sleep loss). □ My sleep is greatly disturbed (3-5 hours sleep loss). □ My sleep is completely disturbed (5-7 hours sleep loss).

Section 10- Recreation □ I am able to engage in all my recreational activities with no neck pain at all. □ I am able to engage in all my recreational activities with some pain in my neck.

□ I am able to engage in most but not all of my usual recreational activities because of pain in my neck.

□ I am able to engage in a few of my usual recreational activities because of pain in my neck.

□ I can hardly do any recreational activities because of pain in my neck. □ I can’t do any recreational activities at all.

Comments: Adapted and reprinted with permission. Vernon H, Mior S. The Neck Disability Index.: A Study of Reliability and Validity. Journal of Manipulative and Physiological Therapeutics 1991; 1 4(7):409-4 15.


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Fear Avoidance Belief Questionnaire (FABQ)

Objective

The Fear-Avoidance Beliefs Questionnaire (FABQ) is a patient reported questionnaire which specifically focuses on how a patient's fear avoidance beliefs about physical activity and work may affect and contribute to their low back pain and resulting disability

With the emergence of the biopsychosocial mode of low back pain (LBP) led to the development of the Fear-Avoidance Beliefs Questionnaire (FABQ) by Waddel et al in 1993. The FABQ is a questionnaire based on the Fear-Avoidance Model of Exaggerated Pain Perception, a model created in attempts to explain why some patients with acute painful conditions can recover while other patients develop chronic pain from such conditions. The FABQ measures patients’ fear of pain and consequent avoidance of physical activity because of their fear.

Areas of assessment include; ADLs, behavior, functional mobility, general health, life participation, mental health, motivation, occupational performance, pain, personality, quality of life, self-efficacy, stress and coping.

The FABQ has been proven to be a reliable and valid assessment tool based on patients with chronic low back pain. In recent research, the FABQ is being used in populations with acute low back pain to identify the risk of long-term disability. It is also used in patients with spinal injuries, musculoskeletal conditions and chronic pain.


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Methods of Use

The questionnaire consists of 16 items in which a patient rates their agreement with each statement on a 7-point Likert scale. Where 0= completely disagree, 6=completely agree. There is a maximum score of 96. A higher score indicates more strongly held fear avoidance beliefs. There are two subscales within the FABQ; the work subscale (FABQw) with 7 questions (maximum score of 42) and the physical activity subscale (FABQpa) with 4 questions (maximum score of 24). The numbers in parentheses below designate which items from the FABQ are included in the scoring of each subscale

Subscale Questions Included Total Possible Points Unreliable Pain

FABQw 6,7,9-12, 15 42 ≥34

FABQpa 2-5 24 ≥14

The questionnaire takes approximately 10 minutes to complete.

A strong relationship exists between elevated fear avoidance beliefs and chronic disability secondary to LBP. “Avoidance may lead to reduced activity levels, an exacerbation of the fear and avoidance behaviors, prolonged disability, and adverse physical and psychological effects”. Thus, the FABQ is an outcome measure that serves as a clinically useful screening tool in identifying patients with high fear avoidance beliefs who are at risk for prolonged disability. Management of patients with elevated FABQ scores requires clinicians to tailor interventions to meet those needs. Research suggests multi-disciplinary approach including cognitive behavioral therapy and graded exposure to physical activity.


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Name: Date: / / _ mm dd yy

Here are some of the things other patients have told us about their pain. For each statement please circle the number from 0 to 6 to indicate how much physical activities such as bending, lifting, walking or driving affect or would affect your back pain.

Completely

Disagree

Unsure

Completely

Agree 1. My pain was caused by physical activity. 0 1 2 3 4 5 6

2. Physical activity makes my pain worse. 0 1 2 3 4 5 6

3. Physical activity might harm my back. 0 1 2 3 4 5 6

4. I should not do physical activities which (might) make my pain worse.

0 1 2 3 4 5 6

5. I cannot do physical activities which (might) make my pain worse.

0 1 2 3 4 5 6

The following statements are about how your normal work affects or would affect your back pain.

Completely

Disagree Unsure Completely

Agree 6. My pain was caused by my work or by an

accident at work. 0 1 2 3 4 5 6

7. My work aggravated my pain. 0 1 2 3 4 5 6

8. I have a claim for compensation for my pain.

0 1 2 3 4 5 6

9. My work is too heavy for me. 0 1 2 3 4 5 6

10. My work makes or would make my pain worse.

0 1 2 3 4 5 6

11. My work might harm by back. 0 1 2 3 4 5 6

12. I should not do my regular work with my present pain.

0 1 2 3 4 5 6

13. I cannot do my normal work with my present pain.

0 1 2 3 4 5 6

14. I cannot do my normal work until my pain is treated.

0 1 2 3 4 5 6

15. I do not think that I will be back to my normal work within 3 months.

0 1 2 3 4 5 6


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16. I do not think that I will ever be able to go back to that work.

0 1 2 3 4 5 6

Borg Rating of Perceived Exertion Formula The occasional/frequent material handling, job simulation and climbing portions of OccuPro’s FCE is a section that takes into consideration a client cardiovascular endurance. During this section the client is asked to lift weights in different positions, perform various job simulated tasks or perform repetitive climbing activities. These activities require a level of cardiovascular endurance. FCE testers can correlate a client’s heart rate to their rating of perceived exertion and use this correlation to determine if their pain reports could be considered to be reliable pain reports using Borg’s Rating of Perceived Exertion formula. The Borg Rating of Perceived Exertion scale used is as follows:

Borg CR-20 Rating of Perceived Exertion Scale

Very, Very Light Fairly Light Hard Very, Very Hard Very Light Somewhat Hard Very Hard

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

The formula utilized in this section is RPE*10-HR=. For instance, if a client has a heart rate of 125 during testing and reports a rating of perceived exertion at 12 than this would be 12*10= 120. Then subtract the heart rate of 125 and the formula calculates out to -5. This would be considered an acceptable correlation. The breakdown occurs as follows. Acceptable Correlation (-15 to +20)


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Large Negative Numbers (<-15) Poor Cardiovascular fitness Underestimating Difficulty

Moderate Positive Numbers (21-49) Mild Exaggeration of Difficulty of Task Poor Musculoskeletal fitness Good CV Fit

Large Positive Numbers (≥+50) Symptom Exaggeration

If a client reports a rating of perceived exertion at hard or 15 and their heart rate is 85 beats per minute following frequent power lifting, then the formula calculates out to 65. This would fall into large positive numbers and would suggest symptom exaggeration. Typically, in this situation the client being tested has lifted minimal weight for a few repetitions and report significant exertion without an appreciable increase in heart rate. The client can even be told that the rating of perceived exertion is not pain related and pain should not be considered in their self report. OccuPro’s FCE considers this an unreliable pain report when the clients Rating of Perceived Exertion Formula calculates out to ≥ +50. The tests that take a look at the Rating of Perceived Exertion Formula are as follows:

Frequent Squat Lift Frequent Power Lift Frequent Shoulder Lift Frequent Overhead Lift Frequent Bilateral Carry Frequent Push/Pull Frequent Unilateral Lift Frequent Unilateral Carry Job Simulated Testing Stair Climbing Ladder Climbing


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Climbing Reliability of Pain The last portion of consistency of effort criteria continues to take a look at a client’s Rating of Perceived Exertion during tests that require a level of cardiovascular endurance. The same criteria are used as discussed above. The tests that are looked at are as follows:


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Stair Climbing RPE vs. Heart Rate Ladder Climbing RPE vs. Heart Rate

Conclusion Consistency of Effort and Reliability of Pain criteria are very important and are an aspect that physicians and insurance carriers tend to weight the value of an evaluation on. There are 38 Consistency of Effort tests backed into the OccuPro FCE software and 62 Reliability of Pain baked in tests as well. Not all of these are used on every single FCE as each FCE may be different based on what an evaluator needs to perform. With 100 effort and pain tests within the OccuPro Functional Capacity Evaluation testing system, no other FCE system has this many baked in measures to determine if your client put forth full effort in the FCE and whether you can or cannot consider their pain reports when making functional return to work decisions. When calculating whether or not your client did put froth full effort the FCE software looks at the total number of effort tests performed and what percentage of them came back as being consistent. The decision on full effort, segmental inconsistencies or self-limiting behavior are as follows. Consistency of Effort


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100% to 70% “During objective functional testing this client demonstrated a

consistency of effort of _____% which would suggest the client

put forth full and consistent effort during this evaluation.”

69.9% to 60% “During objective functional testing this client demonstrated a


presented with segmental inconsistencies during this evaluation

resulting in mild self‐limiting behaviors.”

59.9% and below “During objective functional testing this client demonstrated a


presented with significant observational and evidenced based

contradictions resulting in consistency of effort discrepancies

and self‐limiting behaviors.”

Reliability of Pain measures will also be calculated throughout testing. Whether you use pain to make a functional decision or whether you disregard the pain and make your decision based on biomechanics is based on how many Reliability of Pain tests come back as reliable versus un-reliable. The calculation that occurs determines an overall percentage of the tests that were reliable versus unreliable and the decisions are as follows.

Reliability of Pain

100% to 50% “During objective functional testing this client reported reliable

pain ratings _____% of the time which would suggest that pain

could have been considered a limiting factor during testing.”

49.9% and below “During objective functional testing this client reported reliable

pain ratings _____% of the time which would suggest that this

client reported unreliable pain ratings. The functional results

obtained during this kinesiophysical test were based on the

demonstrated mechanics secondary to these unreliable pain

ratings.”

OccuPro Functional Capacity Evaluation Pre-Testing and Assessment Setup


Chapter 4

Pre Testing and Assessment Setup

Pre Testing Procedures Prior to the client walking into the clinic to have the FCE performed a couple of things need to be completed. The recognition by someone involved in a worker’s compensation case that a Functional Capacity Evaluation will benefit the rehabilitation of an injured worker should be established. This can be established in different ways.

1. The referral can come directly from the physician. 2. The treating therapist may feel that an FCE will benefit the rehabilitation process

and they may call the insurance company to see if they also feel this procedure would benefit the overall case.

3. The insurance company may directly order an FCE based on their need of this documentation.

4. The patient’s employer may ask for an FCE to be performed and they may directly pay for the service. (Most often referred to as a Fit for Duty in the United States)

5. An attorney’s office may request an FCE for return to work or disability purposes. (Make sure you are aware of the specifics of your state licensure regarding your ability to perform testing without a physician’s referral).

6. You may receive an FCE referral for a vocational rehabilitation division within your state or county

Once the need for the FCE is established the authorization of payment needs to be made with the insurance company or other form of payment. Next, the date and time of the evaluation needs to be established with the client and the medical professional performing this evaluation. First, a Job Demands Analysis should be performed. This will provide the specific physical demands of the job the client will be returning to. This will be discussed further in Chapter 5. Second, the FCE will be performed at a facility that is equipped with the proper testing equipment. Basic equipment or designed equipment is all that is needed



when performing a Functional Capacity Evaluation. To see basic equipment that is needed visit www.occupro.net/equipment

Assessment Setup This section of the Functional Capacity Evaluation consists of a number of areas which include demographics, history of present condition, past medical history, present status, medications and assessment purpose and is part of the initial interview process.

Demographics During the initial interview stages of the FCE some important information must be completed and gathered. Clients name, gender, employer, occupation and/or job title, referring physician, diagnosis, evaluator, date of birth, date of FCE, date of injury, and date of surgery or surgeries. The dates are very important as they give the evaluator the first glimpse at the time frame that some major events may have taken place during the injury to full rehab process. Multiple surgery dates are available secondary to many clients undergoing multiple surgeries during the course of treatment.

Basic Diagnostics

In this section, the evaluator will obtain vital information regarding the client. OccuPro’s FCE includes many important diagnostic factors to assist the evaluator during this test. Under the Anthropometry will include asking questions regarding the client’s height (inches), weight (pounds), and hand dominance.



Pre-Evaluation Diagnostics consists of three factors that are imperative to know prior to any testing with the client. These are their resting heart rate, resting blood pressure, and resting respiratory rate. The evaluator will need to obtain their resting heart rate, blood pressure and respiratory rate after the client has been seated for at least 10 minutes.

OccuPro’s FCE consists of having the client wear a Polar heart rate monitor during the entire evaluation. The client’s resting heart rate should be below 100 bpm after sitting for 10 minutes or longer. If the client’s heart rate is 100 bpm or greater, the evaluator will need to maintain a close monitor of the client during all testing. If the client’s blood pressure is above the guideline (listed below) and their heart rate is greater than 100 bpm, the evaluator should contact the referring physician and discontinue the evaluation. Having the client wear the heart rate monitor will assist the evaluator with always knowing the client’s heart rate and with the ease of documenting after each individual task.

The evaluator will need to take the client’s blood pressure. OccuPro uses the guidelines from the National Heart, Lung, and Blood Institute for protocol. In order to proceed with testing, the client’s blood pressure will need to be below 159/99 or lower in order to continue the testing. The client’s initial blood pressure reading should be after the client has been seated for 10 minutes. The classification of blood pressure consists of the following:

Category Systolic BP mmHg Diastolic BP mmHg Normal <120 and >80 Prehypertension 120-139 or 80-89 Hypertension, Stage 1 140-159 or 90-99 Hypertension, Stage 2 _>160 or >_100

The evaluator may utilize both arms for readings and span several readings over a 30-minute span while the client is in a seated position. Prior to discontinuing the entire evaluation, the evaluator may allow the client to relax via supine in attempt to determine if the client has anxiety or high blood pressure. If the client continues to have blood pressure above the Stage 2 guidelines, the evaluation must be terminated, and the client needs to be referred to their physician for written medical clearance. This situation will need to be documented in the evaluation results and summary of the final report. Upon receiving written medical clearance, this evaluation may be resumed on that day or another day.



The web-based software automatically calculates the limiting factors for the client such as the aerobic limit and weight limit. The aerobic limiting factor is the heart rate the client should not exceed during any physical exertion task or at any point during the evaluation. This heart rate is their sub-maximal end point heart rate at 85% of their maximum ability. This limiting factor will pop up during the testing as a reminder to maintain the client under this heart rate. If the client should exceed this heart rate, the task should be immediately stopped, allowing the client to rest, monitor heart rate and respiration. If the evaluator determines it is appropriate for the client to attempt the task again, then resume the testing procedure for that task. Do not exceed the client’s maximal heart rate heart rate more than 3 times during any task. Exceeding this heart rate limiting factor typically suggests cardiovascular de-conditioning however maybe more serious with their diagnosis or any underlying medical conditions and should not be overlooked. As you will read in this manual, the evaluator will be required to document in each task and in the overall results and summary when the client exceeds this limiting factor. OccuPro’s FCE also uses the weight limiting factor that is 60% of the client’s body weight. The weight-limiting factor is a calculation that will provide the evaluator with a safe maximum lifting weight and the evaluator should proceed with caution if the client is lifting greater than this limiting factor. This will be automatically calculated once the client’s body weight is entered. The client may exceed this, if their job requires the ability to perform above this limiting factor. The second section in the demographics area is in regard to the client’s pain report. Now that the client has his heart rate monitor on you can introduce the functional pain scale to the client. This takes a little finesse. The challenge with any FCE is do you ask, or do you not ask the person their pain. A classic 0-10 pain scale is very subjective in nature



both from the client being tested and evaluator perspective. The pain scale as noted in the last chapter is a functionally based pain scale. The client should be handed the pain scale and they should become familiar with the pain levels outlined on the definition side of the pain scale. The definition side of the card should be the side that is always asked of the client and the client should not be shown the Likert pain scale side. Following the introduction of the pain scale the evaluator should determine, “Following the presentation of the OccuPro Functional Pain Scale did this client report that they understood the pain scale? If the client reports understanding the functionally based pain scale this will be your first measure of determining if the you will be able to use the pain scale to determine functional levels later on in the test. If the client does not understand how to appropriately use the functionally based scale based on the definitions, then you may need to rely on a kinesiophysical approach in testing and disregard the pain reports. Following the presentation of the functionally based pain scale the client is asked what their present functional pain is, what their average functional pain has been over the last 1 to 2 weeks, what their worst functional pain has been over the last 1 to 2 weeks and what their least functional pain has been over the last 1 to 2 weeks. These questions offer a teaching moment opportunity. Following the clients report of their worst and average functional pain over the last two weeks or so you have the opportunity to ask what they were doing from a functional standpoint in which they experienced that functional based pain and make sure what they reported matches up with the definitions at that pain level. The following their report of their average, least, worst and present pain you determine if the client reported pain levels that were considered to be reliable. The question you the evaluator asks following this is “Following this client's report of their present, average, worst and least pain did they report a reliable level of pain prior to functional testing based on OccuPro Functional Pain Scale? If the levels they reported match the functional pain/definitions on the scale then yes, they did report a reliable level of pain. If the functional levels of pain they reported did not match up to the definitions, then their pain reports may end up being unreliable and thus you may have to perform testing based on mechanics and disregard pain.



History of Present Condition

The first section to be completed is the history of the present condition. This area should tell a story of the injury up to the date the FCE is being performed. Some of the information that needs to be gathered includes the following: What happened on the date of injury? Was this an injury or an illness? When did you seek medical attention? What did the medical professionals do? What medications were given? What recommendations were given? Was surgery performed? How was your course of treatment and was it beneficial? What diagnostic tests were performed? What type of rehabilitation programs have you participated in? Have you been back to work on full duty or modified duty since the injury? What activities were you performing at work? This information needs to be answered and written under the tab of History of Present Condition in the FCE Software.



Past Medical History The next section pertains to past medical history information that may adversely affect this evaluation. Has the client had other surgeries, broken bones, strain or sprains that may affect their performance in the test outside of the present diagnosis? Also, are there any health concerns that may affect the evaluation outside of their present diagnosis? For instance, is their history of heart problems, breathing problems, diabetes, high blood pressure or other systemic diseases? The text box under the tab Past Medical History needs to be populated with the answers to these questions.



Records Reviewed

The next tab provides the evaluator with a space to document the medical records that were reviewed prior to or during the Functional Capacity Evaluation. This may include Dr’s notes, diagnostic testing or other pertinent medical records that were provided by the referral source or the insurance carrier. It is important to make sure if you review records that you point out what was reviewed prior to or during the FCE.



Present Status

The next tab requires the evaluator to enter information in regard to the present condition of the patient following the rehabilitation or injury process. The information that needs to be gathered for the present status category includes: How does the client feel they are presently doing? What aspects of rehab have been beneficial? What daily activities have become easier or still are a challenge? What activities help any continued deficits or pain symptoms?

Are they independent in ADL's? What activities or therapeutic techniques decrease or minimize pain Does the client have a home exercise program?

The section under the Present Status tab needs to be populated with the answers to the above questions.

Medications

The medications tab is an important tab to see whether or not the client continues to take medication that is directly related to their present diagnosis and to make sure that all past medical history items have been addressed. The FCE only requires you to document the medications that would affect the client’s performance in this evaluation. The medications that should be included in this section are pain medications, anti-inflammatory medications and any other meds directly related to the diagnosis that the



client is still taking. Other meds may include high blood pressure meds or an inhaler for asthma. The following criteria should be included in the medication section. List of Medications Dosage of Medications Most Recent Dose of Medications Note if client denies being on Medication. Are Medications related to primary diagnosis? This section of the evaluation needs to be documented under the Medications tab.

Assessment Purpose/Reason for Referral

This is an integral part of all industrial rehabilitation testing. The question “Why do you need to perform this evaluation”? should be answered. There are many reasons an FCE would need to be performed as discussed earlier. But even if the FCE is for return to work or disability reasons the answer here would need to be more specific. For instance, you may need to answer what kind of job the client needs to return to or are you testing for Social Security Disability or long term disability? Following your interview of the client you need to summarize the overall reason why this evaluation is being performed.



This Assessment Setup section of the evaluation is an important section. Some FCE’s do not get into the history aspect of the diagnosis. As a medical professional it is important to see the entire picture as you are trained to treat holistically, and this section allows you to provide the most valid FCE based on the clients reports and functional needs.

OccuPro Functional Capacity Evaluation Job Demand Analysis


Chapter 5

Job Demands Analysis Having the appropriate physical demands of a job is an integral part of a job specific Functional Capacity Evaluation. Having the correct physical demands help to establish improved content validity during an FCE. Validity asks how well a test measures what it purports to measure. It is clear in the FCE literature regarding functional capacity evaluations suggests that you can enhance validity by knowing more about a client’s job and then performing some job simulated activities during the FCE1. Having defined physical demands and incorporating them into the Job demands Analysis section of an FCE helps in having a better understanding of the job and allows improved job simulation testing. Having accurate physical demands allows the comparison of the client’s functional abilities to these demands in the FCE. The most accurate route to gather the physical demands of a job is to perform an onsite job analysis in conjunction with our FCE. A second approach would be to gather an appropriate job description from the employer. A third route to gather the physical demands of the job is to get them from The Dictionary of Occupational Titles. This is a decent tool to classify occupations however; the DOT does not provide specific physical demands such as bending, squatting, reaching and grasping. This tool is also considered to be outdated. In this Functional Capacity Evaluation Procedure manual, we will focus on gathering the physical demands for the Job Demands Analysis via a patient interview, job description or the Dictionary of Occupational Titles.

Pre Job Demands Analysis The first thing that needs to occur is the recognition that a return to work Functional Capacity Evaluation needs to be performed. This service can be recognized by the treating therapist, physician, internal case management, external case management, insurance carrier, employer, or attorney. If a formal Job Demands Analysis was not performed, you will need to gather the information regarding the return to work physical demands in four other fashions. These can be combined to gather the most accurate data, or one can be used as the primary tool to gather the physical demands. Job Description



Dictionary of Occupational Titles Discussion with the employer Interview of the client

If a formal Job Demands Analysis was performed and the report was created using the stand alone Job Demands Analysis software which is used to create job descriptions then you can click the button that says “Previous Job Demand Data” (see screen shot below) .When this window opens up you can search for the primary job demands you have entered into your software. If a Job Demands Analysis was performed and the software was not used to enter the job demands in the stand-alone section of the software, then you will want to enter the information directly into your FCE in the module titled “Job Demands Analysis.

The Job Demands Analysis Within the FCE software you will see the Job Demands Analysis module within the FCE software. This is where either the physical demands will automatically be populated or where you will enter the information for the 20+ categories of physical demands outlined by the US Department of labor. If you have performed a Job Demands Analysis at a particular company, you would want to use that information to document the physical demands required for full duty return to work and compare this to the client’s abilities. You may also have gotten your information from a job description and will want to use the job description as the source of the job’s demands and compare this to the client’s abilities.



You may use the Dictionary of Occupational Titles, but this resource only handles lift, carry, push and pull and is considered an old resource. You may need to interview the client. There are certain questions you will ask when performing the gathering of the job demands through an interview of your client.

1. How many hours total do you need to be in the sitting/standing position to perform you job?

2. How many hours at once do you need to be in the sitting/standing position before you are able to change positions?

3. What is the heaviest weight you need to lift, carry, push, pull, one handed lift, and/or one-handed carry? (Occasional Material Handling)

4. Do you need to lift/carry/push/pull 100 to 499 times or more during your shift? (Frequent Material Handling)

5. Do you need to lift/carry/push/pull 500 times or more during your shift? (Continuous Material Handling)

6. What percentage of your shift do you need to perform ? (Non-Material Handling such as bend, squat, reach, grasp, etc. etc.)

Vocational Status

Current Work Status

This is a very simple section in which you will choose from a dropdown menu this client’s current work status at the time of this evaluation. Your options include:

Full Duty/Full Time Full Duty Part Time Light Duty Full Time Light Duty Part Time Off of Work

Physical Demands Obtained From

This dropdown menu will require you to choose from where you gathered the physical demands. Your options will be:

On-Site Job Demands Analysis Job Description Dictionary of Occupational Titles Verbal Discussion with the Employer Client



There is an open text for vocational status of the client. This is where the evaluator may enter how many total hours the client works, is there overtime (mandatory or voluntary and how many hours on average per week), how long the client has been employed with the company, how long has the client been working within their occupation, and previous work history that may be valued.

Sitting and Standing Sitting and standing can be documented based on hours or frequency. Within the workers compensation system, it is common that you will document sitting and standing based a frequency and use never, occasional, frequent and constant. When performing a disability FCE it is common that the disability industry would like sitting and standing documented based on the number of hours this is needed to be performed. Within the FCE software you have both options to choose from. It would be common in an FCE that sitting and standing would add up to the entire shift. For example, 4 hours of sitting, 4 hours of standing, and the client works an 8-hour shift. This is not the case all of the time. For instance, a client may perform different activities on different days. One activity on one day may require 6 hours of standing and on the next day the client’s activity may require 7 hours of sitting however, they work an 8-hour shift. This would suggest that this client’s full duty job would require them to sit for 7 hours and stand for 6 hours to perform their regular duty job. This needs to be documented in the JDA in this manner. Walking



Walking is measured in frequency per day (occasional, frequent or constant). When analyzing the amount of walking required the amount of standing needs to be taken into account. If a client is only standing 4 hours out of an 8-hour shift that is 50% of the shift. Thus, it is impossible that the patient performs continuous walking during their shift. Walking is generally one of the easiest frequencies per day classifications to determine. During an 8 hour shift the client should be observed and asked, “what percentage of your shift do you perform walking?” The percentage they report can easily be classified within occasional, frequent or constant.

Material Handling Lift, Carry, Push, Pull, Unilateral Lift/Carry These need to be documented based on the weight in pounds required to perform that activity. The various material handling activities that could be required include: Occasional-Frequent-Continuous Floor to Waist Lift Occasional-Frequent-Continuous 12 inch to Waist Lift Occasional-Frequent-Continuous Shoulder Lift Occasional-Frequent-Continuous Overhead Lift Occasional-Frequent-Continuous Unilateral Lift Job Specific Bend Lift Occasional-Frequent-Continuous Bilateral Carry Occasional-Frequent-Continuous Unilateral Carry Occasional-Frequent-Continuous Push



Occasional-Frequent-Continuous Pull The pushing and pulling weights need to be documented in horizontal force pounds. Horizontal force pounds are the amount of force required to push and pull the object that is manipulated. Horizontal force pounds are used based on the variability of objects that are pushed and pulled. The object could be a cart on good or poor casters or the pushing or pulling of a lever on a machine. The cart being pushed or pulled may have up to 1000 pounds in it. The employee however is not exerting a force of 1000 pounds to move a cart that has good casters. The cart may require 100 horizontal force pounds to manipulate that cart. How are horizontal force pounds measured? Horizontal force pounds should be measured using a force gauge. A force gauge will provide the amount of force required getting an object moving and if that object needs to be moved a certain distance then the force gauge will provide the amount of force required to maintain the momentum of the movement. The higher quality force gauges of today have numerous attachments that will help you attach the force gauge to the object that needs analysis. Many employers continue to document the amount of actual weight in a cart for instance that needs to be pushed i.e. the 1000 pounds. When performing the write up portion of this JDA you would want to mention that the horizontal force pounds that were measured calculates out to the amount of weight in the cart.



Positional Tolerances Squatting, Bending, Kneeling and Crawling These categories are more challenging to establish if the activity is performed occasionally, frequently or constantly during a shift. The best way to analyze these activities is through direct observation of the job at hand through a formal on-site Job Demands Analysis. In an interview process the easiest way to determine whether these activities are performed on an occasional, frequent, or constant basis is to ask the client, “What percentage of your shift would you say you are required at most to perform the following activities”? The client will provide you with an estimate and as the evaluator you need to verify based on your understanding of that job that yes, I agree with the clients estimate.



Climbing Stairs, Ladders and climbing

Stair climbing and ladder climbing also get entered based on whether the client is required to perform this on their job on an occasional, frequent, or constant basis. Again, the best way to determine this if you do not have a formal on-site JDA or ask the client what percentage of their shift do they feel at most they would need to perform stair climbing, climbing onto other items/objects or ladder climbing.

Static Balance and Dynamic Balance Static and dynamic balance also get entered based on whether the client is required to perform this on their job on an occasional, frequent, or constant basis. Again, the best way to determine this if you do not have a formal JDA nor a job description is to ask the client what percentage of their shift they feel at most they would need to perform this balancing.



Upper Extremity Reaching above and below shoulder

Below and above shoulder reaching are two areas that require the evaluator to document whether the client needs to perform these activities on an occasional, frequent or constant basis while at work. If interviewing the client to gather this information you again would ask what percentage of their shift at most do, they perform this.

Fine Motor and Gross Motor coordination Fine and gross motor coordination are two areas that require the evaluator to document whether the client needs to perform these activities on an occasional, frequent or constant basis while at work. If interviewing the client to gather this information you again would ask what percentage of their shift at most do, they perform this.

Simple Grasp, Firm Grasp and Pinch These three areas require the evaluator to document whether the client needs to perform these activities on an occasional, frequent or constant basis while at work. If interviewing the client to gather this information you again would ask what percentage of their shift at most do, they perform this.



Job Simulation

This section allows you to determine a job simulation activity that you may test for and provides an area to document whether the activity you will create is required to be performed on an occasional, frequent or continuous basis during the course of a shift.



Sources Cited

1. Howe C. T. Validity is an important component in work capacity evaluations. Advance for Directors in Rehabilitation. 2000; 63.

2. JIST Works. The revised handbook for analyzing jobs. JIST Publishing, Inc. 1991.

OccuPro Functional Capacity Evaluation Musculoskeletal Testing


Chapter 6

Musculoskeletal Testing

Posture Posture testing includes checking a client’s overall posture and making some comments in regard to the clients overall poster based on objective documentation.

Palpation

Palpation testing includes any abnormality noticed upon palpating the client’s musculoskeletal system. Document objectively in regard to the items founds while palpating.



Reflexes Reflex testing may be performed on any part of the body based on the clients need and diagnosis to determine normal reflexes.

