We are pleased to announce or to introduce Dr. Lisa Fitzpatrick. She was with us in Tampa and we invited her back. Dr. Lisa Fitzpatrick is a recognized leader in injury management with over 25 years professional experience. She has spoken internationally on injury reduction and prevention and FCDs. She is currently the organizer for the Fourth International FCE Research Symposium in San Diego, California. She has authored a book called Call Someone Help Me, Can Someone Help Me? In addition to her speaking and publications, she has spent the past 20 years as CEO of Accelable and has established relationships with top insurance companies and won contracts with leading employers, such as USPS and several workers at top insurance companies. She has nothing to disclose and she has also been asked by Department of Labor. They are looking for providers and she's going to start with letting those in virtual land plus here know of opportunities and also especially with CDL license. She'll also be announcing that in our course this afternoon. So, Dr. Lisa Fitzpatrick, please welcome her. Let me make sure my phone is on. That's why I skipped over that. Minimize this. I just wanted to leave it open in case you have chat questions. And they'll come through there. Yeah, right here. And then a microphone so everyone can hear me. Absolutely. There's a holder here. I kind of like to walk around a little bit. Well, do I need to be behind so Zoom people can see me? Yes. And let me tilt it back because you're taller than me. That's not saying much. That's a very long bar. So, many people here have seen me now in my casual attire as well. So, this is a little bit of a change. Thank you for the wonderful introduction. And I do see some of the people that I saw last year in Tampa. So, it's great to see. Thank you. I don't think that's true. But just a little bit about my background. The OT, I'm an occupational therapist, certified hand therapist, and have been practicing for many, many years. I don't want to date myself, but this is my 30th year being an OT. And it's been a lot of changes through the medical system, as many of us have seen over the course of 30 years. So, I went back to school and got my post-professional doctorate degree back in. I went on the long road. So, I started in 2000 and finished in 2015. Gave birth to three children and not all at the same time. I have a 12-year-old and a set of twins that are nine. But started Accelable in 2000, and we work with a lot of insurance companies. I've been doing a lot of work with the Department of Labor, so I think I'll start there. Because there is a desperate need for providers to do Department of Labor. And I see a couple people shaking their heads. Is anybody in here already doing Department of Labor? More specific. FECA. So, really, there's three different branches. Well, there's many different branches. But FECA is one of the many. And FECA would deal a lot with your TSA agents, your USPS, your FBI agents, your Border Patrol. Then there's Department of Energy. And there's Longshore. And, anyway, there's different divisions. But FECA is where we're kind of branched or working out of. And I've been working with the Director of Workers' Club through OWCP. And a lot of the providers, good physician providers, good physical therapists are leaving because it's a nightmare to get your cases authorized. It's a nightmare to go through the billing process. So I want to let you know that we do have resources available. When OWCP switched over to CNSI, it became a nightmare for many of the physicians to be able to see patients because you would see a patient submit the paperwork, and then you would not get your case approved, and then you wouldn't be paid for the service. So it's very difficult with kind of dotting your I's and crossing your T's and how the paperwork should be submitted so it can get approved. We've been working very closely with some consultants who have experience in that realm. And we've lost so many physician providers along the way that a lot of the patients are waiting three to six months to even get into a provider, or they're waiting or driving longer distance to have to see a provider. We are working with a physician in Kentucky who can do what's called a schedule award. So when a federal government employee receives an MMI rating, they have to go through what's called a schedule award. So our clinical team is doing all of the physical measurements, and then the orthopedic surgeon is able to do the schedule award to help out. But part of my reason for talking about this, that if any one of you are interested in becoming a provider, please reach out to me directly. I can set you up with consultants who can kind of walk you through the process. I would love to introduce you to the Director of Office of Workers' Compensation, Chris Godfrey, so we can really kind of move the process forward in providing better services, qualified physicians to be able to see these patients. We do the functional capacity evaluation, so we now have a clinical network of over 100 therapists. And we're starting to work with a physical therapy network that will be able to provide good quality care to these federal workers in providing that transparent pricing as well. So we can kind of help you through that CNSI process, because on the physician end, it really is a pain to get these treatments authorized. So now I'm going to jump into my other part of my presentation, which is about functional capacity evaluations. There is information that I will be discussing today that we covered in the Tampa meeting. There hasn't really been any significant changes about functional capacity evaluations, but I want to talk about the approach that we're trying to have other clinicians utilize and to let you be aware of that the FCEs that we did 20 years ago are completely different than what we're doing today. Unfortunately, there's no standardization. So I was reading a presentation by a physical therapy group, and they have over 50 facilities, and they talk about validity and reliability and how they're utilizing the equipment to assess whether