By: AMFS Occupational Medicine Expert
Not all FCE's are alike. In fact, there are a myriad of systems, machines and protocols available today. Unfortunately, when scrutinized, most of them do not hold up to peer reviewed published science or supreme court decisions. If this is the case, why would you ever want one of your clients going through an FCE that can be easily and successfully challenged in court or potentially dangerous?
The reasons are quite simple. About 99 percent of the time I am only asked 2 questions; How much does the testing cost and how fast can you get them in? If these are your only true concerns, you may want to read Indergard vs. Georiga Pacific and the State of California vs. Loma Linda University Medical Center to see that a bad decision can cost more than $250k in fines and that does not include the lawsuits that will likely follow. Most commonly though, is that the treating physician will just not accept a poor quality FCE and you will end up paying for another one or a quality attorney will have the testing critiqued by a seasoned evaluator that will point out serious flaws rendering the report useless in court.
So how do physicians tell a good FCE from a bad one? Having a few simple questions ready can solve this problem. The best FCE's will be based on peer reviewed published science, current supreme and circuit court decisions. This is called a best practice or evidence based approach that will stand up to scrutiny and any legal challenge when done by an experienced evaluator.
Here is a simple list of questions you will want to ask a provider prior to scheduling:
1. How long do their FCE's take?
If they are 4 hours or less, they are likely flawed tests unless the worker only works part time. There is no way to determine a workers ability to perform into the full frequent or constant levels as defined by the Dept. of Labor or the ability to sustain any work over an 8 hour day in this format. This is also true for the 2 half day format as well. Testing should last 6-8 or until questions of ability have been answered.
2. Does the FCE include effort and reliability testing?
The answer to this should be multi-faceted and not simply, “yes we use CV's”. There are many peer reviewed protocols to use for effort and reliability and if the provider cannot tell you what they are, this should indicate a red flag. Some systems use a "Validity Profile" that combines effort and reliability. This also has not stood up in court as reliability and effort are separate issues. The items in the profile are given equal weight even when some might be peer reviewed.
3. Does your testing utilize a standard protocol?
By standard protocol I mean the same test is given to the worker regardless of the injury or job. They would start with test A then go to test B, etc. This is what most systems do and this was exposed in Indergard vs. Georgia Pacific and resulted in a $250k fine. Each test needs to be related to or consistent with business necessity. For example, having a worker lift from floor to overhead or run on a treadmill when they do not do this at work will certainly get the test thrown out in court or discounted if another provider performed a full day of testing that was designed and administered to address the actual physical demands of the job.
4. Does your testing utilize an iso-based machine such as Hanoun, Ergos, BTE, Cybex, J-tech, etc.?
If so, these have also been shown in the peer-reviewed literature to be invalid systems that also tend to use standardized protocols regardless of injury or job. Secondly they have been and continue to result in many lawsuits with workers becoming injured using them. The reason being that when you are asked to push, pull and lift multiple time at various heights and angles on an isometric, isotonic or isokinetic machine, the forces exerted can often exceed the job demand. For example, a worker may only be required to lift 20 pounds at work, however when lifting isometrically they exert forces of say, 150 ft/pounds repetitively and injure themselves. The provider will need to explain why they were having the worker exert such force when the job only requires 20 pounds to perform. Another common issue with machine based FCE's is that providers are trained simply as technicians to operate the machine that in turn generates a report with no real knowledge as to the scientific literature or case law if any is behind the protocols or report.
These simple questions will help you determine the qualifications and experience of a potential FCE provider. If in doubt, ask to see a report they have done in the past. Other things you can look for is if they are formally certified, how many FCE's have they done, are they an Expert Witness and have they ever successfully defended their tests in court?
In closing it is also prudent to avoid scheduling an FCE to be done by the treating physician or in the same office where therapy is done. This will eliminate any conflict of interest, bias or self serving motives such as stating the worker needs further treatment, work conditioning or functional restoration of which the evaluator can then provide.