Principles of Inclinometry and Spine Motion Measurement



Since spinal motion is compound, it is essential to measure simultaneously motion of both the upper and lower extremes of the spine region being examined. Because the small joints of the spine do not lend themselves readily to two-arm goniometric measurements and measuring a spine segment’s mobility is confounded by motion above and below the assessed points, an inclinometer is the preferred device for obtaining accurate, reproducible measurements in a simple, practical, and inexpensive way. The subcutaneous bony structures that mark the upper and lower ends of the three spine regions can be palpated readily. Inclinometers, also called angle finders or level indicators, are small angle-measuring devices traditionally used by carpenters, mechanics, and trades people. Recently, physicians, therapists, and veterinarians have used them to measure angles and ranges of motion in humans and animals. Inclinometers work like a plumb line, operating on the principle of gravity, which is a constant. An inclinometer used by a physician should be marked off in 2° increments or less and in good operating condition. A mechanical inclinometer has a starting or 0° position indicated by a weighted needle or pendulum. A fluid level can cause errors in reading the meniscus. A fluid-filled inclinometer should allow rotation of its inclinometer face so any number on the face can be set as the initial position. Electronic inclinometers use gravity sensors to determine an angle from the vertical, and then perform internal calculations. Features of a properly designed inclinometer for medical use include a dial large enough to allow easy reading of 2° increments but small enough to enable application on the spine and all joints of the body; features to enable repeated, accurate application and stabilization of the instrument on the body; and a dial that can both display the 0° gravity position when the body part cannot be placed in a 0° gravity or neutral position. The following principles, discussed in greater detail by Mayer, 17 Gerhardt et al, 20, 21 and in forthcoming AMA educational material, are important to follow to obtain accurate measurements. Gravitational plane An inclinometer works only in the vertical position because only that plane allows the pointer or sensor to move freely in response to gravity. An inclinometer will not operate properly if tilted or at all when horizontal. Therefore, the individual being examined must be in a position that permits motion of the part being tested in a vertical plane. For spinal measurements in the sagittal and frontal (coronal) planes the individual should be standing or sitting, with the spine vertical. Measurements in the transverse or axial plane must be made with the individual in the supine, prone, or flexed hip position. Measure spinal ROM in three principal planes: sagittal (extension-flexion), frontal or coronal, and transverse or axial (rotation). If a spinal region has two or more impaired motions, the ratings for each range of motion impairment are added. Impairments of two or more regions of the spine are combined using the Combined Values Chart. Stabilization



If the caudad (superior), or lower, part of a spine region can be stabilized so it does not move when the superior, or upper, part moves, a single mechanical inclinometer may be used, as with measuring cervical rotation. However, two inclinometers are usually needed to measure most movements of the spine. Single electronic inclinometers use microprocessors to duplicate functions of mechanical inclinometers. Their use will not be described in detail here as information is available from the manufacturer. The user should ensure that the features described above are addressed. Manual pressure during use The inclinometer should be held so it remains firmly applied to the subcutaneous skeletal structure while the spine is moving through the entire range of motion. It must not deviate from the original position because of skin movement or uneven pressure on the skin overlying the bony landmark, which might occur with an obese individual. The inclinometer design is important to allow proper prominences. Firm contact of two points of the instrument with the structure is essential, especially if a convex surface such as the sacrum or calvarium (top of the head) is involved.

Ankylosis and Motion with Ankylosis Ankylosis is defined as the complete absence of joint motion and is expressed as a fixed position. In the spine, which has multiple motion segments in each region with vertebrae moving together and separately, complete absence of regional motion is rare. For spine impairment evaluation only, when an individual cannot reach the neutral (0°) position, the position or angle of restriction closest to neutral is considered the position of ankylosis or end restricted movement. If the individual has end-restricted movement, this value, taken as the ankylosis value, is used to determine impairment instead of the ROM. If the motion crossed the neutral position in any plane, the examiner should use the abnormal motion section of the appropriate table to determine the impairment for that plane. In determining ankylosis impairments, the examiner should add the ankylosis impairments in several planes within a single region or combine the ankylosis impairments of two or more regions. If a spinal region has several range-of-motion impairments and an ankylosis impairment, the ROM impairments are added, and the total is combined with the ankylosis impairment. Impairments of two or more regions are always combined.

Cervical Range of Motion

When assessing the cervical spine for range of motion, the evaluator may use the goniometric method or the dual inclinometric method which both measure in degrees. The evaluator should assess the following motions of the cervical spine: flexion, extension, lateral flexion (right and left) and rotation (right and left). This would consist of AROM only, not PROM. The cervical spine should be assessed for functional



abilities/limitations and document any inconsistencies observed. For example, the client presented with significant decreased ability to perform lateral rotation however was observed turning their head when called. Inclinometric method

Flexion and Extension Two-Inclinometer Technique 1. Provide information to the individual about the procedure and allow for

appropriate warm-up exercises. 2. Locate and place a horizontal skin mark over the T1 spinous process. With the

individual seated, place the first inclinometer, aligned in the sagittal plane, over the T1 spinous process. Place the second inclinometer at the side of the face, from the corner of the eye to the ear, along a parallel line where the temple of eyeglasses would sit (Figure 15-15a). From this position, set the inclinometer to 0. This represents the 0° true neutral position. Move the second inclinometer to the calvarium and set the head to the neutral position in both the sagittal and frontal planes, where the inclinometer again reads 0 (Figure 15-15a).

3. Ask the individual to flex maximally and record both angles. Subtract the T1 angle from the calvarium angle to obtain the cervical flexion angle (Figure 15-15b) and record it. Return the head to the neutral position so both inclinometers read 0° again.

4. Instruct the individual to extend the neck as far as possible, keeping the chin close to the sternum, again recording both inclinometer angles. Subtract the T1 angle from the calvarium angle to obtain the cervical extension angle (Figure 15-15c). Ask the individual to return the head to the neutral position.

5. Repeat the procedure three times. The cervical flexion and extension angles should be consistently measured within 5° or 10%, whichever is greater. The impairment reading is based on the greatest angle of a valid set of three consecutive measurements.

6. Using the largest valid cervical flexion and extension measurements, obtain the whole person impairment rating for cervical flexion and extension using Table 15-12.

7. Add the cervical flexion and extension impairment ratings and combine the sum with any ratings for diagnostic criteria (Table 15-7) and/or neural impairment.

Ankylosis 1. Note whether there is motion of the cervical spine in the sagittal plane or

plane or whether the spine is unable either to flex or extend beyond the neutral point. Determine if the ankylosis or restricted motion is in flexion or extension. If some motion is possible in the sagittal plane, ask the individual to hold the position closest to the neutral point.

2. Place the inclinometer’s base against a vertical surface to set the inclinometer to the neutral 0 position. Then place it at the side of the face, from the corner



of the eye to the ear, along a parallel line where eyeglass temples would lie (Figure 15-15b). Move the inclinometer to the calvarium and set the head to the neutral position in both the sagittal and frontal planes, where the inclinometer again reads 0 (Figure 15-15b).

3. Place the second inclinometer at T1 and record the angle. Subtract or add the T1 angle from the first-read angle to obtain the angle of ankylosis in either flexion or extension.

4. Add the impairment percent for left rotation and right rotation. Their sum is the whole person impairment contributed by abnormal rotation of the cervical region.

Figure 15-15 Two-Inclinometer Technique for Measuring Cervical Flexion and Extension

Lateral Bending Two-Inclinometer Technique 1. Provide information to the individual about the procedure and allow for

appropriate warm-up exercises 2. Place a skin mark over the T1 spinous process. With the individual in the

seated position, place the first inclinometer aligned in the coronal plane over the T1 spinous process while holding the second inclinometer over the calvarium (Figure 15-16a). The head should be in the neutral position while the inclinometers are set at 0°.

3. Ask the individual to tilt the head maximally to the left and record both angles (Figure 15-16b). Subtract the T1 angle from the calvarium angle to determine the degrees of left lateral bending. Return the head to the neutral position.

4. Instruct the individual to tilt the head maximally to the right as far as possible, recording both inclinometer angles. Subtract the T1 angle from the calvarium angle to determine cervical right lateral bending (Figure 15-16c).

5. Repeat the above procedure at least three times. The angles measured should be within 5° or 10% of the mean of the three measurements, whichever is greater. The measurement used for impairment rating is the greatest angle of a valid set of three consecutive measurements.



Add the impairment percent from left lateral bending and right lateral bending. Their sum represents the whole person impairment related to abnormal lateral bending of the cervical region. Ankylosis 1. Place both inclinometer bases against a desk or tabletop and adjust until they

read 0°, or the neutral position. 2. Place one inclinometer in the frontal plane at T1 (Figure 15-16b) and the

second inclinometer over the calvarium. 3. Determine whether the individual has cervical lateral motion or is unable to

attain the neutral position. If there is motion and the individual cannot reach the neutral position, read the angle closest to neutral 0. This is the angle of ankylosis used for rating (Figure 15-16b).

Figure 15-16: Two-Inclinometer Technique for Measuring Cervical Lateral Flexion

Cervical Rotation Because the technique for cervical evaluation stabilizes the trunk in the supine position, with the shoulders on the table, only one inclinometer is required for measurement of rotation.

1. Provide information to the individual about the procedure and allow for appropriate warm-up exercises. Set the inclinometer to 0° or the gravity position.

2. Have the individual lie supine on a flat exam table with shoulders exposed to permit observation of any truncal (thoracolumbar) rotation. Stand at the head of the table and place the inclinometer in the transverse plane with the base applied to the forehead (Figure 15-17a). Record the neutral 0° position with the individual’s nose pointing to the ceiling.



3. Ask the individual to rotate the head maximally to the left and record the cervical left rotation angle.

4. Ask the individual to rotate the head maximally to the right and record the cervical right rotation angle (Figure 15-17b).

5. Repeat the procedure three to six times to obtain a valid set of three consecutive measurements. The left and right cervical rotation angles should be within 5° or 10% of the mean of a valid set, whichever is greater. The impairment rating is based on the greatest angle of a valid set.

Ankylosis

1. Determine whether the individual has cervical axial motion and is unable to attain the neutral position. If the individual has some motion, ask him or her to maintain the position closest to neutral and record the ankylosis angle closest to neutral (Figure 15-17).

2. Place the inclinometer on the calvarium with the cervical region in the ankylosis position and record the ankylosis angle.

Figure 15-17: Measuring Cervical Rotation



Thoracic Range of Motion

Inclinometric Method Flexion and Extension



Thoracic flexion and extension are relatively limited motions. The amount of extension is determined mainly by the individual’s posture and the degree of fixed kyphosis or curvature of the thoracic spine. To determine the ranges of motion of this region, the individual is measured in the military brace posture to obtain the angle of extension or minimum kyphosis. Then, with the individual fully flexing the thoracic spine, the flexion angle is determined. The angle of minimum kyphosis is actually a measure of ankylosis, and impairment resulting from deformity corresponding to this angle… Two-Inclinometer Technique 1. Provide information to the individual and allow for the appropriate warm-up

exercises. Measurements are obtained with the individual standing or sitting. 2. Locate and place horizontal skin marks over the T1 and T12 spinous

processes. Place both inclinometers, which do not show gravity 0 automatically against a true vertical surface, such as a wall, and set the neutral 0° positions. Place the inclinometers over the T1 and T12 spinous processes while instructing the individual to maintain the maximally extended military brace posture position (Figures 15-11a and 15-11c). Subtract the T12 inclinometer reading from the T1 inclinometer reading (if both are inclined in the same direction from the vertical) to obtain the angle of minimum kyphosis. If T12 and T1 are inclined in opposite directions from the vertical, add the angles. Find the impairment percent in the Ankylosis part of table 15-10.

3. Set the inclinometers to 0° with the individual standing in the erect military brace posture. Then ask the individual to fully flex the thoracic spine. Flexing at the hips is permitted. Subtract the T12 inclinometer reading from the T1 reading obtained in step 1 above to obtain the angle of thoracic flexion (15-11b and 15-11d).

4. Repeat either the sitting or the standing test up to six times to obtain three measurements within 5° of the mean or 10%, whichever is greater.

5. A reproducibility test is done after a positional change, having the standing individual sit or vice versa. If the initial measurements were made standing, seat the individual on a stool, record the neutral 0° position, and ask him or her to flex the thoracic spine maximally from the military brace position. The thoracic flexion sitting angle should be nearly identical to the flexion angle obtained in the erect position.



Figure 15-11: Two-Inclinometer Technique for Measuring Angles of Minimum Kyphosis and Thoracic Flexion

Ankylosis The angle of minimum kyphosis of the thoracic spine may be considered equal to the angle of ankylosis. Excessive kyphosis or thoracic lordosis is evaluated as impairment according to Table 15-10. Rotation Two-Inclinometer Technique 1. Provide information to the individual about the procedure and allow for

appropriate warm-up exercises. 2. The individual should be seated or standing, whichever is more comfortable,

and in a forward flexed position, with the thoracic spine in as horizontal a position as can be achieved (Figure 15-12a). Locate and place horizontal skin marks over the T1 and T12 spinous processes. The trunk should be in the neutral position for rotation. The inclinometers are set to 0 by placement against a flat, horizontal table or floor if they do not automatically indicate gravity 0°. Place the first inclinometer aligned vertically in the transverse (axial) plane over the T1 spinous process while holding the second over the T12 spinous process.

3. Ask the individual to rotate the trunk maximally to the left and record both angles (Figure 15-12b). Subtract the T12 angle from the T1 angle to obtain the thoracic left rotation angle. Return the trunk to the neutral position (Figure 15-12a).

4. Instruct the individual to rotate the trunk maximally to the right, again recording both inclinometer angles; subtract the T12 angle from the T1 angle to obtain the thoracic right rotation angle.



5. Repeat the procedure three to six times per side to obtain a valid set of three consecutive measurements. The angles of a valid set should be within 5° or 10% of the mean of the set, whichever is greater. The final impairment percent is based on the best (least impairing) angle measured.

Figure 15-12: Two-Inclinometer Technique for Measuring Left Thoracic Rotation

Lumbar Range of Motion

When assessing the client’s lumbar range of motion and determining overall percentages of motion, the evaluator will need to look at the following motions: lumbar flexion, extension, lateral flexion (right and left), and trunk rotation (right and left). When



performing dual inclinometric lumbar range of motion the evaluator will not be able to perform rotation as the lumbar spine does not rotate. Rotation comes from the thoracic spine. There are input boxes to put the amount of percentage the client demonstrates range of motion or the range of motion at the spine. For example: trunk range of motion is assessed in percentage from 0 (no forward flexion at the hip joint) to 100% (full forward flexion with fingers touching the floor or the client’s toes). When the client demonstrates the decreased lumbar flexion, the evaluator will need to determine hamstring tightness (may assess 90/90 hamstring length or perform straight leg test). This may assist with the diagnosis and consistent to subjective report by the client. If the client presents with a decrease spinal motion, the evaluator will need to identify any compensatory techniques/compensations utilized and observe for physical pain behaviors. Inclinometric method Flexion and Extension Two-Inclinometer Technique

1. Provide information about the test and allow warm-up within pain tolerance. Warm-up exercises are done as tolerated by the individual, based on physician judgment.

2. The individual should be standing with knees extended and weight balanced on both feet, ideally with hands on hips for support to permit greater motion. The spine should be in the neutral position while the inclinometers are set at 0° (See Figure 15-8a). Locate and place horizontal skin marks over the T12 spinous process and the sacrum. Center the first inclinometer aligned in the sagittal plane, over the mark for the T12 spinous process. Center the second inclinometer over the sacral horizontal mark. It is generally best to place the sacral mark at the midpoint of the posterior superior iliac spine because if the mark is place too high on the sacral convexity, the inclinometer may be displaced during extension. Be certain of the bony landmarks.

3. Instruct the individual to flex the trunk as far as possible (Figure 15-8b), again recording both inclinometer angles and subtracting the sacral (hip) from the T12 inclinometer angle to obtain true lumbar flexion angle. Ask the individual to return the trunk to the neutral position.

4. Ask the individual to extend maximally while holding the inclinometers firmly, and record both angles (Figure 15-8c). Subtract the sacral (hip) inclination from the T12 inclinometer angle to obtain the true lumbar extension angle. Return the trunk to the neutral position (verify that the inclinometers are still at 0°).

5. Repeat the procedure at least three times and at most six times for flexion and extension to obtain a valid measurement set (three consecutive, reproducible measurements). Only the true lumbar spine flexion and extension angles need to be consistently measured within 5° if the average is less that 50°, or within 10° if the average is greater than 50°. The impairment is based on the maximum true extension and flexion angles from within the three measurements. The average of the three is only used to determine consistency.



6. An accessory validity test can be performed for lumbosacral flexion and extension. In this test, record the straight-leg-raising angle of the supine individual by placing an inclinometer on each tibial crest with the knees extended and the hip flexed (Figure 15-8d). Compare the straight-leg-raising angle to the sum of the sacral flexion and extension (sacral or hip motion) angles (Figures 15-9a and 15-9c). If the straight-leg-raising angle exceeds the sum of sacral flexion and extension angles by more than 15°, the lumbosacral flexion test is invalid. Normally, the straight-leg-raising angle is about the same as the sum of the sacral flexion-extension angle. If the individual resists passive SLR without other evidence of radiculopathy, the accessory test is also invalid. If invalid, the examiner should either repeat the flexion-extension test or disallow impairment for lumbosacral spine flexion and extension. Tightest SLR – (sacral flexion + sacral extension) ≤ 15° for validity (assumes sacral flexion and extension are less than normal). Note: This accessory validity test is useful only when sacral flexion plus extension is less that the average for normal individuals (i.e., 65° for women and 55° for men). At these levels or above, the difference between sacral motion and supine straight leg raising will usually exceed 15° because the hamstring and gluteal muscles are contracted in the standing flexed position and relaxed in the supine position. However, below the threshold of 65° for women and 55° for men, the tightest supine straight-leg-raising angle should not be more than 15° greater that the combined sacral (hip) flexion and extension angle in the standing position. Figure 15-8: Two-Inclinometer Technique for Measuring Lumbar flexion and Extension



Ankylosis Ankylosis in the lumbosacral spine is rare. It is important mainly if immobility occurs in both the hips and lumbar spine, so the neutral position cannot be attained in the sagittal plane. Isolated fusion of either a hip or two or more lumbar vertebrae places larger stresses on adjacent segments but does not lead to mechanical failure of the lumbosacral region. Ankylosis impairments related to fusion of the hip or part of the hip motion complex should be evaluated on abnormal motion of the lumbosacral region. Lateral Bending (Flexion): Two-Inclinometer Technique 1. Provide information to the individual about the procedure and allow for the

appropriate warm-up exercises. 2. With the individual standing erect with knees extended, locate and place

horizontal skin marks over the T12 spinous process and the sacrum. Verify with the inclinometer that the skin marks are truly horizontal; do not rely solely on visual assessment. Place the first inclinometer aligned in the frontal (coronal) plane over the T12 spinous process and hold the second over the sacrum (Figure 15-9a). The trunk should be in the neutral position while the inclinometers show gravity at 0°.

3. Instruct the individual to bend the trunk laterally to the left and record both angles. Subtract the sacral (hip) inclination angle from the T12 inclination angle to determine the lumbar left lateral angle. Ask the individual to return to the neutral position.

4. Instruct the individual to bend the trunk to the right as far as possible (Figure 15-9b), again recording both inclinometer angles and subtracting the sacral (hip) angle from the T12 inclinometer angle to obtain the lumbar right lateral bending angle. Ask the individual to return to the neutral position.

5. Repeat the procedure at least three times per side. To be valid, three of six consecutive measurements must lie within 5° or 10% of the mean, whichever is greater. The impairment estimate is based on the highest (least impairing) angle of a valid set. The mean is used only for a test of reproducibility.

With measurements for left and right lateral bending and any ankylosis, use Table 15-9 to determine the whole person impairment. Add the impairments within the lumbar region. If other regions are impaired, the lumbar impairment should be combined with the other region impairment. Figure 15-9 Two-Inclinometer Technique for Measuring Lumbosacral Lateral Bend\



Ankylosis Ankylosis in lumbar spine lateral bending (flexion) is generally associated with a scoliosis and usually produces only limited impairment. Mark the T12 and spinous process and sacrum and ask the individual to stand in the most erect position possible that corrects the deformity. Using measurements made in the frontal (coronal) plane, subtract the sacral (hip) inclination from the T12 inclination and record the ankylosis angle or the angle of restriction (closest to the 0° neutral position).



Spine Comments Spine comments provides a text box to summarize your findings during cervical, lumbar and thoracic range of motion testing.



Manual Muscle Testing

Manual Muscle Testing for the lower extremities and the upper extremities is required during this portion of the evaluation. This is an important component to the orthopedic exam of the client. The following is the grading scale on how muscle strength is measured. Grade 5 Normal Client can hold the position against maximum resistance and through the full

range of motion. Grade 4 Good Client can hold the position against gravity and full range of motion with

moderate resistance

Grade 4- Good minus Client can hold the position against gravity through full range of motion with less than moderate resistance

Grade 3+ Fair plus Client can move through full range of motion against gravity takes minimal resistance and then breaks

Grade 3 Fair Client can move through full range of motion against gravity with no resistance

Grade 3- Fair minus Client moves less than full range of motion against gravity

Grade 2+ Poor plus Client moves through full range of motion on a gravity-eliminated plane, takes minimal resistance and then breaks

Grade 2 Poor Client moves through full range of motion on a gravity-eliminated plane with no added resistance

Grade 2- Poor minus Client moves less than full range of motion on a gravity-eliminated plane

Grade 1 Trace Tension is palpated in the muscle on the tendon, but no motion occurs at the joint in the gravity-eliminated plane

Grade 0 Zero No tension or contractile activity is palpated in the muscle or the tendon in the gravity-eliminated plane

Below are some basic principles for muscle testing:

1. Stabilizing the joint proximal to the joint being tested. 2. Place the joint in the test position instructing the client to “hold” when pressure is

applied. 3. Apply resistance near the distal region or where the muscle insertion is. 4. Grade the muscle on the numeric scale of 0 to 5. 5. Observe any compensatory strategies and record reported pain.

Lower Extremity Range of Motion and Manual Muscle Testing

When assessing the lower extremities, the client may be supine or seated. In the comments, the evaluator may note the position of the client during the testing or for a particular movement pattern. The evaluator should assess all muscles affected by the area of injury or diagnosis. The evaluator will need to determine what muscle groups are necessary to be tested and should compare the affected extremity to the unaffected extremity in order to determine limitations.



Special tests may consist of the following: Fabers test, Scour test, Seated compression/distraction test, Lachman’s test, Valgus/Varus test, PCL test, anterior drawer test, or any other tests that may apply.

Upper Extremity Range of Motion and Manual Muscle Testing

The evaluator may need to assess the upper extremities via range of motion and muscle testing. When looking at the following, the evaluator will need to identify AROM and if needed to identify PROM noting insufficient range of motion in the joint. The evaluator will need to perform manual muscle testing for the AROM tested with. This section will focus on the distal upper extremity for shoulder, elbow, and forearm. Again, the evaluator may want to perform special tests that may consist of the following: Speed’s bicep test, Empty can test, Varus/Valgus Stress Test, Tennis elbow and Golfer’s elbow tests, Elbow collateral/lateral ligament The following section will include the hand.



Comments

After the evaluator has completed the entire musculoskeletal evaluation, they will need to input the finding of abilities or deficits in the text box under “comments”. The evaluator will also need to input the client’s post heart rate and reported post pain level after this section has been completed. Any special tests the need to be performed should be documented in this section.



Hand Range of Motion and Manual Muscle Testing

Under Upper Extremity Testing, the “more” tab lies the testing for hand range of motion and manual muscle testing. Since the hand is more complicated, this was designed for more specific measurements involving the hand. The evaluator may need to test all areas of the hand, bilaterally, depending on the client’s diagnosis. This will consist of AROM, PROM and strength testing. Before assessing the client’s hand range of motion, it maybe beneficial to comment on their skin condition. This may consist of the client’s skin color, any ecchymosis observed, and or texture of their skin. The evaluator may perform special tests pertinent to the client’s diagnosis. Listed below are just a few that may have to be written in manually if needed to test: Intrinsic/extrinsic tightness: Bunnel-Litter test for intrinsic tightness, Tinel’s sign at wrist, Inflation test: inflate the sphygmomanometer cuff around the forearm- release of pressure results in persistence of “pins and needles” sensation for 5-10 seconds, Phalens and Reverse Phalens, and DeQuervains test. The hand section separates each digit to allow for specific AROM and MMT. There is a specific hand section comment to list areas of deficit and abilities.



Orthotics In orthotics, the evaluator is to describe what types of orthotics or any assistive device the client may currently use. The open text box is where the evaluator may explain the time of day any orthotics/assistive device is being used. It would be imperative as well to note



if the client is using any orthotics at the time of the evaluation or if the client removes or stops using the orthotics or assistive device. For example, if the client uses a straight leg cane when walking in and during the evaluation, the client discontinues the use of the cane, the evaluator must make note of this change and evaluate the need for the cane. This may be done by testing the client in walking with the cane and then perform the same test without the cane and show the comparative value in the open text box for the walking test.

Circumferential/Volumetric Measurements

The evaluator will need to determine if taking edema measurements is important to the client and the diagnosis. The evaluator has the option of performing this in two ways, circumferential or volumetric measurement. Circumferential measurements are to be measured both pre-evaluation and post-evaluation for right and left region/extremity. The evaluator must click in the radial button for the type of measurement chosen. The open text box to where the evaluator will list the joint line, landmark of joint area, or distal and proximal region/area with specific measurements. For example, 10 cm distal to elbow joint line, 15 cm proximal of patella, or ankle figure 8.

Volumetric Measurement is mainly used for determining the amount of edema in the distal upper extremity. This is to be measured both pre and post evaluation. There are specific instructions the client should be given prior to proceeding with this testing procedure. The evaluator must fill the entire volumeter up to the top of the spout so there is no water dripping out of the spout. Note: water temperature should be at room temperature. The client should be instructed to slowly insert their upper extremity, so the



bar is resting between digits 3 and 4 to MCP. The client must not bounce, proceed rapidly, or insert their extremity farther than the bar. The evaluator will collect all the water dispersed out of the spout, measure the amount of milliliters dispensed, and repeat the process to the other extremity. Then the amount dispersed should be compared to the client’s unaffected extremity as well as performed post-evaluation. After the volumetric measurement has been performed both pre and post evaluation, the evaluator will need to comment on the presence or lack of edema present.

Sensation

OccuPro’s FCE has a comprehensive area for assessing sensibility. The specific test or tests used for the assessment is up to the clinician’s discretion regarding the client’s diagnosis. Testing sensation may be performed in a few different ways, which are described below. It is imperative to determine any loss of sensation prior to material handling testing, for safety concerns, which will help in determining functional limitations. This will also assist with areas of deficit that are relevant to the client’s diagnosis. If sensation is tested, the evaluator should continue to assess the client’s sensory abilities throughout the evaluation via testing fine motor coordination and gross motor coordination.

Two Point Discrimination

One way is performing static two-point discrimination. This is performed by using an aesthesiometer or disk, while the client’s vision is occluded, in order to assess deficits.



- Testing is begun with using 5mm distance between the two points. This is performed for the phalanges, as these are the most important surfaces to discriminate sensation.

- One or two points of the test instruments are randomly applied in a longitudinal orientation perpendicular to the skin just to the point of blanching.

- The client is required to state “one” or “two” depending upon how many points they feel touch their skin.

- Seven out of 10 responses must be accurate for scoring at a given distance of millimeters

o Less than 6mm = Normal/Intact About 3mm for the distal phalanx About 4 to 5mm for the middle phalanx About 6 for the proximal phalanx

o 6 to 15mm = Impaired (fair or poor sensation) o One point to no points perceived throughout = absent

Once the evaluator has tested the affected areas and has determined any deficits, these will need to be inputted in the table provided. The table allows the evaluator to specify volar/dorsal, right/left, and to each specific area of the hand. Upon determining any deficits, the evaluator may perform other sensation tests and will then provide the overall assessment results under the “comment” tab.

Sharp/Dull Awareness



A second form of testing for sensation is performing Sharp/Dull Awareness. This is performed in order to determine the extent of the client’s sensation loss. The evaluator is first to explain to the client that they may feel a “sharp-pain” sensation or “dull-pressure feeling”. The evaluator will proceed with the following:

- Client’s vision is occluded - Randomly apply the sharp or blunt end of safety pin, perpendicular to client’s skin

at constant pressure - Client responds with “sharp” or “dull” after each stimulus - This should be performed for both sharp and dull in each test area - Number of correct responses our of number of stimuli

100% equals Normal/Intact 1% -99% equals impaired 0% equals absent

Once the evaluator has determined areas of intact or impaired, the “Comment” tab will be the place to summarize the findings for Sharp/Dull Awareness as well as any other sensation test performed. The following criteria should be included in the comment section: observed pain behaviors, client subjective comments during testing, reported pain rating (on scale 0-10), and overall deficits.

Self Report

This is where the evaluator may ask the client where their sensation impairment is, loss of sensation, hypersensitivity and any other abnormal sensations reported by the client. The evaluator should also inquire about time of day sensation appears or diminishes, location on their body, and the type of quality (numbness, tingling, sharp, shooting, etc.), duration



(intermittent or constant), and present symptoms. This section may include the specific area pertaining to their diagnosis or another part of the body.

Two-Point/Sharp Dull Sensation Comments This is an open text box to summarize all the sensation testing into a formalize statement on area(s) of deficit. The evaluator will need to have inputting the necessary comments for an overall understanding of this testing section in the final report. The information that needs to be included may consist of the following: reported discomfort/pain level, physical pain behaviors, and palpation responses (withdrawal responses, reported pain to tenderness, etc.). If no formal sensation testing is performed, then the evaluator will leave these areas blank.

Semmes Weinstein Monofilament Testing

This formal test is for determining protective loss of sensation. Prior to performing this evaluation, demonstrate the test and the equipment with the client.

o To administer the test, the client’s hand is fully supported on the table and vision is occluded (can use blindfold, client turns head, or use a paper as a divider).

o The client is instructed to say, “touch” when recognizing being touched by the particular filament.

o The filament should be applied systematically for a few reasons: to maintain even pressure applied, logically determining area of sensation of intact or absent.



o Testing is usually begun with the monofilament marked 2.83 since this is represented as “normal” sensitivity except for the plantar surface.

o The examiner applies a selected monofilament perpendicularly to the skin in the center of a selected test zone until it bows

o Do not allow the side of the filament to come in contact with the skin being tested.

o The filaments marked 1.65 through 4.08 are applied 3 times to a spot for a test stimulus.

o Filaments marked 4.17 through 6.65 are applied once to the skin for a test stimulus

o The filament is applied to the skin for 1 to 1.5 seconds and removed without a bouncing effect.

o A positive or negative response is marked in the corresponding zone on the grid worksheet using the colored pencils.

o A filament must be perceived on two out of three applications in a test zone for a positive result

o Testing proceeds with progressively thicker filaments until a positive response has been achieved in each segment.

Code Level Filaments

Green Normal Light Touch 2.36 – 2.83 Blue Diminished Light Touch 3.22 – 3.61 Purple Diminished Protective Sensation 3.84 – 4.31 Red Loss of Protective Sensation 4.65 – 6.64 Red Lined Unresponsive/Untestable above 6.65

Green: D 2.83 refers to Normal Sensitivity for the client is able to discriminate between both light touch and deep pressure sensations.

Blue: F 3.61 refers to Diminished light touch noting possible signs of loss of sensitivity- the client may not be aware of this change and may lead to early detection.

Purple: J 4.31 refers to Diminished Protective Sensation and indicates the client has absence of texture discrimination noting a loss of sensitivity. This client may have impaired temperature discrimination as well.

Red: S: 6.64 refers to Loss of Protective Sensation when the client does not respond to any filament less than 4.31 but does notice the filaments between 4.65 and 6.64. This client may only have rudimentary deep cutaneous peripheral nerve response.

Red Lined: T6.65 Unresponsive/Untestable is when the client does not respond to any of the filaments.

Comment Section



After testing Semmes-Weinstein, the evaluator will be able to comment on the findings in the text box under the test. This will allow the evaluator to document specific findings or client subjective comments.

Lower Extremity Sensation

For lower extremity testing, there is an open text box to comment in at the evaluator’s discretion. The evaluator may test any of the formal testing of sensation for the lower extremities as needed. The testing procedures and protocols remain the same. Please refer to each individual test. If a specific test is performed, such as Semmes Weinstein, the evaluator will need to input all areas tested (or comment on the impaired or absent areas) due to no grid or input boxes in this section.