or not someone is malingering. And I'm going to talk about that in depth a little bit today, because it's very frustrating for me that we're just using a piece of equipment to determine if someone who has chronic pain or issues that they're actually a malingerer, and there's not other things going on with that individual that we need to address. Before I get started on this presentation, how many of you are using functional capacity evaluations or referring out for those in your practice? So a few of you, and I can't tell with the people online. So on the FCEs, and if I may ask, and I don't know if I ask just to this group, what things are you seeing in the FCEs that you're using currently that you like or dislike? Is it hard to read the report? Anyone wants to shout out? The ones I did seem to be pretty understandable and usable. Okay. Same. So good quality in providing those level of restrictions. Okay, and that's good. There's different brands and systems that are out for FCEs and computerized technology versus looking at it from a manual input, and we're really focusing on can we do a shorter FCE version and still be able to talk about someone's ability to work, and I'm going to talk about that today as well. So what is an FCE? And I think I mentioned this in our Tampa presentation. It's basically—so SORA is one of the individuals who is part of our international FCE research group, and we're really focusing on that international classification of functioning from the WHO. So it's looking at the person's body functions, their physical changes within the body and the structure, the environment and how that may impact someone's ability to return to work, and then, of course, their personal factors. So kind of from that social end, that psychological end, that may impact their ability to work. In the functional capacity evaluation, we may find that the focus is really on the physical capabilities and not as much on that psychosocial model, and that's really what we're trying to promote, really that differentiation between the two. So when we look at—there's two types of FCEs that are out there. One of them is job-specific, and the other one is general purpose. I love when we get job-specific FCEs. So when we look at the USPS as an example with the letter carriers, we are very well versed on what they need to do to return to work. So whether they're using a satchel and working as a city letter carrier or driving in their vehicle and delivering mail, we want to gear the evaluation towards what's relevant to their specific job. So a USPS mail carrier, part of their day is spent about two hours just casing mail, and very often when they're returning to work, they may have a shoulder injury, and the restrictions are, oh, they can use their upper extremities in the functional capacity evaluation for, on an occasional basis, two and a half hours a day. So I laugh when—not laugh realistically, but when they return to the Department of Labor to their employer, they're having them case mail. So imagine I have a shoulder strain, rotator cuff injury, and I'm spending two hours doing this repetitively, but now when I'm returning back to light duty, instead of going back to carrying mail, they'll have me case mail or pull a route down for two mail carriers because that's their light duty status. So now I'm doing this repetitively, casing mail, with my shoulder injury, three to four hours a day. And so the key is, if we know that it is a job-specific and we have a clear understanding of what that job is, in the functional capacity evaluation, to make your life easier, it should delineate those specific tasks. So I'm going to use that postal employee again and say, all right, I only want that person casing mail for an hour. And they have to have the ability to use both the left and the right arm, and they need a stepstool to be able to case mail. So that should be in that FCE report. And then when you're turning in for the federal government, they need an OWCP-5C or CA-17 that the physician would need to fill out. That is going to be as part of that recommendation in that report. Again, with the letter carrier, they have to carry a satchel. That is the requirement by the Department of Labor. So many times we'll say they can lift a parcel weighing 10 or 15 pounds, but they need to have an empty satchel because having that 10 or 15 pounds walking 20,000 steps a day is still problematic for their shoulder, back, neck injury. So the point being, when you're getting these FCEs and communicating with your physical therapy network or the physical therapists that are doing them, we need more detail when it's a job-specific, and it can be from any industry. And I'm going to show you a couple of videos that I took of a client and where we were able to break down specifically what he could do during his daily task and as far as it is with work. General purpose, this is where we probably get 75% of our referrals. So to give you an indication, we have 100 clinicians right now at Accelable, and we're doing 200 FCEs a month. So that is our only area of focus is just doing functional capacity evaluations because we want to focus on the evidence-based practice and how can we make this a better system and being able to help the physicians. But a lot of the companies out there, if you're working with a single entity in a physical therapy practice, they're getting referrals through a third-party administrator, and they're coming in as a general purpose FCE. It makes it very difficult for all of you to treatment plan when you have a general purpose FCE because we're looking at with any job, how long can they sit? How long can they stand? How long can they walk, bend, squat, use their hands in any job? So from working at McDonald's to sitting at a desk job to doing a manufacturing heavy labor job working at Amazon, do they have the ability to do that on an occasional, frequent, or constant basis? And we're evaluating them over a three- to six-hour span and providing those recommendations. So general purpose are very hard for us to do because you're having to look at all of the jobs that exist