photo caption: A common myth about FCEs is that they exist primarily to determine whether an injury is being used or feigned to get out of work.
by Neil Taylor, OT, CWCE, CWcHP, and Ari Kaplan, PT, DPT, SCS, CSCS, COMT, Cert MDT
A functional capacity evaluation (FCE) in the context of workers’ compensation is a set of objective standardized assessments to evaluate an individual’s ability to return to work following an injury on the job. An FCE consists of questionnaires based on the individual’s injury, a musculoskeletal evaluation, and a variety of tests to determine how well the individual can perform functions that will be necessary to their job demands. Typically, an FCE occurs after the individual goes through acute physical or occupational therapy to rehabilitate after an injury, though the timeline and treatment needed are customized to each case.
Broadly, FCEs are most beneficial for case resolution. Depending on what is asked of the evaluation, an FCE can answer a variety of questions about the state of the rehabilitating worker, including when they can return to work and what they will be capable of upon return. However, FCEs inform more parties than the injured worker alone. They inform the employer, too, as well as the therapist—all for the goal of protecting the patient from more injuries and getting them back to their everyday life—including work and life outside of work with activities of daily living and avocational interests.
Helping the Injured Employee Get Back to Work Safely
The most important use of an FCE is to inform when the injured employee is physically ready to get back to work—and back to life—after appropriate rehabilitation. Sometimes, an FCE will show that the patient needs more therapy or a different route of care before returning to work. Or, an FCE may determine that an individual’s day-to-day at work will be different from before the injury—such as working part-time or being assigned certain tasks that the individual can safely complete. These results are crucial for ensuring the individual returns to work safely and avoids further injury. If the employee goes back to work before fully recovering, more injuries may occur, which will likely put them back into therapy.
A common myth about FCEs is that they exist primarily to see if people are using their injury or feigning one as a way to get out of work. While an FCE can measure if someone is not providing full effort, its purpose is not to imply intent about why one may not be giving good effort. However, something an FCE does reveal is whether someone’s perception of their level of function or disability is greater than objectively what they can actually do when the time comes to go back to work. For example, a recent patient of ours scored himself as 86% disabled on a questionnaire portion of his FCE. This put him in the bed-bound category, though he successfully participated in 4 hours of physical testing. Does that mean he is “faking” or not in pain impacting his ability? No—it means he perceives himself as more disabled than he presented (not atypical for someone who has been in chronic pain for a long time). A patient’s perception is their reality based on their course of care, outcomes, and other mitigating factors in recovery.
Helping the Therapist Provide Objective Recommendations
To a therapist, the highest value of the data provided by an FCE following appropriate therapy is its objectivity and measurability. The results are not a guess—they’re a safe determination of someone’s function and how that translates to their return to work. The FCE provides validity and reliability in the next steps a therapist recommends.
As well, the FCE’s objective data can also be used to assist the employee and/or employer in ensuring proper steps are taken to legally help an employee’s safe return to work: plaintiff attorneys want assurance that their client (the injured worker) can return, while defense attorneys (representing the employer and workers’ compensation carrier) want objective evidence that the injured worker can transition from temporary total disability to partial or full return to work.
Above all, the most important purpose of an FCE for a therapist is to ensure appropriate recommendations are made to avoid exposing the patient to further risk or injury, helping to protect them. As with what the FCE determines for the patient, this may mean the therapist recommends more therapy or provides them the resources they need to work again.
Typically, the second round of therapy following an initial course of acute therapy involves work conditioning/work hardening, a rigorous program on the continuum of care. A more intensive version of physical or occupational therapy, work conditioning/work hardening is the increased hardening of exercises that are specific to the patient’s injury and job responsibilities, often mixed in with job simulation (for example, firefighters wear their gear or carpenters wear their tool belts). If the patient’s job demand level is medium physical demand level (21-50 pounds occasionally, 11-25 pounds frequently) or greater, it is thought that a higher volume and intensity of rehabilitation is needed than traditional therapy in order to return to that demand level pre-injury. In these cases, the original FCE stands as a baseline of function for the therapist, and after the program, a repeat FCE can be administered.