There are numerous areas that need to be considered when performing the musculoskeletal testing with each client. Prior to performing each individual body part or the spinal segments the evaluator will need to consider the client’s diagnosis and why the client is having the evaluation performed. The evaluator will need to assess the client’s Active and Passive Range of Motion in regards to the upper and lower extremities and then proceed to assessing the client’s strength in the same regions. The evaluator should use goniometry for the extremities and can use either goniometry or inclinometric measurements for the degree of motion for the spinal region. If performing a disability rating or if the results you obtain in regards to spinal range of motion will be used for disability then dual inclinometric measurements should be used based of the Guide to Evaluation of Permanent Impairment, Fifth Edition. Please note that much of the following sections were taken directly from the Guide to Evaluation of Permanent Impairment, Fifth Edition. This publication was highly referenced secondary to its international use for evaluating permanent impairment. This section is only a portion of what is available in the Guide to Permanent Impairment and if further study is needed on this topic the Guide should be purchased. In states were therapists are able to make impairment ratings then the guide should be purchased and referenced often. Please note that the Online Assessment Application does not provide the tester with impairment ratings but does provide the evaluator with all of the measurements needed for them or a physician to determine what the impairment rating is based off of the range of motion numbers gathered.



Sources Cited

Daniels, L., & Worthingham, C. (1986). Muscle testing: Techniques of manual examination (5th ed.). Philadelphia: W. B. Saunders. Cocchiarella, L. and Anderson, G. (2001). Guides to the Evaluation of Permanent Impairment (5th ed.). American Medical Association. Bell, J.A. Sensibility Evaluation. In Rehabilitation of the Hand. Hunter, Schneider, Mackin, & Bell (Eds): Mosby, 1978. Bell, J.A. Semmes-Weinstein monofilament testing for determining cutaneous light touch/deep pressure sensation. The Star, November/December, 1984. 44(2). Bell-Krotoski, J. (1990). Light touch-deep pressure testing with Semmes-Weinstein monofilaments. In J. Hunter, L. Schneider, E. Mackin, & A Callahan (Eds.), Rehabilitation of the hand (3rd ed., pp.585-593). St. Louis: C. V. Mosby. Callahan, A. (1990). Sensibility testing: Clinical methods. In J. Hunter, L. Schneider, E. Mackin, & A. Callahan (Eds.), Rehabilitation of the hand (3rd ed., pp. 594-610). St. Louis: C. V. Mosby. Joy R Karges, Beth E Mark, S Jill Stikeleather, and Teddy W Worrell. Physical Therapy Volume 83 ꞏ Number 2 ꞏ February 2003. Moberg, E. (1990). Two-point discrimination test. A valuable part of hand surgical rehabilitation, e.g. in tetraplegia. Scandinavian Journal of Rehabilitation Medicine, 22, 127-134. National Heart, Blood, and Lung Institute. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). NIH Publication No. 03-5231 www.nhlbi.nih.gov. Pendleton, K. (1981). OT management of physical dysfunction. Loma Linda University. Brookfield, IL: Sammons.

OccuPro Functional Capacity Evaluation Upper Extremity Testing


Chapter 7

Upper Extremity Testing

HAND STRENGTH Hand strength is an activity that each and every client must have to complete the tasks needed throughout their daily life, work and throughout this test. Numerous tests throughout this evaluation require the client to have functional hand strength. Without functional hand strength, the client would struggle with all of the material handling tests. Simple and firm grasping needs to be observed during this test and correlated to the results of formal grip and pinch strength testing. A client’s hand strength is measured using a standard hand and pinch strength dynamometer and the results are compared to Mathiowetz age and gender norms. The Functional Capacity Evaluation allows for documentation of the clients grip and pinch numbers, the norms and ranges per the Mathiowetz age and gender norms are automatically populated within the software, and the coefficient of variation between the three trials is calculated. *Please note that in functional testing per, the Americans with Disabilities Act, comparing someone’s ability to norms CANNOT be used to determine if someone can or cannot perform a job. In OccuPro’s FCE we use Matheowitz age and gender norms to assist in determining if someone can perform grasping and pinching on an occasional, frequent or constant basis. We also use the other functional tests performed during testing to make our overall decision.

Grip Testing Grip Strength Grip strength is assessed using the hand strength dynamometer- Jamar, and three separate tests are performed on both the right and left upper extremity. The highest score noted in these tests are used to help determine a client’s abilities. Typically, when performing this testing the mean or average grip strength is compared to the Mathiowetz age and gender norms and more importantly the ranges. The goal of grip strength is for the client to be within the Mathiowetz age and gender ranges that are provided in appendix A and in the grip strength tables in the FCE software. Being within these ranges would suggest that the client has the ability to perform simple work-related grasping activities on a constant basis during an average work shift and firm grasping on an occasional to frequent basis. However, the mean will not be the route in which these levels are determined from. It will be the highest score from position two of the dynamometer based on the three separate tests performed. If the physical demands of the job require firm grasping frequently to constantly during an average shift, then the clients grip strength ability achieved in any of the three tests would need to



exceed Mathiowetz’s age and gender mean. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a grip strength test and you will hold the grip strength dynamometer at your side with your elbow at 90 degrees.” “Please squeeze the dynamometer as hard as you can.” “You will be performing three separate tests on each hand and we will then determine your maximum grasping strength.” After each test, you will document right and left next to trial 1, 2, and 3. Throughout testing the peak grasping strength will be compared to the range and mean per the Mathiowetz age and gender norms. These are gathered from appendix A in the procedure manual or within the software. The comparison of the client’s highest score from three trial grips, five span grip position 2 or rapid grip exchange to the range and mean will establish whether the client can perform occasional, frequent, or constant firm and simple grasping throughout an average shift. The next item is the consistency of effort criteria! The coefficient of variation between each trial should be calculated and reported on. If the coefficient of variation is greater than or equal to 15% then the three-trial grip test is considered to be inconsistent. Secondly, the software will calculate the clients grip strength and compare it to the second position on five span grip strength testing. This will help to establish a client’s consistency of effort between multiple tests in that the client needs to perform within 15% of each other for a consistent test. If the coefficient of variation between the three-trial grip strength and the second position during 5 span grip strength testing is greater than or equal to 15% then the test is considered to be inconsistent.



Five Span Grip Strength Testing Five span grip strength testing helps to establish consistency of effort and whether the client put forth full effort during three trial grip strength testing. The clients grip strength is tested in all five positions on the grip strength dynamometer starting in the first position or the position where the handle is closest to the bar. The client should be instructed that they will only get one opportunity to exert full effort with each hand in each position and that they need to put forth their fullest effort. The client should be instructed, “The next test you will perform is called the five span grip strength test and what I would like you to do is again squeeze the dynamometer as hard as you can.” We are going to place the dynamometer into the five different positions starting in this first position.” “You will first start on the right and then we will place the dynamometer into your left hand and again you will squeeze as hard as you can.” We will continue until all five positions have been tested.” Following each trial, the scores should be documented. The results of this test are to produce a bell shaped or modified bell-shaped curve. If one of these is not obtained, then this clients grip testing will be considered to be inconsistent.

The above graph demonstrates a bell-shaped curve on the right and left. The OccuPro software will calculate whether a bell-shaped curve is achieved based on the research performed by Stokes in 1983. Much research has been done since this time that does not support Stokes findings in regard to Five Span Grip Strength Testing. OccuPro’s FCE allows a modified to flattened bell shaped curve which allows a consistent test. A non-bell-shaped curve would suggest the client was inconsistent in regard to their effort.



Rapid Exchange Grip Strength Test Rapid exchange grip strength testing helps to establish consistency of effort and whether the client put forth full effort during grip strength testing. The handle of the dynamometer should first be placed in the 2nd position. The evaluator holds the dynamometer with one hand grabbing at the back of the dial and the other hand supporting the bottom. The client is asked to sit with both arms at their side and their elbows at 90 degrees. The dynamometer should then be placed into one of the hands and the client should be instructed to squeeze with maximum effort for a split second. After the split second, the dynamometer is removed from the first hand and placed instantly into the second hand. The dynamometer should then be moved back and forth between the two hands for split seconds and up to 8 grips per hand. The entire test should take no more than 8 – 9 seconds. The evaluator should monitor the dynamometer gauge throughout testing and determine the client’s peak forces for both hands between repetition 5 and repetition 8. The first four repetitions should be disregarded in regard to the numerical values achieved. These peak forces should then be compared to the peck force during three trial grip testing and position number two during five span testing. The client should be instructed, “The next test you will perform is the rapid exchange grip strength test and what I would like you to do is again squeeze the dynamometer as hard as you can but now each squeeze will be a fraction of a second and I will alternate between both of your hands 8 times.” “ Please sit with your elbows at 90 degrees and both of your hands ready to accept the dynamometer” “I will first start on your right, you will squeeze for less than a second, and then we will place the dynamometer into your left hand and again you will squeeze as hard as you can for less than a second.” “We will continue until we have reached 8 trials on each hand”. The peak scores noted on the right and left between repetition 5 through repetition 8 should then be compared to the three trials on the right and left during three trial grip strength testing and position number 2 during 5 span grip testing. If either of these peaks was greater than any of the three trials on that same side than that would suggest inconsistency.



The most important part of this test is to determine if the client can perform simple and firm grasping on an occasional, frequent, or constant basis throughout an average day. Both simple and firm grasping needs to be determined based on their abilities when performing three trial grip strength, five span grip strength and rapid exchange grip testing. The following table is provided to assist in this determination, but it should be recognized that there is no cookie cutter answer. The hints provided under the occasional, frequent, and constant columns would suggest that the client is at that level regarding their functional abilities. To achieve occasional, frequent or constant a claimant needs to pass each box within a column for you to place them at that functional return to work level. To document the level of avoid the client needs to demonstrate a zero in regard to grasping and/or pinching strength.



Pinch Testing Key/Lateral Pinch Strength Key or Lateral pinch strength is assessed using the pinch strength dynamometer and three separate tests are performed on both the right and left upper extremity. The highest demonstrated ability during pinch testing is then used to calculate the client’s lateral pinch strength abilities and used as a comparison to the Matheowitz age and gender norms. The goal of lateral pinch strength is for the client to be within the Matheowitz age and gender ranges that are provided in appendix A or in the table provided in the software. Being within these ranges would suggest that the client has the ability to perform simple work-related pinching activities on a constant basis during an average work shift. If the physical demands of the job require firm pinching frequently too constantly during an average shift, then an ergonomic consultation needs to be performed secondary to the likelihood of ergonomic related risk factors. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a pinching test and you will hold the pinch strength dynamometer with your arm at your side with your elbow at 90 degrees.” “Please squeeze the pinch dynamometer as hard as you can in a fashion in which you would be holding a key.” “You will



be performing three separate tests on each hand and we will then look for your maximum pinch strength from each trial.” After each test, you will document the right and left pinch strength abilities next to trial 1, 2, and 3. The comparison of the client’s maximum pinch strength to the range and mean will establish whether the client can perform occasional, frequent, or constant pinching throughout an average shift. The next item is the consistency of effort criteria! The coefficient of variation between each trial is calculated. If the average percent difference is greater than or equal to 15% then the test is considered to be inconsistent. Palmar Pinch Strength Palmar pinch strength (three jaw chuck/three point pinch) is assessed using the pinch strength dynamometer and three separate tests are performed on both the right and left upper extremity. The highest score of these three tests are then used to calculate the client’s palmar pinch strength abilities and then used as a comparison to the Matheowitz age and gender norms. The goal of palmar pinch strength is for the client to be within the Matheowitz age and gender ranges that are provided in appendix A or in the software. Being within these ranges would suggest that the client has the ability to perform simple work related palmar pinching activities on a constant basis during an average work shift. If the physical demands of the job require firm pinching frequently too constantly during an average shift, then an ergonomic consultation needs to be performed secondary to the likelihood of ergonomic related risk factors. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a pinching test and you will hold the pinch strength dynamometer with your arm at your side and your elbow at 90 degrees.” “Please squeeze the dynamometer as hard as you can in a fashion in which you would be pinching using your pointer and middle finger and pinching with your thumb.” “You will be performing three separate tests on each hand and we will then calculate your maximum palmar pinch strength.” After each test, you will document the right and left palmar pinch ability next to trial 1, 2, and 3. The results of the highest pinch would then be compared to the range and mean per the Matheowitz age and gender norms. These are gathered from appendix A or in the software. The comparison of the client’s maximum palmar pinch strength will be compared to the range and mean which will help to establish whether the client can perform palmar pinching on an occasional, frequent, or constant basis throughout an average shift. Tip Pinch Strength Tip pinch strength is assessed using the pinch strength dynamometer and three separate tests are performed on both the right and left upper extremity. The highest achieved score is used to calculate the client’s tip pinch strength abilities and then used as a comparison to the Matheowitz age and gender norms. The goal of tip pinch strength is for the client to be within the Matheowitz age and gender ranges that are provided in appendix A or within the software. Being within these ranges would suggest that the client has the ability to perform simple work-related tip pinching activities on a constant basis during an average work shift. If the physical demands of the job require firm pinching frequently too constantly during an average shift, then an ergonomic



consultation needs to be performed secondary to the likelihood of ergonomic related risk factors. The testing position is demonstrated in the picture to the right. The client is instructed “The next test is a pinching test and you will hold the pinch strength dynamometer with your arm at your side with your elbow at 90 degrees.” “Please squeeze the dynamometer as hard as you can in a fashion in with your index finger on top and your thumb on the bottom.” “You will be performing three separate tests on each hand and we will then calculate your maximum tip pinch strength.” After each test, you will document the right and left tip pinch results next to trial 1, 2, and 3. The highest achieved pinch strength is then compared to the Matheowitz age and gender norms. The comparison of the client’s highest level compared to the range and mean will help to establish whether the client can perform occasional, frequent, or constant simple pinching throughout an average shift. The next item is the consistency of effort criteria! If the coefficient of variation is greater than or equal to 15% then the test is considered to be inconsistent.



Fine Motor Coordination Fine motor coordination may be used in a variety of occupations and employment settings. This may consist of using or manipulating small electrical wires, small mechanical parts/objects, hand tools, or manipulating various objects. Assessing fine motor coordination and finger dexterity may be demonstrated in 2 different standardized tests. Ultimately any fine motor test can be used as long as it is research based and has some type of scoring mechanism. Secondly, if a job requires pinching then the job also requires fine motor coordination. If the client has a sensation deficit, these tests will assist in determining the client’s functional limitations and may be able to correlate to the client’s sensation limitations. Purdue Pegboard The standard test used for coordinational testing is the Purdue Pegboard however; many of the standardized coordinational tests can be used to supplement the Purdue Pegboard. When performing the Purdue Pegboard test the subject should be comfortably seated at the testing table directly in front of the Purdue Pegboard. The far right and far left cups should have 25 pins in each to equal a total of 50 pins. For right-handed subjects, the cup to the right of center should have 20 collars and the cup to the left of center should have 40 washers. If the subject is left-handed, the collar and washer locations should be on the reverse side of center. The following directions are for single subject testing.



4 TESTS: “This is a test to see how quickly and accurately you can work with your hands. Before you begin each battery of the test, you will be told what to do and then you will have an opportunity to practice. Be sure you understand exactly what to do.” Right Hand (30 seconds) Begin by saying and demonstrating: “Pick up one pin at a time with your right hand from the right-handed cup. Starting with the top hole, place each pin in the right-hand row. Now you may insert a few pins for practice. If during the testing time you drop a pin, do not stop to pick it up. Simply continue by picking another pin out of the cup.” “Stop. Now take out the practice pins and put them back into the right-hand cup”. “When I say ‘Begin,’ place as many pins as possible in the right-hand row, starting with the top hole. Work as rapidly as you can until I say ‘Stop.’” “Are you ready? Begin.” At the end of the exactly 30 seconds, say: “Stop.” Left Hand (30 seconds) “Pick up one pin at a time with your left hand from the left-handed cup. Starting with the top hole, place each pin in the left-hand row. Now you may insert a few pins for practice.” Same as above for the right hand. Both Hands (30 seconds) “For this part of the test, you will use both hands at the same time. Pick up a pin from the right-hand cup with your right hand, and at the same time pick up a pin from the left-hand cup with your left hand. Then place the pins down the rows. Begin with the top hole of both rows. (Demonstrate. Then replaced the pins used for demonstration.) Now you may insert a few pins with both hands for practice”. “Stop. Take out the practice pins and put them back in the proper cups.” Then say: “When I say ‘Begin,’ place as many pins as possible with both hands, starting with the top hole of both rows. Work as rapidly as you can, until I say ‘Stop.’” “Are you read? Begin.” Start timing when you “Begin.” Assembly (1 minute): “Pick up one pin from the right-hand cup with your right hand. While you are placing it in the top hole in the right-hand row, pick up a washer with your left hand. As soon as the pin has been placed, drop the washer over the pin. While the washer is being placed over the pin with your left hand, pick up a collar with your right hand. While the collar is being dropped over the pin, pick up another washer with your left hand and drop it over the collar. This completes the first ‘assembly,’



consisting of a pin, a washer, a collar, and a washer. While the final washer for the first assembly is being placed with your left hand, start the second assembly immediately by picking up another pin with your right hand. Place it in the next hole, drop a washer over it with your left hand, and so on, completing another assembly. Now, take a moment to try a few practice assemblies.” “Stop. Now return the pins, collars, and washers to their proper cups.” Then say: “When I say ‘Begin,’ make as many assemblies as possible, beginning with the top hole. Work quickly until I say ‘Stop.’” Emphasize that both hands should be operating at all times: one picking up a pin, one a washer, one a collar, and so on. The client should be allowed to make four or five complete assemblies before the test is begun to make certain they fully understand the “alternating” procedure. The client must keep both hands moving at the same time. If he or she fails to do this, the evaluator should give further instructions. Note: If the client is left-handed, the washer and collar locations in the cups are switched. The client begins by picking up the pin with his/her left hand, the washer with his/her right hand, the collar with his/her left hand, another washer with his/her right hand and so on through all assemblies. Count the number of parts assembled and record the number of parts assembled in the pieces section. Beyond completed assemblies, if there are additional parts properly placed at the end of the minute, they are also added to the Assembly score. For example, if there is another pin and first washer, in addition to those 2 parts, the score is 32 + 2, or 34. After you record the score, the subject should return the pins, collars, and washers to the proper cups. The worker is classified as poor fine motor skills (0-23 parts), low speed assembly (24-29 parts), high-speed trainable (30-39 parts) and high-speed assembly (greater than 40 parts). The overall goal of coordinational testing with an FCE is to meet or exceed 30 parts, which would suggest that the client is at a high-speed trainable level. If the client is unable to meet or exceed this level it does not in and of itself mean the client cannot perform coordinational activities. The client’s ability to perform in a coordinational fashion must be observed along with the number of parts assembled. Figure 2C Male & Female Production Work (n=454)

Right Hand

Poor Low Avg. Average High Avg. Excellent 12 13 14 15 16 17 18 19 20 21 2 2 23 24 11.85 13.88 15.91 17.94 19.97 22.00 24.03 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Left Hand

Poor Low Avg. Average High Avg. Excellent 12 13 14 15 16 17 18 19 20 21 11.85 13.47 15.14 16.81 18.48 20.15 21.82 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.



Both Hands

Poor Low Avg. Average High Avg. Excellent 10 11 12 13 14 15 16 17 18 9.60 11.10 12.60 14.10 15.60 17.10 18.60 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Assembly

Poor Low Avg. Average High Avg. Excellent 20-27 28-33 34-40 43 44- 50 5 1-60 20.60 27.29 33.98 40.67 47.36 54.05 60.74 -3 S.D. -2 S.D. -1 S.D. Mean 1 S.D. 2 S.D 3 S.D.

Moberg’s Pick up Test Moberg’s test was designed for discriminative sensibility testing. This will involve assessing the client’s motor function, sensation, and may assist with identifying median nerve injuries rather than ulnar or radial nerve deficits. This is due to the median nerve innervates the digits that are required for grasping and precision pinching. This test will assess the client’s fine motor coordination/prehension with each hand when using basic household and everyday objects. Included in the box are 12 standard objects: wing nut, screw, key, nail, large nut, nickel, dime, washer, safety pin, paper clip, small hex nut, and small square nut. The evaluator will instruct the client and



perform the following:

1. Tape small and ring digits to palm to prevent use. With the client using vision, have the client pick up and place objects in a box as quickly as possible. Time the performance on two trials.

2. Response: Client picks up each object and deposits it in the box as quickly as

possible.

Measure the time to pick up and place all 12 objects into the box. The evaluator will input these trials in the boxes provided in the input page of the FCE. The average speed the client should be performing these tasks at are listed below, eyes open for trials 1 and 2.

Trial 1=10 to19 seconds

Trial 2= 9 to 16 seconds

The evaluator will then instruct the client to close their eyes and perform the same task in the same fashion.

3. Then occlude vision, place one object at a time between three-point pinch in random order and measure response; do two trials with each object.

4. Response: Client manipulates the object

and names it as quickly as possible. Measure the time to recognize each object on each of two trials (up to a maximum of 30 seconds).

Trial 1= 2 seconds per object Trial 2= 2 seconds per object.

The evaluator will need to identify the limiting factors and determine the frequency of the client’s ability to perform at “occasional, frequent, or constant”. Then document in the comment section regarding the client’s ability and performance during this test. The evaluator should, also note any compensatory techniques, mechanical changes/deficits and/or limiting factors during this testing.



Gross Motor Coordination Gross motor coordination is part of every tasks as well as part of every occupation for essential functional tasks. Assessing gross motor coordination (manual dexterity) is different than fine motor coordination-which was discussed above. There are many gross motor tests on the market and any gross motor test can be used in this testing as long as it is research based and the client is able to be scored against a scoring system. The following test was initially developed to measure manual dexterity with people who had severe coordination deficits or physical disabilities. Box and Block test allow the evaluator to assess each upper extremity dexterity, skillful abilities, and eye/hand coordination when handling large objects. This test will also give the evaluator the ability to assess the client’s endurance dynamically of the upper extremity due to this is a light repetitive activity. Box and Block The test box is placed lengthwise along the edge of a standard height table. Seat the client in a standard height chair facing the box. The 150 cubes are in the compartment of the test box to the dominant side of the client. The evaluator sits facing the client to monitor the blocks being transported. The following instructions are given: “I want to see how quickly you can pick up one block at a time with your right [left] hand (the evaluator points to the hand). Carry it to the other side of the box and drop it. Make sure your fingertips cross the partition. Watch me while I show you how.” The evaluator transports three blocks over the partition in the same direction the client is to move them. After the demonstration the evaluator says: “If you pick up two blocks at the same time, they will count as one. If you drop one on the floor or table after you have carried it across, it will still be counted, so don’t waste time picking it up. If you toss the blocks without your fingertips crossing the partition, they will not be counted. Before you start you will have a chance to practice for 15 seconds. Do you have any questions? Place your hands on the sides of the box. When it is time to start, I will say “Ready” and then “Go”. Perform the 15-second practice. Start the stopwatch and when the 15 seconds have elapsed, say, “stop”. If mistakes are made during the practice period correct them before the actual testing period begins. On completion of the practice period return the transported blocks to the starting compartment. Mix the blocks to assure random distribution. Continue with the following instructions. “This will be the actual test. The instructions are the same. Work as quickly as you can. Ready. Go. [After 1 minute] “Stop”. Count the number of blocks transported and record. If the client transported more than one block at a time, or their fingertips did not cross the partition, this is noted by the evaluator and subtracted from the total. Turn the box so all blocks are in the same side as the next hand to be tested.

“Now you are to do the same thing with your left (right) hand. First you can practice. Put your hands on the sides of the box, as before. Pick up one block at a time with your hand and drop it on the other side of the box. Ready.” The evaluator waits 3 seconds. “Go”. (After 15 seconds).



“Stop”. The score is the number of blocks carried from one compartment to the other in 1-minute subtracting from the total those transported 1 at a time. The evaluator will need to input the total number of blocks transported for each right hand and left hand. After the evaluator has completed the test, record the number in the data page of the software. Then document any of compensatory techniques utilized by the client, observed pain behaviors, reported pain during the task (quality of pain, location, and intermittent or constant), and identify any deficits.



Consistency of Effort

For all of the hand tests, there are various consistency of effort tests being performed. They include basic observational consistency, coefficient of variation during three trial grip, five span grip testing, coefficient of variation between 5 span and three trial, rapid exchange grip testing, and coefficient of variation between pinch testing. This is summarized under the Validity Profile module for your review. The software, as described above, will automatically calculate whether the client is presenting with consistency of effort concerns or not. A sample is listed below and will also be described in the Consistency of Effort/Reliability of Pain chapter earlier in this manual.



Sources Citied Mathiowetz V., Volland G., Kashman N., Weber K.: Adult Norms for Box and Block Test of Manual Dexterity. Am J Occup Ther 39386-391, 1985. Mathiowetz V., Volland G., Kashman N., Weber K., Dowe, M., & Rogers, S. (1985). Grip and pinch strength: Normative data for adults. Archives of Physical Medicine and Rehabilitation, 66 (2), 69-74. Mathiowetz V., Volland G., Kashman N., Weber K. (1984). Reliability and validity of grip and pinch strength evaluation. Hand Surgery, 9A(2), 222-226. Moberg, Eric: Objective Methods for Determining the Functional Value of Sensibility in the Hand. J. Bone Joint Surg. 40B:454, 1958. Stokes, HM. The Seriously uninjured hand – weakness of grip, Journal of Occupational Medicine, 1983; 25: 683-684 Tiffin, J. (1968). Purdue Pegboard: Examiner Manual. Chicago: Science Research Associates.

OccuPro Functional Capacity Evaluation Non-Material Handling


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Chapter 8

Non-Material Handling

Walking Fast Paced Walking The Functional Capacity Evaluation is organized in a way that allows a client to warm up general areas of their body prior to performing weighted material handling testing. The first non-material handling test that is performed is the client’s ability to perform fast paced walking. The client in question may also need to perform prolonged walking testing as well if the client’s job requires constant walking or you are performing a baseline FCE. The client is instructed that they are about to begin the next test involving the client walking 100 yards at his or her fastest possible walking pace. The United States Army regulation time for 100 yards suggests that an average individual will be able to complete this distance in 66 seconds. If you also mathematically go backwards from a normal walking pace of 3.1 miles per hour you will also find that 100 yards should be completed in 66 seconds. During this test, the client’s gait pattern is observed and the amount of time it takes to complete the 100 yards is documented. The client is instructed, “You will now be performing a walking test on a level carpeted surface. You will be walking 100 yards without stopping. Please perform this test in the fastest possible walking pace that you feel you can tolerate. I will be timing you to see how fast you can perform this 100-yard walking test”. During the test, there are certain things you need to observe and questions you need to answer. Did the client use an assistive device? Did the client require a cane to complete the test? Was the client wearing any splints? Was the client holding a body part or otherwise guarding during ambulation? Did the client exhibit a non-antalgic gait pattern on their right or left lower extremities? The evaluator may identify the client’s gait or any deficits with the stance phase or the swing phase. Was their speed considered a fast, slow, or average pace? Finally, was the client’s stride length equal? Any of these limiting factors may decrease the client’s ability to perform walking on a constant, frequent, or even an occasional basis throughout an average shift.



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The client’s reported pain rating on the zero to ten functional pain rating scale and their heart rate is then documented. The key with the pain rating scale is to determine the client’s self reported pain rating while performing the activity.

It should also be noted that, as the evaluator, you are making a decision that a client can tolerate walking on a constant basis during the course of an average shift and their job requires constant walking then the client should be tested on prolonged walking to make a full walking decision. Example: Client demonstrates the ability to complete the 100 yards of walking in 68 seconds and reports no increases in pain, with an antalgic gait pattern. The client would be at a level that would allow him to walk on an occasional basis throughout an average shift. As a medical professional, you would be hard pressed to recommend frequent or constant walking when a client exhibits a deviation in gait and is unable to complete 100 yards of walking within 66 seconds. Prolonged Walking

Following the client’s demonstration of the 100-yard walking ability it is determined if the client needs to perform constant walking and/or if the client demonstrated mechanical changes or not during the fast-paced walking. If the evaluator determines that yes, the client needs to perform constant walking and the client did not demonstrate any mechanical changes or deficits during fast paced walking then prolonged walking testing should be performed.



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The evaluator should set up the treadmill for and explain how to safely get on and off the treadmill to the client. The evaluator should instruct the client by “I want to test your ability to walk at one time for as long as you are able to tolerate up to 15 minutes, using the treadmill. We will start out at a slow pace for a few seconds and increase as you can tolerate up to 3.0 mph or faster”. The speed should start at a comfortable walking pace for the client between 2.0 and 3.0 mph or what is similar to the pace the client would normally walk. The treadmill speed should then be increased up to 3.0mph. This is done to simulate a walking pace that is a normal walking pace.

For example, the client may be a meter reader and walks all day long reading meters. This would be considered constant walking and as the evaluator, this should be tested to determine the client’s constant walking ability. The following table is provided to assist in whether the client can perform walking on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The hints provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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Walking Comments

The most important portion is answering the question client can tolerate walking within the following frequency? The answer is one of the following: avoid, occasional, frequent, or constant throughout an average day. There is a text box for both fast-paced walking and prolonged walking in order to thoroughly document the client’s abilities and deficits for each area. Since these tasks focus on different aspects of the client’s abilities it is important to identify any changes in gait pattern, areas if discomfort reported by the client, overall cardiovascular condition, and any other limiting factors identified.

Forward Reaching It would be safe to say that all jobs and during daily activities of living require forward reaching. This is a reaching evaluation to determine a client’s functional ability to perform forward reaching activities. There are three separate tests that are performed with forward reaching. The first test is a one-time forward reach, the second test is forward reaching for 10 repetitions, and the third test is forward reaching for 10 repetitions in the fastest possible pace the client can tolerate. Prior to this specific test, asks the following question. Does the client have a history of neck or shoulder injuries? This question will help to establish the client’s consistency of effort in this area. If the



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client does not have a history of neck or shoulder injuries and they are unable to achieve a constant level than there is a concern regarding consistency of effort.