and then making that assumption of what can they do with any job at any point in time, as well as looking at their ability to return to work on a light, medium, or heavy capacity. So what we're really trying to focus on and, again, reaching out with the physicians is getting those job descriptions, working more directly with the employers because it's a significant cost to the employers to have these employees out of work and making sure that we get correct job descriptions. We're trying to pull away a little bit from these third-party administrators that are directing care towards the clinical providers, towards the physical therapy groups, because we're not getting enough accurate information about that employee. And I think back in the early 90s when I started practicing, there was always such a good communication between the therapist and the physician. And I feel like we kind of have shied away from that a little bit in multiple areas because you have these larger hospital organizations coming in, kind of buying out the physician practices, and then you have your physical therapy groups that are owned by larger organizations. And it's very difficult to keep those lines of communication open between the doctor and the clinician to be able to really help the employee. So one of the things on the bottom is how does a general purpose reduce overall validity? When we talk about validity, which will be in my next slide, the premise is can the test determine that someone's ability to return to work? And when you're doing a general purpose FCE, it reduces that validity because it's so broad on workability. Can they work at McDonald's? Can they work at Amazon? Can they work in a sedentary desk job? It's so broad in looking at that workability construct that it reduces the overall validity of the examination. So validity and reliability. I know for me in college, and I've gone multiple years, 15 years of my doctorate and then four for my undergrad, validity and reliability, I hate it. I hated learning about it. I could never figure it out. For me, for all of you, it was very easy, but these were two of the areas that I struggled with. And I still struggle with because I think about what we're doing on the functional capacity evaluation. We need to make sure the question we could ask, is it a valid test and is it a reliable test? So to break it down in the level of understanding that I'm able to understand, when we look at validity, we're looking at that construct of workability. Is the test designed to measure someone's ability to return to work? And if you're using different test sequences that measure someone's ability to return to work, then that test will be valid. For the test to be reliable, you're looking at what we call test-retest reliability or iterator reliability. So can you perform that test and receive consistent results? A test could be reliable, meaning we can have consistent results, but it may not always be valid. And this is what I learned in getting my doctorate degree. One of the things that we use frequently in the FCE test are grip strength, is taking a grip strength measure. And we still get this request by multiple disability insurance companies. We want to do maximum grip test, and then there's something called five rung. So on the dynamometer, there's five different rungs. We want to see if there's a bell-shaped curve. And then you do what's called a rapid exchange grip, where on the highest point on that five rung, they're tossing it back and forth 10 times, and that maximum level should fall below the highest level on the five rung grip test. The problem with that is multifactorial. Number one, there's multiple areas that can cause someone to not have accurate testing. So fear, the fear of squeezing the grip device because I have a hand injury, the fear of working with a provider, the lack of understanding when you're doing multiple trials as they get used to it. It may show a difference from beginning to end. My research was all based on, is grip strength a true determination of workability? I did a scoping review and all of the research that we could find, the only time that it is truly relevant is if you're performing a task such as a rock climber, or a firefighter, or a police officer and looking at shooting your weapon. Other than that, where you're not doing hand intensive work, a grip strength measure is not a good determinant of someone's ability to work. So when I'm out presenting and talking to clinicians about why are we continuing to spend so much time taking a grip strength measure and then seeing the grip strength is within the normative data, therefore this individual can return to work. Our normative data for grip strength measurements dates back to 1985. So we're still kind of far behind the times. As we've changed in technology, 1985 was when we were first starting to use computers and doing more hand intensive work. So when we look now and we're taking the normative data and saying because someone can have this grip strength, they have the ability to return to this type of work, it's not an accurate determination of their workability. And when you see that in a report, please take that into account. It is not an accurate measure of their ability to return to work. So circling back to the presentation that I looked at from another group, they were doing this presentation in 2015, which isn't that far back, and they talked about the grip strength measure, the five-run grip test, and the rapid exchange grip being a measure of validity in determining someone's ability to return to work and determining if they are malingering or faking it. And I cringed when I saw that because research, if we follow evidence-based research, Arit Schechtman in 2001 did a very in-depth study in looking at this rapid exchange grip, five-run grip test, and found that it is not a good source of validity measure. And focusing on if someone's giving a valid result in the test and if someone is able to perform work. And when we think about it, is valid the right terminology to use? Because are we looking at validity as that construct of