Okay, our next presentation is the Brent Lovejoy Memorial Lecture in Disability and Impairment Medicine. It will be presented by Alexandra Peters and Lisa Fitzpatrick. The Brent Lovejoy Memorial Lecture is given in honor of Brent Lovejoy, D-O-F-A-O-C-O-P-M, a founding member of the Division of Disability and Impairment Evaluations. Dr. Lovejoy served the A-O-C-O-P-M as a tireless worker. He was the first to seek recognition of this field of medicine in the osteopathic profession and developed the first formal course of study for the college. He was most interested in continuing medical education and was a frequent lecturer. He was born in Hastings, Missouri on September 18, 1943. He graduated from the Kirksville College of Osteopathic Medicine in 69. He was board certified in occupational medicine and his practice centered on the treatment of patients with work-related injuries. Over the years, Dr. Lovejoy was involved in the research and development of new and better ways to treat patients with back injuries and repetitive motion injuries. He also worked closely with employers to develop return to work programs for his patients who had been injured on a job. When the ADA was passed, he served on several committees that helped employers and businesses comply with the act. In the last five years of his practice, he served as medical director to several large national construction companies. In that capacity, he worked closely with safety professionals and risk managers to reduce the rate of injuries in the workplace. When there were injuries, he worked with the treating physicians developing rehabilitation and return to work programs. In 1997, Dr. Lovejoy was diagnosed with a glioblastoma, a multiforme brain tumor. In the year before his brain tumor was diagnosed, Dr. Lovejoy traveled all over the United States giving lectures and workshops on the most effective ways to manage and treat patients who had been injured on a job. Everyone he worked with appreciated his energy and hard work. He was a fellow of the American Osteopathic College of Occupational and Preventive Medicine and was designated posthumously a full professor under the faculty status for the college. He served on a number of committees and held all offices of the college, including president-elect. Due to illness, he was unable to serve as president, but was designated as honorary assistant to the president prior to his death in 1998. Established in 1998, this prestigious lecture is presented to an individual member or non-member who has demonstrated proficiency in the area of disability and impairment evaluations and a desire to promote this area of medicine for the public good. We have two plaques, one for Lisa Fitzpatrick and another plaque for Alexandra Peter. Thank you. Take a photo of this distinguished looking group here. All right. Thank you. Can't say it's going to make the New York Times, but it's going to make our newsletter. A little bit about Alexandra Peters. She has her Bachelor of Science in Physical Therapy from Northeastern University. She currently works for Specialty Therapy Solutions in Tampa, Florida. She does industrial healthcare, post-doctorate employment testing, ergonomics, and functional capacity evaluations. She has performed FCEs, JSAs, ergonomic analysis, and it says she's a poet. I think that means something different in literature, right? Oh, most definitely. Okay, she'll explain what that is. She's recommended work functions, limitations, and return to work statuses. She's participated in depositions with plaintiffs and defendant counsels, a lot of experience. Lisa Fitzpatrick, OTCHD CAECEAS, is a recognized leader in injury management with over 25 years of professional experience. She has spoken internationally on injury reduction and prevention and FCEs. She's currently the organizer for the fourth International FCE Research Symposium in San Diego. She has authored a book called Can Someone Help Me? In addition to her speaking and publications, she has spent the past 20 years as CEO for Accelable and has established relationships with top insurance companies and won contracts with leading employers such as the Post Office and several workers' comp insurance companies. Please welcome Alexandra Peters and Lisa Fitzpatrick. Can you all hear us okay in Zoom? Yeah. Great. Okay, thank you. Coming in loud and clear. Wonderful. So I'm Dr. Fitzpatrick. Nice to meet all of you. And thank you for the wonderful introduction. I don't have to go into any further of my background. You've covered it all very well. So thanks so much. Before we get started, how many that are here in the room utilize functional capacity evaluations? So a few of you. Wonderful. And so what we want to talk about today is really the utilization of FCEs and... I'm going to change this out. Battery, I think, is going dead. Sorry. No worries. Can you all hear me okay? I might fold it. This is much easier. Can you hear me okay? So we really... to talk about how these can be utilized in the medical practice. We work a lot with physicians nationwide in really providing functional capacity evaluation services as well as employers and how we can collectively help with getting the injured workers back to work. And so without further ado, I'm going to go ahead and get started. So what is an FCE? A lot of the literature that's out there right now talks, there's some negative connotations around FCEs, but also positive in the utilization of FCEs in the medical practice. So an FCE is an evaluation of looking at the activities that a worker is going to be able to perform at work and doing the full musculoskeletal evaluation, but we're really considering looking at the body functions. So how that injury has impacted that a person's musculoskeletal system, the environmental factors, and then really looking at those psychosocial components as well. A lot of the literature talks about or different systems that we have a standardized FCE. There is no standardized FCE. It's a battery of different standardized assessments that may be used, but we're going to talk about a couple of things that you want to look at is this biopsychosocial approach and how we utilize the functional capacity evaluation. Hi, how are you? I'm Alexandra Peters and again, Dr. Balsasitis did a wonderful introduction of me. I am a