One Time Forward Reach The client is asked to start with their hands at their side and then forward reach to a fully extended position at roughly shoulder height one time. “The next test you will perform is forward reaching and I would like for you to start with your hands at your side and then reach out in front of you one time and back down to your side.” The percent of forward reach is documented, the time the reach took to complete could be recorded, and then the limiting factors that were reported or observed are documented. These include the clients speed, movement pattern in regard to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not the reported pain correlates with the diagnosis. The evaluator enters the client’s heart rate and reported functional pain level. Following this documentation, it is determined if the client can perform the 10-repetition test next. A reason the client would not be able to proceed was an inability to perform one repetition secondary to biomechanical deficits or a significant increase in self reported functional pain symptoms. Forward Reach Times 10 Repetitions The client is asked to start with their hands at their side and then forward reach to a fully extended position at roughly shoulder height ten times at a comfortable pace. “The next test you will perform is forward reaching and I would like for you to start with your hands at your side, then reach out in front of you as many times as you can up to 10 repetitions at a comfortable pace while returning your hands to your side after each repetition. I will be palpating your shoulders to determine if there are any concerns while you are reaching” The percent of forward reach is documented, the time it took to complete the 10 repetitions is recorded, and the limiting factors that were reported or observed are documented as well. These include the clients speed, movement pattern in regard to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not the reported pain correlates with the diagnosis. The evaluator enters the client’s heart rate and reported pain level. During this test, the client should be palpated for crepitus. This is a non-documented validity test. Non-documented means that the test does not account for this however, if a client has an inability to complete the 10 repetitions and reports increase in pain symptoms it would be safe to say that you would palpate an



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increase or a significant level of crepitus or possibly other biomechanical changes. Following this documentation, it is determined if the client can perform the 10-repetition test at a fast pace which is next. Some reasons they may not be able to proceed is an inability to complete the 10 repetitions secondary to biomechanical limitations or an increase in self reported pain symptoms. Forward Reach Times 10 Repetitions in a Fast Pace The client is asked to start with their hands at their side and then forward reach to a fully extended position at roughly shoulder height ten times at the fastest possible pace they can tolerate. “The next test you will perform is forward reaching and I would like for you to start with your hands at your side, then reach out in front of you as many times as you can up to 10 at the fastest possible pace you can tolerate while returning your hands to your side after each repetition. I will be timing you to see what your speed is and I will be palpating your shoulders to determine how they move biomechanically” The percent of forward reach is documented, the time it took to complete the 10 repetitions fast is recorded and the limiting factors that were reported or observed are documented as well. These include the clients speed, movement pattern in regard to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not the reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s heart rate and reported pain level. During this test, the client should be palpated for crepitus. If the client is able to complete the 10 repetitions at a fast pace and exhibits a faster pace than the previous test without any documentable limiting factors then it would be safe to say that the client is able to forward reach on a constant basis throughout an average shift.



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The following table is provided to assist in whether the client can perform forward reaching on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The levels provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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Example: Client demonstrates the ability to complete the 10 repetitions of reaching with noted crepitus and the client reporting a mild increase in pain symptoms. Client is asked to perform the 10 repetitions at a fast pace, and they are able to complete this but report higher pain symptoms to a 5 and their overall speed did not change from the first set of 10 reps. This would suggest that the client is at a level that would allow frequent forward reaching abilities. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regard to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Above Shoulder Reaching Again, it would be safe to say that all jobs require forward reaching however, not all jobs require above shoulder reaching, if performing a job specific FCE. If the FCE is assessing overall functional abilities, then above shoulder reaching should be tested. This is a reaching evaluation to determine a client’s functional ability to perform reaching activities above the level of their shoulder. There are three separate tests that are performed with above shoulder reaching. The first test is a one-time above shoulder reach, the second test is reaching above their shoulder level for 10 repetitions, and the third test is above shoulder reaching for 10 repetitions in the fastest possible pace the patient can tolerate. Prior to this specific test, ask the following question. Does the client have a history of neck or shoulder injuries? This question will help to establish the client’s consistency in this area. If the client does not have a history of neck or shoulder injuries and they are unable to achieve a constant level than there is a mild concern regarding consistency of effort at this time. One Time Above Shoulder Reach The client is asked to start with their hands at their side and then reach over the level of their shoulder to a fully extended position one time. “The next test you will perform is above shoulder reaching and I would like for you to start with your hands at your side and then reach over the level of your head one time and back down to your side.” The percent of above shoulder reach is documented with the limiting factors that were reported or observed. These include the clients speed, movement pattern in regard to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not the reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s heart rate and reported functional pain level. Following this documentation, it is determined if the



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client can perform the 10-repetition test next. Some reasons they may not be able to proceed is an inability to perform one repetition secondary to biomechanical limitations or a significant increase in self reported pain symptoms. Above Shoulder Reach Times 10 Repetitions The client is asked to start with their hands at their side and then reach over the level of their shoulder to a fully extended position ten times at a comfortable pace. “The next test you will perform is above shoulder reaching and I would like for you to start with your hands at your side, then reach over the level of your head as many times as you can up to 10 at a comfortable pace while returning your hands to your side after each repetition. I will be palpating your shoulders to evaluate any biomechanical limitations” The percent of above shoulder reach, the time it took to complete the 10 repetitions and any limiting factors reported or observed is documented. These limiting factors could include the client’s speed, movement pattern in regard to scapulohumeral rhythm, and whether the movement pattern correlated with the pain reported. During this test, the client should be palpated for crepitus. This is a non-documented validity test. Non-documented means that the test does not account for this however, if a client has an inability to complete the 10 repetitions and reports increase in pain symptoms it would be safe to say that you would palpate an increase or a significant level of crepitus with certain diagnosis. Following this documentation, it is determined if the client can perform the 10-repetition test at a fast pace which is next. Again, a few reasons they would not be able to proceed is an inability to complete the 10 repetitions secondary to biomechanical limitations or an increase in self reported pain symptoms. Above Shoulder Reach Times 10 Repetitions in a Fast Pace The client is asked to start with their hands at their side and then reach to a fully extended position over the level of their shoulder ten times at the fastest possible pace they can tolerate. “The next test you will perform is above shoulder reaching and I would like for you to start with your hands at your side, then reach over the level of your head as many times as you can up to 10. I would like for you to perform this at the fastest possible pace you can tolerate while returning your hands to your side after each repetition. I will be timing you to see how quickly you can perform this test and I will be palpating your shoulders to determine if there are any biomechanical limitations” The percent of above shoulder reach, the time to complete the 10 repetitions fast and any reported or observed limiting factors are documented. These include the clients speed, movement pattern in regard to scapulohumeral rhythm, compensatory techniques observed, was crepitus noted and quality, whether the movement pattern correlated with the pain reported, and whether or not you reported pain correlates with the diagnosis. The evaluator continues to identify and enter the client’s



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heart rate and reported pain level. During this test, the client should be palpated for crepitus. If the client is able to complete the 10 repetitions at a fast pace and exhibits a faster pace than the previous test without any documentable limiting factors then it would be safe to say that the client is able to above shoulder reach on a constant basis throughout an average shift.

The following table is provided to assist in whether the client can perform above shoulder reaching on an avoid, occasional, frequent, or constant basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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Example: Client demonstrates the ability to complete the 10 repetitions of above shoulder reaching with audible and palpable crepitus noted. The client also exhibits biomechanical changes secondary to “a hitch” in his scapulohumeral rhythm. Client is not asked to perform above shoulder reaching times 10 reps at a fast past secondary to the biomechanical changes doing 10 reps at a comfortable pace. The question is now, is the client at the level that would allow occasional or frequent above shoulder reaching? Other factors need to be documented such as the client’s self reported ability and the reported pain. If the client reports no increase in pain and they report they don’t feel they have any deficits, then the client is at an occasional level secondary to the biomechanical changes. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regard to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Bending The bending test is the first test that primarily tests the client’s ability to perform activities that involve the low back. This is an activity that a client should be able to attempt, or it is questionable if they are ready for a functional capacity evaluation. As medical professionals, we have a primary goal related to teaching an injured client how to perform correct body mechanics while performing the essential functions of their job.



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This focus on correct body mechanics would suggest that the client should refrain from bending as much as possible, especially if they are being treated for a low back injury. Biomechanical studies however have shown bending and lifting an object is better than squatting when the object lifted is wider than the lifters stance. When the object being lifted is a wide or a large object, studies have shown that there is less compressive force on the lumbar discs when bending and lifting compared to squatting, reaching forward to get to the box, and lifting. When the object to be lifted is a wide object and the lifter needs to reach out in front of them to grasp the object, because they cannot get close to the object, they are increasing the lever arm with their lumbar region being the fulcrum. Thus, bending and grasping the object keeps the object closer to the body and decreases this lever arm. Also, it needs to be recognized that clients in general will get into situations where they will need to bend or will forget the correct body mechanics. Because of these two points a bending test needs to be performed to determine the client’s bending abilities. The bending test consists of three separate tests with the evaluator asking the client to perform one repetition, as many bends as they can up to 10 repetitions, and thirdly, as many bends as they can up to 10 repetitions at the fastest possible pace they can tolerate. The bends should be to a height that allows them to stay comfortable and return to an erect position. During the instruction of this test the client needs to be instructed that they should bend to a height as close to their toes as possible but that they should go to a height that they can safely return to a full erect position without losing their balance or without causing undue biomechanical stress. Bending Times One Repetition The client is asked to start with their hands at their side and then bend to as close to their toes as they can for one repetition. “The next test you will perform is bending and I would like for you to start with your hands at your side, feet shoulder width apart, and then bend to as close to your toes as you can one time. The key to this bend is that I would like you to bend to a height off of the floor where you can return to an erect position without loss of balance and without a significant increase in pain.” The percent of full bend is documented with touching their toes being 100%, bending to mid calf being 75%, bending to their knee height being 50% and bending to their mid thigh being 25% of a full functional bend. The next section to be identified is in regard to the limiting factors that were reported or observed. These include the client’s speed, movement pattern in regard to bending mechanics, whether the movement pattern correlated with the pain reported, and regarding pain symptoms in comparison to the client’s ability. Following this documentation, it is determined if the client can perform the 10-repetition test next. Some reasons they would not be able to proceed was an inability to perform one repetition secondary to biomechanical limitations or a significant increase in self reported pain symptoms.



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Bending Times Ten Repetitions The client is asked to start with their hands at their side and then bend to as close to their toes as they can ten times at a comfortable pace. “The next test you will perform is bending and I would like for you to start with your hands at your side and then bend to as close to your toes as you can for as many repetitions as possible up to 10 reps. The key to this bend again is that I would like you to bend to a height off of the floor where you can return to an erect position without loss of balance and without a significant increase in pain.” The percent of full bend is documented with touching their toes being 100%, bending to mid calf being 75%, bending to their knee height being 50% and bending to their mid thigh being 25% of a full functional bend. The FCE tester is encouraged to time the 10 repetitions and document the time it took to complete these repetitions. The next section to be identified filled out is in regard to the limiting factors that were reported or observed. These include the client’s speed, movement pattern in regard to bending mechanics, whether the movement pattern correlated with the pain reported, and whether or not you observed an overreaction regarding pain symptoms in comparison to the client’s ability. Following this documentation, it is determined if the client can perform the 10 repetition at a fast pace next. Some reasons they would not be able to proceed was an inability to perform the ten repetitions secondary to biomechanical limitations or a significant increase in self reported pain symptoms. Bending Times Ten Repetitions at a Fast Pace The client is asked to start with their hands at their side and then bend to as close to their toes as they can ten times at the fastest possible pace they can tolerate. “The next test you will perform is bending at the fastest possible pace that you can perform. I would like for you to start with your hands at your side and then bend to as close to your toes as you can for as many repetitions as possible up to 10 reps. The key to this bend again is that I would like you to bend to a height off of the floor where you can return to an erect position without loss of balance and without a significant increase in pain while performing these ten reps as fast as you feel you can.” The percent of full bend is documented with touching their toes being 100%, bending to mid calf being 75%, bending to their knee height being 50% and bending to their mid thigh being 25% of a full functional bend. The FCE tester is encouraged to time the 10 repetitions fast and document the time it took to complete these repetitions. Next, is identifying the limiting factors that were reported or observed. These include the client’s



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speed, movement pattern in regard to bending mechanics, whether the movement pattern correlated with the pain reported, and regarding pain symptoms in comparison to the client’s ability and diagnosis. Please note that if bending 10 times fast in contraindicated secondary to the diagnosis the FCE evaluator is encouraged to use their clinical judgement and refrain from this 10 times fast test.

The following table is provided to assist in whether the client can perform bending on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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Example: Client demonstrates the ability to complete the 10 repetitions of bending and reports increased pain symptoms to a 3.5. The client also exhibits a decrease in rhythm from the first rep to the tenth rep. Client is not asked to perform bending times 10 reps at a fast past secondary to the increase in pain and the decrease in pace towards the end of the bending. The question is now, is the client at the level that would allow occasional or frequent bending? Other factors need to be documented such as the client’s self reported ability and the reported pain. If the client reports that they don’t feel they have any deficits in regard to bending, then the client is at a frequent level and it would make sense to attempt the bending times 10 at a fast pace. If the client reports an increase in pain symptoms and that they continue to have difficulty regarding day-to-day bending, then the client would be better off at the occasional level. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regard to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Squatting Squatting ability is usually an important aspect of most jobs. This is your first opportunity to observe the client’s ability to perform correct body mechanics prior to lifting. The squatting test is the second test that primarily tests the client’s ability to



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perform activities that involve the low back and or the lower extremities. This is an activity that a client should be able to attempt. If not, it is questionable how they perform functional tasks at work and home and will need to identify compensatory techniques with functional activities. Squatting testing involves repetitive squatting and sustained squatting. These two tests are described below Repetitive Squatting Unlike the tests up to this point, the repetitive squatting test consists of two separate tests with the evaluator asking the client to perform one repetition and as many squats as they can up to 10 repetitions. The client is not asked to perform 10 repetitions of squatting at a fast pace because it is very rare that a client you are testing would need to perform constant repetitive squatting throughout their day. If the client does need to perform constant repetitive squatting during their shift, you would be better off testing this in the job simulation section of this evaluation and potentially coming back to this section and choosing a physical demand level if you would like. The squats should be to a height that allows them to stay comfortable. During the instruction of this test the client needs to be instructed that they should squat to a height as close to the floor as possible but that they should go to a height that they can safely return to a full erect position without losing their balance or without causing undue biomechanical stress. Squatting Times One Repetition The client is asked to start with their hands at their side and then squat to as close to the floor as they can for one repetition. “The next test you will perform is squatting and I would like for you to start with your hands at your side and then squat to as close to the floor as you can one time. The key to this squat is that I would like you to squat to a height off of the floor where you can return to an erect position without loss of balance, struggle, and without a significant increase in pain.” The percent of full squat is documented with the fingers touching the floor being 100%, squatting and the hands reaching mid-calf being 75%, squatting with their hands reaching knee height being 50% and squatting with their hands reaching mid-thigh being 25% of a full functional squat. The next section to be filled out is in regard to the limiting factors that were reported or observed. These include the clients speed, movement pattern in regard to squatting mechanics, whether the movement pattern correlated with the pain reported, and whether or not you observed an overreaction regarding pain symptoms in comparison to the client’s ability. A typical change in regard to biomechanics during squatting is the client not being able to weight bear evenly on their lower extremities. This would be considered a change in biomechanics. Following this documentation, it is determined if the client can perform the 10-repetition test next. Some reasons they would



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not be able to proceed was an inability to perform one repetition secondary to biomechanical limitations or a significant increase in self reported pain symptoms. Squatting Times Ten Repetitions The client is asked to start with their hands at their side and then squat to as close to the floor as they can ten times at a comfortable pace. “The next test you will perform is ten reps of squatting and I would like for you to start with your hands at your side and then squat to as close to the floor as you can for as many repetitions as possible up to 10 reps. The key to this squat again is that I would like you to squat to a height off of the floor where you can return to an erect position without loss of balance, struggle, and without a significant increase in pain.” The percent of full squat is documented with the fingers touching the floor being 100%, squatting and the hands reaching mid-calf being 75%, squatting with their hands reaching knee height being 50% and squatting with their hands reaching mid-thigh being 25% of a full functional squat. The next section to be filled out is in regard to the limiting factors that were reported or observed. These include the clients speed, movement pattern in regard to squatting mechanics, whether the movement pattern correlated with the pain reported, and whether or not you observed an overreaction regarding pain symptoms in comparison to the client’s ability.

The following table is provided to assist in whether the client can perform repetitive squatting on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their



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functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.

Example: Client demonstrates a significant struggle to complete the one repetition of squatting, exhibits unequal weight bearing, and reports increased pain symptoms. Client is not asked to perform squatting times 10 reps secondary to the above mentioned items. The client is at a level where they should avoid all squatting activities.

Sustained Squatting Sustained squatting testing is performed on the rare occasion that the job specific FCE you are performing requires sustained squatting to perform the job. This testing should always be performed in job simulation testing fashion. This will not only improve the overall content validity of your testing, but sustained squatting is never performed without some need to perform sustained squatting to complete a job specific task. For example, a finish carpenter needs to be able to perform sustained squatting while using their nail gun to attach base boards. While, this is not straight sustained squatting and may involve some kneeling and some walking in a squatting position. Most importantly the finish carpenter will also be holding and carrying their nail gun. The more job simulation you can perform with this task the better off your test will be.



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The first aspect will be to create and document the job simulated sustained squatting test you will be performing. This should include the activity you will be simulating, a description of the tools you will be using for simulation, the weights of these tools, the duration of the simulation, the mechanics required for successful completion and the overall expectation. Secondly, the amount of time requested should be entered into the appropriate text box. Following the completion of the job simulated activity the amount of time the client was able to complete should be entered, as well as movement pattern, pain correlation, compensatory techniques, and equal weight bearing. Then the overall heart rate and pain level should be documented. Other items requiring documentation may include pain behaviors, overall mechanics, location of pain, types of compensatory techniques, and inconsistencies.

The following table is provided to assist in whether the client can perform sustained squatting on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regard to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Kneeling Client’s performing kneeling activities at work generally perform one or both of the following when it comes to kneeling. They may perform frequent or constant kneeling which would involve them getting into a kneeling position on numerous occasions during their shift but not maintaining that position for a period of time and the opposite where the client gets into a kneeling position and maintains that position for a length of time. Both areas of kneeling may need to be tested. This is an observational test to see if the client can tolerate 10 repetitions of kneeling which will help to establish frequent or constant kneeling or 2 minutes of prolonged kneeling which will help to establish the client’s ability to perform occasional kneeling. Sustained Kneeling The sustained kneeling test involves the client ascending into a tall kneeling position and they are asked to maintain the tall kneeling position for as long as they can up to two minutes. This test is best performed with an item in front of the client that would allow them the safety of grabbing this item and pushing off of it to stand back up if needed. The best item to use in a clinic setting is a plinth. This item should only be used if necessary and should be avoided if the client is able. The client is instructed to “The next test you are going to



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perform is a prolonged kneeling test”. “I would like you to get into a tall kneeling position for as long as you can up to two minutes”. “Go ahead and use the table in front of you only if you need it for safety reasons when getting into the kneeling position or standing up”. The client may need a demonstration of what a tall kneeling position is, or they will sit down on their legs during this kneeling test. Some of the items you are observing is the client’s ability to demonstrate equal weight bearing, can they tolerate the two minutes, and pain symptoms. The documentation of whether the movement pattern was normal or abnormal, did the movement correlate with the pain reported, did the client present with equal weight bearing, did the client require upper extremity assistance, noted crepitus, input heart rate and reported pain level, and was the client demonstrating compensatory techniques during sustained kneeling.

The following table is provided to assist in whether the client can perform sustained kneeling on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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Repetitive Kneeling The repetitive kneeling test looks at a client’s ability to descend to a kneeling position and ascend out of a kneeling position for as many repetitions as possible up to 10. This should be done in the same area as the sustained kneeling test so the client with safety concerns has the opportunity to use the object for upper extremity assistance. The client should be instructed that they should not use the plinth, table, or other object and that they should only use it if they are unable to stand or feel that they are feeling unsafe during the repetitions. This is to help determine if the client is at a level that they can perform frequent or constant repetitive kneeling activities. If the client is able to complete the 10 repetitions of kneeling without the assistance of the table or plinth in front of them then they are able to perform kneeling frequently. If they require the use of the plinth or table to complete the 10 reps, then they are at a level that they can perform occasional repetitive kneeling. Few jobs require constant repetitive kneeling. One job that may require constant repetitive kneeling for instance is a carpet layer. The client should be asked to ascend and descend for as many repetitions as they can up to 10 without using anything to hold on to unless they need to. The client should be instructed “Now you are going to perform a repetitive kneeling test and I would like



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you to kneel and stand up as many times as you can up to ten”. “I do not want you to use the table unless you need to for safety reasons or if you are unable to get down or back up from the kneeling position”. The FCE allows for documentation of the percent of full kneel, whether the speed was slow, normal, or fast, whether the movement pattern was normal or abnormal, did the pain correlate with the movement pattern and diagnosis, upper extremity assistance used, and was there crepitus noted. The evaluator will need to input heart rate and reported pain level post this task.

The following table is provided to assist in whether the client can perform repetitive kneeling on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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Example: Client demonstrates a struggle to complete the two minutes of kneeling, exhibits unequal weight bearing, and reports increased pain symptoms. Client is not asked to perform kneeling times 10 reps secondary to the above-mentioned items. The client is at a level where they should avoid all kneeling activities. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regard to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Crawling The test of crawling is functional and job specific. This task should be tested when assessing a client for disability reasons or if it pertains to the client’s specific job tasks. Crawling may be performed in a variety of jobs for instance: fire fighters, HVAC, carpenters, carpet layers, concrete finishers, housekeepers-industrial/hotel/residential, electricians, plumbers, mechanics, landscapers, etc., which involves the entire body to perform this task. Crawling is assessed in both forward and backward mobility. The evaluator will instruct the client to: “The next test you are going to perform is the crawling test”. “I would



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like you to get into a crawling position and crawl forwards for 30 seconds and then backwards for 30 seconds for a total of 1 minute”. “Go ahead and use the table in front of you only if you need it for safety reasons when getting into the crawling position or when standing up”. Crawling testing is job simulated in nature. There are no researched crawling tests on the open market so crawling needs to be demonstrated in minutes per hour in regard to occasional, frequent or constant. Some of the areas you may observe are the client’s ability to demonstrate upper extremity and lower extremity equal weight bearing, can they tolerate the one minute of crawling, can they ambulate both in a forwards and backwards direction, and pain symptoms. The documentation of whether the movement pattern was normal or abnormal focusing on spine positioning, scapulohumeral rhythm, and hand/wrist positioning. Other questions may be, did the movement correlate with the pain reported, did the client present with equal weight bearing on upper and lower extremities, did the client require upper extremity assistance to ascend or descend into position, noted crepitus, input heart rate and reported pain level, and was the client demonstrating compensatory techniques during crawling.

The following table is provided to assist in whether the client can perform crawling on an avoid, occasional, frequent or constant basis but it should be recognized that there is no cookie cutter answer. The descriptions provided under the occasional, frequent and constant columns would suggest that the client is at that level regarding their functional abilities. Start at the right column and the client needs to pass each category to be scored at that level.



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Example: Client completes the one minute of crawling without any mechanical deficits. The client is at a level in which they can perform crawling on an occasional basis. The comments section is an important aspect and available to document the client’s report of pain, the limiting factor in regard to the reasoning behind the physical demand level, normal or changes in mechanics, abnormal activities, inconsistencies regarding effort, or other pertinent observation that where observed during the test.

Off of the Ground Balance Static and dynamic balancing are activities that are usually taken for granted in regard to the client’s occupation. For instance, an ironworker needs to be able to perform frequent dynamic balance and even a painter needs frequent static balance when performing ladder or scaffold work. Balance of the client, following a lower extremity injury, is highly important and overall balance deficits may be recognized during this functional test. This may require a referral to a vestibular and balance specialist. Static Balance When testing the ability of the client for static balance, there are several different tests that may be performed. They are listed below in the order of most basic too most difficult of balancing tasks. Romberg’s Test:



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Instructions: “Stand with feet together and arms folded across chest and hold for 30 seconds”. The evaluator should note the client’s sway pattern and if the client presents with a loss of balance while attempting to maintain the narrow stance. Keep in mind the client’s heart rate or reported pain level with observed pain behaviors (facial grimacing, holding breath, shortness of breath, holding affected body part, etc). Sharpen Romberg’s Test: Instructions: “Stand with one foot in front of the other; arms are folded across chest and hold for 30 seconds”. This test if formally tested with either foot in test position. It may be tested in 2 trials, first with right foot in front and second with right foot in back, and the client is only able to have 2 attempts per trial. It should be noted if there is a difference, loss of balance, or reported pain during either test. Keep in mind the client’s heart rate or reported pain level with observed pain behaviors (facial grimacing, holding breath, shortness of breath, holding affected body part, etc). If the client presents with the ability to perform these two tests without a safety concern, then continue to test the clients functional reach assessment. The Functional Reach Assessment is to assess how far the client is able to balance outside their center base of support. This assessment has normative data to assist with categorizing the client within the frequency. During this test, the evaluator may identify weight-bearing strategies with sway patterns, any compensatory techniques observed, and safety concerns with noted loss of balance. In the comment section, be sure to document identify reported pain, observed pain behaviors, and safety concerns of the client. Functional Reach Assessment: Instructions:

Positioning of the client: Align acromion process with yardstick. Flex arm to 90° with elbow extended and measure the end of their fingertips. Instruct the client to: “Lean forward as far as able without your feet moving”. After this is performed, measure the distance from start position to end position and calculate the difference between 1st and 2nd measurement. This number is then inputted into the box (norms are listed below). The evaluator must document any problems areas or deficits with this task in the balance comment section. A loss of balance is noted by taking a step with either foot or holding on to the wall/evaluator.

Norms: Young male 18-35=17 inches Young female 18-35=15 inches Middle age male 35-55=15 inches Middle age female 35-55= 14 inches Elderly male 55+ = 13 inches Elderly female 55+ = 10 inches



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The next tests for static balance are: Single Leg Stance - eyes open (SLS EO) Single Leg Stance - eyes closed (SLS EC) Both SLS are testing for strength of the lower extremities and proprioception. Static balance testing is performed with the client performing some basic balancing tasks. Each of the tasks is 30 seconds in duration. Single leg Stance is tested with the client independently balancing on their right leg and left leg for up to 30 seconds. The client is asked to “I would like you to balance on your left and right leg for as long as you can up to 30 seconds, with your arms folded across your chest, and you can start with whichever leg you would like to since we will be attempting this on both legs”. If the client demonstrates the ability to balance for the 30 seconds bilaterally, they would be considered to have average functional static balance. The client has the opportunity to attempt 2 trials of each extremity. If they are unable to complete the 30 seconds, it needs to be determined if the balance deficit was vestibular in nature, due to pain, orthopedic in nature, or muscular weakness while noting sway pattern, compensatory strategies, ability to recover or a loss of balance occurred. Single leg stance with eyes closed is a higher-level balancing and proprioceptive task. The client is instructed the following: “I would like you to balance on your left and right leg for as long as you can up to 30 seconds, with your eyes closed and arms folded across your chest, and you can start with whichever leg you would like to since we will be attempting this on both legs”. If vestibular in nature, a referral to a vestibular specialist would be highly beneficial for a client that requires static balance in their occupation. If the balance is pain related, then a goal needs to be set and as pain decreases throughout the program balance needs to be retested for improvement documentation. When the balance deficits are due to muscular strength, then the work hardening program job simulation, functional activities and general strengthening must be incorporated.



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Example: The client was able to demonstrate Romberg’s test and Sharpen Romberg’s test for 30 seconds without a loss of balance, reported pain and was within the normative range for the functional reach assessment. The client was then able to demonstrate 30 seconds of SLS-EO bilaterally however unable to demonstrate SLS-EC for more than 15 seconds at which time the client demonstrated a loss of balance. This client was placed on a frequent basis for static balancing abilities. The following is provided to assist in the determination of the level of frequency based on the balancing evaluation, but it should be recognized that there is no cookie cutter answer.



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Dynamic Balance The following is the testing that will consist of identifying the client’s dynamic balance abilities. In the software, the evaluator will need to identify if the client passes or fails the individual test. The following is a progression of the most basic ambulation task to the most difficult. During all the above dynamic balancing tasks if the client does not meet the criteria listed in “pass” column, the client “fails” that task. Gait on level surface Instructions: “Walk at your normal speed from here to the next mark (6 m (20 ft)).”

Pass – Walks 6 m (20 ft) in less than 5.5 seconds, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside of the 30.48 – cm (12-in) walkway width.

Change in Gait speed Instructions: “Begin walking at your normal pace (for 1.5 m [5 ft]). When I tell you “go,” walk as fast as you can for (1.5 m [5 ft]). When I tell you “slow,” walk as slowly as you can for (1.5 m [5 ft]).”

Pass – Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. Deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.



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Gait with horizontal head turns Instructions: “Walk from here to the next mark 6 m (20 ft) away. Begin walking at your normal pace. Keep walking straight; after 3 steps, turn your head to the right and keep walking straight while looking to the right. After 3 more steps, turn your head to the left and keep walking straight while looking left. Continue alternating looking right and left every 3 steps until you have completed 2 repetitions in each direction.”

Pass – Performs head turns smoothly with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.

Gait with vertical head turns

Instructions: “Walk from here to the next mark (6 m [20 ft]). Begin walking at your normal pace. Keep walking straight; after 3 steps, tip your head up and keep walking straight while looking up. After 3 more steps, tip your head down, keep walking straight while looking down. Continue alternating looking up and down every 3 steps until you have completed 2 repetitions in each direction.” Pass – Performs head turns with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.

Gait with pivot/turns

Instructions: “Begin with walking at your normal pace. When I tell you, “turn & stop,” turn as quickly as you can to face the opposite direction and stop.”

Pass – Pivot turns safely within 3 seconds and stops quickly with no loss of balance

Step over obstacle

Instructions: “Begin walking at your normal speed. When you come to the shoe box, step over it, not around it, and keep walking.”

Pass – Is able to step over 2 stacked shoe boxes taped together (22.86 cm [9 in] total height) without changing gait speed; no evidence of imbalance.

Gait with narrow base of support

Instructions: “Walk on the floor with arms folded across the chest, feet aligned heel to toe in tandem for a distance of 3.6 m [12 ft]. The number of steps taken, in a straight line, is counted for a maximum of 10 steps.”

Pass – Is able to ambulate for 10 steps heel to toe with no staggering.

Gait with eyes closed

Instructions: “Walk at your normal speed from here to the next mark (6 m [20 ft]) with your eyes closed.”

Pass – Walks 6 m (20 ft), no assistive devices, good speed, no evidence of imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. Ambulates 6 m (20 ft) in less than 7 seconds.

Ambulating backwards Instructions: “Walk backwards until I tell you to stop”.

Pass – Walks 6 m (20 ft), no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.



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Sources Cited

Duncan PW, Weiner DK, Chandler J, Studenski S. Functional Reach: A new clinical measure of balance. J Gerontol. 1990. 45: M192-M197, 1990. Romberg, M.H. Tabes Dorsalis. Berlin, 1846;vol. 1 p795.

OccuPro Functional Capacity Evaluation Occasional Material Handling


Chapter 9

Occasional Material Handling

Material Handling

This is the primary section that most insurance carriers, disability companies and physicians are concerned about when it comes to return to work and/or establishing the physical demand category. When a physician is prescribing return to work, whether it is regular duty or modified duty, the client is given weight restrictions. The FCE establishes the client’s present weight restrictions and will help to determine if the client can return to work on modified duty or full duty work. The first part of this section is for the evaluator to establish the client’s heart rate and level of pain following the non-material handling activities. This will help to establish their cardiovascular abilities because their heart rate would most likely have decreased to a resting heart rate similar to the first time it was checked in the beginning. The client’s functional pain rating can be cross referenced with what they reported in the beginning to establish whether or not their resting pain level has increased or remained the same at this juncture of the evaluation.