workability? So maybe the question should be how reliable is your data first to look at are we seeing multiple, when we're looking at these tests, are we seeing consistent measures between the tests that you're performing? And then the question should be, is your FCE valid to determine someone's ability to work? Yes, you have a question. You have the perfect example in the U.S. Army right now. Annual physical fitness test. There are now how many evolutions of that, again, looking for the validity, how healthy a soldier is, can they perform the full measure of anything in combat, and we're still trying and testing. It hasn't been determined for them yet. And to me, it's kind of the, I go back to the definition of insanity. Of, you know, we continue to do the same thing over and over again and expecting a different result. So we have the, and I always mispronounce the acronym, is it ODG guidelines? ODG or OGD? ODG. Thank you. I always want to say ODG, but I always want to say OGD. I met with one of the, I don't know, someone in the C-suite on their guidelines, and they pull the data to make these guidelines of when an FCE should occur and how long treatment should last, and it's all based on information we're pulling out. And I said, well, if you're taking 100 clinics and they're all doing it the wrong way, and this is what you're basing your guidelines on, why are we thinking that that is correct? Why do we think that grip strength is still a component of an FCE that is important to determine someone's workability? Why, when we're looking at the Army, are we doing just this physical evaluation and not focusing on do they have any disruption in their musculoskeletal area that would limit or prohibit their ability, help strengthen that area, and allow them to practice and focus on the specific tasks that they need to be able to perform? So to me, that's really kind of the focus with our team, is we need to look at how can we change the system, make it better, and it's not going to happen overnight. But I'm hoping as we continue to do more of these presentations and we can collaborate more clinically as a team and leave out some of the middlemen of these are the specific guidelines and you have to follow, like why does it say a rotator cuff tear has to have this many treatments before you have an MRI and this many treatments before you have a functional capacity evaluation? There are so many new, and this could be a whole nother talk, but new technology that is coming out that does help with people getting better and stronger quicker. And we need to kind of focus on those as far as clinicians and less on kind of that old school and what we were doing before, because that does, to me, just bring me back of why are we still doing the same thing we did 30 years ago? And I see that with a lot of these disability insurance companies. So if any of you see ERISA cases or your social security cases or your disability, Unum, MassMutual, Hartford, they're still asking our clinicians to do the fibrin grip test because the orthopedic surgeon who has now retired and is 80 years old, and some of us may be getting closer to 80, I'm nothing against that, but they're sitting back and saying this is how it was done 30 years ago and we still have to do it this way, despite the evidence showing that that is no longer relevant. And it's not a new scenario. Yes. Schaffner and Taylor, their work with randomized grip and touch showed that the validity of the effort was almost that you could use that for. Yes. Is that what you're getting at? It's the yes and no. I mean, do we still do an FCE as part of our exam, or do we still do a grip strength as part of our examining? Yes, because that's what we're used to seeing. But the relevance is it's not really needed. I mean, I want to look at, as part of my musculoskeletal evaluation, I would do it as a baseline. Is there weakness? Because that's a good baseline measure. If they have a hand injury, I'm going to have the employee engaged in a hand-intensive activity, such as typing, and seeing is there any change in function between baseline and between where they are at the end of their test stage. So typically, when you look at muscle function, muscles should start when you're cold. It's not going to be at your strongest point. When you start warming up that muscle, you want that muscle strength to stay pretty consistent or go up. If we see a drop in muscle strength of 20%, that's typically when we would start restricting clients from their ability to work, or with their complaints of pain, or any change in heart rate biometric measures as well. So when we look at those strength measures that we take as part of that functional capacity evaluation, it's not necessarily the effort per se, but you want to look at it from baseline to second testing and what happens after the fact. Does that answer your question? We can chat afterwards as well, because there's a lot of work that Shukman did back in the early 2000s in looking at grip strength and kind of these different validity measures. The other one is coefficient of variance. You've probably heard of that as well, that if you have three trials with any strength test and the change between those trials, if you have more than 15% difference, then someone is not giving a valid effort. So that goes back to the scenario of what happens if I take that grip strength measure, my first one, I'm a little bit fearful, I don't squeeze as hard as I can, I get 30 pounds. The next one, I put a little bit more force into it, I get 60 pounds, and then that hurt. So now I'm going to back off on my third one and I get 45 pounds. So now my variance is greater than 15%. Does that mean as the employee, I'm not giving a valid effort? No. It just means you have to be aware of those observable behaviors. So the functional capacity evaluation is observable behaviors, pre- and post-test measurements, and looking at the reliability between those pre- and post-test measurements. What I don't want to see is someone giving a grip strength of 45 pounds, and then we re-measure them, and it's 130 pounds after we do the activity. You