physical therapist for 25 plus years and I have been in the industrial med sector for about 20 plus years working with injured workers, insurance disability, and auto accident claims. So the FCEs are used in many aspects, many facets, and why do we use an FCE? The total disability rating, a return to work status, determination of how work-related illnesses and injuries impact the work performance, intervention, and case management, case closure, and I'm going to elaborate on all of those just a little bit to give you a good idea of why you would be requesting an FCE. Temporary total disability rating, the FCE is going to be used as a tool, a quantitative data to assist the doctor in determining a TTD. So whether it's a temporary total disability rating or a PIR, a permanent impairment rating. So the quantitative data collected in the FCE is going to assist the doctor in making those or determining those numbers. Return to work status, is the injured worker or claimant able to return to work full duty or light duty with restrictions? And again, the FCE is going to determine whether they are able to return to work full duty or whether they will have restrictions and what are those restrictions? What capacity can they return back to work? Determination of non-work-related injuries and how it impacts their work performance. What is their past medical history? What comorbid factors are involved unrelated to their work injury that might affect their return to work? Intervention and treatment planning based on the FCE, what's the next step? We are going to assist or use the FCE or the doctor is going to use the FCE as a tool. What is his next step? Should I MMI him or her? Should I obtain additional diagnostic testing? Should I plan some other course of treatment? That's what the FCE is also going to help in determining. Case management and case closure. Again, this is going to be used as a tool to help not only the doctors but the case managers and adjusters in determining which direction they are going to go in. Case closure, again, can the injured worker or claimant return to work? If not, where are we going to put them maximally? Oh, okay. Sorry. Thank you. Yeah, forget about that. Sorry. So a lot of times when FCEs have been requested, we've been asked by physicians, is it best to wait until their entire treatment is completed? And typically the best time to do an FCE is when that employee is ready to return to work. So we're really providing that independent evaluation to assist you and objectify of what their restrictions are. And so it's not a guesstimation of how much can they lift? What are they able to do as far as squatting, bending, reaching, twisting, turning? And we're able to objectify that and spending that time with the patient to look at them musculoskeletally, look at their biomechanics, and then look at the psychosocial impacts that they may have and really assisting even with those light duty restrictions. So as soon as that employee is where you feel they are ready to go back to work, that is when an FCE should be prescribed. In many cases when we're doing FCEs, we may see the same client one, two, or three times throughout their return to work process. So we may assist with that light duty specification. We may assist as they're progressing through their treatment to see if there's any change in their physical demand classification. And then when they get to that final determination of their permanent stationary status, we really assist there as well in determining what their long-term physical demands may be. So as I mentioned, really moving that patient from that temporary total disability to that return to work status. The main thing that the takeaway when we work with a lot of physicians across the nation is really helping them in assisting with their practice and providing that objective information on their patient to allow them to safely return back to work. We're going to talk a little bit about safety, but it's taking away that, for lack of a better term, the guess of a patient telling you, oh, I can lift 10 pounds. And you're thinking, can they really lift 10 pounds or can they lift 20 pounds? And you don't have the ability to do that within your practice, that's where we come into play in assisting through that ability and looking what their overall abilities are. In general, there are two types of FCEs, a job-specific FCE and a general purpose FCE. A general purpose FCE, a job-specific FCE, I, or the evaluator, would be given a job description for that injured worker or that claimant. And the FCE is going to be, or should I say, the job description is going to be used as a reference for the FCE to determine, can this patient return back to work full duty and meet all of their job demands to do the job? If not, based on the job description, where are they? Light duty, modified duty, etc., etc. So a job-specific FCE is obviously going to determine, in this case, can they return to the same job or not? A general purpose FCE is just that, a general FCE to determine a baseline of their functional abilities compared to their work tasks or a job task. So again, keeping in mind, a job task, can they return to work at all and in what capacity and what physical demand category? We will discuss physical demand categories a little bit later, but that's what we're determining at this point with the FCE. And just one thing I wanted to add in there, with employers, it's very difficult in many cases to get a job-specific FCE, or even when we do get a job-specific FCE, the physical demands written on the job description are, the client needs to walk sometimes, needs to stand sometimes, so it doesn't provide that level of detail that we need. Unfortunately, with the FCE, a job-specific FCE is going to increase the validity of an FCE process. So imagine if you're sending over a patient for an FCE and there is no job description, we're assessing them at capacity of what they can do even at the sedentary level, but what their maximum capacity is. And we have a short snippet of time to spend with that individual over a three, four-hour period, so job-specific allows us to really dive in deep and do kind of a simulated work task to see what they're able to perform. Just to add to that, as far as job description and job specificity, when I do