Job-Specific/Bend Lift This is the first of five lifts that will be performed and is considered the lift that is specific to a client’s job or is a lift that is performed in a forward bending fashion. This particular lift is not always performed in the FCE. It is tested if the client performs bending and lifting or if a specific type of lift is performed during the course of a normal shift. A primary goal of injured client rehabilitation is to teach proper body mechanics in order to assist in the healing process or to decrease the likelihood of a future injury. Even though our focus is proper body mechanics there may still be situations that a client will be required to lift in a bending fashion based on situations at their job. This lift is performed using the Hausmann lifting station. The bottom shelf of the lifting station should be positioned at or slightly higher than the client’s waist. The client should be asked to lift the box that has an opening and closing lid and they should use the top handles of the box with the box starting off to the side of the lifting stations. The client should perform a 90 degree turn when placing the box on the shelf and a 90 degree turn when placing the box



back on the floor. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of an injury. The client should be instructed to perform this lift in a forward bending fashion. The box itself weighs 15 to 15 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation, then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform a job specific lift”. “I would like you to perform a lift in which you are forward bending to the top handles, lift the box, turn and place the box on this shelf, and then return the box to the floor in the same position it started”. When instructing the client on the procedure you should demonstrate what you mean by a job specific lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete, mechanical deficits, with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds at a safer level with only a biomechanical change. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are there to use as a tool for later reference when documenting in the comments section for limiting factors and overall mechanics. The last item that needs to be documented is the client’s self reported functional pain symptoms.



Squat Lift This is the second of five lifts that will be performed and is considered the lift that the first set of mechanics is observed. One of the primary goals of injured worker rehabilitation is to teach proper body mechanics to assist in the healing process or to decrease the likelihood of future injury. This lift requires documentation in regard to these body mechanics and in certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann lifting station. The bottom shelf of the lifting station should be positioned so the bottom handles of the lifting box are at waist height and then the shelf should stay at this level for the rest of the lifting testing. The worker should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting off to the side of the lifting stations. The client should perform a 90 degree turn when placing the box on the shelf and a 90 degree turn when placing the box back on the floor. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The client should be instructed to perform this lift in a full squatting fashion. The box itself weighs 15 to 17 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach.



If performing this lift in psychophysical approach during a work hardening evaluation, then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform a full squat lift”. “I would like you to perform a lift in which you are squatting to the bottom handles, lift the box, turn and place the box on this shelf, and then return the box to the floor in the same position it started”. When instructing the client on the procedure you need to demonstrate what you mean by a full squat lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete, mechanical deficits, with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds at a safer level. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. The boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported functional pain symptoms.

Power Lift



This is the third of five lifts that will be performed and is considered the lift that is the primary lift to observe the client’s body mechanics. A primary goal of injured client rehabilitation is to teach proper body mechanics, which will assist in the healing, process or decrease the likelihood of a future injury. The power lift is the lift that many rehabilitation professionals teach in regard to proper body mechanics. The clients overall body mechanic performance should be documented. In certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann lifting station. The bottom shelf of the lifting station should be positioned as adjusted during squat lifting. They should be asked to lift the box that has an opening and closing lid and they should use the top handles of the box with the box starting off to the side of the lifting stations. The client should perform a half squat, they should lift the box, perform a 90 degree turn when placing the box on the shelf, and a 90 degree turn when placing the box back on the floor in the same half squat fashion. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The client should be instructed to perform this lift in this half squatting/power lifting fashion. The box itself weighs 15 to 17 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation, then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform a power lift”. “I would like you to perform a lift in which you are squatting to the top handles, lift the box, turn, and place the box on this shelf, and then return the box to the floor in the same fashion and position it started”. When instructing the client on the procedure you need to demonstrate what you mean by a power lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very



different. A client may lift 50 pounds and demonstrate a significant struggle to complete, mechanical deficits, with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds at a safer level. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported functional pain symptoms.

Shoulder Lift This is the fourth of the five lifts that are performed and is considered the lift that focuses on the client’s ability to lift items from their waist to their shoulder height. This lift is usually performed with all FCE’s but may be avoided if a Job Demands Analysis reveals that the client does not need to lift to shoulder height. This lift is performed using the Hausmann lifting station. The bottom shelf should still be in the same position from squat lifting and the top shelf should be placed at level in which the hands are placed on the bottom handles and lift to shoulder height. The client should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting on the bottom shelf. They should grasp the bottom handles and lift the box to the top shelf with no weight in the box. The box should not be let go of and then placed back on to the bottom shelf. The box itself weighs 15 to 17 pounds empty and based on the client’s ability following the empty box lift you can



add 10 pounds, or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation, then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform a shoulder lift”. “I would like you to grasp the bottom handles, lift the box from waist level height to the top shelf, place the box on this shelf, and then return the box to the same position it started”. When instructing the client on the procedure you need to demonstrate what you mean by a shoulder lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 pounds at a safer level. This would be the safe occasional weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These check boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the clients self reported functional pain symptoms.



Overhead Lift This is the last of the five lifts that are performed and is considered the lift that focuses on the client’s ability to lift items overhead. This lift again is only performed if the client needs to perform overhead lifting as part of their job or daily life. This lift is performed using the Hausmann lifting station. The bottom shelf should still be at the height from the squat lift test and the client will be lifting to the top of the Hausmann lifting station. The client should be asked to lift the box that has an opening and closing lid and they can lift the box in any fashion they would like from the bottom shelf. The client should grasp the box in any fashion they would like to keep them as safe as possible when lifting overhead. In the real work environment, the client would perform such a lift in the safest fashion, and this should be adhered to in this evaluation. The client should lift the box to the top of the lifting station initially with no weight in the box. The box can be let go of and then it should be placed back on to the bottom shelf. The box itself weighs 15 to 17 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation, then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum.



There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. The client should be instructed to “I am now going to evaluate your ability to perform an overhead lift”. “I would like you to grasp the box in any fashion that is most comfortable for you, lift the box from waist level height to the top of the lifting station, place the box on the top, and then return the box to the same position it started”. When instructing the client on the procedure you may need to demonstrate what you mean by an overhead lift if possible. Do not put yourself at risk if this is too difficult for you. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may lift 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45-pouns at a safer level. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms.

Bilateral Carry



The client’s ability to carry items is also an important material handling task since it should be within the same ballpark as their ability to perform power lifting. Carrying is also an important material handling activity that determines the physical demand category the client is able to perform within. Carrying uses the same two handled, open and closed lid box, as the lifting evaluations used. The box should be placed on the bottom shelf that is still in the same position as when lifting was performed, the client should grasp the bottom handles, carry the box for 25 feet, turn around and return to the lifting station. The box itself weighs 15 to 17pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics. When considering a kinesiophysical approach 5 pounds should be added at the mechanical change level and 10 pounds at the level in which there are no mechanical problems. This lift should be performed until the client reaches their kinesiophysical endpoint during a kinesiophysical approach. If performing this lift in psychophysical approach during a work hardening evaluation, then the client can stop the lift when they feel they cannot proceed. As a professional you need to agree with the client that you also feel they reached their baseline maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The peak weight is then considered the maximum weight you observed the client lift and the occasional weight is the weigh the client could perform on an occasional basis throughout an average shift. This test allows for mild variations in the carrying distance. For instance, if a client performs up to 100-pound carrying throughout their normal shift, they may not need to carry this much weight for 50-feet. In this situation, the client should carry the weight the job specific distance and this should be properly documented in the carrying comments section. The client should be instructed, “The test you will now perform is the carrying test”. “I would like for you to grasp the box using the bottom handles and then carry the box for 25 feet and then turn around and bring the box back to the lower shelf”. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to carry. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may carry 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to



perform 45 pounds and they may have demonstrated safer overall mechanics. This would be the safe occasional weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms. The comments section is available to summarize the client’s abilities during bilateral carrying. If there is ever any question regarding a client’s carrying abilities, this is the section that should answer those questions. The comments section should be a summary of the carrying test. This summary should include the amount of weight carried in a safe and occasional fashion, the observed behaviors, pain levels reported, biomechanical abilities and most importantly, the limiting factor in regard to the amount of weight tolerated.

Unilateral Lift This is a specific upper extremity lift that is performed in regard to upper extremity strength. This test will also provide a comparison of upper extremity strength between dominant/non-dominant and between affected and un-affected extremity. This lift is performed using the Hausmann lifting station. The bottom shelf of the lifting station should be positioned as noted in squat lifting. The position could certainly be changed however to make the test a more job specific test based on the heights a client needs to unilaterally lift on their job. The client will be asked to start with a five-pound ankle weight/dumbbell/or disc weight and lift this weight from the top of the closed lid box to the shelf at waist height for 1 repetition. The weight is then transferred to the other side of the body to test the opposite arm. The client should perform a 90 degree turn when placing the ankle weight/dumbbell or disc weight on the shelf and a 90 degree turn when



placing the weigh on the shelf. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The test is then raised by 5 pounds up to a 10-pound ankle weight/dumbbell/or disc weight and performed utilizing the right and left upper extremity. The next level up is the 15-pound box and the smaller of the two, handled Hausmann lifting box is utilized. This box begins at 15 pounds empty and again is manipulated from the floor to the shelf at waist height. The box is increased by 5-pound increments until a safe maximum level is reached. This is completed on both upper extremities until a peak weight level is achieved on both the right and left upper extremity. In a kinesiophysical approach test this peak weight would be the weight in which the client demonstrated a kinesiophysical endpoint. The occasional weight would then be documented the weight which was at a level that was the safe unilateral lift weight. If the weight is different on both upper extremities, then the lower weight should be the one placed in the occasional weight category. If a psychophysical approach test is being performed like in a work hardening evaluation and the client discontinues a test secondary to psychophysical reasons, then as a professional you need to agree with the patient that you also feel the client has reached their baseline maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. This occasional weight is then considered the weight the client could perform on an occasional basis throughout an average shift from knee to waist. It should be noted that per a Job Demands Analysis or a detailed job description, this client might need to perform unilateral lifting up to and exceeding the level of their shoulder based on their job. This test then needs to be modified to allow testing that is related to the essential physical demands of their job and the heights associated with their job. The client should be instructed to “I am now going to evaluate your ability to perform lifting using your left and right arm”. “I would like you to perform a lift in which you are squatting to this ankle weight/dumbbell/disc weight on the top of this box, lift the weight, turn and place the ankle weight on this shelf, and then return the weight to the box.” “I am going to ask you to perform this one time with your right arm and then you will perform the same thing with your left arm.” “Depending how you do we will then increase the weight as appropriate.” When instructing the client on the procedure you need to demonstrate what you mean by this type of lift. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The safe occasional weight needs to be the lowest weight the client performed regardless of the extremity. For instance, if the client tolerated 25 pounds maximum on the right upper extremity and only 15 pounds on the left, then the safe occasional weight the client could tolerate in an employment setting would be the 15-pound weight. The peak weight is the maximum weight the client was able to lift. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different.



Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These check boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported functional pain symptoms.

Unilateral Carry The client’s ability to carry items unilaterally is important to test whether it’s related to function or job specific. The evaluator may test this with the smaller box with the tool bar handle or dumbbell/disc weight; which ever best resembles the job. However, if the evaluator used an object other than the box, it should be clearly documented. This test allows for mild variations in the carrying distance. For instance, if a client performs up to 50-pound toolbox from their truck to work site during their normal shift but may not need to carry this much weight for their hand tools. In this situation the client should carry the weight the job specific distance and this should be properly documented in the carrying comments section. The client should be instructed, “The test you will now perform is the unilateral carrying test”. “I would like for you to grasp the box using the top handle and then carry the box for 25 feet and then turn around and bring the box back to the lower shelf”. The FCE allows for documentation that includes the peak weight, the safe occasional weight, and the heart rate. The peak weight is the maximum weight the client was able to carry. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may carry 50 pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on



your observation? The client may have demonstrated the ability to perform 45 pounds and they may have demonstrated safer overall mechanics. This would be the safe occasional weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms.

Pushing and Pulling

The push and pulling evaluation utilizes the push pull cart and is also an important task in regard to material handling. The push pull test can be measured in regard to weight pushed or pulled in two different fashions. It can be measured in terms of the amount of weight in the push pull sled or it can be measured by the amount of force required to push and pull which is termed horizontal force pounds. These two measurements are important because someone pushing 500 pounds on a cart with great wheels really does not apply 500 pounds of force to push or pull that cart. They may be exerting only 50 pounds of force. The opposite may occur when a client is pushing and pulling an item with 50 pounds in it and it may require 100 horizontal force pounds to move the cart because of poor wheels or the type of floor it is pushed on. Thus, we need a constant scale to use because it is impossible to get a cart and put 500 pounds on it in a therapy clinic. This is where the push pull cart comes into play while taking into account the friction factor of the floor and horizontal force pounds this generates. The best way to determine the amount of horizontal force pounds required to push and pull your cart with weight in it is to load up the cart, attach a force gauge, and give the cart a whirl. On a normal carpeted floor, the push pull cart requires 20 horizontal force pounds (hfp) to



operate it. Typically, then as you add 15 pounds of weight it adds 5 hfp to push and pull the cart. The client should be instructed, “The test you will now perform is the push/pull test”. “I would like for you to grasp any handle of the sled and then push the sled for 25 feet and then pull the sled for 25 feet”. The cart begins empty and the client is instructed to push the cart for 25 feet and then pull it back to the start. The cart itself weights 20 horizontal force pounds empty or requires 20 pounds of force to push and pull. Based on the client’s ability following the cart push and pull you can add 15 pounds, which increases the hfp by 5 pounds. This should be done based off of the effort they exhibited and/or the pain they reported. This push and pull evaluation should be performed until the client reports they have reached their maximum one-time ability to push and pull. As a professional you need to agree with the client that you also feel they reached their maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. This maximum push and pull is then considered the weight the client could perform on an occasional basis throughout an average shift. The FCE allows for documentation that includes the peak weight, the safe occasional horizontal force pound push and pull weight, and the heart rate. The peak weight is the maximum weight the client was able to push or pull. This weight however may not be the weight in which you as a medical professional feel are the safe maximum weight for the client. The weights may be the same and they may be very different. A client may push and pull 50 horizontal force pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 horizontal force pounds and it was a safer level. This would be the safe occasional weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self reported pain symptoms. The comments section is available to summarize the client’s abilities during pushing and pulling. If there is ever any question regarding a client’s abilities, this is the section that should answer those questions. The comments section should be a summary of the both pushing and pulling. This summary should include the amount of weight pushed and pulled in a safe and occasional fashion, the observed behaviors, pain levels reported, biomechanical abilities, and most importantly, the limiting factor in regard to the amount of weight tolerated.



Consistency of Effort OccuPro’s FCE uses biomechanical consistency of effort criteria during material handling testing. When clients are lifting the box with the closing lid, they are asked to lift this box in 5 different positions. Each position requires different biomechanical movements. Some of these movements are easier than others. For instance, the lift from knee to waist should biomechanically be easier and less physically exerting than the overhead lift. This would suggest the client would lift more weight during the power lift from knee to waist in comparison to the overhead lift. The FCE automatically checks consistency of effort as the test proceeds and calculates this in the end of the evaluation. Please see the chapter that discusses the overall consistency of effort for more details. There are three separate biomechanical consistency of effort criteria that are automatically checked during the FCE. The first is whether the power lift weight is greater than the full squat lifting weight. Biomechanically, a client should lift more weight when lifting from knees to waist then from floor to waist. There is more muscle recruitment and less end range of the knees. The second internal biomechanical consistency of effort check is the weight difference between power lift and the shoulder lift. Again, a client should be able to lift more weight from knees to waist then from waist to shoulder height. The third biomechanical consistency of effort check was mentioned above and is the power lift as compared to the overhead lift. A client should be able to lift more weight from knees to waist then from waist to overhead. These are checked and documented in the end of the report under the section of consistency of effort and then help to establish whether the claimant put forth their best effort in this evaluation. The percentage of full effort functional tests graph in the end of the report.

OccuPro Functional Capacity Evaluation Job Simulated Functional Abilities


Chapter 10

Job Simulated Functional Abilities

JOB SIMULATION There are critics of job simulation in a work hardening setting or during a functional capacity evaluation. These critics suggest that when performing a job simulation, it is impossible to simulate a client’s job. Some may argue that the only way someone can simulate a job is by actually performing the job. Some may also argue that performing Job Simulation tasks is an invalid tool to use in functional capacity evaluations. As functional capacity evaluators we need to always have a balance between the reliability and validity of our individual FCE. With that said it is important to include job simulated testing or actual job testing into a job specific FCE to increase the content validity of that particular FCE Job simulation in an FCE should never be a determining factor on whether a client can or cannot perform the essential physical demands of their job but should be a way to view, document, and critique a client’s biomechanics when performing job simulation. Remember, an FCE has standard lifting protocols to see if a client can tolerate a certain amount of weight. Is the box that is being lifted during this test the same as the box they would be lifting on the job? No, it is not, but we are making recommendations in regard to their ability to tolerate weight through different means. It should be the same with job simulation and it should be used as an overall tool to observe and document a client’s ability and ultimately decide whether they can do a job simulation task on an avoid basis, occasionally, frequently or continuously. This being said, job simulation should only happen if you are able to completely simulate the biomechanical movements that are required within your client’s employment. The best way to obtain what those biomechanical movements are would be through a Job Demands Analysis. This is the only tool that can definitively allow you to properly set up a job simulation task and be able to say that you had the client perform the tasks in a perfect biomechanical fashion. If the evaluator or someone else performed the JDA then use that information in that JDA to develop the job simulation activity. Document all steps leading up to the test and the client’s ability during the test.



There are two types of job simulated testing you may perform on a client. The first type could be considered the type in which you combine various tests you have already performed into one job simulated test for better overall ability documentation or if that client is concerned about performing that particular aspect of their job. The second type of job simulation would be an aspect of a job in which you have not formally tested because it is not a standardized testing procedure. For instance, a drywall installer needing to use a 4-pound air powered screwdriver overhead to put drywall screws into the ceiling. This is not a standard test in any FCE so it may be an aspect that needs to be tested. There are ten areas that allow for a Job Simulated Functional testing within the Online Assessment Application. In the JDA module you had the opportunity to name the job simulation test you plan on performing and determining the level required on the job. If you had done this in the JDA module, the name of the task to be performed will have pre-populated into the Job Simulated Functional Abilities tab as to remind you which tests you will need to perform and where they go.

The first thing you will need to do is describe the job simulation task you plan on performing. This description should include a description of the viewed job, the way it was set up in regard to simulating the biomechanical movements, the duration and or the amount of repetitions asked of the client. Following this documentation, the job simulation should be set up and the client perform it in the prescribed manner. Following the job simulated test, the client’s pain rating, heart rate and overall limiting factors should be documented. Then the client’s overall ability in regard to avoid, occasional, frequent or continuous should be chosen based on the length of time the client tolerated the prescribed activity. The client’s ability to perform the job simulated activity should also include the observed ability, the time and repetitions tolerated, the



biomechanics noted, pain behaviors, pain symptoms, location of pain reported, and the clients view on the accuracy of the simulation. The client’s view of the simulation will help to validate or not validate the test as a true test of what is being measured. Remember, the client’s ability to perform or not perform this is not an indication if the client can or cannot perform their job. If the client being tested is failing the primary tests, then it would be safe to say that they may be unable to perform job simulated testing. If they are unable to complete job simulated testing, you have more data to support your results and vice versa. Examples of job simulated tasks:

1. Right Shoulder Carrying: The client was requested to carry a bench press bar on his right shoulder totaling 80 pounds for 100 feet. The client was requested to perform this task for 10 consecutive repetitions or 1000 feet in order to be classified on a frequent basis.

2. Sustained Overhead Lifting: The client was requested to perform sustained

overhead reaching using his right upper extremity. This task to be performed at 30 seconds in duration for a total of 25 minutes repetitions using a 10-pound dumbbell for simulation of hand tools at shoulder flexion at 170 degrees working in 4 quadrants while standing on 6" foam for balance and stability.

3. Turing and Loosening Bolts: The client was requested to perform turning

counterclockwise to tighten and loosen a bolt. The client was to perform using the BAPS board at 90 degrees of shoulder flexion/abduction, which is the position the client's arm would be when working on vehicles. This task to be performed for 10 repetitions at both planes of motion.

4. Unilateral Lifting and Drilling: The client was requested to lift an 8-pound

dumbbell overhead from the floor to simulate lifting a drill and drilling overhead. The typical drill may weigh 8 pounds. The client was requested to lift 8 pounds for 10 repetitions and hold 15 to 20 seconds in duration.

5. Ladder Climbing with Tool Bag: The client was requested to perform ladder

climbing using a 6-foot ladder while carrying his 30# tool bag full of the tools he would use on the job, with the shoulder strap over his right shoulder. He was requested to climb using a reciprocal gait pattern, 3 rungs, for 24 repetitions for a frequent basis to simulate climbing a 20-foot ladder. This would place him on a frequent basis.

6. Cashier: The task was simulated cashier and moving the products down the line.

The client may perform this task on a continuous basis during the course of his workday. This task was simulated using various weights of dumbbells ranging from 1-15 pounds for the products. He was requested to perform this task for 15



minutes with 30-second rest break after every 5 minutes in order to meet the continuous basis.

7. Carrying Glass: The client was requested to perform the task of carrying glass.

There was a piece of Plexiglas in the clinic for this simulation. This glass was approximately 10 pounds and 4 feet by 2.5 feet. The Plexiglas sheet was held by the client in 110 degrees of left shoulder flexion and 10 degrees of left shoulder adduction with right arm supporting bottom of glass sheet. Client was instructed to ambulate while carrying glass sheet in this position. The client was requested to hold for 1 minute in duration for 30 repetitions.

8. Garbage Can Disposal: Client was requested to simulate garbage can disposal, by

performing 2-handed carrying for 50 feet using a 40-pound garbage container and lifting to shoulder level height. Client was asked to perform 2 sets of 10 repetitions with a 1-minute break between each set. Client disposes garbage containers on an occasional basis throughout a normal workday.

9. Continuous Lifting: The job simulated consists of lifting 35 pounds on a

continuous basis per physician orders. The task consisted of power lifting from knee to waist at 35 pounds. The client reported that he does not perform lifting on a repetitive basis and within the short time frame. The client was requested to lift 35 pounds for a minimum of 25 repetitions in order to demonstrate lifting on a continuous basis.

10. Lifting and Maneuvering the Stretcher: The task simulated was that of

maneuvering the Stryker stretcher in and out of the ambulance at 35 inches from ground to the floor of an ambulance bay, lifting and lower the stretcher (weighs 70 pounds) with 150 pounds of plate weights totally the amount of weight at 220 pounds for 2 times in 5 minutes. The stretcher was a squat lift of using the handles of 13" from the floor to handles. The ambulance brought the stretcher to the clinic for this assessment.

OccuPro Functional Capacity Evaluation Frequent Material Handling


Chapter 11

Frequent Material Handling

This is an important section that many insurance carriers and physicians are concerned about when it comes to return to work and/or establishing the physical demand category. When performing a job specific functional capacity evaluation, you would only perform frequent material handling testing if the job requires frequent material handling activities on the job. During a baseline FCE a clinician needs to establish the physical demand category outlined through the US Department of Labor definitions. This would be to determine whether the client is able to work within the sedentary, light, medium, heavy or very heavy physical demand category. During baseline FCE testing this means that frequent material handling needs to be performed and the specific tests that need to be performed for frequent material handling include squat lift, power lift, bilateral carry, and push/pull. Occasional material handling and the physical demand level that is generated from that section of testing should co-inside with this frequent section and generally should be somewhere around half of what the occasional material handling is. Research would suggest that frequent material handling should be 50% to 70% of occasional material handling abilities. When a physician is prescribing return to work, whether it is regular duty or modified duty, the client is given weight restrictions. The FCE establishes the client’s present weight restrictions and will help to determine if the client can return to work on modified duty or full duty work. This section will help to establish what the client is able to perform on a frequent basis during an average shift. Multiple tests are performed in this section and are performed in the same biomechanical manner as in occasional material handling. They are frequent squat, power, shoulder, overhead, push, pull unilateral carry and unilateral lifting. Any lifting activity can be performed using this kinesiophysical lifting technique. When performing frequent lifting in this section the lifts are performed for five repetitions. When performing frequent material handling testing and performing a kinesiophysical approach there are three criteria that would stop a client while performing the 5 repetitions at each weight level.

1. Exceeding their aerobic limiting factor (220-age *.85)



2. Mechanical Change 3. A decrease in within repetition pace or cadence (suggests a decrease in muscle

endurance) If performing in a psychophysical approach like during a baseline work hardening evaluation the same three criteria will be used but the client may also stop a test based on their psychophysical feelings.

Frequent Squat Lift This is the first frequent lift test that will be performed and is considered the lift that the first set of mechanics is observed in regard to frequent lifting. Remember though you should have performed this test already occasionally if you test frequent squat lift so your mechanics would have been observed previously. One of the primary goals of injured client rehabilitation is to teach proper body mechanics to assist in the healing process or to decrease the likelihood of future injury. This is a lift that these body mechanics can be documented and in certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann lifting station or a similar lifting station. The bottom shelf of the lifting station should be positioned so the client’s hands lift using the bottom handle and end up at waist height. The client should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting off to the side of the lifting stations. They will perform each weight for five repetitions to establish frequency. The client should perform a 90 degree turn when placing the box on the shelf and a 90 degree turn when placing the box back on the floor. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The client should be instructed to perform this lift in a full squatting position. The starting weight for a frequent lift should be 25% of what they lifted occasionally. The box itself may weigh 15 to 17 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics or the pain they reported. You may even need to start with a lighter weight as the box lift may start at greater than 25% of what they did occasionally. When performing this lift in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have no mechanical changes. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regard to frequent lifting.



There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift from floor to waist. The first part of this section is to obtain the client’s heart rate and document this. This helps to establish a resting heart rate and can be compared to the client’s heart rate following exertion. The client should be instructed to “I am now going to evaluate your ability to perform frequent full squat lifting”. “I would like you to perform a lift in which you are squatting to the bottom handles, lift the box, turn and place the box on this shelf, and then return the box to the floor in the same position it started.” “I would like you to perform each weight for five repetitions.” “If you need to stop during this test for safety reasons feel free to.” When instructing the client on the procedure you may need to demonstrate what you mean by a full squat lift however the client should have already performed this lift during occasional material handling testing. The FCE allows for documentation that includes the peak frequent weight, the frequent weight, the heart rate and exertion level. The peak frequent weight is the maximum weight the client was able to lift for one to five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may lift 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the client’s ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported functional pain symptoms. The frequent lifting utilizes a rating of perceived exertion formula to calculate the client’s self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, reliability of pain, or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 50-70%. This depicts the client’s ability of their material handling ability and should be close or within this range.



Frequent Power Lift This is the second frequent lifting test that will be performed and is considered the lift that is the primary lift to observe the clients body mechanics. One of the primary goals of injured client rehabilitation is to teach proper body mechanics to assist in the healing process or to decrease the likelihood of future injury. This is a lift that many rehabilitation professionals teach, and these body mechanics can be documented. In certain situations, the client may be asked to cease this lift based on poor body mechanics. This lift is performed using the Hausmann lifting station or something similar. The bottom shelf of the lifting station should be positioned based on the frequent squat lift. The client should be asked to lift the box that has an opening and closing lid and they should use the top handles of the box with the box starting off to the side of the lifting stations. The client should perform a half squat, they should lift the box, perform a 90 degree turn when placing the box on the shelf, and a 90 degree turn when placing the box back on the floor in the same half squat position. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. This lift as well is performed for five repetitions at each weight to establish that the client can perform frequent lifting. The client should be instructed to perform this lift in this half squatting/power lifting position. The starting weight for a frequent lift should be 25% of what they lifted occasionally. The box itself may weigh 15 to 17 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics or the pain they reported. You may even need to start with a lighter weight as the box lift may start at greater than 25% of what they did occasionally. When



performing this lift in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regard to frequent lifting. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift from floor to waist. The client should be instructed to “I am now going to evaluate your ability to perform frequent power lifting”. “I would like you to perform a lift in which you are squatting to the top handles, lift the box, turn, and place the box on this shelf, and then return the box to the floor in the same position and position it started”. “I would like you to perform each weight for as many repetitions as you can up to five repetitions.” When instructing the client on the procedure you may need to demonstrate what you mean by a power lift however you did just perform occasional power lifting. The FCE allows for documentation that includes the pre-lift heart rate, the peak frequent weight, the safe frequent weight, the heart rate and the exertion level. The peak frequent weight is the maximum weight the client was able to lift for one to five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may lift 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the client’s self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average



client’s percent range should be within the 50-70%. This depicts the client’s ability of their material handling ability and should be close or within this range.

Frequent Shoulder Lift

This is the third frequent lift test that is performed and is considered the lift that focuses on the client’s ability to lift items to their shoulder height. This lift is only performed if a Job Demands Analysis, job description or client reveals that the client needs to lift frequently to shoulder height at their job. This lift is performed using the Hausmann Work Well Systems lifting station or something similar. The bottom shelf should be positioned as adjusted in squat lifting. The client should be asked to lift the box that has an opening and closing lid and they should use the bottom handles of the box with the box starting on the bottom shelf. They should grasp the bottom handles and lift the box to the top shelf with no weight in the box for up to five repetitions at each weight level. The box should not be let go of in between each repetition and then placed back on to the bottom shelf after the fifth repetition. The box itself may weigh 15 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics or the pain they reported. The starting weight for a frequent lift should be 25% of what they lifted occasionally. When performing this lift in a kinesiophysical approach you will ask the



client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. You may even need to start with a lighter weight as the box lift may start at greater than 25% of what they did occasionally. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regard to frequent lifting. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift from floor to waist. The client should be instructed to “I am now going to evaluate your ability to perform frequent shoulder lifting”. “I would like you to grasp the bottom handles, lift the box from waist level height to the top shelf, place the box on this shelf, and then return the box to the same position it started”. Please do not let go of the box and I would like you to perform as many repetitions as you can up to five repetitions.” When instructing the client on the procedure you may need to demonstrate what you mean by a shoulder lift however you did recently perform shoulder lifting in occasional material handling. The FCE allows for documentation that includes the pre-lift heart rate, the peak frequent weight, the safe frequent weight, the heart rate and the exertion level. The peak frequent weight is the maximum weight the client was able to lift for one to five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may lift 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.



Frequent Overhead Lift

This is the fourth frequent lift test that is performed and is considered the lift that focuses on the client’s ability to lift items overhead. This lift is only performed if a Job Demands Analysis, job description or client reveals that the client needs to lift frequently to overhead height at their job and is rarely if ever performed. This lift is performed using the Hausmann Work Well Systems lifting station or something similar. The bottom shelf should be positioned as adjusted in squat lifting. The client should be asked to lift the box that has an opening and closing lid and they should be allowed to lift the box in any fashion they feel safe in lifting the box overhead. They could use the handles or lift the general aspects of the box. They should grasp the bottom handles or the box in any fashion they would like and lift the box to the top of the lifting station with no weight in the box for up to five repetitions at each weight level. The box should not be let go of in between each repetition and then placed back on to the bottom shelf after the fifth repetition. The box itself may weigh 15 pounds empty and based on the client’s ability following the empty box lift you can add 10 pounds, or 5 pounds based on their mechanics or the pain they reported. The starting weight for a frequent lift should be 25% of what they lifted occasionally. When performing this lift in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. You may even need to start with a lighter weight as the box lift may start at greater than 25% of what they did occasionally. This test will commence until one of the three criteria listed earlier are achieved.