could then say that's not consistent, not reliable to use that data. However, it doesn't mean that person is malingering either. So there's many components that have to come into play. I hope that clarifies things a little bit more. But if not, we can chat after too. So what is the concept of workability? Again, I'm very, very passionate about what is workability, because it's more than having the physical capabilities to be able to return back to work. And I'm sorry I don't know everybody's name, but going back to your thought in the back, it's not just that physical ability. So workability is taking and thinking in terms of a house. And I'm sorry this is kind of blurry. It wasn't blurry on my computer. But we look at really our physical components, our environmental components, the social components, and all of these intertwined together that affect someone's ability to work. So they're motivational factors. How often do you see an employee coming into your practice who has so much stress and anxiety and fear, they don't want to go back to work, and they're begging you, please don't return me back to work, or I have to take care of my sick friend or mom, or it's better if I stay home with my kids, and, oh, my back hurts, and I don't want to go back to work. Those things happen, but it doesn't necessarily mean they're malingering. Or I end up where I have chronic pain. And one of the main culprits of chronic pain that we found in our research are anxiety and stress. So if we can minimize that anxiety and stress, and we're seeing it with a lot of the Amazon workers, that their injury rates are significantly increasing 20% year over year instead of decreasing. So in 2021, Amazon had 38,300 injuries in their facilities. Typical in a warehouse is 3.1 workers get injured per 100. Amazon is now up to, on average, in 2021, it's 7.7. And in some of their locations, they're at 13 workers per 100 are getting injured. So the stress and anxiety on these employees is so profound, it makes it very difficult for them to return to work, resulting in these chronic pain issues. So the basis for workability is more than just those physical components. It's focusing on the other culprits of what we consider to be what's called the biopsychosocial model. So what's the most effective approach to determining workability is what I just said, going back to the initial, is using the ICF because it's that biopsychosocial understanding of someone's ability to return to work. It's a dynamic construct. It's not as simple as can this person perform these repetitions and have that ability to return to work? Do they have adequate grip strength to perform their job? Do they have adequate muscle strength? Can they stand? Can they walk? So for an FCE to be truly effective, it has to utilize that biopsychosocial approach in their model. That doesn't mean taking away from the musculoskeletal evaluation. That is a component of it. But it's also understanding what is the motivating factors that are allowing that person to be able to work, and then communicating that to you as the provider, like, oh, I'm also seeing they have severe anxiety and stress. How can we work together to be able to get this person back to work, and communicating with this to the employer? So when we look at the effectiveness of FCEs, and I'm going to—I totally understand. I'm showing two that are positive. There are multiple reports out saying FCEs are not providing credible data for someone's workability. So the jury is still out. Is the FCE a good tool, or is it not a good tool? Our premise is based upon the way it's performed, and it's a good tool if it's performed correctly. And I don't care whether you use a BTE system, a Blankenship system, a JTEC system, an Eiserhagen. There's so many different models—Occupro. All of those are great, but it shouldn't be a cookie-cutter approach. I shouldn't be able to put someone behind who is the system as a PT assistant or an OT assistant and evaluate this client's ability to return to work because it's really important to look at those observable behaviors and all of the other dynamic constructs that are going to limit this person's ability to return to work and then communicating that back to the treating provider of what we see. I don't feel that someone with a limited education about evaluating this dynamic construct can make that determination for someone's ability to return to work. If I put the data into the computer system and do my musculoskeletal evaluation and it spits out, based on what we see objectively, this person can perform this job, I would say that's not accurate data. That's not accurate data in what we're seeing in that physical component because we're not taking everything into consideration. So in 2017, just on these two reports, that the addition of the FCE, the physician changed the majority of their physician-assigned DOT levels, and then another study in 2017—and this is the insurance physicians—changed the physical work capability of clients with MSDs. Now we don't know without digging deeper into the different—I think one of them in 2017, they used the BTE evaluation system. Again, a great evaluation system, but it's all behind how the user is using that evaluation system for it to be effective. So when should you use FCEs in your practice? Determining workability. You have an employee come in, they are concerned about their ability to return to work, and you're trying to determine, they have an injury, should they go back to light duty, medium duty, full duty? How do I make this determination, and how do I provide objective support and data to be able to make this determination? This is when you can use a functional capacity evaluation. Be mindful of the clinicians in your area and who are doing them. Interview them. Have them come in, take you out to lunch, so you can understand what process they're doing. And if you're not comfortable with the process they're doing, then it's probably not going to provide the data you want to be able to use for that employee to return to work. Work restrictions are number one. Again, going back to the federal