not have a job description, I am basing it on subjective, not written, but subjective job demand. And I do use the injured worker or the claimant as a guideline. What do you do on your job? What do you do at work every day on a daily basis? And again, like Lisa mentioned, job descriptions are not always specific and not always a determination or an indication of what they do at work. So I use the job description in addition to interviewing the patient and saying, okay, what do you really do at work? And that's going to give me a good balance of where the FCE, or should I say a good balance of what the FCE will determine. So now I'm going to take you all into what constitutes a good FCE. There's many FCE providers out there in the world, and there's many different types of FCE systems. And typically you're going to get a report that's anywhere from 10 pages to 20 pages. And you're looking at this information and going, what does all this mean? And what should I be looking for for a good FCE? So typically, and both Alex and I have reviewed hundreds and hundreds of FCEs, and there are bad FCEs out there. There's quite a few, and there are good FCEs out there. The first thing is it doesn't matter what type of FCE system that a clinician uses. So if they tell you, oh, I'm using Blankenship, I'm using JTAC, this is the best one. There is no best FCE system. It's the clinician that is utilizing the FCE and doing the assessment. That's what truly matters. So we look at, first thing, clinical expertise. Both of us have been practicing for a few years, as was mentioned before. So we don't want to age ourselves, so a few years. So having that clinical expertise of working with musculoskeletal injuries and how that's going to impact overall job performance is going to be important. But we're also big proponents in the research. What does the research state about work performance and how musculoskeletal injuries can impact overall work performance? So we're constantly, especially as part of our group, I mentioned that I'm the organizer of our International FCE Research Symposium here in the United States. We've had them all over the world. So we pulled delegates from Netherlands, Germany, Canada, England, South Africa, Australia, and we collectively meet together to comb through the research that's happening around the world as far as musculoskeletal demands and overall workability and work performance. And then lastly, which I feel is one of the most important things, are the patient's values and the patient's expectations. So as we know, working in this workers' comp space, it is kind of this unspoken, oh, the patient doesn't want to return to work, or the patient's faking it. What we have found in our research that less than 2% of the patients, and I've done hundreds, if not tens of thousands of FCEs, less than 2% of the patients are actually faking their injury. What we find is it's really tapping into their motivation. They have chronic pain. They're having issues that are outside of the musculoskeletal issues related to their injury. There's stress at work. There's anxiety with returning to work. They have PTSD because their injuries occurred at work and they don't want to return to the work. They are not making enough money and they're losing their home. They're going through a divorce. So it's really kind of combing through all of those things. And what we're able to do in diving deeper, spending that quality time with the patient and providing this information back to the provider and saying, here's what's going on with the patient. Maybe we need to work more collectively and bringing in other partners to help with their treatment so we can get them back to work? Well, the overall goal is to return them to work in some way, shape, or form. Sorry. In some way, shape, or form or in some capacity. And Lisa mentioned the psychosocial aspect of it. A lot of times they get injured at work and there is an animosity. I don't like my boss. My boss made me do this. So they don't want to go back to work because they've got an animosity or a beef with their boss or their employer. So if we can overcome that obstacle or at least work around it, we can get them back to work in some capacity. Maybe not at the same employer, but we can get them back to work. And I just wanted to add one thing. So for those 2% of the people that are faking their injury, we're able to, utilizing the systems and the objective measures, is to pick those people out pretty quickly. So if you have a question in your mind, is this person giving a valid effort? Is there injury or what they're depicting? Is it truly real or are they malingering a little bit? By the time they go through the process, there are certain parameters and certain things that we look at. We're going to talk about just on the reliability side that we can really be able to track with employees. I've had employees come in and say, oh, I can't raise my arm above my head. And they have a mannequin arm and they're wearing a hat. I'm like, oh, by the way, can you take your hat off? And you probably see the same thing in your practice as well. Oh, you can move your arm. Magically, it now works. So it's not like we're trying to catch the patient, but a lot of times it's also that fear avoidance of I'm afraid to move my arm. And when they come in, it's kind of that white coat fear of coming in and talking with their doctor. So it really allows us to get in a little bit deeper with these patients. We do utilize Waddell's. We do utilize subjective pain questionnaires that, again, we use as a tool in the whole aspect of the FCE. And we're going to talk about the pain questionnaires and the subjective a little bit later. So on this part, I just want to go through a criteria for an FCE. What's of most importance to us is safety. Safety is number one. In 25 years of doing FCEs, knock on wood, I have never had a client get injured. And it's not about, again, you may read through some of the research or some of the information that's out there on the internet of when a patient does an FCE, they're going to have an increase in pain. Or we're pushing them to their maximum pain point. If you have a provider that that's the way they're doing the FCE, it's not based on clinical evidence and find another provider. Because the patient should