If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regard to frequent lifting. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift from floor to waist. The client should be instructed to “I am now going to evaluate your ability to perform frequent overhead lifting”. “I would like you to grasp the box in any fashion you feel comfortable, lift the box from waist level height to overhead, place the box on this overhead shelf, and then return the box to the same position it started”. Please do not let go of the box and I would like you to perform as many repetitions as you can up to five repetitions.” When instructing the client on the procedure you may need to demonstrate what you mean by an overhead lift however you did recently perform overhead lifting in occasional material handling. The FCE allows for documentation that includes the pre-lift heart rate, the peak frequent weight, the safe frequent weight, the heart rate and the exertion level. The peak frequent weight is the maximum weight the client was able to lift for one to five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may lift 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.



Frequent Bilateral Carrying

Carrying uses the same two handled, open and closed lid box, as the lifting evaluations used. The box should be placed on the bottom shelf that is still in the same position as when lifting was performed, the client should grasp the bottom handles, carry the box for 25 feet, turn around and return to the lifting station. The box itself may weigh 15 pounds empty and based on the client’s ability following the empty box carry you can add 10 pounds, or 5 pounds based on their mechanics or the pain they reported. The starting weight for a frequent lift should be 25% of what they lifted occasionally. When performing this carry in a kinesiophysical approach you will ask the client “would you like to add 5 or 10 pounds” as long as the client is at a level that they have not mechanical changes. You may even need to start with a lighter weight as the box lift may start at greater than 25% of what they did occasionally. This test will commence until one of the three criteria listed earlier are achieved. If performing this test in a psychophysical approach as, during a baseline work hardening evaluation, then as a professional you need to agree with the client that you also feel they have reached their baseline maximum in regard to frequent carrying. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. The maximum weight they can safely perform for five repetitions is then considered the weight the worker could perform on a frequent basis throughout an average shift for carrying. This test allows for mild variations in the carrying distance. For instance, if a client performs up to 100-pound carrying throughout their normal shift, they may not need to carry this much weight for 50-feet. In this situation the client should carry the weight the



job specific distance and this should be properly documented in the carrying comments section. The client should be instructed, “The test you will now perform is the carrying test”. “I would like for you to grasp the box using the bottom handles and then carry the box for 25 feet and then turn around and bring the box back to the lower shelf”. “Please do not let go of the box and I would like you to perform as many repetitions as you can up to five repetitions.” The FCE allows for documentation that includes the peak frequent weight, the safe frequent weight, the heart rate and the exertion level. The peak frequent weight is the maximum weight the client was able to carry for one to five repetitions. This weight however may not be the weight in which, you as a medical professional feel, is the safe frequent weight the client can perform. The weights may be the same and they may be very different. A client may carry 50 pounds frequently and demonstrate mechanical changes prior to completing the 5 repetitions. The client may have demonstrated the ability to perform 45 pounds on a frequent basis at a safer level while completing those 5 repetitions. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided to use for determining the reasons this lift was terminated. The last item that needs to be documented is the client’s self reported pain symptoms.

Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.



Frequent Unilateral Lift

This lift is performed using the Hausmann Work Well Systems lifting station or a similar lifting station. The bottom shelf of the lifting station should be positioned at or slightly higher than the client’s waist. The client will be asked to start with a five-pound ankle weight/dumbbell/or disc weight and lift this weight from the top of the closed lid box to the shelf at waist height for 5 repetitions. The weight is then transferred to the other side of the body to test the opposite arm. The client should perform a 90 degree turn when placing the ankle weight/dumbbell or disc weight on the shelf and a 90 degree turn when placing the weigh on the shelf. This is important in that you want to make sure the client is fully facing the way they are lifting or placing to decrease the likelihood of injury. The test is then raised by 5 pounds up to a 10-pound ankle weight/dumbbell/or disc weight and performed utilizing the right and left upper extremity. The starting weight for a frequent lift should be 25% of what they lifted occasionally. The next level up is the 15-pound box and the smaller of the two, handled Hausmann lifting box is utilized. This box begins at 15 pounds empty and again is manipulated from the floor to the shelf at waist height. The box is increased by 5-pound increments until a safe maximum level is reached. This is completed on both upper extremities until a maximum safe level is achieved on both the right and left upper extremity. As a professional you need to agree with the patient that you also feel the client has reached their maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well. This maximum weight is then considered the weight the client could perform on an occasional basis throughout an average shift from knee to waist.



It should be noted that per a Job Demands Analysis or a detailed job description, this client might need to perform unilateral lifting up to and exceeding the level of their shoulder based on their job. This test then needs to be modified to allow testing that is related to the essential physical demands of their job. The client should be instructed to “I am now going to evaluate your ability to perform lifting using your left and right arm. I would like you to perform a lift in which you are squatting to this ankle weight/dumbbell/disc weight on the top of this box, lift the weight, turn and place the ankle weight on this shelf, and then return the weight to the box. I would like you to perform as many repetitions as you can up to five repetitions. Depending how you do we will then increase the weight as appropriate.” When instructing the client on the procedure you may need to demonstrate what you mean by this type of lift. The FCE allows for documentation that includes the peak frequent weight, the safe frequent weight, and the heart rate. The safe frequent weight needs to be the lowest weight the client performed regardless of the extremity. For instance, if the client tolerated 25 pounds maximum on the right upper extremity and only 15 pounds on the left, then the safe frequent weight the client could tolerate in an employment setting would be the 15-pound weight. The peak frequent weight is the maximum weight the client was able to lift during the test for one to five repetitions. This weight however may not be the weight in which you as a medical professional feel are the safe maximum frequent weight for the client. The weights may be the same and they may be very different. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These check boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.



Frequent Unilateral Carry

This carry is performed with the weight starting at a job specific height or on the top of the lifting box. The client will be asked to start with a five pound ankle weight/dumbbell/or disc weight and carry for 25 feet out and 25 feet in return for up to 5 repetitions. The weight is then transferred to the other side of the body to test the opposite arm for carrying 5 repetitions. The test is then raised by 5 pounds up to a 10-pound ankle weight/dumbbell/or disc weight and performed utilizing the right and left upper extremity. The next level up is the 15-pound box and the smaller of the two, handled Hausmann lifting box is utilized. The starting weight for a frequent lift should be 25% of what they lifted occasionally. This box begins at 15 pounds empty and again is carried for 25 feet. The box is increased by 5-pound increments until a safe maximum level is reached. If the clients job requires a certain distance for unilateral carrying on a frequent basis then the test should be changed to carry that specific distance and not the standard distance of 50 total feet. The client should be instructed to “I am now going to evaluate your ability to perform one handed carrying using your left and right arm. I would like you to perform a carry for 25 feet out in which you are squatting to this ankle weight/dumbbell/disc weight on the top of this box, lift the weight, turn and carry it for 25 feet, and then return this position to place the weight down for a moment and then carry for the next repetition. I would like you to perform as many repetitions as you can up to five repetitions. Depending how you do we will then increase the weight as appropriate.” When instructing the client on the procedure you may need to demonstrate what you mean by this type of unilateral carry. The FCE allows for documentation that includes the peak frequent weight, the safe frequent weight, and the heart rate. The safe frequent weight needs to be the lowest weight the client performed regardless of the extremity. For



instance, if the client tolerated 25 pounds maximum on the right upper extremity and only 15 pounds on the left, then the safe frequent weight the client could tolerate in an employment setting would be the 15-pound weight. The peak weight is the maximum weight the client was able to carry. This weight however may not be the weight in which you as a medical professional feel are the safe maximum frequent weight for the client. The weights may be the same and they may be very different. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. These check boxes allow you to document the overall mechanics observed and the limiting factor. The last item that needs to be documented is the client’s self-reported pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the clients self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests. For a Reference: There is also a computerized calculation showing the correlation between the occasional lifting task and the frequent lifting task. This percentage will appear at the bottom of the “weights handled” under the frequent weight. The average client’s percent range should be within the 55-75%. This depicts the client’s ability of their material handling ability and should be close or within this range.

Frequent Pushing and Pulling

The pushing and pulling evaluation utilizes the push/pull sled and is also an important task in regard to material handling. The push/pull test can be measured in regard to



weight pushed or pulled in two different fashions. It can be measured in terms of the amount of weight in the push pull sled or it can be measured by the amount of force required to push and pull which is termed horizontal force pounds. These two measurements are important because someone pushing 500 pounds on a cart with great wheels really does not apply 500 pounds of force to push or pull that cart. They may be exerting only 50 pounds of force. The opposite may occur when a client is pushing and pulling an item with 50 pounds in it and it may require 100 horizontal force pounds to move the cart because of poor wheels or the type of floor it is pushed on. Thus, we need a constant scale to use because it is impossible to get a cart and put 500 pounds on it in a therapy clinic. This is where the push pull cart comes into play while taking into account the friction factor of the floor and horizontal force pounds this generates. The starting weight for a frequent lift should be 25% of what they lifted occasionally. The best way to determine the amount of horizontal force pounds required to push and pull your cart with weight in it is to load up the cart, attach a force gauge, and give the cart a whirl. On a normal carpeted floor, the push pull cart requires 20 horizontal force pounds (hfp) to operate it. Typically, then as you add 15 pounds of weight it adds 5 hfp to push and pull the cart. The client should be instructed, “The test you will now perform is the frequent push/pull test”. “I would like for you to grasp any handle of the sled and then push the sled for 25 feet and then pull the sled for 25 feet”. “I would like you to perform as many repetitions as you can up to five repetitions.” The sled begins empty and the client is instructed to push the sled for 25 feet and then pull it back to the start. The sled itself may weigh 20 horizontal force pounds empty or requires 20 pounds of force to push and pull. Based on the client’s ability following the sled push and pull you can add 15 pounds, which may increase the HFP by 5 pounds based on your coefficient of friction. *Please Note: the force the sled takes to push/pull empty should be calculated with the carpet or surface in your particular clinic by using a Chatillon Gauge. This should be done based off of the effort they exhibited and/or the pain they reported. This push and pull evaluation should be performed until the client reaches one of the three criteria outlined earlier in this chapter for stopping a frequent test. If performing in a psychophysical approach, then as a professional you need to agree with the client that you also feel they reached their maximum. There may also be times when the client wants to continue, and you feel that they have reached their safe maximum as well.



The frequent push and pull is then considered the weight the client could perform on a frequent basis throughout an average shift. The FCE allows for documentation that includes the peak frequent weight, the safe frequent horizontal force pound push and pull weight, and the heart rate. The peak frequent weight is the maximum weight the client was able to push or pull. This weight however may not be the weight in which you as a medical professional feel are the safe frequent weight for the client. The weights may be the same and they may be very different. A client may push and pull 50 horizontal force pounds and demonstrate a significant struggle to complete with verbal grunting, facial grimacing and significant biomechanical changes. The client completed the weight but is it a safe weight based on your observation? The client may have demonstrated the ability to perform 45 horizontal force pounds and it was a safer level and did not exceed their aerobic limiter, did not have mechanical changes and they’re within pace cadence stayed the same. This would be the safe frequent weight and the weight that the report will generate as the clients ability for return to work. Drop down boxes are then provided as a tool for later reference when documenting in the comments section. The last item that needs to be documented is the client’s self reported functional pain symptoms. Frequent lifting testing utilizes a rating of perceived exertion formula to calculate the client’s self report of the tasks difficulty and comparing this to the client’s heart rate. This helps to establish cardiovascular endurance, symptom exaggeration or if the client is underestimating the difficulty of the task. The specifics of this are described below for each of the frequent tests.

RATING OF PERCIEVED EXERTION FORMULA Following each of the frequent material handling tests the client’s heart rate is recorded. The client is then asked to rate their perceived exertion using the Borg Rating of Perceived Exertion scale. Borg demonstrated a correlation between a client’s heart rate



during an activity involving fatigue of large muscle groups and their rating of perceived exertion. In essence a client reporting significant exertion during frequent lifting testing should have a correlated increase in their heart rate. If the client does not have a correlated increase in heart rate there are questions of symptom exaggeration that should be raised. This formula also allows for cardiovascular fitness documentation. If a client lifts minimal weight for only four repetitions but exhibits a significant increase in heart rate than cardiovascular concerns are present. The Borg scale used is as follows:

Borg CR-20 Rating of Perceived Exertion Scale

Very, Very Light

Fairly Light Hard Very, Very Hard

Very Light Somewhat Hard Very Hard 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

The formula utilized in this section is RPE*10-HR=. For instance, if a client has a heart rate of 125 during testing and reports a rating of perceived exertion at 12 than this would be 12*10= 120. Then subtract the heart rate of 125 and the formula calculates out to -5. This would be considered an acceptable correlation. The breakdown occurs as follows. Acceptable Correlation (-15 to +20)

Large Negative Numbers (<-15) Poor Cardiovascular fitness Underestimating Difficulty

Moderate Positive Numbers (21-49) Mild Exaggeration of Difficulty of Task Poor Musculoskeletal fitness Good CV

Fit Large Positive Numbers (≥+50)

Symptom Exaggeration

If a client reports a rating of perceived exertion at hard or 15 and their heart rate is 85 beats per minute following frequent power lifting, then the formula calculates out to 65. This would fall into large positive numbers and would suggest symptom exaggeration. Typically, in this situation the client being tested has lifted minimal weight for a few repetitions and report significant exertion without an appreciable increase in heart rate. The client can even be told that the rating of perceived exertion is not pain related and pain should not be considered in their report.



Sources Cited

Borg. Perceived exertion is how hard you feel your body is working. It is based on the physical sensations a person experiences during physical activity, including increased heart rate, increased respiration or breathing rate, increased sweating, and muscle fatigue. Although this is a subjective measure, a person's exertion rating may provide a fairly good estimate of the actual heart rate during physical activity* (Borg, 1998). Borg RPE scale © Gunnar Borg, 1970, 1985, 1994, 1998

Research (Journal of Sports Sciences, 2002,20,873-899) found that there is a correlation between an athlete's rate of perceived exertion (RPE) and their heart rate, lactate levels, % VO2 max, and breathing rate.

OccuPro Functional Capacity Evaluation Constant Material Handling


Chapter 12

Constant Material Handling

Very few jobs require constant material handling. The American Physical Therapy Association Current Concepts in Functional Capacity Evaluations suggests that constant is 500 or more repetitions during a work shift. However, the United States Department of Labor classifies constant as being 66% of the time. Within an 8-hour workday there is 28,800 seconds. 66% of this would be 19,008 seconds. If you performed a time study on one lift you may give it a healthy 5 seconds to complete one lift. 500 lifts times 5 seconds comes out to 2,500 seconds to achieve constant lifting in a work shift. 2,500 seconds of lifting is nowhere near 66% of a shift or 19,008 seconds. However, since the current and accepted documentation in the United States says 500 repetitions constitute constant, we will also go with this number of repetitions being constant. Within the OccuPro Functional Capacity Evaluation software there are a few ways to document constant lifting, carrying, pushing and pulling. These various methods are outlined below.

Disability Based FCE’s A disability based FCE could be performed for long term disability reasons, Social Security Income reasons, Social Security Disability Income reasons or other disability-based reasons. When these types of FCE’s are performed there is typically no job demands to compare the clients abilities to. When performing these types of FCE’s you will perform occasional material handling and frequent material handling. You will also perform upper extremity testing and positional tolerances. If your client is able to achieve some weight occasionally and frequently the software looks at what that tasks also requires regarding upper extremity and positional tolerances. As long as the upper extremity and positional tolerances are also constant the software will calculate 20% of what the client did occasionally as the constant weight. For example, if your client demonstrates the ability to lift 50 pounds occasionally and 20 pounds frequently, the software looks to see if they achieved grasping, reaching and squatting constantly as well. If they have, then the software will calculate constant lifting at 10 pounds.



However, if a client is able to lift 50 pounds occasionally, lift 20 pounds frequently but is only able to grasp frequently, and/or squat frequently, and or reach frequently then the software will calculate constant as being zero pounds. This is due to the fact that this client is unable to for instance grasp a box constantly. So, if they cannot grasp a box constantly then they would not be able to lift constantly.

Job Specific FCE

When performing a job specific return to work FCE within the workers compensation system you will have gathered the physical demands of the job via a job description, via an on-site job analysis, through the Dictionary of Occupational Titles, or via an interview of the client. If through one of these methods, it is determined that the job requires some material handling constantly then in the Job Demands Analysis module within the software you can document this constant material handling need. This documentation of the job demands can happen in one of two ways:

1. In the Job Demands Analysis module you can documents a Job Simulated constant material handling test (best method)

2. In the material handling tab, you can document some constant material handling levels.

Calculation method If you decide to document the jobs constant material handling requirements in the material handling tab within the Job Demands Analysis module the software will calculate the claimants constant material handling abilities based on the following calculation method. If your client is able to achieve some weight occasionally and frequently the software looks at what that tasks also requires regarding upper extremity and positional tolerances. As long as the upper extremity and positional tolerances are also constant the software will calculate 20% of what the client did occasionally as the constant weight for the specific constant material handling job demand needed For example, if the job demand suggest your client needs to lift floor to waist constantly and your client demonstrates the ability to lift 50 pounds occasionally from floor to waist and 20 pounds frequently from for to waist , the software looks to see if they achieved grasping, reaching and squatting constantly as well. If they have met all of these criteria, then the software will calculate constant lifting at 10 pounds. However, if a client is required to lift floor to waist constantly and is able to lift 50 pounds occasionally from floor to waist, lift 20 pounds frequently from floor to waist but is only able to grasp frequently, and/or squat frequently, and or reach frequently then the software will calculate constant flor to waist lifting as being zero pounds. This is due to the fact that this client is unable to for instance grasp a box constantly. So, if they cannot grasp a box constantly then they would not be able to lift constantly.



Job Simulation Method When performing a job specific Functional Capacity Evaluation, you may have a claimant whose job requires constant material handling. It would be common that this constant activity would require both lifting and carrying to and from a specific height and at a specific distance. It would be most prudent to perform job simulated lifting and carrying in a job specific FCE. This would be completed by documenting the specific lift and carry job simulated test in the software Job Demands Analysis module and within the Job Simulation tab. Then later on in the test you would actually perform the job simulated test and document this in the Job Simulated Functional Abilities module. See Chapter 10 Job Simulated Functional Abilities section for specifics on performing job simulated tests.

OccuPro Functional Capacity Evaluation Sit – Stand – Climb


Chapter 13

Sit – Stand – Climb

Climbing Stair Climbing Stair climbing is a functional task that may be assessed for either a baseline FCE or job specific FCE. Stair climbing is usually an important aspect in most of the client’s home situation. This is an activity that a client should be able to attempt. If not it is questionable how they perform functional tasks at work or home and will need to identify compensatory techniques with functional activities. This task is used with the 7” rise and a 11-inch run on the step or a formal staircase in the clinic. The client is requested to ascend the stairs using a reciprocal gait pattern and using the handrails for only safety reasons. If a client requires the use of a gait belt while ambulating, at the evaluator’s discretion may not test stair climbing due to safety concerns. In this case, the client may use the 4” step rise to determine the actual deficit the client has whether it is negotiate stairs, balance, or lower extremity strength which will assist in the streamlining of the client’s plan of care for therapy. This may be tested if the client lives independently and is required to negotiate stairs in the home environment. Stair climbing 36 steps The first set of stair climbing consists of 1-36 steps. The evaluator should request the client to perform stating: “I want you to climb up the staircase and come back down without using the handrails- unless you need them for safety for a total of 36 steps”. After the task is completed the evaluator will need to obtain the client’s heart rate, reported functional pain level, and the client’s perceived rate of exertion using the Borg Scale. Stair climbing 72 steps The second set of stair climbing consists of 36-72 steps. The evaluator should request the client to perform stating: “I want you to climb up the stair case and come back down without using the handrails- unless you need them for safety for a total of 36 steps”. After the task is completed the evaluator will need to obtain the client’s heart rate,



reported functional pain level, and the client’s perceived rate of exertion using the Borg Scale. Stair climbing 108 steps The third set of stair climbing consists of 71-108 steps. The evaluator should request the client to perform stating: “I want you to climb up the stair case and come back down without using the handrails- unless you need them for safety for a total of36 steps”. After the task is completed the evaluator will need to obtain the client’s heart rate, reported pain level, and the client’s perceived rate of exertion using the Borg Scale. The overall number of stairs that the client was able to perform may assist the evaluator in classifying the frequency level the client is able to perform. Listed below is only an example that may assist in classifying the frequency.

For Example: If the client’s job requires continuous stair climbing, the evaluator may want to test the client greater than 108 steps and combine this task with a particular material-handling task depending on the job. For instance: the client’s occupation is of a residential realtor, which requires stair climbing when showing various homes. The client may show a 2-story home and 2 per hour, which may result to stair climbing 120 steps per hour. The client should then be tested for the ability to negotiate stairs of 120 steps within an hour to fully document the client’s ability to perform the essential functions of the job.



Comment Section The evaluator will need to identify the frequency the client is able to perform this task at via the radial button. The software will pre-populate the frequency in the comment section. The evaluator should also identify any compensatory techniques used, gait pattern, weight bearing deficits, balance deficits, client reports of increased pain/discomfort and any physical pain behaviors observed.

Ladder Climbing Ladder climbing is a functional task that may be performed for daily activities or job specific activities. Some jobs that may require ladder climbing consists of: roofer, fire fighter, carpenter, painter, warehouse laborer, tanker driver, department of public works employees, trimming trees, etc. The task of ladder climbing is typically tested when performing a job simulated FCE or combined with a job simulation task. However, the evaluator may test this task separately to ensure the client’ ability prior to pairing with multiple tasks. The clinic should have at least a 6-foot ladder to use for this testing. If the client demonstrated ladder climbing using a different size ladder, the evaluator should identify the height difference in the comment section. Please note: If the client demonstrates balance deficits, the evaluator may decide this task should not be tested at this time and defer testing to a later date. The evaluator will need to document any and all safety concerns presented. This task may then be placed on an avoid basis.



Ladder climbing times 5 repetitions The evaluator will instruct the client “I want you to climb up this ladder to the fourth rung for 5 repetitions, alternating your step with both feet touching the top fourth rung and then both feet touching the floor”. The first is ladder climbing for a total of 5 repetitions. The evaluator will need to obtain the client’s heart rate, rate of perceived exertion and the client’s pain level. The evaluator will need to determine whether the client is able to continue or not. The evaluator will need to use the drop down boxes for determining or identifying the limiting factors that occurred during this task. Ladder climbing times 10 repetitions (5-15) for total of 15 The second section of ladder climbing is to request the client to climb for a total of 15 repetitions. “I want you to climb up this ladder to the fourth rung for 10 repetitions, alternating your step with both feet touching the top fourth rung and then both feet touching the floor”. The evaluator will need to obtain the client’s heart rate, rate of perceived exertion and the client’s pain level. The evaluator will need to use the drop-down boxes for determining or identifying the limiting factors that occurred during this task. Ladder climbing times 10 repetitions (16-25) for total of 25 The last section is having the client perform ladder climbing for a total of 25 repetitions up to the 4 rungs. “I want you to climb up this ladder to the fourth rung for 10 repetitions, alternating your step with both feet touching the top fourth rung and then both feet touching the floor”. The evaluator will need to obtain the client’s heart rate, rate of perceived exertion and the client’s pain level. The evaluator will need to use the drop down boxes for determining or identifying the limiting factors that occurred during this task. Comment Section The evaluator will need to identify the frequency the client is able to perform this task at via the radial button. It should also be noted to identify all the limiting factors that the client demonstrated or exhibited during this task via using the drop down boxes and the software will automatically put into the comment box. The software will pre-populate the frequency in the comment section. The evaluator should also identify any compensatory techniques used, gait pattern, weight bearing deficits, balance deficits, client reports of increased pain/discomfort and any physical pain behaviors observed.



Reliability of Pain Criteria In the COE/ROP module under the tab for climbing there is a calculation that looks at the rating of perceived exertion of climbing activities and whether the pain reports were reliable pain reports for each level of climbing.



Sitting and Standing

Sitting and standing should be tested from the start of your FCE. If using the OccuPro software, you should have used the sitting and standing timer throughout your FCE. It is common that in the workers’ compensation system sitting and standing is determined based on avoid, occasional, frequent and/or constant. If you are performing a FCE for disability reasons it is common that sitting and standing is determined based on the hours a person can sit or stand. Sitting When performing a workers’ compensation based FCE and determining sitting ability based on occasional, frequent or constant you will want to know the total time it took to perform your FCE. Then you will want to know the total amount of time the claimant sat during your FCE. Then take a percentage of this compared to the total time. For instance, if the FCE took 4 hours and during the FCE the client sat for 2 hours total that would be 50% of the FCE and thus the client would be placed at Frequent for sitting abilities. If you are performing a disability based FCE and are required to document sitting based on the total hours a person can sit during a work day and how many hours at one time a person can sit then you will use a method in which you document the demonstrated time in your test along with some self-reported sitting questions. During the evaluation, the client will demonstrate a total amount of sitting time and an amount of sitting at one time they can tolerate. Then various sitting questions will be asked to determine their sitting before the test and what they perceive their ability will be after the test. The questions that need to be answered are as follows:



1. Sleeping and Lying Down a. How many hours did you sleep last night? b. How many hours do you lie down during a day? (Not sleeping)

2. Total Sitting

a. How long did it take you to drive to this evaluation? b. How long were you sitting prior to driving to this evaluation? c. How many hours do you anticipate being in a sitting position after this

evaluation? d. How many hours total did the client sit during this evaluation? e. How many hours total could you sit during your workday?

3. At one time Sitting a. What was the longest this client sat at one time during this evaluation? b. How many hours at once could you tolerate sitting before needing to

change positions? Body mechanics, sitting posture, and changing of positions should be observed and noted, as this is an important aspect of an individual that may perform prolonged sitting throughout their shift. The software will automatically calculate the final totals for the report of the sitting abilities of the client based on the numbers that were entered. Sitting ability should be documented in the recommendation section of this evaluation with a frequency of ability based on what the client was able to demonstrate. For instance, a client who is a rural mail carrier, their job requires them to perform 4 hours of sitting and they have sustained a lumbar injury. Their job simulation may be to perform 4 hours of sitting while twisting to place simulated mail into mailboxes. The client was a quarry worker who drove a dump truck around the quarry for up to 12 hours and they needed to demonstrate the ability to sit for up to 10 of those hours prior to discharge. This may seem excessive, but it was in the client’s best interest. The doctor could not make the call if the client could work for 12 hours bouncing in a dump truck and needed to have documentation that stated whether or not the client could perform this for return to work.



Standing When performing a workers’ compensation based FCE and determining standing ability based on occasional, frequent or constant you will want to know the total time it took to perform your FCE. Then you will want to know the total amount of time the claimant stood during your FCE. Then take a percentage of this compared to the total time. For instance, if the FCE took 4 hours and during the FCE the client stood for 1-hour total that would be 25% of the FCE and thus the client would be placed at Occasional for sitting abilities. If you are performing a disability based FCE and are required to document standing based on the total hours a person can stand during a work day and how many hours at one time a person can stand then you will use a method in which you document the demonstrated time in your test along with some self-reported standing questions. During the evaluation, the client will demonstrate a total amount of standing time and an amount of standing at one time they can tolerate. Then various standing questions will be asked to determine their standing before the test and what they perceive their ability will be after the test. The questions that need to be answered are as follows:

1. Total Standing a. How many hours were you in a standing position prior to coming to this

evaluation? b. How many hours total did the client stand during this evaluation? c. How many hours do you anticipate being in a standing position after this

evaluation? d. How many hours total could you stand during your work day?

2. At one time Standing a. What was the longest this client stood at one time during this evaluation?



b. How many hours at once could you tolerate standing before needing to change positions?

Posture/Body mechanics is also noted, as this is an important aspect of an individual that may perform any amount of standing throughout their shift. The software will automatically calculate the final totals for the report of the standing abilities of the client based on the numbers that were entered- using the drop-down boxes. Examples:

1. An individual may need to stand in an 8 foot by 4-foot work cell and work on 2 different machines. He would be walking between the separate machines but only taking a few steps and a pivot/turn. You may need to document what the client demonstrated during job simulation activities that would correlate to this standing tolerance physical demand.

2. A client may be a cashier at a grocery store. This would consist of standing for

several hours at a time and may be paired with another task in the job simulation section. The client should be assessed during this evaluation for standing ability/tolerance in order to determine if the client is able to return to work in regard to standing. When identifying the client’s ability to stand at one time, the evaluator should consider what limiting factors the client has, equal weight distribution to their lower extremities, leaning on a table/wall, etc. since this would decrease the overall client’s ability.

Standing frequency should be documented in the recommendation section of this evaluation with a frequency of ability based on what the client was able to demonstrate.

OccuPro Functional Capacity Evaluation Results and Recommendations


Chapter 14

Results and Recommendations The evaluation results and summary tab includes five tabs that will be described later in the section. In this area, the evaluator will need to proof the text and add pertinent information into each text section. There are buttons in this module that will assist in the finalizing of the report. They consist of the following: Check Request Review This is a feature that will allow the evaluator to send the report to OccuCare for a quality assurance check. This will ensure that the final report to correct. ABC Spell check This spell check tab will assist with the proof all the text on that particular data page. It will find any spelling errors, allow for correction, to add to the word to the dictionary, and to option to ignore the individual word. Create Report This tab is what the evaluator will do when the report has been completed finished. This edition of the report ensures full security of the final product maintaining the inability to change or edit the report. Once this has been completed, the report is ready for Help This tab will let the evaluator scroll on this as a reminder as to what the evaluator will need to test or how to perform the particular test/task. View JDA Data This tab allows the evaluator to view the JDA information that was inputted in the beginning of the evaluation.

Evaluations Results/Summary Assessment Purpose This section will re-populate the information you put in early in the evaluation in regard to the overall purpose of the FCE.



Functional Abilities to Job Demands Match This text box is where the software will automatically calculate and pre-populate a statement reflecting the percentage the client has matched the physical demands to their occupation/job. The client’s current functional abilities that were tested and demonstrated will be directly compared to the job demands. The evaluator will need to test all areas entered in the JDA section in order to accurately display the percentage the client has matched their job/occupation. Consistency of Effort/Reliability of Pain This text box is automatically calculated by the software and will list the percentage of consistency of effort/validity the client has presented during the entire evaluation. This is a pre-populated statement performed by the software but maybe changed or added to if needed. If information has been changed but all the information has saved, this should be double checked to make sure that the graphs and statement are the same. Client/Occupation Physical Demand Level This text box area will identify the physical demand level the client is currently performing within. The evaluator will need to enter in the physical demand level (Sedentary, Light, Medium, Heavy, and Very Heavy) and remove the underscore pre-populated in this text box. Limiting Factors Noted During Testing The software will automatically put the information that has been entered in the previous areas of the software in to this section. Return to Work Recommendations The software will pre-populate the statement that is entered in the Job Demands Analysis section on the client’s current working status. Secondly, the evaluator will be able to add a recommendation in regard to their client’s ability to return to work. If the evaluator has enough information, they may make a decision in regards to whether the client is able to perform within the following recommendations: Full Duty Return to Work Full Duty Restricted Hours Return to Work Trial Modified/Light Duty

Modified/Light Duty Restricted hours Transitional/Gradual Return to Work Overtime Restriction Restricted from Work



If there is any other information that is pertinent to add to this section; the evaluator has the option to add to the text. The information in the return to work recommendation sheet will end up in your one-page Return to Work Recommendation sheet.