government, as an independent provider, providing those work restrictions can make your life a little bit easier, because you don't have the employer coming down on you and saying, well, you're the primary treater, and now you're providing work restrictions and placing them out of work or restrictions on light duty. By having an independent provider, whether it be a clinic in your area, utilizing someone like us to come in and provide that independent assessment, it provides greater credibility to your reports, and it just provides that support of why you may be restricting that employee. MMI status, so when they are at maximum medical improvement, when are they able to return to work? And if you feel they're at maximum medical improvement, can they perform their essential job duties to return back to that job? Impairment determination, disability determination, so states between—I don't know if some states are still under fourth, but fifth and sixth edition, so we have fourth, fifth, and sixth, federal government sixth, and helping to utilize the impairment calculators that are built into some of these programs. Again, making your life easier, hopefully, and doing these different level of impairments. And then the last one kind of goes back to workability when they're ready to return to work. So thinking about not necessarily following the ODG guidelines, we like to do the FCs right at the point when they're ready to return back to work, and then when they get an MMI status and seeing where they are fully at that level. So we get a baseline, going back to baseline, going back to full duty status at that point and providing that level of support. So what does an FCE entail or what should it entail? An in-depth interview with the patient. So if you think about the FCE process, we're typically spending three to six hours with a patient, and I am assuming most of you don't have that kind of time to spend with your employees that come in. So we have the ability to really do that in-depth interview process. Typically what I find in working with a lot of physicians, they have 15 to 30 minutes. Is that correct with employees or sometimes even less? Somewhere around that range. So you can't get into the amount of detail in looking at what that employee needs to do and the factors that may be limiting their ability to function. On the interview process, when we're sitting down with an employee, it typically takes 45 minutes to an hour of just going through that interview process, of asking them about their work, looking at their postures. So for all of you sitting here, I can assume most of you are, I see people adjusting their posture. But most of you are able to sit and perform some type of work because you're not moving, you're not standing, you're not adjusting. So I'm looking at your posture and how you're positioning yourself. And you may be adjusting based upon, oh, I have some sciatic nerve pain, or my back is bothering me, or these chairs aren't the most ergonomically correct. Nothing against Marriott, but they're not the best ergonomic chairs that are out there. So when we look at that with our employees, while they're sitting there through that interview process, from the point they come in and start filling out their paperwork and doing their level of assessments, we're constantly looking at, are they adjusting their posture? Can they maintain a seated position for 45 minutes to an hour? And it's funny, as part of the interview process, they may tell us, oh, I can only sit for 15 minutes. At the end of the period they've been sitting, I'm like, do you know you've been sitting for an hour? I'm like, no, I can't do this at home. And I'm like, well, you're doing it here. So you probably can. One of the questions we ask is, have you been to the movies lately? And like, oh, yeah, I saw this movie, blah, blah, blah. And I went to see, what's the movie now that's eight hours long? Not eight hours, but. Sorry, 3 Plus Avatar, I think. Yes, the Avatar one, yes. Have you seen Avatar yet? And so you're engaging in this conversation with the employee. Oh, yeah, it was great. Oh, my gosh, I had to get up to go to the bathroom. Did you? No, I sat through the whole thing. And I was like, OK, they can sit for 3 and 1 half hours. So it's really kind of engaging them in that conversation. And then you're letting them know, hey, you could sit through that entire show. Or can you sit through a movie? And oh, my gosh, I had to get up 20 times. Did you drive here today? Like, oh, yeah, I drove. And oh, did you have to stop? I noticed that your commute was, this is great in Los Angeles. Your commute was 45 minutes. Oh, no, I was running late, and I had to get here. But I can only sit for 10 minutes. I'm like, well, you know. No, you can sit for the 45. You didn't stop. So that's part of that in-depth interview process. We've had clients tell us that, no, they can't bend over. And I'm like, wow, you came here by yourself. What happens if you have to go to the bathroom? And you have to sit down. Like, how do you not bend forward? You'll ask them to bend. And I don't know if everyone can see me, but they can only bend like, this is as far as I can get. Or can you squat down? I can't go any further than this. And again, you have to be able to go to the bathroom. Well, I don't. I actually had one person tell me that my spouse pulls my pants down, pulls them back up. But he actually drove to the appointment himself. And I'm like, you're going to be screwed, because I'm not going to the bathroom with you. So that's not how it's going to happen. Other little things where we do use that grip strength measure and someone might be squeezing the dynamometer, and they do it without a lot of resistance. So we'll get a pound or two of strength. And oh, that's the best I can do. And then I'll have them open a door. So it takes 12 pounds of grip strength to open up a door. 7 pounds of strength to zip up a zipper. So I know if they can do those simple tasks, I may hand them a water bottle, ask them to pick it up, put weight in a bag, or I'll lift their purse. So especially with the females who carry