not be taken to the point where they're in so much pain when they're walking out of the FCE. They should not be getting injured for doing an FCE, because that's not a true measure of their physical demands. So safety, and we're going to talk about that a little bit further and how we use the biometric measures is most important. The other two concepts that I'll dive into just briefly are reliability and validity, and talking about how those terms are used kind of interchangeably, but they're actually different things in terms of an FCE process. And then the last two, the practicality and utility. So when we're looking at someone's ability to return to work, what does workability truly mean? And a lot of the research that I did for my dissertation was on what is workability? What is that construct? And what measures should we be looking for to determine someone's workability? And frequently, we're asked to do objective measures, but an objective isometric measure of strength does not determine someone's ability to return to work. And we're going to talk about that. I don't know if you want me to jump into that. So on the physiological measures, one of the things that we require in our FCE process and should be required of your FCE providers are the biometric measures. What is the heart rate? What is the blood pressure? You're having a person returning to work at, and Alex will be going through these later, of sedentary to very heavy work classification. And as you all know, when people have pain, there's going to be an increase in blood pressure, and there's going to be typically an increase in heart rate. So if they come in and they haven't had blood pressure issues before, but they're having chronic pain, that's when we start to know maybe some initial signs of hypertension. So can this person return to work? Is the hypertension related to the work injury? Is it something that they had previously? And is it going to impact their overall work performance? And then we want to look at their heart rate. So every single clinician we see is wearing a pulse oximeter or a heart rate monitor. Is there a change in heart rate? So if I walk in and my pain level is a one, and I'm not having much discomfort, and now I go to do an activity and my pain subjectively increases to seven, I would expect to see a jump in someone's heart rate. So think of all of you, if you've had a pain experience, your heart rate doesn't stay at resting heart rate. If you're having pain, your heart rate jumps up a little bit. We should be able to see that when we're measuring subjectively. The other thing that we look at when we're doing that FCE and that change of heart rate is when they're doing the functional activities. If I'm lifting, if I'm squatting, bending, and my heart rate stays consistently at 70 beats per minute, and now I've done five squats and I'm still at 70 beats per minute, and I'm telling you I can't do anymore because I'm fatigued, I would try to push that patient a little bit more. Well, you're not really fatigued. I'm not seeing a change in heart rate. I'm not seeing any change in biomechanics. Do you think you could do a little bit more? So it's getting to where they can do things safely. So we're looking at from a physiological measure, and then we're also looking at biomechanically. So if I'm doing a squat, for example, and I know the people on Zoom can't see, but if I'm doing a squat and I'm maintaining that great position, good biomechanics, but then I start to kind of hike up this hip or I'm doing this type of motion, I'm not doing it safely. So I'm not going to have the patient continue to do that activity. And then that's psychophysical. When patients come in, it's fear avoidance. I don't want to get injured. I've injured my back multiple times. I have a hip injury right now. So it really wants, I really, even for myself, if I'm working out, I'm doing exercise, I kind of avoid that area because it hurts. I don't want to do it. And so we're looking at that psychophysical model and how that's impacting their overall work performance as well. Okay. The FCEs obviously are, again, used to determine validity and reliability. What is validity? Validity is going to determine, or the accuracy of it, the accuracy of the results, the accuracy of the FCE. Sorry, I didn't, I'm not going to go back. Anyway, the validity of the FCE is going to help determine at the end where our final determination lies. Is this a valid or invalid? Is this valid or invalid? Is this consistent or inconsistent? Is this full effort or a self-limited FCE? So all of the components, everything we've discussed so far, and what we are going to discuss is all pieces to the pie to determine end result validity, end result determination of our findings. Okay. So getting that validity, the reason that we can determine that is with the quantified data that we collect and the testing measures, the testing tasks, the testing procedures, and the testing equipment. For example, a JTEC system uses equipment, digital equipment, to get quantified data. Blankenship, again, uses equipment to determine or to get quantified data. The, excuse me, the FCE is also going to determine or provide the provider, the physician, et cetera, with the necessary information to make a work determination at the end of the day. Are they going to return to work? So making that determination is going to be affected by validity. Where are they going to go next in this case? So when we look at these two research parameters, validity and reliability, they're used a little bit interchangeably. And I want to try to, without going back to our schooling days, what's the difference between validity and reliability? So we think of validity, what are we measuring? We're measuring someone's ability to return to work. So if the FCE is just spitting out objective data and it's not providing a true measure of someone's ability to work, is it a valid test? No. So the test then should just be thrown away. So if you're getting an FCE and it has all this objective data of range of motion, strength measures, and there's no comparison of how that person, how that correlates with a person's ability to return to work, that is a junk FCE. And it is not providing good data because it's no longer valid. So looking at the first question you should ask