Evaluation Summary



Recommendations This is the most important section of the final report. This is what the physician or referral source is most concerned with, in order, to determine the next plan of care with the client. The evaluator needs to be detailed and very clear as to what the client is able to perform based on what they demonstrated during the evaluation. Recommendations The recommendation section is a blank text box for the evaluator to input their recommendations of the client. This should include the following but not limited to: what are the weight and levels the client is able to perform, list all the positional tolerances and abilities for the appropriate frequency level, whether the client is able to return to work-at what physical demands and job duties, and whether there are any physical demands or positional tolerances that should be avoided need to be clearly identified. Rehabilitation Recommendations This specific text box it designed to list the evaluator’s medical opinion regarding any therapeutic recommendations and plan of care for the client. This should include any treatment protocol, frequency and duration, follow-up reassessment, and any other rehabilitation that the client may benefit from.

Evaluation Comments The evaluation comment section is a summary of all the comments that have been inputted in all the other areas of the tests. In each individual text box, the evaluator is



able to change and edit the text in this area- the evaluator does not need to go back to the individual task to change or edit wording. Again, the spell check is available on this section in order ensure the final product in the report is correct and accurate.

Report Customization Throughout the results and recommendations module you will notice check marks next to each text box. If there is information in these text boxes the check mark will be checked and this information will be in your report. If there is no information in the text box, because you did not perform that test, then that information by default will not show up in your reports. You have the option of un-checking the check box if you wouldn’t like that information in your final report. Some of the reasons to customize your reports would be

1. Sending a short report to the physician 2. Sending a long report to the insurance carrier 3. Sending only the aspects of the evaluation the client was unable to complete

fully

The report customization tab allows you to customize specific tables, graphs, and charts. You are also able to decide which material handling data you would like in the beginning of your reports



Charts and Graphs In this tab section, the charts and graphs consist of the summary of the how the client performed during the entire evaluation. The first pie graph is that of Job Demands Match. In the graph sample below, the client met 79.4% of the physical demands of the job, represented in the color yellow and was 20.6% a non-match of the client and occupation, represented in the color red. The second pie graph is Consistency of Effort. In the sample graph below, the client presented with 52.2% consistency of effort- noted in the yellow color. The 47.8% inconsistency, noted by the color red, reflects the overall inconsistency of all the tests performed. The third pie graph is Reliability of Pain. In the sample graph below, the client presented with 89.3% reliability of pain- noted in the yellow color. The 10.7%, noted by the color red, reflects the overall unreliable pain reports during all the tests performed.



Material Handling/Positional Tolerances/Non-Material Handling/Sitting/Standing Chart The first column in the chart below lists what physical demands were tested during the evaluation. The second column details what the client is currently able to perform and has demonstrated during the evaluation. The third column is that of what their job/occupation requires the client to be able to perform in order to return to work at full duty/full time. The fourth column documents whether there is a current match in the client’s abilities when compared to the physical demand requirements for the job/occupation.



Pain Rating Summary Line Graph The following graph consists of all the pain ratings that were reported during all the tests and summarized in the graph below. This graph will only show the particular tasks tested. This graph will provide valuable information for the evaluator when assessing the client’s physiological responses when compared to the heart rate summary graph as well.



Heart Rate Summary Line Graph The following graph consists of all the heart rate ratings that were reported during all the tests and summarized in the graph below. This graph will only show the particular tasks tested. This graph will provide valuable information for the evaluator when assessing the client’s physiological responses when compared to the pain ratings summary graph as well.

OccuPro Functional Capacity Evaluation Written Report


Chapter 15

Written Report

Create Report

The final report may be viewed after clicking the button titled “Create Report” in the lower left-hand side of the software. This will generate the final version of the report in order to distribute to all parties. If there is an error noted in text of the report, the evaluator will be able to correct and change by returning to the Evaluation Results and Summary section in the OAA. Create Report This button is what the evaluator will click when the report is ready to be generated. This edition of the report ensures full security of the final product maintaining the inability to change or edit the report. After clicking he create report button a screen will appear titled Assessment Download. In this screen you may have the option of inputting an assessment addendum, adding a second signature line to your report, adding your signature to the Return to Work Recommendation sheet, or change the name of your FCE. The assessment addendum provides you an area to document any changes to your results following a previous distribution of your report. There may be instances were you had already distributed your report to your customers and realized that you had made a mistake that requires further documentation. The assessment addendum will place a written paragraph at the beginning of your second report outlining why your customer is receiving a second report on the same client. The second signature box allows clinicians who require a co-signature to put their primary therapists name and credentials in the software to ultimately provide them a professional signature line to sign off on the report. The RTW Rec. Signature allows the clinician to put your professional software based signature onto the Return to Work Recommendation sheet which is generated along with your reports. Some clinicians want to let employers know that they performed objective functional testing and were responsible for the results on this one page sheet. Other clinicians like to not have their signature on this form and allow the Dr to decided if they would like to use this or not.



Lastly on this screen clinicians in different parts of North America call their reports various names and in this section, you have the ability to call your report what you would like to call based on your market or state legislation.

Now that all of your report choices and customization is complete you will now create the assessment PDF and once this is completed you will have two links as noted in the screen shot below. The first link is your report and the second link is a one page return to work recommendation sheet. The one-page cover letter will summarize the most pertinent information from the FCE. The report will be your final documentation of the clients ability’s for a baseline FCE and the physical demand comparison for a job specific FCE. The one page Return to Work Recommendation sheet is used to provide your customer with a quick summary of the client’s functional abilities and can be used as a tool in which the Dr. signs off on this sheet and it is used for the return to work abilities.



Once the evaluator has finalized the report the next step is to save the report and/or the cover letter and/or the one page return to work recommendation sheet.

1. Click on “Save a Copy” 2. Then choose what file you wish to save it in 3. Create file name: last name.first name JDA date

a. For example: Smith.Tom JDA 12-21-05 4. Save as type: should default to “Adobe PDF Files (*.pdf)” 5. Then click “Save”

The final step is process the report by distribution to all necessary parties. Once the evaluator has clicked on the PDF Report, the report will then be generated. There is a sample of what the final version of the report will look like.


211

APPENDIX A

* The above mean scores for older subjects may be slightly lower (0-10 pounds lower than they should be) due to instrument error detected after study.

Average Performance of Normal Subjects on GRIP STRENGTH

(pounds) MALES FEMALES

Age Hand Mean* SD Range Mean* SD Range 20-24 R 121.0 20.6 91-167 70.4 14.5 46-95

L 104.5 21.8 71-150 61.0 13.1 33-88

25-29 R 120.8 23.0 78-158 74.5 13.9 48-97 L 110.5 16.2 77-139 63.5 12.2 48-97

30-34 R 121.8 22.4 70-170 78.7 19.2 46-137 L 110.4 21.7 64-145 68.0 17.7 36-115

35-39 R 119.7 24.0 76-176 74.1 10.8 50-99 L 112.9 21.7 73-157 66.3 11.7 49-91

40-44 R 116.8 20.7 84-165 70.4 13.5 38-103 L 112.8 18.7 73-157 62.3 13.8 35-94

45-49 R 109.9 23.0 65-155 62.2 15.1 39-100 L 100.8 22.8 58-160 56.0 12.7 37-83

50-54 R 113.6 18.1 79-151 65.8 11.6 38-87 L 101.9 17.0 70-143 57.3 10.7 35-76

55-59 R 101.1 26.7 59-131 57.3 12.5 33-86 L 83.2 23.4 43-117 47.3 11.9 31-76

60-64 R 89.7 20.4 51-137 55.1 10.1 37-77 L 76.8 20.3 26-116 45.7 10.1 29-66

65-69 R 91.1 20.6 56-131 49.6 9.7 35-74 L 76.8 19.8 43-117 41.0 8.2 29-63

70-74 R 75.3 21.5 32-108 49.6 11.7 33-78 L 64.8 18.1 32-93 41.5 10.2 23-67

75+ R 65.7 21.0 40-135 42.6 11.0 25-65 L 55.0 17.0 31-119 37.6 8.9 24-61

All Age R 104.3 28.3 32-176 62.8 17.0 25-137 Groups L 93.1 27.6 27-160 53.9 15.7 23-115


212

Average Performance of Normal Subjects on KEY PINCH


Age Hand Mean SD Range Mean SD Range 20-24 R 26.0 3.5 21-34 17.6 2.0 14-23

L 24.8 3.4 19-31 16.2 2.1 13-23

25-29 R 26.7 4.9 19-41 17.7 2.1 14-22 L 25.0 4.4 19-39 16.6 2.1 13-22

30-34 R 26.4 4.8 20-36 18.7 3.0 13-25 L 26.2 5.1 17-36 17.8 3.6 12-26

35-39 R 26.1 3.2 21-32 16.6 2.0 12-21 L 25.6 3.9 18-32 16.0 2.7 12-22

40-44 R 25.6 2.6 21-31 16.7 3.1 10-24 L 24.8 4.0 19-31 15.8 3.1 8-22

45-49 R 25.8 3.9 19-35 17.6 3.2 13-24 L 24.8 4.4 18-42 16.6 2.9 12-24

50-54 R 26.7 4.4 20-34 16.7 2.5 12-22 L 26.1 4.2 20-37 16.1 2.7 12-22

55-59 R 24.2 4.2 18-34 15.7 2.5 11-21 L 23.0 4.7 13-31 14.7 2.2 12-19

60-64 R 23.2 5.4 14-37 15.5 2.7 10-20 L 22.2 4.1 16-33 14.1 2.5 10-19

65-69 R 23.4 3.9 17-32 15.0 2.6 10-21 L 22.0 3.6 17-28 14.3 2.8 10-20

70-74 R 19.3 2.4 16-25 14.5 2.9 8-22 L 19.2 3.0 13-28 13.8 3.0 9-22

75+ R 20.5 4.6 9-31 12.6 2.3 8-17 L 19.1 3.0 13-24 11.4 2.6 7-16

All Age R 24.5 4.6 9-41 16.2 3.0 8-25 Groups L 23.6 4.6 11-42 15.3 3.1 7-26


213

Average Performance of Normal Subjects on PALMER PINCH



L 25.7 5.8 15-42 16.3 2.8 11-24

25-29 R 26.0 4.3 19-35 17.7 3.2 13-29 L 25.1 4.2 19-36 17.0 3.0 13-26

30-34 R 24.7 4.7 16-34 19.3 5.0 12-34 L 25.4 5.7 15-37 18.1 4.8 12-32

35-39 R 26.2 4.1 19-36 17.5 4.2 13-29 L 25.9 5.4 14-40 17.1 3.4 12-24

40-44 R 24.5 4.3 17-37 17.0 3.1 10-23 L 24.8 4.9 15-37 16.6 3.5 10-25

45-49 R 24.0 3.3 19-33 17.9 3.0 12-27 L 23.7 3.8 18-33 17.5 2.8 12-24

50-54 R 23.8 5.4 15-36 17.3 3.1 12-33 L 24.0 5.8 16-34 16.4 2.9 12-22

55-59 R 23.7 4.8 16-34 16.0 3.1 11-26 L 21.3 4.5 12-28 15.4 3.0 11-21

60-64 R 21.8 3.3 16-28 14.8 3.1 10-20 L 21.2 3.2 15-27 14.3 2.7 10-20

65-69 R 21.4 3.0 15-25 14.2 3.1 8-20 L 21.2 4.1 14-30 13.7 3.4 8-22

70-74 R 18.1 3.4 14-27 14.4 2.6 9-19 L 18.8 3.3 13-27 14.0 1.9 10-17

75+ R 18.7 4.2 9-26 12.0 2.6 8-17 L 18.3 3.8 10-26 11.5 2.6 6-16

All Age R 23.4 5.0 9-45 16.3 3.8 8-34 Groups L 23.0 5.3 10-42 15.7 3.6 6-32


214

Average Performance of Normal Subjects on TIP PINCH



L 17.0 2.3 12-33 10.5 1.7 8-14

25-29 R 18.3 4.4 10-34 11.9 1.8 8-16 L 17.5 5.2 12-36 11.3 1.8 9-18

30-34 R 17.6 6.7 12-25 12.6 3.0 8-20 L 17.6 4.8 10-27 11.7 2.8 7-17

35-39 R 18.0 3.6 12-27 11.6 2.5 8-19 L 17.7 3.8 10-24 11.9 2.4 8-16

40-44 R 17.8 4.0 11-25 11.5 2.7 5-15 L 17.7 3.5 12-25 11.1 3.0 6-17

45-49 R 18.7 4.9 12-30 13.2 3.0 9-19 L 17.6 4.1 12-28 12.1 2.7 7-18

50-54 R 18.3 4.0 11-24 12.5 2.2 9-18 L 17.8 3.9 12-26 11.4 2.4 7-16

55-59 R 16.6 3.3 11-24 11.7 1.7 9-16 L 15.0 3.7 10-26 10.4 1.4 8-13

60-64 R 15.8 3.9 9-22 10.1 2.1 7-17 L 15.3 3.7 9-23 9.9 2.0 6-15

65-69 R 17.0 4.2 11-27 10.6 2.0 7-15 L 15.4 2.9 10-27 10.5 2.4 7-17

70-74 R 13.8 2.6 11-21 10.1 2.6 7-15 L 13.3 2.6 10-21 9.8 2.3 6-17

75+ R 14.0 3.4 7-21 9.6 2.8 4-16 L 13.9 3.7 8-25 9.3 2.4 4-13

All Age R 17.0 4.1 7-34 11.3 2.6 4-20 Groups L 16.4 4.0 8-36 10.8 2.4 4-18


215

Average Performance of Normal Subjects on the Box and Block Test

(blocks transferred in one minute) MALES FEMALES


L 86.4 8.5 70-102 83.4 7.9 66-99

25-29 R 85.0 7.5 71-95 86.0 7.4 53-96 L 84.1 7.1 69-100 80.9 6.4 53-93

30-34 R 81.9 9.0 68-95 85.2 7.4 75-101 L 81.3 8.1 69-99 80.2 5.6 66-92

35-39 R 81.9 9.5 64-104 84.8 5.1 71-95 L 79.8 9.7 56-97 93.5 6.1 72-97

40-44 R 83.0 8.1 69-101 81.1 8.2 60-97 L 80.0 8.8 59-93 79.7 8.8 57-97

45-49 R 76.9 9.2 51-93 82.1 7.5 63-99 L 75.8 7.8 50-88 78.3 7.5 59-91

50-54 R 79.7 9.7 62-106 77.7 10.7 57-91 L 77.0 9.2 50-97 74.8 9.9 53-93

55-59 R 75.2 11.9 45-97 74.7 8.9 56-94 L 73.8 10.5 43-94 73.6 7.8 54-85

60-64 R 71.3 8.8 52-64 75.1 6.9 53-95 L 70.5 8.7 47-82 73.6 6.4 52-85

65-69 R 68.4 7.1 55-80 72.0 6.2 50-82 L 67.4 7.2 48-86 71.3 7.7 51-79

70-74 R 66.3 9.2 50-85 53.6 7.0 55-87 L 64.3 9.8 45-84 58.3 7.0 53-89

75+ R 53.0 7.2 47-75 65.0 7.1 52-79 L 51.3 8.4 46-74 63.6 7.4 51-81

All Age R 17.0 4.1 7-34 11.3 2.6 4-20 Groups L 16.4 4.0 8-36 10.8 2.4 4-18

OCCUPRO Functional Capacity Evaluation Appendix B

216


APPENDIX B – Functional Capacity Evaluation Research

General

James, C.L., Reneman, M.F. and Gross, D.P. (2015) “Functional Capacity Evaluation Research: Report from the second international functional capacity evaluation research meeting” Journal of Occupational Rehabilitation

Trippolini, M.A, Dijkstra, P.U., Geertzen, J.H.B. and Reneman, M.F. (2014) “Construct validity of functional capacity evaluation with whiplash associated disorders” Journal of Occupational Rehabilitation

Fore, L. Perez, T., Neblett, R., Asih, s., Mayer, T, and Gatchel, R. (2015) “Improved Functional Capacity Evaluation Performance Predicts Successful Return to Work One Year after Completing a Functional Restoration Rehabilitation Program” Physical Medicine and Rehabilitation 7:4 365-375

Ratzon, N.Z., Amit, Y. Friedman, S., Zamir, S. and Rand, D (2015) “Functional capacity evaluation: Does it change the determination of the degree of work disability” Disability and Health Journal 8:1 80-85

Orthopedic Section of the American Physical Therapy Association (2018). Occupational Health Physical Therapy: Evaluating Functional capacity Guidelines. Accessed 10/28/2018 https://www.orthopt.org/uploads/content_files/files/2018%20Current%20Concepts%20in%20OH%20PT-FCE%2006-20-18%20FINAL.pdf

American Physical Therapy Association (2011). Defensible Documentation: Setting Specific Considerations in Documentation. Accessed 11/30/11 from http://www.apta.org/documentation/defensibledocumentation/specificconsiderations/

OWind, H., Gouttebarge, V., Kuijer, P., Sluiter, J. and Frings-Dresen, M. (2009) “Complementary value of functional capacity evaluation for physicians in assessing the physical work ability of workers with musculoskeletal disorders” International Archive Occupational and Environmental Health (82) 435-443

Mitchell, T. (2008) “Utilization of the functional capacity evaluation in vocational rehabilitation” Journal of Vocational Rehabilitation (28) 21-28

Soer, R., Geertzen, J. Reneman, M, Groothoff, J., and van der Schans, C (2008) “Towards consensus in operational definitions in functional capacity evaluation: a delphi survey” Journal of Occupational Rehabilitation (18) 389-400

Innes, EV and Straker, L (1999). “Validity of work related assessments”. Work 13: 125-152


217


Innes, EV and Straker, L (1999). “Reliability of work related assessments”. Work 13: 107-124

Innes, E (2006) “Reliability and validity of functional capacity evaluations: an update” International Journal of Disability Management Research (1)1 135-148

Simons, G. (2006). “Credibility Crisis in FCE’s”. Ptproductsonline.com

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996). “Evidence based medicine: what it is and what it isn’t”. BMJ 312: 71-2.

Matheson, L (2003) “The functional capacity evaluation”. Disability Evaluation 2nd edition G. Anderson & S. Detmer & G. Smith. Mosby Yearbook, Chicago, IL.

James, C. Mackenzie, L. and Higginbotham, N. (2007) “Health professionals attitudes and practices in relation to functional capacity evaluations” Work (29) 81-87

OccuPro Specific Research Scheel, C., Mecham, J., Zuccarello, V. and Mattes, R. (2018) “An evaluation of the inter-rater and intra-rater reliability of OccuPro’s functional capacity evaluation” Journal of Work 60 465-473

Devaguptapu, N. (2009) “The Intra Rater reliability of lifting, carrying, pushing/pulling of OccuPro’s Functional Capacity Evaluation” Unpublished Manuscript, Concordia University of Wisconsin Research Project Gunda, A. (2009) “The Inter Rater Reliability of lifting, carrying, pushing/pulling of OccuPro’s Functional Capacity Evaluation” Unpublished Manuscript, Concordia University of Wisconsin Research Project Demars, A., Dulmes, J., Lewright, R., Schraufnagel, A. and Virgil, K. (2012) “Inter-rater reliability of the Functional Capacity Evaluation “Occupro”” Unpublished Manuscript, Concordia University of Wisconsin Research Project Bates, C., Hintz, J., Zamzow, B., Lundstrum, M., and Prescher, D. (2012) “Occupro’s Functional Capacity Evaluation: A study of Inter-rater reliability” Unpublished Manuscript, Concordia University of Wisconsin Research Project Buckley, R., Ferracane, J. and Pickerill, L. (2013) “Inter-rater reliability of the Occupro Functional Capacity Evaluation” Unpublished Manuscript, Concordia University of Wisconsin Research Project Glass, S., Holtackers, K. and Stolte, A. (2013) “An evaluation of the inter-rater reliability of OccuPro’s Functional Capacity Evaluation” Unpublished Manuscript, Concordia University of Wisconsin Research Project


218


Job Demands Analysis Lysaght, R. (2004) “ Approaches to worker rehabilitation by occupational and

physical therapists in the United States: Factors impacting practice” Work 23: 139-146

Lindstrom, I., Ohlund, C., Nachemson, A. (1994) “Validity of Patient Reporting and Predictive Value of Industrial Physical Work Demands” Spine Vol. 19, No. 8: 888-893

Musculoskeletal Testing Jones T. and Kumar, S. (2002) “Functional capacity evaluation of manual

material handlers: a review”. Disability and Rehabilitation 25 (4-5): 179-191

Fishbain, D., Cutler, R., Rosomoff, H. and Rosomoff, R. (1999) “Chronic pain disability exaggeration/malingering and sub-maximal effort research”. The Clinical Journal of Pain 15: 244-274

Lechner, D., Bradbury, S., and Bradley, L. (1998) “Detecting Sincerity of Effort: A Summary of Methods and Approaches”. Physical Therapy (78)8 867-888

Sensation

Reliability of Pain Oesch, P. Meyer, K., Jansen, B. and Kool, J (2014) “Functional Capacity

Evaluation: Performance of Patietns with Chronic Non-specific Low Back Pain Without Waddell Signs” Journal of Occupational Rehabilitation 25:2 257-266

Chan, C., Goldman, S., Iistrup, D., Kunselman, A. and O’Neil, P. (1993) “The pain drawing and Waddell’s non-organic physical signs of chronic low back pain”. Spine 18(13): 1717-1722

Reneman, M., Jorritsma, W., Dijkstra, S. and Dijkstra, P. (2003) “Relationship between kinesiophobia and performance in a functional capacity evaluation”. Journal of Occupational Rehabilitation 13(4): 277-285

Novy, D. M., Simmonds, M. J., Olson, S. L., Lee, E. and Jones, S. C. (1999) “Physical Performance: Differences in Men and Women With and Without Low Back Pain”. Archives of Physical Medicine and Rehabilitation 80: 195-198

Reneman, M. F. Kuijer, W., Brouwer, S. Schiphorst Preuper, H. R., Groothoff, J. W., Geertzen, J. and Dijkstra, P. U. (2006) “Symptom increase following a functional capacity evaluation in patients with chronic low back pain: an explorative study of safety”. Journal of Occupational Rehabilitation 16: 197-205

Reneman, M. F., Geertzen, J. H. B., Groothoff, J. W. and Brouwer, S. (2008) “General and specific self efficacy report of patients with chronic low back pain: are they related to performances in a functional capacity evaluation?”. Journal of Occupational Rehabilitation 18: 183-18

Psychometric Testing


219


Fairbank, J., Davies, J., Couper, J., O’Brien, J. (1980) “The Oswestry Low Back Pain Questionnaire” Physiotherapy Vol. 66, No 8: 271-273

Melzack, R. (1975) “The McGill Pain Questionnaire: Major Properties and Scoring Methods”. Pain 1: 277-299

Vernon, H. and Mior, S. (1991) “The Neck Disability Index: A Study of Reliability and Validity”. Journal of Manipulative and Physiological Therapeutics. 14(7): 409-415

Ransford, A.O., Cairns, D., Mooney, V. (1976) “The Pain Drawing as an Aid to the Psychologic Evaluation of Patients With Low-Back Pain”. Spine Vol. 1, No 2: 127-134

Functional Pain Scale

Gross, d. P., Battie, M. C. and Asante, A. K. (2008) “The patient-specific functional scale: validity in workers’ compensation claimants”. Archives of physical Medicine and Rehabilitation 89: 1294 - 1299

Pain, Heart Rate, Blood Pressure, Respiratory Rate Coghill, R., Talbot, J., Evans, A., Meyer, E., Gjedde, A., Bushnell, M. and

Duncan, G. (1994) Distributed processing of pain and vibration by the human brain”. The Journal of Neuroscience 14(7): 4095-4108

Kregel, K., Seals, D. and Callister, R. (1992) “Sympathetic nervous system activity during skin cooling in humans: relationship to stimulus intensity and pain sensation”. Journal of Physiology 454: 359-371

Keefe, F., Wilkins, R. and Cook, W (1984) “direct observation of pain behavior in low back pain patients during physical examination”. Pain 20: 59-68

Jensen, I., Bradley, L. and Linton, S. (1989) “Validation of an observation method of pain assessment in non-chronic back pain”. Pain 39: 267-274

Dirks, J., Wunder, J., Kinsman, R., McElhinny, J. and Jones, N (1993) “A pain rating scale and a pain behavior checklist for clinical use: development, norms and the consistency score”. Psychotherapy Psychosomatic 59: 41-49


Moltner, A., Holzl, R. and Strian, F (1990) “Heart rate changes as an autonomic component of the pain response” Pain 43: 81-89

Keefe, F. and Hill, R. (1985) “An Objective Approach to Quantifying Pain Behavior and Gait Patterns in Low Back Pain Patients” Pain, 21: 153-161

Matheson, L. (1996) “Relationships Among Age, Body Weight, Resting Heart Rate, and Performance in a New Test of Lift Capacity” Journal of Occupational Medicine, Vol 6 No.4: 225-237


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Brouwer, S., Dijkstra, P., Stewart, R., Goeken, L., Groothoff, J., Geertzen, J., (2005) “Comparing self-report, clinical examination and functional testing in the assessment of work-related limitations in patients with chronic low back pain”. Disability and Rehabilitation, Vol 27(17): 999-1005

Coghill, R., Talbot, J., Evans, A., Meyer, E., gjedde, A., Bushnell, M.C., Duncan, G. (1994) “Distributed Processing of Pain and Vibration by the Human Brain” The Journal of Neuroscience 14(7): 4095-4108

Kregel, K., Seals, D., Callister, R. (1992) “Sympathetic Nervous System Activity During Skin Cooling in Humans: Relationship to Stimulus Intensity and Pain Sensation” Journal of Physiology 454: 359-371

Keefe, F., Wilkins, R., Cook, W. (1984) “Direct Observation of Pain Behavior in Low Back Pain Patients during Physical Examination”. Pain 20: 59-68

Jensen, I., Bradley, L., Linton, S (1989) “Validation of an observation method of pain assessment in non-chronic back pain” Pain 39: 267-274

Dirks, J., Wunder, J., Kinsman, R., McElhinny, J., Jones, N. (1993) “A Pain Rating Scale and a Pain Behavior Checklist for Clinical Use: Development, Norms, and the Consistency Score” Psychother Psychosom 59: 41-49

Lechner, D., Bradbury, S., Bradley, L. (1998) “Detecting Sincerity of Effort: A Summary of Methods and Approaches”. Physical Therapy Volume 78, No 8: 867-888

Moltner, A., Holza, R., Strian, F. (1990) “Heart rate changes as an autonomic component of the pain response”. Pain 43: 81-89

Waddell Signs Fishbain, D., Cole, B., Cutler, R., Lewis, J., Rosomoff, H. and Rosomoff, R.