these heavy purses, I'm like, oh, let me grab that for you. And I lift it up, and I'm like, this is like 10 or 15 pounds that they walk around with every single day. So those are all part of that FCE assessment. And you're really trying to be creative, but it's what they're telling you matching up with physically what you're seeing during the evaluation. The musculoskeletal evaluation is next. So looking at range of motion, looking at manual muscle testing, looking at their grip strength, doing any of the provocative tests to see if they're testing positive for any of the areas in consistency. And then we move to a posture evaluation. So do we see any muscle discrepancies or biomechanical discrepancies? Do they have increased lordosis, kyphosis, one shoulder higher than the other? Every single carrier that I've seen, and it's been hundreds, those that carry the satchel, they are uneven. The side that they have the satchel on is always elevated. Does that mean they can't perform their job? No, but I do want to make note that this is an uneven muscular pattern and can be contributing to their pain, which may not always show up on the diagnostic test. And then the greater portion of the evaluation, so the musculoskeletal part of the evaluation takes about 20 to 30 minutes to do. The major part of the evaluation is doing the work simulation, whether it's general purpose or job specific. And I've gone outside with clients. I've been inside. I've had firefighters lift me up and carry me up the stairs. And the same with the clinicians. What do I do? I have a firefighter. You're a body. Have them lift you up. They have to be able to do this as part of their work. So them lifting a box of weight and carrying it is not indicative of their ability to return to work as a firefighter. I want them coming into the clinic fully geared up with all their equipment and carrying you down the hallway, depending, of course, on the size of the individual. But that's what they need to be able to do. Yeah. Yeah. It's like you're a truck driver. Right. You've got to get a job. It's indicative of any other job. We had a guy, and he was doing, he's one of the individuals, if you think of Las Vegas, when you go in, and even here in Marriott. But his area was Las Vegas. And he inserts the card holders on the doors. And he's done it in almost every hotel, casino in Las Vegas. And he injured, it's not one of the videos I'm showing here, but he injured his back. And so we went out and got a door from some scrap lumber. And he came in and brought his equipment. And we're holding onto the door while he's putting one of these things in. And we were doing kind of the, the doctor said he can return to work because he had good grip strength. He had the ability to do it. But every single time he went in to do it, he could only do two doors. And normally, he would do 20 at a time, so 20 in a day. By the time he got done doing those two doors, but it was the way he had to hold the door. So he had to stabilize and doing abduction with that dominant shoulder and kind of holding on and then screwing with the other arm. He didn't have the strength to maintain and hold that for a period of time. His strength levels on his grip strength actually dropped almost 36% between just doing those two doors. And so we were able to show that he cannot return back to work at his full capacity because he doesn't have the ability to sustain that over a period of time. And we had the objective data to prove that out. So it's doing that simulation. And the other thing that drives me crazy when I see reports, I also, not only do I review 200 reports a month, but I review other clinicians reports when they don't have biometric measures. I cannot believe that we do functional capacity evaluations in determining someone's workability and they've never taken a blood pressure reading or a pulse reading in that patient or that employee. So you're putting them through a physical examination. The research supports, if you have pain, you're already going to have elevated blood pressure and elevated heart rate. So we wanna see, is there a change in that heart rate function, but what is their baseline in their blood pressure? And in many cases, you would be surprised when they come in and no joke, we had one a couple of weeks ago where the blood pressure was 217 over like a hundred and I don't know, 112 or 113. And the therapist called me and said, what should I do? I said, well, maybe call 911. And if they refuse, then you're gonna get that client out of the office as quickly as possible. Or you have a lot of paperwork on your hands. So we need to document, document fairly, but under no circumstances do you move forward with that evaluation. And the response I get from the employee is, oh, I can do it. I said, well, that's great. You might be walking around fine at home, but you're not gonna have a stroke when you're in our clinic. And knock on wood, in 20 plus years of running this business, no one has had a stroke in our clinic, shit, because we take those measurements and we follow the guidelines very closely. The same with heart rate, and I'm gonna talk about this in a little bit with long-term COVID cases and what we're seeing in long COVID. I don't know if any of you have dealt with that in your practices yet, but we have had many nurses come through and doing FCEs, and there's a big problem with the biometric measures, and I'll talk about that. Lifting assessments are difficult to explain, difficult to do. And what we try to focus on is, again, as the clinician, can they perform the weight safely? Yes, they might be going to Costco, they might be showing up on surveillance tape, lifting that 40 canister of water and being able to do that one time. But can they do that safely and consistently over the course of their work? Going back to our USPS workers, they have to be able to lift 70 pounds to perform their essential job functions. I have yet to see a carrier that can lift 70 pounds safely. And more often than not, they're not lifting at that capacity. They might be lifting 20 or 30, but I want to know, can they do this