yourself when you're reviewing an FCE is the clinician or even the clinicians should be asking themselves, are we measuring workability and what tools do we need to use to measure workability? So really that's what validity means. It's a workability, it's a very dynamic construct, and we're using that biopsychosocial model to be able to look at that. So predictive validity, going back to job-specific FCEs, the research shows that job-specific FCEs have greater predictive validity because you're simulating the person's ability to perform that specific job test. And that's where we love job-specific FCEs. So what is reliability? Reliability is the extent to what those measures are providing that consistent information. So when we're doing an examination, we might measure somebody's grip strength. So a grip strength measure, if I'm going to open up a door, it takes 12 pounds of grip strength to do that. It takes seven pounds of pin strength to zip a zipper. It takes about 25 pounds of grip strength to do activities of daily living. So if I have someone squeeze the dynamometer, the grip strength device, and they're at five pounds, and then I ask them to go in and open the door, and they do it without difficulty, or they're lifting a five-pound weight, their grip strength is not a reliable measure of their ability to perform gripping tests. Does that mean that the person is malingering or not giving a consistent effort? That's up to the clinician to really decide what kinds of things am I seeing? Is there a fear avoidance? Am I afraid to squeeze that device because it may put a little bit of pressure where I had my carpal tunnel surgery, but I'm used to picking up a five-pound weight and I'm doing it in a different manner? So those are the things that we're looking at. We also look at inter-rater reliability. When we're doing muscle testing, when we're doing range of motion testing between clinicians, we want to have consistent measures. So we all know this is 180 degrees of flexion or close to it without measuring, and this is about 90 degrees of shoulder flexion. Probably all of you here can eyeball within five to ten degrees someone's range of motion measures at any joint throughout the body. We can do the same as well, but if we're saying that this is 90 degrees of shoulder flexion, we don't have good inter-rater reliability. And then the other piece of that is looking at test-retest reliability. So if I measure somebody's grip strength in the initial point of the test, and then I do a post-test measurement, and there's a significant difference between the two, I don't have good test-retest reliability. What I want to see when I'm doing an FCE or when our clinicians are doing FCEs is, is there a change in strength and why did that strength change? So if you're starting out cold and I measure someone's strength, that's where their maximum capacity is at that given point in time. As you start to warm up the muscle, the muscles should eventually get a little bit stronger. What happens though when there is a muscle that's not working properly, or you have some type of nerve impingement, is you will start to see a sliding scale where that muscle will start to decrease. So let's say I take somebody's grip strength, it's 50 pounds, they do a lot of hand activities. After doing the hand activities, I measure their strength again, and now it's at 40 pounds. And they've been providing a consistent effort. For our determination, when there's a 20 percent, the research shows a 20 percent drop in strength indicates that there's a significant deficit there. We might be able to point out something that you're not even seeing as part of your evaluation. Like, oh my gosh, there's something going on with the nerve or with the muscle that you might not even notice, and we're going to provide that information back to you. But it also helps in making that determination for their overall workability. I just want to add in, as far as reliability and inter-tester reliability and findings, for example, the JMR dynamometer. Lisa mentioned taking the JMR and getting 50 pounds at the beginning, and hopefully getting a different number later on in the test, or getting a decrease of 20 percent later on in the evaluation, showing fatigue or showing that there is a deficit somewhere. That also needs to, you have the clinical or the clinician expertise, that's where that's important, because the clinician has to make that determination and analyze that data or those findings and say, okay, is it self-limited behavior? Is it a deficit? Is it a problem that we need to further look into? So that's where clinical expertise and the evaluator expertise comes into play to make that determination and see where this possibly might be going. So the next thing I want to talk about is just consistency of effort, which is a measure of reliability. One of the most frustrating things that I get as far as a referral, and it typically comes from an insurance company and as a hand therapist, is I want to have you measure this person's grip strength to see if they're able to return to work. My entire research, my dissertation was grip strength is not a determinant of workability. I have a 100-page report that I could send all of you if you'd like to receive it, but there is no minimal to little correlation between someone's grip strength and someone's ability to perform grasping tasks, unless you have a measure like a police officer and the grip strength required to shoot a gun, a firefighter and the grip strength required to hold on to the hose, a person that does rope climbing. There was a research article and their grip strength was correlated between their ability to climb ropes. If you're doing dexterity work, such as typing on a computer, if you're doing even just some material handling, there is not a correlation between someone's grip strength and someone's ability to return to work. I did a lot of work for Unum, which is a large disability insurance carrier. Some of you may have a disability policy. In the initial stages of my career, I was asked to fly around the country, meet with dentists and doctors, and measure their grip strength to see if they were able to return to work after an injury. I continue to fight with Unum and still continue to this day to fight with them that there is no