Ultimately, the purpose of any and all physical therapy in the context of employee rehabilitation is to build up patients and prepare them to return to work. Going through a work conditioning/work hardening program or comprehensive acute phase physical therapy (working on the motion and strength of the injured body part) sets the patient up for success and readiness. It builds the foundation—like the bottom block of a pyramid—for the next steps to be taken successfully. Physical therapy not only gets patients work-ready, it gets them life-ready.
Helping the Employer Accommodate
Following proper therapy training, an FCE can specifically measure and definitively outline for the employer exactly what tasks an employee can safely perform upon their return to work. For example, they may be able to work full duty with no restrictions, or light or modified duty with specific restrictions and need for accommodation. Or, there may be a different job that better suits their abilities post-injury.
The FCE can also inform how the employer can reasonably accommodate the rehabilitated employee. An employee returning from an injury may need to work fewer hours than prior to the injury or may need a new task to perform that better accommodates their current physical state. Other common accommodations include equipment to help the employee adjust to their day-to-day work life, such as using a standing, adjustable-height work surface or a specific chair. These changes help protect the employee from further on-the-job injury until completely healed.
If an employer does not accommodate appropriately, they risk injuring and losing the employee again, which can create high costs for an employer—the cost of the employee’s rehabilitation and treatment, the cost of their wages when they’re not at work, the cost of a temporary replacement and more. Adhering to therapists’ recommendations to avoid additional injuries benefits the employer by saving them money and ensuring a safe working environment for their entire organization.
Helping Everyone Involved
One case scenario where we have seen the benefit of an FCE for all parties involved was with a 72-year-old woman working in a light manufacturing job. The woman needed surgery after a trip-and-fall injury, common among older people in the workforce. The accident resulted in a broken humerus and neck injury. Before coming to therapy at ATI Physical Therapy, this patient had an open reduction internal fixation surgery to help repair the fractured humerus. Although the patient was compliant throughout her therapy, the rehab process didn’t go as well as expected. The results of her FCE determined that many accommodations were needed to be made for her to return to work in a light-duty capacity.
Due to the poor functional deficits determined by the initial FCE, we worked with her employer to determine an alternate route to rehabilitation. The employer identified two jobs within the company that could accommodate the employee’s physical state. The woman went back to her doctor for a second surgery to have the hardware removed from her shoulder after it healed and came back to ATI for a second round of therapy, where her therapists used the job descriptions provided by her employer to create a customized approach that would prepare her to return to work. After this second round of therapy, which went better than the first time, the patient completed her FCE successfully, and we were able to objectively show significant improvement from the initial FCE demonstrating her ability to safely return to full, unrestricted work.
This example shows a successful FCE process that benefited all parties involved:
1) The patient was able to safely return to work after appropriate rehab.
2) The physical therapists were able to use objective information from both FCEs to determine her abilities and communicate these with the referring physician to coordinate a clearance for return to work.
3) Her employer was able to identify a job that she could do safely with little accommodations.
Like this case, everyone involved in a worker’s rehabilitation journey must understand that FCEs are objective and systematic in informing determinations about patients. An FCE’s results and the therapist’s subsequent recommendations are safe to be trusted and are more than just a way to determine a patient’s perception of their injury and physical state.
FCEs are beneficial to all parties involved, existing for the ultimate purpose to help people return to work and life and avoid more injuries. They are a highly valuable tool in the rehabilitation continuum of care when the patient is ready to transition back to the workplace, with impartial findings that can make a definitive impact in a work-injury case for resolution for job or injury or future jobs. FCEs are an objective, measurable way to determine an injured employee’s journey to get back to work and back to life. RM
Neil Taylor, OT, CWCE, CWcHP, is Director of Workers Compensation Services at ATI Physical Therapy.
Ari Kaplan, PT, DPT, SCS, CSCS, COMT, Cert MDT, is a Physical Therapist at ATI Physical Therapy. For more information, contact RehabEditor@medqor.com.