(2003) “A structured evidence based review of the meaning of nonorganic physical signs: Waddell signs”. Pain Medicine 4(2): 141-181

Bradish, C., Lloyd, G., Aldam, C., Albert, J., Dyson, P., Doxey, N and Mitson, L. (1988) “Do nonorganic signs help to predict the return to activity of patients with low back pain”. Spine 13(5): 557-560

Pransky, G. and Dempsey, P. (2004) “Practical aspects of functional capacity evaluations”. Journal of Occupational Medicine 14(3): 217-229

Waddell, G., McCulloch, J., Kummel, E. and Venner, R. (1980) “Nonorganic physical signs in low back pain”. Spine 5(2): 117-125

Lehmann, T., Russell, D. and Spratt, K (1983) “The impact of patients with non-organic physical finding on a controlled trial of transcutaneous electrical nerve stimulation and electroacupuncture”. Spine 8(6): 625-634

Lechner, D. (2004) “Functional capacity evaluation: an evidence based approach” Pre Training required reading from the internet


221




Waddell, G., Main, C., Morris, E., Paola, M., Gray, I. (1983) “Chronic Low-Back Oain, Psychologic Distress, and Illness Behavior”. Illness Behavior: 209-211

Gallagher, R. (2003) “Waddell Signs: Objectifying Pain and the Limits of Medial Altruism”. Pain Medicine Volume 4, No.2: 113-115

Karas, R., McIntosh, G., Hall, H., Wilson, L., Melles, T. (1997) “The Relationship Between Nonorganic Signs and Centralization of Symptoms in the Prediction of Return to Work for Patients With Low Back Pain”. Physical Therapy Volume 77, No.4: 354-360

Scalzitti, D. (1997) “Screening for Psychological Factors in Patients With Low Back Problems: Waddell’s Nonorganic Signs” Physical Therapy Volume 77, No. 3: 306-312

Spratt, K., Lehmann, T., Weinstein, J., Sayre, H. (1990) “A New Approach to the Low-Back Physical Examination”. Spine Volume 15, No. 2

Fishbain, D., Cutler, R., Rosomoff, H., Rosomoff, R., Steele (2004) “Is There a Relationship Between Nonorganic Physical Findings (Waddell Signs) and Secondary Gain/Malingering?”. Clin J Pain Volume 20 (6): 399-408

Keefe, F., Crisson, J., Maltbie, A., Bradley, L., Gil, K. (1986) “Illness Behavior as a Predictor of Pain and Overt Behavior Patterns in Chronic Low Back Pain Patients”. Journal of Psychosomatic Research Vol. 30, No. 5: 543-551

Feinberg, S., Kirz, Joshua. And Mackey, S. (2005) “Symptom magnification & Waddell behavior signs” www.cwce.com/feinbergarticles

Gaines, W. and Hegmann, K. (1999) “Effectiveness of Waddell’s nonorganic signs in predicting a delayed return to regular work in patients experiencing acute occupational low back pain”. Spine 24(4): 396-401

Fear Avoidance Beliefs Questionnaire Moffett, J. A., Carr, J. and Howarth, E (2004) “High fear avoiders of physical

activity benefit from an exercise program for patients with back pain” Spine 29:11 1167-1173

Fritz, J.M., George, S, and Delitto, A (2001) “The role of fear avoidance beliefs in acute low back pain: relationships with current and future disability and work status” Pain 94 7-15

Kovacs, F, Muriel, A., Medina, J.M., Abraira, V, Sanchez, M.D.C., and Jauregui, J.O (2006) Spine 31:1 104-110


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Waddell, G, Newton, M, Henderson, I, Somerville, D and Main, C (1993) Pain 52 157-168

Grotle, M,, Vollestad, N., and Brox, J. (2006) “Clinical course and impact of fear avoidance beliefs in low back pain” Spine 31:9 1038-1046

Reneman, M., Schiphorts, P., Kleen, M., Greetzen, J. and Dijkstra, P. (2007) “Are pain intensity and pain related fear related to functional capacity evaluation performances of patients with chronic low back pain?” Journal of Occupational Rehabilitation 17:247-258

Obaidi. S., Beattie, P., Al-Zoabi, B. and Al-Wekeel, S. (2005) “The relationship of anticipated pain and fear avoidance beliefs to outcome in patients with chronic low back pain who are not receiving workers’ compensation” Spine 30:9 1051-1057

Fritz, J and George, S. (2002) “Identifying psychosocial variables in patients with acute work related low back pain: the importance of fear avoidance beliefs” Physical Therapy 82:10 973-983

Consistency of Effort Lechner, D., Bradbury, S., and Bradley, L. (1998) “Detecting Sincerity of Effort:

A Summary of Methods and Approaches”. Physical Therapy (78)8 867-888

Saunders, R. (1999) “Letters and responses: sincerity of effort”. Physical Therapy 79(1): 94-96

Matheson, L. (1988) “How do you know that he tried his best?” – The Reliability Crisis in Industrial Rehabilitation” Industrial Rehabilitation Quarterly Vol.1, No 1:1-3

Lemstra, M. Olszynski, W. and Enright, W (2004) “The sensitivity and specificity of functional capacity evaluations in determining maximal effort: a randomized trial”. Spine 29: 953-959

Kaplan, G., Wurtele, S. and Gillis, D. (1996) “Maximal effort during functional capacity evaluations: and examination of psychological factors”. Archives of Physical Medicine and Rehabilitation 77: 161-164

Grip/Pinch Testing King, P (1998) “Analysis of approaches to detection of sincerity of effort through

grip strength measurements”. Work 10: 9-13(23) Joughin, K., Gulati, P., Mackinnon, S.,

McCabe, S., Murray, J., Griffiths, S. and Richards, R. (1993) “An evaluation of rapid exchange and simultaneous grip tests”. The Journal of Hand Surgery 18A(2): 245-252

Hildreth, D., Breidenbach, W., Lister, G. and Hodges, A (1989) “Detection of sub-maximal effort by use of the rapid exchange grip”. The Journal of Hand Surgery 14A(4): 742-745


223


Matheson, L., Isernhagen, S. and Hart, D (2002) “Relationship among lifting ability, grip force, and return to work”. Physical Therapy 82(3): 249-256

King, J and Berryhill, B (1991) “Assessing maximum effort in upper extremity functional testing”. Work 1(3): 65-76

Taylor, C and Shechtman, O (2000) “The use of the rapid exchange grip test in detecting sincerity of effort, part I: administration of the test” Journal of Hand Surgery 13: 195-202

Taylor, C and Shechtman, O (2000) “The use of the rapid exchange grip test in detecting sincerity of effort, part II: validity of the test” Journal of Hand Surgery 13: 203-210

Shechtman, O., Gutierrez, Z. and Kokendofer, E. (2005) “Analysis of the statistical methods used to detect sub-maximal effort with the five-rung grip strength test”. Journal of Hand Therapy 18: 10-18

Goldman, S., Cahalan, T. and An, K. (1991) “The injured upper extremity and the jamar five handle position grip test”. American Journal of Physical Medicine and Rehabilitation 70(6): 306-308

Matheson, L (1998) “Use of maximum voluntary effort testing to identify symptom magnification syndrome”. Employment Potential Improvement Corporation http://www.epicrehab.com/abstracts

Matheson, L and Dakos (2000) “Re-visiting “how do you know he tried his best”… the coefficient of variation as a determinant of consistent effort” Employment Potential Improvement Corporation http://www.epicrehab.com/abstracts

Shechtman, O. (2001) “The coefficient of variation as a measure of sincerity of effort of grip strength, part I: the statistical principle”. Journal of Hand Therapy 14: 180-187

Shechtman, O. (2001) “The coefficient of variation as a measure of sincerity of effort of grip strength, part II: sensitivity and specificity”. Journal of Hand Therapy 14: 188-194



Gutierres, Z. and Shechtman, O. (2003) “Effectiveness of the five handle position grip strength test in detecting sincerity of effort in man and women”. American Journal of Physical Medicine and Rehabilitation 82(11): 847-855

Westbrook, A.P., Tredgett, M.W., Davis, T.R.C., Oni, J.A. (2002) “The Rapid Exchange Grip Strength Test and the Detection of Submaximal Grip Effort”. The Journal of Hand Surgery 27A: 329-333


224


Hamilton, A.., Balnave, R., Adams, R. (1994) “ Grip Strength Testing Reliability”. J Hand Ther 7: 163-170

Agre, J., Magness, J., Hull, S., Wright, K., Baxter, T., Patterson, R., Stradel, L. (1987) “Strength Testing with a Portable Dynamometer: Reliability for Upper and Lower Extremities”. Arch Phys Med Rehabilitation Vol. 68: 454-458

Stokes, H., Landrieu, K., Doinangue, B., Kunen, S. (1995) “Identification of Low-effort Patients Through Dynamometry”. J Hand Surg 20A: 1047-1056

Joughin, K., Gulati, P., Mackinnon, S., McCabe, S., Murray, J., Richards, R. (1993) “An evaluation of rapid exchange and simultaneous grip tests”. J Hand Surg 18A: 245-252

Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., Rogers, S. (1985) “Grip and Pinch Strength: Normative Data for Adults”. Arch Phys Med Rehabil 66: 69-72

Ashton, L.A., Myers, S. (2004) “Serial Grip Strength Testing-Its Role in Assessment of Wrist and Hand Disability”. The Internet Journal of Surgery Volume 5 Number 2

Niebuhr, B. and Marion, R. (1990) “Voluntary Control of Submaximal Grip Strength”. American Journal of Physical Medicine & Rehabilitation Vol. 69, No 2: 96-91

Stokes, H. (1983) “The Seriously uninjured Hand-Weakness of Grip” Journal of Occupational Medicine Vol 25, No 9:683-684

Niebuhr, B., Marion, R. (1987) “Detecting Sincerity of Effort when Measuring Grip Strength” American Journal of Physical Medicine Vol. 66, No 1: 16-23

Coordination King, P, Tuckwell, N. and Barrett, T (1998) “A critical review of functional

capacity evaluations”. Physical Therapy 78(8): 852-866

DesRosiers, J., Hebert, R., Bravo, G., Dutil, E. (1995) “The Purdue Pegboard Test: normative data for people aged 60 and over”. Disability and Rehabilitation Vol. 17, No. 5: 217-224

Non Material Handling

Walking Keefe, F and Hill, R (1985) “An Objective Approach to Quantifying Pain Behavior

and Gait Patterns in Low Back Pain Patients” Pain 21: 153-161

Balance Testing Wrisley, D., Marchetti, G., Kuharsky, D., Whitney, S. (2004) “Reliability,

Internal Consistency, and Validity Obtained With the Functional Gait Assessment”. Physical Therapy Volume 84, No. 10:


225


Bending Reneman, M.F., Bults, M. W. W. E., Engbers, L. H., Mulders, K. K. G. and Goeken, L. N. H. (2001) “Measuring Maximum holding times and perception of static elevated work and forward bending in healthy young adults”. Journal of Occupational Rehabilitation 11:2 87 – 97

Above Shoulder Reaching Reneman, M.F., Bults, M. W. W. E., Engbers, L. H., Mulders, K. K. G. and Goeken, L. N. H. (2001) “Measuring Maximum holding times and perception of static elevated work and forward bending in healthy young adults”. Journal of Occupational Rehabilitation 11:2 87 – 97

Material Handling Soer, R. Poels, B., Geertzen, J., and Reneman, M. (2006) “A comparison of two

lifting assessment approaches in patients with chronic low back pain” Journal of Occupational Rehabilitation (16) 639-646

Isernhagen, S., Hart, D. and Matheson, L. (1999) “Reliability of independent observer judgments of level of lift effort in a kinesiophysical functional capacity evaluation”. Work 12: 145-150

King, P, Tuckwell, N. and Barrett, T (1998) “A critical review of functional capacity evaluations”. Physical Therapy 78(8): 852-866

Jay, M., Lamb, J., Watson, R., Young, I., Fearon, F., Alday, J., and Tindall, A. (2000) “Sensitivity and Specificity of the indicators of sincere effort of the EPIC lift capacity test on a previously injured population”. Spine 25(11): 1405-1412

Gardener, L. and McKenna, K. (1999) “Reliability of occupational therapists in determining safe, maximal lifting capacity”. Australian Occupational Therapy Journal 46: 110-119

Reneman, M., Jaegers, S., Westmaas, M., Goeken, L. (2002) “The reliability of determining effort level of lifting and carrying in a functional capacity evaluation”. Work 18: 23-27

Matheson, L., Mooney., Grant, J., Affleck, M., Hall, H., Melles, T., Lichter, R., McIntosh, G. (1995) “ A Test to Measure Lift Capacity of Physically Impaired Adults –Part 1 - Development and Reliability Testing” Spine Volume 20, No. 19: 2119-2129

Reneman, M., Fokkens, A., Dijkstra, P., Geertzen, J., Groothoff, J. (2005) “ Testing Lifting Capacity: Validity of Determining Effort Level by Means of Observation” Spine Volume 30(2): E40-E46

Snook, S and Ciriello, V. (1991) “The design of manual handling tasks: revised tables of maximum acceptable weights and forces”. The design of manual handling tasks: 1197-1213


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Matheson, L. ( 1996) “Relationships Among Age, Body Wight, Resting Heart Rate, and Performance in a New Test of Lift Capacity”. Journal of Occupational Rehabilitation, Vol.6, No. 4: 225-237

Matheson, L., Mooney, V., Holmes, D., Leggett, S., Grant, J., Negri, S., Holmes, B. (1995) “A Test to Measure Lift Capacity of Physically Impaired Adults- Part 2 Reactivity in a Patient Sample”. Spine Volume 20, No. 19: 2130-2134

Smith, R. (1994) “Therapists’ Ability to Identify Safe Maximum Lifting in Low Back Pain Patients During Functional Capacity Evaluation” JOSPT Volume 19, No. 5: 277-281

Gross, D and Battie, M. (2002) “Reliability of Safe Maximum Lifting Determinations of a Functional Capacity Evaluation”. Physical Therapy Volume 2, No.4: 364-370

Saunders, R., Beissner, K., McManis, B. (1997) “Estimates of Weight That Subjects Can Lift Frequently in Functional Capacity Evaluations”. Physical Therapy, Volume 77: 1717-1728

Mayer, T., Barnes, D., Kishino, N. Nichols, G., Gatchel, R., Mayer, H. and Mooney, V. (1988) “Progressive isoinertial lifting evaluation I. a standardized protocol and normative database”. Spine 13(9): 993-996

Kuijer, W., Dijkstra, P. U., Brouwer, S. Reneman, M. F., Groothoff, J. W. and Geertzen, J. (2006) “Safe lifting in patients with chronic low back pain: Comparing FCE lifting teak and NIOSH lifting guideline”. Journal of Occupational Rehabilitation 16:4 579- 589

Job Simulated Testing Sit –Stand – Climb

Nicholls, A., Gibson, L. McKenna, K., Gray, M and Wieland, T. (2011) “Assessment of standing in functional capacity evaluations: an exploration of methods used by a sample of occupational therapists”. Work 38: 145 - 153


Non-Material Handling/

Positional Tolerance Decision Charts Avoid Occasional Frequent Constant

S I

M P L E

G R A S P I N G

Ability Client is unable to generate

any poundage on dynamometer

Client able to generate some poundage on dynamometer

Client able to achieve grip strength that is within normal age and gender ranges per Matheowitz

norms

Male clients are able to achieve grip strength that is

within 21 points of their mean and female clients are

within 12 points of their mean or greater per

Matheowitz age and gender norms

Mechanics

Client demonstrates mechanical deficits to include but not limited to significant loss of distal upper extremity

range of motion.

Client demonstrates mechanical changes to

include but not limited to distal upper extremity range

of motion.

Client demonstrates no loss of distal upper extremity

mechanics


mechanics

Functional Pain

Client understands and appropriately uses the

OccuPro pain intensity scale, has minimal to no reliability

of pain issues and reports increases in pain symptoms to

a 6 or higher specifically associated with the distal

upper extremity.

Client understands and appropriately uses the OccuPro pain intensity

scale, has minimal to no reliability of pain issues, and reports pain at a 5 or

less specifically associated with the distal upper

extremity.


scale, has minimal to no reliability of pain issues and

reports pain at a 4 or less specifically associated with the distal upper extremity.



of pain issues and reports pain symptoms at a 2.5 or less specifically associated

with the distal upper extremity.

Pain Behaviors

Client exhibits significant facial grimacing, verbal grunting, holding, and/or

requires a break following this test and is specifically associated with pain in the

distal upper extremity.

Client exhibits mild pain behaviors including but not limited to facial grimacing

and is specifically associated with pain in the


Client exhibits no pain behaviors specifically

associated with pain in the distal upper extremity.



Functional Demonstration

Client exhibits an inability to perform material handling

activities secondary to functional grip strength

Client exhibited the ability to perform occasional

material handling activities at low weight levels

Client exhibited the ability to perform all occasional

and frequent material handling activities at low

weight levels

Client exhibited the ability to perform all material handling

activities without deficit


Avoid Occasional Frequent Constant

F I R M

G R A S P I N G

Ability

Client is unable to generate grip strength poundage that is within normal ranges per Matheowitz age and gender

norms

Client able to achieve grip strength that is within normal

age and gender ranges per Matheowitz norms

Male clients are able to achieve grip strength that is

within 21 points of their mean and female clients are

within 12 points of their mean or greater per

Matheowitz age and gender norms

Client able to achieve grip strength that is greater than the mean per Matheowitz

age and gender norms

Mechanics

Client demonstrates mechanical changes and/or

mechanical deficits to include but not limited to significant loss of distal upper extremity range of

motion


mechanics


mechanics


mechanics

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with the distal

upper extremity.


OccuPro pain intensity scale, has minimal to no reliability of pain issues, and reports

pain at a 5 or less specifically associated with the distal upper extremity.


scale, has minimal to no reliability of pain issues and reports pain at a 2.5 or less specifically associated with the distal upper extremity.





Pain Behaviors





and is specifically associated with pain in the distal upper

extremity.






Client exhibited an inability to perform maximal

occasional material handling testing

Client exhibited the ability to perform occasional maximal

material handling testing without deficit

Client exhibited the ability to perform frequent

maximal material handling activities without deficit

Client exhibited the ability to perform all frequent

maximal lifting material handling activities without

deficit



S I

M P L E

P I N C H I N G

Ability Client is unable to generate

any poundage on pinch dynamometer

Client able to generate some poundage on pinch

dynamometer

Client able to achieve pinch strength that is within normal age and gender ranges per Matheowitz

norms

Male clients are able to achieve pinch strength that is within 4 points of their mean and female clients are within

3 points of their mean or greater per Matheowitz age

and gender norms

Mechanics

Client demonstrates mechanical deficits to

include but not limited to significant loss of distal upper extremity range of

motion


include but not limited to distal upper extremity range

of motion


mechanics


mechanics

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with distal upper

extremity.



pain at a 5 or less specifically associated with




reports pain at a 4 or less specifically associated with




of pain issues and reports pain symptoms at a 2.5 or less specifically associated with distal upper extremity.

Pain Behaviors






extremity.






Client exhibited an inability to perform fine motor testing

secondary to functional pinch strength

Client exhibited the ability to perform some fine motor activities without deficit

Client exhibited the ability to perform most fine motor


Client exhibited the ability to perform all fine motor




F I N E

M O T O R

C O O R D I N A T I O N

Ability Client is unable to complete any of the fine motor testing

Client able to perform fine motor testing and generate

some results

Client able to perform fine motor testing and generates

results in which at least 50% of the tests are able to be scored within the tests

scoring system

Client able to perform all fine motor testing and all

results are able to be scored within the tests scoring

system

Mechanics


include but not limited to significant loss of distal UE

ROM, hand eye coordination and/or median nerve

sensation


include but not limited to distal UE ROM, mild hand

eye coordination and/or mild median nerve sensation

deficits

Client demonstrates no loss of distal UE mechanics, hand eye coordination and/or median nerve

sensation

Client demonstrates no loss of distal UE mechanics, hand

eye coordination and/or median nerve sensation

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with the distal

upper extremity.



pain at a 5 or less specifically associated with the distal upper extremity.



reports pain at a 4 or less specifically associated with the distal upper extremity.





Pain Behaviors






extremity.






Client exhibits an inability to perform pinching testing

Client exhibits an ability to perform pinching on an

occasional level.

Client exhibits an ability to perform pinching on a

frequent level.

Client exhibits an ability to perform pinching on a

constant level.


G R O S S

M O T O R

C O O R D I N A T I O N

Ability Client is unable to complete

any of the gross motor testing

Client able to perform gross motor testing and generate

some results

Client able to perform gross motor testing and generates

results in which at least 50% of the tests are able to be scored within the tests

scoring system

Client able to perform all gross motor testing and all results are able to be scored

within the tests scoring system

Mechanics


include but not limited to significant loss of upper

extremity range of motion, hand eye coordination and/or

sensation


include but not limited to upper extremity range of motion, mild hand eye

coordination, and/or mild sensation deficits

Client demonstrates no loss of upper extremity

mechanics, hand eye coordination and/or

sensation

Client demonstrates no loss of upper extremity

mechanics, hand eye coordination and/or

sensation

Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically associated with the upper

extremity.




the upper extremity.




the upper extremity.



of pain issues and reports pain symptoms at a 2.5 or less specifically associated with the upper extremity.

Pain Behaviors



upper extremity.


and is specifically associated with pain in the upper

extremity.


associated with pain in the upper extremity.


associated with pain in the upper extremity.


Client exhibits an inability to perform forward reaching

and above shoulder reaching

Client may be able to perform forward reaching

and/or above shoulder reaching on an occasional

basis.


and/or above shoulder reaching on a frequent

basis.


and/or above shoulder reaching on a constant basis.



W A L K I N G


100 yards of walking. Client able to complete the

100-yard walk. Client able to complete the

100-yard walk.

Client able to complete the 100-yard walk and 15 minutes of prolonged walking at 3.0 mph or

greater on the treadmill

Time Client exceeds 2 minutes

during demonstration of 100-yard walk.

Client completes 100 yards in greater than 66 seconds

due to slow pace.

Client completes the 100 yards in 66 seconds or less.

Client completes the 100 yards in 66 seconds or less

and completes 15 minutes of prolonged walking at 3.0

mph or greater

Mechanics

Client exhibits mechanical deficits including but not limited to unequal stride,

splinting, and/or an antalgic gait pattern.

Client exhibits mechanical changes including but not

limited to the use of a cane, unequal stride, splinting,

and/or antalgic gain.

Client exhibits no changes in regard to walking

mechanics.

Client exhibits no changes in regard to walking mechanics.

Functional Pain



of pain issues and reports increases in pain symptoms to a 6 or higher specifically

associated with the back and/or lower extremities.




the back and/or lower extremities.




back and/or lower extremities.



of pain issues and reports pain symptoms at a 2.5 or less specifically associated with the back and/or lower

extremities.

Pain Behaviors


requires a break following this test and is specifically

associated with pain in back and/or lower extremities.


and is specifically associated with pain in the back and/or

lower extremities.


associated with pain in the back and/or lower

extremities.


associated with pain in the back and/or lower

extremities.


Client exhibits an inability to perform walking throughout

this evaluation or re-assessment

Client demonstrates the ability to walk during this

evaluation or re-assessment

Client demonstrates the ability to perform walking

with no difficulty throughout this functional

test

Client demonstrates the ability to perform walking

with no difficulty throughout this functional test



F O R W A R D

R E A C H I N G


one repetition of forward reaching.

Client able to complete one repetition of forward

reaching.

Client able to complete 10 reps of forward reaching at

a comfortable pace.

Client able to complete 10 reps of forward reaching

while exhibiting a faster pace than the 10 reps at a comfortable pace.

Time No specific time involved Client completes the one rep

within roughly 3 seconds

Client completes the 10 repetitions within a

reasonable time

Client completes the 10 reps at a faster pace than 10 reps

at a comfortable pace

Mechanics

Client exhibits mechanical deficits including but not limited to scapulohumeral rhythm, shoulder hiking, compensation and painful

crepitus.

Client exhibits mechanical changes including but not limited to scapulohumeral

rhythm, hiking, compensation and

palpable/audible crepitus

Client exhibits no changes in mechanics with normal

crepitus.


crepitus.

Functional Pain




associated with the shoulder.




the shoulder.




the shoulder.




with the shoulder.

Pain Behaviors



shoulder.


and is specifically associated with pain in the shoulder.


associated with pain in the shoulder.




Client exhibits an inability to perform gross motor

activities during this test

Client is able to perform gross motor activities during

this functional test

Client is able to perform gross motor activities throughout this entire

functional test.


functional test.


A B O V E

S H O U L D E R

R E A C H I N G


one repetition of above shoulder reaching.

Client able to complete one repetition of above shoulder

reaching.

Client able to complete 10 reps of above shoulder

reaching at a comfortable pace.

Client able to complete 10 reps of above shoulder

reaching while exhibiting a faster pace than the 10 reps

at a comfortable pace.




reasonable time



Mechanics

Client exhibits mechanical deficits including but not limited to scapulohumeral rhythm, shoulder hiking, compensation and painful

crepitus.

Client exhibits mechanical changes including but not limited to scapulohumeral

rhythm, hiking, compensation and

palpable/audible crepitus


crepitus.


crepitus.

Functional Pain




associated with the shoulder.




the shoulder.




the shoulder.




with the shoulder.

Pain Behaviors



shoulder.


and is specifically associated with pain in the shoulder.






Client exhibits an inability to perform gross motor

activities during this test

Client is able to perform gross motor activities during

this functional test


functional test.


functional test.



B E N D I N G

Ability Client is unable to complete one repetition of bending at 25% of a full bend or more.

Client able to complete one repetition of bending at 25%

of a full bend or more.

Client able to complete 10 reps of bending at 25% of a

full bend or more at a comfortable pace.

Client able to complete 10 reps of bending while

exhibiting a faster pace than 10 reps at a comfortable pace

and is able to perform at 50% or more of a full bend.




reasonable time



Mechanics

Client exhibits mechanical deficits including but not

limited to range of motion, equal weight bearing,

compensation, and single plane lumbar flexion.

Client exhibits mechanical changes including but not limited to range of motion,

equal weight bearing, compensation, and single

plane lumbar flexion.

Client exhibits no changes in mechanics.


Functional Pain




associated with the low back.




the low back.




the low back.




with the low back.

Pain Behaviors



low back.


and is specifically associated with pain in the low back.


associated with pain in the low back.


associated with pain in the low back.


Client exhibits an inability to perform the Bend Lift

Client is able to perform the Bend Lift if performed

Client is able to perform bending within 66% of this

test

Client is able to perform bending within 99% of this

test


S Q U A T T I N G

Ability Client is unable to complete one repetition of squatting to 50% of a full squat or more.

Client able to complete one repetition of squatting to

50% of a full squat or more.

Client able to complete 10 reps of squatting at a

comfortable pace while demonstrating a squat at

50% of a full squat or more.

Client demonstrates the ability to perform job

simulated squatting for 41 to 60 minutes




reasonable time

41 to 60 minutes of job simulated repetitive

squatting

Mechanics


limited to decreased weight bearing on one side, single plane movement pattern,

and/or compensation.






Functional Pain




associated with the low back and lower extremities.




the low back and lower extremities.








with the low back and lower extremities.

Pain Behaviors



low back and lower extremities.


and is specifically associated with pain in the low back

and lower extremities.


associated with pain in the low back and lower

extremities.



extremities.


Client exhibits an inability to the squat lift during this test

Client is able to perform occasional squat lifting

Client is able to perform frequent squat lifting

Client is able to perform squatting activities within

99% of this test



S U S T A I N E D

K N E E L I N G


the tall kneeling. Client able to complete the

tall kneeling for one minute.

Client able to complete the tall kneeling for two

minutes.

Client able to complete the tall kneeling for greater than

41 to 60 minutes in a job simulated test.

Time Unable to complete one

minute

Client completes the sustained kneeling and achieves one minute

Client completes the sustained kneeling and achieves two minutes

Client completes the sustained kneeling and

achieves greater than 41 minutes in a job simulated

test

Mechanics

Client exhibits mechanical deficits including decreased weight bearing on one side, compensation, single plane movement pattern and/or requires significant upper

extremity assistance.

Client exhibits mechanical changes including decreased

weight bearing, compensation, single plane movement pattern and/or requires upper extremity

assistance.



Functional Pain

















Pain Behaviors









extremities.



extremities.


S U S T A I N E D

S Q U A T T I N G


any sustained squatting. Client is able to complete

sustained squatting Client is able to complete

sustained squatting Client is able to complete

sustained squatting

Time 0 Minutes 1 – 20 minutes of sustained

squatting simulation

21 – 40 minutes of sustained squatting

simulation

41 - 60 minutes of sustained squatting simulation

Mechanics



compensation, and/or requires significant upper

extremity assistance.






Functional Pain

















Pain Behaviors









extremities.



extremities.



R E P E T I T I V E

K N E E L

Ability

Client was placed on avoid for tall kneeling or is unable to complete one repetition of

repetitive kneel

Client able to complete the tall kneeling and/or one

repetition of repetitive kneel.

Client able to complete 10 reps of repetitive kneeling

with minimal upper extremity assistance

Client able to complete 10 reps of repetitive kneeling in

a faster fashion than repetitive kneeling at a

comfortable pace or perform in a job sim.

Time No time achieved Client completes one minute of prolonged kneeling or one repetition within 8 seconds


reasonable time

Client completes the 10 reps at a faster pace than the previous test or 41 to 60 minutes of job simulated

repetitive kneeling

Mechanics


limited to decreased weight bearing on one side,

significant upper extremity assistance, compensatory techniques and/or single plane movement pattern.


limited to decreased weight bearing, upper extremity assistance, compensation

and/or single plane movement pattern.



Functional Pain

















Pain Behaviors









extremities.



extremities.


C R A W L I N G

Ability Client is unable to get into 4-point position and perform 1

minute of crawling.

Client able to complete the 1 to 20 minutes of crawling

forward and backward.

Client able to complete crawling, forward and

backward mobility, with intermittent rest breaks.

Client able to complete consecutive crawling both

forward and backward mobility

Time Unable to complete one

minute Client completes 1 to 20

minutes of crawling Client completes the 21 to

40 minutes of crawling Client completes the 41 to 60

minutes of crawling

Mechanics


limited to decreased weight bearing on one side,

compensatory techniques and significant upper extremity assistance.


limited to decreased weight bearing, compensatory techniques and upper extremity assistance.



Functional Pain




associated with the low back, lower extremities and/or

upper extremities




the low back, lower extremities and/or upper

extremities.




the low back, lower extremities, and/or upper

extremities



of pain issues and reports pain symptoms at a 2.5 or less specifically associated with the low back, lower extremities, and/or upper

extremities.

Pain Behaviors



low back, lower extremities, and/or upper extremities.


and is specifically associated with pain in the low back, lower extremities, and/or

upper extremities.


associated with pain in the low back, lower

extremities, and/or upper extremities.


associated with pain in the low back, lower extremities,

and/or upper extremities.



S T A T I C

B A L A N C E

Ability

The client is unable to complete Romberg’s test,

Sharpen Romberg’s test and Functional Reach

Assessment

The client is able to perform Romberg’s and Sharpen

Romberg’s without a loss of balance and the Functional Reach Assessment is within

normative ranges.

The client is able to perform Single Leg Stance with eyes open with no loss

of balance bilaterally.

The client is able to perform Single Leg Stance with eyes closed and no loss of balance

bilaterally.

Time/ ability demonstration

No time achieved

Client completes Romberg’s/ Sharpened Romberg’s for 30

seconds and Functional Reach per procedure manual

norms

Client completes 30 seconds of Single Leg

Stance eyes open bilaterally

Client completes 30 seconds of Single Leg Stance eyes

closed bilaterally

Mechanics

Client exhibits mechanical deficits including but not limited to lower extremity weakness, decreased range

and/or significant compensatory techniques to

maintain balance.

Client exhibits mechanical changes including but not limited to lower extremity weakness, decreased range

and/or minimal compensatory techniques with no safety concerns.

Client exhibits no changes in mechanics with minimal

compensatory strategies noted with ability to

demonstrate safe recovery patterns.

Client exhibits no changes in mechanics with minimal compensatory strategies

noted with ability to demonstrate safe recovery

patterns.

Functional Pain

















Pain Behaviors









extremities.



extremities.


D Y N A M I C

B A L A N C E

Ability

The client fails gait on level surface, change in gait speed,

gait with horizontal and vertical head turns

The client passes gait on level surface, change in gait speed, gait with horizontal

and vertical head turns

The client passes gait and pivot turn and step over

obstacle bilaterally

The client passes gait with narrow base of support, gait

with eyes closed, and ambulating backwards.

Time/ ability demonstration

Time/ability and pass/fail as defined in procedure manual

Time/ability and pass/fail as defined in procedure

manual

Time/ability and pass/fail as defined in procedure manual

Mechanics Mechanics as outlined in

procedure manual Mechanics as outlined in



procedure manual

Functional Pain

















Pain Behaviors









extremities.



extremities.



S T A I R

C L I

M B I N G


36 steps of negotiation Client able to complete the 36 steps of stair climbing

Client able to complete 72 steps of stair climbing

Client able to complete 108 steps of stair climbing

Mechanics

Client exhibits mechanical deficits, which include but are not limited to use of an assistive device, unequal

stride, splinting, and/or an antalgic gait pattern.

Significant safety or balance concerns while ascending/

descending stairs.

Client exhibits mechanical changes, which include but are not limited to use of an assistive device, unequal




Dynamic Balance

Client was placed on an avoid for dynamic balance

Client is able to perform dynamic balancing on an

occasional basis

Client is able to perform dynamic balancing on a

frequent basis

Client is able to perform dynamic balance on a

constant basis

Functional Pain

















Pain Behaviors



low back/lower extremities.






extremities.



extremities.


L A D D E R

C L I

M B I N G


1 rung of negotiation

Client able to complete the 4 rungs at 5 repetitions of

ladder climbing (20 ladder rungs total)

Client able to complete 4 rungs 15 repetitions of

ladder climbing (60 ladder rungs total)

Client able to complete the 4 rungs 25 repetitions of ladder climbing (100 ladder rungs

total)

Mechanics

Client exhibits mechanical deficits, which include but are not limited to use of an assistive device, unequal


Significant safety or balance concerns while ascending/

descending the ladder.

Client exhibits mechanical changes, which include but are not limited to use of an assistive device, unequal




Static/Dynamic Balance

Client was placed on an avoid for dynamic balance

and/or avoid for static balance if ladder climbing requires static balancing

Client was placed on an occasional level for dynamic balance and/or an occasional

level for static balance if ladder climbing requires

static balancing

Client was placed on a frequent level for dynamic balance and/or a frequent level for static balance if ladder climbing requires

static balancing

Client was placed on a constant level for dynamic balance and/or a constant level for static balance if ladder climbing requires

static balancing

Functional Pain

















Pain Behaviors









extremities.



extremities.

· 2020-05-19 · Table of Contents Chapter Page Chapter 1...

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