correlation between a doctor's grip strength and their ability to perform their task at work. When we look at the FCEs, and if you get an FCE that says this is the person's grip strength at 70 pounds and they're able to perform gripping activities solely based on their grip strength measure, because we see it all the time, it is not a good measure of someone's workability. There's a professor out of the University of Florida, Arit Shukman, so sorry for people that are not University of Florida fans, but she did a lot of research on grip strength measures as well. There's another measure that we were asked to take in the initial stages of our career called the rapid exchange grip. You're basically taking the dynamometer and moving it back and forth as quickly as possible, 10 repetitions on each hand. What the old thought was that the rapid exchange grip should be lower than someone's maximum grip strength. Arit Shukman disproved this in 2000, 22 years ago, that that was not a good measure of reliability. I will tell you in 75 percent of the reports that I review, they're still using this as a measure of reliability. The other measure they're using is consistency of effort. When we're looking at coefficient of variance, it's a statistical calculation of taking three measures. When you're doing those three measures, is there a difference of 15 percent between those three separate measures? I take my grip strength, I'm five pounds, 10 pounds, and 15 pounds. The difference between those three measures is greater than 15 percent. Now my coefficient of variance on that one becomes higher. The research used to state that if your coefficient of variance is the averages, so let's say you do 70 tests and 69 of those tests are below 15 percent, someone's giving a valid effort. Again, this has been disproved as using this as a sole determination of reliability for an FCE because of those psychosocial variables that can come into play. I am measuring my grip strength. I have a carpal tunnel release. I'm going to squeeze as hard as I can. Ow, that hurt. The second time I go to measure it, I do it a little bit lighter, that wasn't so bad. The third time I go to measure it, I can put a little bit more force into it, but not as much as I did the first time. And now my difference is more than 15%. Does that mean that I'm not giving a valid effort? No, it means that I have some fear avoidance and pain when I'm doing it. And what are the measures or what are the variables that we're seeing from the patient? But again, based on the coefficient of variance, that is going to be a clinician's determination and a clinician's expertise in analyzing that coefficient of variance, analyzing the person's performance, analyzing the heart rate, analyzing all of the information to make that determination. So is it injured worker or patient avoidance? Or, yes. Can you ask them during the test, like I noticed the second test was last, is there a reason? No. I do. So the question was when they have a change or where they show something different, would you ask them what's going on? I would, after the test was complete, I noticed there was a difference. I noticed a change in posture. I always pointed out to the patient, tell me what's going on. These are the things that I'm seeing. Biomechanically, I've had patients where, again, just going like with the squatting, where they do normal squats and then a change in position. I said, well, we're going to stop that test. It's no longer safe for you to continue. And they'll turn around and say, well, why? I feel like I'm doing fine. I'm like, well, your hips are completely uneven and you're going to end up, you're not firing through your glute med, your glute max, your hamstrings. There's a lot of different things going on. If you continue doing that activity, you're going to increase your pain. You're going to increase your injury. So yes, I think it's important to communicate to the patient what we see and what we're observing. If someone's faking their injury, I do call them out on it. Like, hey, this is what I see. Your grip strength's five pounds. You just went and opened that door. It takes 12 pounds to open a door. So, or you just lifted that box, you know, tell me. And I've had patients stand and argue with me. Well, this is the best I can do. I realize this is the best you can do. Are you scared? Is something else going on that's causing you? Is there some ulterior motive here? Please, please share with us. And that's the information we can provide back. That, to more elaborate on that, on your question, it's also tester style. Despite the fact that Lisa and I are very well-versed in FCEs and have been doing this for such a long time, we do have different styles. And I prefer not to discuss, unless I'm calling the patient out on something, but I prefer not to discuss because I don't want to skew the data or skew the results because I am bringing that to their attention. Essentially, you know, let them trip and fall is a little more my style. Whether it's good, bad, or indifferent, I don't want to skew the data because I am influencing the injured worker or the patient. So again, it's just, you know, different styles, but both of them, whether it's Lisa or myself, we're going to get the answers or the determination that we are looking for and get an accurate number or an accurate, you know, outcome. Yes. It's a simple vocabulary question. You used the word clinician a whole bunch of times. You mean the person ordering the exam or do you mean the person doing the FCE? Who do you mean by clinician? So he just asked who is the clinician in this case because we keep referring to the clinician. The clinician, we are referring to the evaluator, the FCE evaluator. Any more questions right now? No. No. So I will move over to the physical demand levels that we talk about is we're measuring occasional, frequent, and constant. And I get this question frequently from physicians. What does that mean when you say someone can do something occasionally, frequently, or constantly? So occasionally, zero to 33% of the day, or it's one repetition every 30 minutes. Zero to 33% is about 2.65 hours. Frequent, 34 to 66% is about 5.5 hours. And constant is, of course, most of the day. One rep every two minutes, one rep every 30 seconds for constant. And how do we make that determination over a three or four hour evaluation? It's taking all of that information. Again, the accuracy with our research panel, with this international FCE research, we're actually this year discussing a shorter FCE. So if clinicians tell you it has to be eight hours, it has to be six hours, it has to be two days, it does not have to be six hours, eight hours, or two days. It has to be a good objective measure because you're looking at the biometric changes within the individual biomechanical changes, the changes in their strength, and then the biometric changes that occur. And then you're making that assessment. I'm sure most of you could probably look at your patients and say, I think they can return to sedentary light, medium heavy work, but we're just helping to objectify that more. Maybe there's some fine tuning and support that you need from an independent evaluator because you have an insurance company or an employer telling you what are the job demands. That's where we really come into play. So the other piece is their physical demand level. We look at sedentary, light, medium, heavy, and very heavy. So sedentary falls within zero to 10 pounds. So are they able to lift 10 pounds? Are they able to sit for approximately six hours a day? And that doesn't mean they have to sit six hours continuously. There's 85% of the population is going to have a back injury at some point in their life. And I see a couple of you standing. I don't know if your back's sore or if you're just fatigued, but we all have to get up and move. You can't sit six hours without moving at any job. So it's six hours is the sitting and then being able to stand and walk. Light is being able to lift from 11 to 20 pounds. You're doing more walking and sitting as well. And then you're going further down into that classification of the lifting requirements. When you're getting into the medium and heavy, you have to integrate some of your squatting and twisting, more of the demands on your lower back, more of those dynamic postures. But your sedentary classification is that clinical person sitting there working. When we are looking at doing these FCEs, and it's a general purpose, we're measuring them to their maximum capacity. But we're also, the question I always like to ask myself is, can this person return to work eight hours a day at a sedentary capacity? Can they sit for up to six hours? Are they able to lift up to 10 pounds? Are they able to use their hands to do some type of dexterity? They might be only able to type for 10 minutes continuous. They might be only able to type for a combined total of two hours a day. And we would specify that in their report. But they have the ability to sit and they have the ability to maintain that for a full eight hour workday. Excuse me, I apologize for my little disappearance for a minute, but I'm gonna back up to the physical demand categories again, and elaborate more on the PDC levels or the physical demand levels. There are three, occasional, frequent, and constant. Occasional, frequent, and constant is repetitions, it's time, and it's space. So occasional, zero to 33% of the day. Obviously that's one third of a regular eight hour workday. But making that determination can come by or via time, one minute to 20 minutes, or it can come by repetitions. If the person is a warehouse worker, obviously we're not gonna make that determination based on time. We're gonna make that determination based on repetitions. How many times on average do they have to bend in an hour or in an eight hour workday to do their job? So that's where we're using occasional, frequent, and constant based on time and repetition. And back to the physical demand levels. Again, Lisa was discussing the PDC, excuse me, PDLs that fall into different categories. And those categories are determined by what we call material handling. So it's a combination of actually lifting, but also performing material handling tasks, bending, squatting, twisting, and so on and so forth. So just because we are getting an actual quantified poundage for the lift, that's the basis or the basis of making our determination into what level they belong in. So I think Lisa left off at light. So let's go down to medium. A medium PDL is obviously 21 to 50 pounds. It's a broad range, a very broad range. 22 pounds versus 49 pounds is a big difference. So again, using the clinician or the tester to figure out where they fall into that range or what their limitations are is going to be determined by the whole picture, not just the lifting. Because again, 22 pounds is big difference to 49 pounds. Heavy, again, 51 to 100 pounds, that's a big range. I don't know if any of you have even tried to lift 50 pounds versus 100 pounds. I can't do it. So, but you're going to get that heavy category. Okay, so we've got to make a determination on where their cutoff point is. Okay, so the last part is what should happen in an FCE. So when you're working with a clinician, what things should you see in your report? Number one, biopsychosocial approach. It should look at the person holistically, biologically, musculoskeletally, doing the musculoskeletal assessment, but also are there other social environmental factors impacting that ability, a person's ability to work? So you're doing your in-depth musculoskeletal and posture assessment. As a clinician therapist, we are trained to look at the biomechanics of the body and how that impacts somebody's ability to function. We look at posture. Do they have increased kyphosis? Do they have increased lordosis? Do they have limitations in their thoracic spine that's going to prevent them from twisting and turning? Do they have tight hip flexors? Do they have limitations with their hands? Then you're doing a review of ADL and work... I just want to intervene on the musculoskeletal and postural assessment. It is also the clinician's responsibility, not only to look for muscle imbalances, et cetera, et cetera, but also biomechanics and lifting mechanics. If you see that this injured worker is lifting wrong, or not using proper body mechanics to lift that box or lift that object, do they have a greater potential of injuring themselves again? Yes. So it would be the employer's responsibility at that point. We would make that aware, but we would make the employer aware and say, okay, maybe you need to work on educating your employees with proper posture and body mechanics so that we have now injury prevention in addition to getting these people back to work or getting them back to work in some capacity. So I know we're running a little bit short in time, but just to recap is doing the review of the ADL work function and then your job simulation. So it's not just doing, I can do 10 squats. It's a simulated work task to make it more functional and then pre and post strength measures. Where were they at the beginning of the examination? Where were they at the end? And then providing that assessment and recommendations to you that should clearly be read. One of the things that we really try to promote is in our assessment, it's just kind of having a front page physical demand sheet that's showing the different classifications, sitting, standing, walking, bending, squatting, reaching, occasional, frequent, constant, their continual period of time they can do it and their repetitions. So it makes it very easy for you as the provider to read and based on that assessment, you should be able to take that front sheet and go, everything on the back is just supporting the information that's on the front. Are there any questions? Okay. Pull up the chat for us. Go ahead, Al. For evaluating firefighters, we're frequently asked to find a rule regarding that firefighters' aerobic capacity to do the job. I have two questions. Number one is testing for aerobic capacity still a valid way of assessing firefighters for the two weeks, as you guys know, all the latest and greatest. And number, the second question, if it is one type of aerobic capacity that you do, direct testing, indirect testing, step testing, what happens? Do you want to ask that question on the video so that they know? I think they heard it. They may not have seen it, but they heard it. Hey, did y'all hear the question from Dr. Baltracitis? Nothing. No, okay. He just asked for a little more detail on how we do the aerobic capacity. And more specifically for firefighters. And yes, there is an aerobic component and there is aerobic testing. For example, firefighters, they are wearing 62 pounds of gear, 62 pounds of gear. So having a firefighter come to an FCE, which I do a lot of fire and law enforcement, but more specifically a firefighter coming to an FCE without their gear is pretty much a mute point because in the field and in reality, they have 62 pounds of gear on. So first and foremost, is gear versus not gear going to affect their aerobic capacity or affect their performance? Yes, it is. Mask versus no mask. They have to wear a rebreather, they have to wear their oxygen mask. Is that going to affect their aerobic capacity? We do a combination of direct and indirect doing a step test, doing a ladder test, et cetera, et cetera to give us a good determination of whether this firefighter specifically in this case can return to work and perform their job with every aspect of it. Now, we don't have a crystal ball and unfortunately firefighters, law enforcement, et cetera, et cetera, is a volatile job. You might go to work one day as a law enforcement officer and sit in your car all day, but the next day you're doing the 40 yard dash or the a hundred yard dash chasing a perk. So we don't have a crystal ball to know what they're going to do. Dr. Fitzpatrick, could you take the question from Dr. Estep on the screen there? What do you use for reliability of lifting? Is that the one? Yes. Okay, so what do you use for reliability for lifting based on their maximum lift? How do you determine an occasional versus continuous lift? And the determination is made really on, for us, three different factors. We're looking at their biometric measures, change in heart rate, change in blood pressure. We're looking at pain level. We're looking at the biomechanics of the motion and then rate of perceived exertion. I guess that's four reasons, not three. So when we're doing the lifting and then what makes that determination based on occasional, frequent or constant, that goes back to the slide where we talked about repetitions. So how many repetitions are within occasional? How many are within frequent? How many are in constant? And what are their requirements for that specific job? And to elaborate on that as well, based on statistics, when you obtain a one repetition max, if this person can lift 50 pounds on a one repetition max, statistics show that frequently they should be able to lift half of that. So 50% of that frequently. So that would be 25 pounds. And continuously, they should be able to lift about 10 pounds or 25% of that. So there is a statistical determination based on their one rep max on what they could do frequently and continuously in an eight hour workday. And thank you all so very much. I'm gonna try to make up a little time because it's not your fault, it's mine. We took a 10 minute break, which got y'all started a little off schedule, but I do want to be kind to Dr. Glade and not get too far into his hour. So y'all may be able to be around in the back or outside if there's any other questions from our live audience. I was just gonna say, we're going to be around for the rest of the day and at the happy hour event and then the event you guys are going to. So happy to answer any questions that you have. Our email, mine is on hero, is the L Fitzpatrick at accellable.com. So if you X-C-E-L-A-B-L-E is the name of the company we provide nationwide, we work together. So please feel free to reach out with any questions. We have some business cards as well. And thank you very much for your time. Thank you. Thank you. So while I'm queuing up Dr. Glade's slides, I'll answer Dr. Evans's question. After the one o'clock, after the noon lecture adjourns at one o'clock, you'll be free for the rest of the afternoon. If we're able to get any video or other materials from Clarios during the onsite visit, we will spin those into another module for you to look at at your leisure. Hopefully that answers your question.

Brent Lovejoy Memorial Lecture

Disability and Impairment Medicine

Functional Capacity Evaluations

FCEs

work-related injuries

Americans with Disabilities Act

industrial healthcare

biopsychosocial approach

return-to-work programs

osteopathic medicine