safely and being able to return to work? So if someone's lifting and they're bending forward like this and they're lifting and not using good body mechanics, but that's how they've always lifted, I'm not gonna prevent them from not returning to work at that level. I'm gonna show them good body mechanics, but if someone's going to lift that 20 pounds and their heart rate spikes and they're straining when they're lifting up and they go into a lot of back extensions to move it forward and I know they're going to get injured, I'm going to minimize their ability to continue to perform that job. Sorry, I got kind of chatty today. What's wrong? One quick comment on the lift. It really drives me nuts. A lot of the posters that you show, it's in companies that show lifting. They show the guy squatted down, but his back is bent forward. We try to instruct a lot of my patients on what it should look like. It's always bending through the hips. And I always try to tell the clients that you can get to the same position, bending through your hips as you can doing kind of curvature of your back. So that's the hip flexion. Is that you're gonna lift a box from the floor. You should look like this. Yeah, we could take a picture of you right now. So when you lift, you're doing it with your legs, not with your back. I'm sorry that the people on Zoom could not see that. That was perfect. Absolutely perfect. Okay, and then we'll all kind of demonstrate. So this is the gentleman that we saw in the clinic. He had a severe, you'll see, upper extremity injury to his dominant side. He was military and trying to get back to, he really, as you'll see with most of the military people, I wanna keep working, I wanna keep working. And so we were playing a card game as part of our FC. So the fun thing about our job is I use the operation game for my doctors and dentists. We do the operation, we play cards, we do all kinds of things. So you'll see in this picture. Maybe you won't. Maybe we won't. Maybe I can, what do we have? Yeah, okay. And it was such severe fatigue in that right upper extremity. So then you- What was the injury? Looking at that forearm, it looks like- Radial nerve. So you had a radial, I mean, multiple- Well, radial nerve, yeah, but I see it looks like you missed- Yeah, and he's missing- That's what I'm saying. Yeah, yeah. And there should be another video that's not showing up on here as well, which was we did an evaluation at MMI status. So he was able to get a little bit more supination. So on his report, the right arm, we didn't say he could not use it at all. He could use it as a basically just working on kind of a functional standpoint of assisting with the other activities. I'm gonna jump through these next slides because as I said, I'm sorry, I got a little bit chatty today on certain areas. So components of an FCE, functional activities. This is a daily activity questionnaire that we're trying to standardize as part of the FCE process that we use. So we're just asking the question during the interview process. And I don't know if you all get copies of this, you'll be able to read it a little bit better. And then components of the report. So you should have your physical demands and I'd like to have the notes on the side so they're easily readable of what the restrictions are. These are the frequencies, the physical demands, you're lifting, and it should be very easily readable to you to say, can they return back to work? Yes or no, and then the notes surrounding that. So this should all occur for you in the first one or two pages of your report to be able to read that clearly. PDL classification. So these are your physical demand levels, sedentary, light, medium, heavy, and then occasional, frequent, or constant. So occasional is typically about zero to 100 reps or one rep every 15 minutes. Frequent is 101 to 500, one rep every five minutes and constant's over 500 reps. So typically if we're not measuring to that constant ability, but it's not part of the functional capacity evaluation, our clinicians may put in they're not tested or they are not restricted based on what they saw because we're not measuring to that constant level. Specialty FCEs. So long COVID is a really big thing that we're seeing in a lot of cases. We have nurses come in, have been released to work and their resting heart rate is around a 90 to 100. We had a nurse a few weeks ago who walked down the hallway and her heart rate went up to 150. So we said she cannot return to work because she can't maintain the biometric or that ability to be able to function in that type of task. Traumatic brain injury, ocular motor cases, cognitive are all specialty FCEs that clinicians can perform with additional training. We love doing the traumatic brain injuries because there is such a cognitive executive functioning piece in there, as well as seeing how that may impact their overall workability. So working with a lot of your neuropsychologists on that piece. Here is my contact information. And I have my cards up here with my cell phone. If anybody wants to reach out to me directly, my cell phone is 858-444-6510. And you can feel free to reach out to me directly, but any of these numbers, feel free to call us as well. A little plug just for our company, we'd love to work with you guys. This is what we push through all of our clinicians. We have speakers come in every month with our clinical team. So if any of you are interested in speaking to our clinical team, we'd love to have you as a speaker. And if anybody wants to do Department of Labor stuff, please reach out to me and I can connect you and help you. It'll be a way to generate additional revenue in your practice. I don't work for Department of Labor. We just more good providers out there. I know I'm cutting into your lunchtime. Any questions? Yes. Yeah, could you go back to the slide which you can use FCEs for? I'm a big believer in FCEs, but the courts are increasingly hostile to FCE. Are you familiar with the Jim Neos Cedras-Lavalle case? Yes. Which stated that an FCE in the Fourth Circuit is the illegal technical exam under the ADA. So you have to be, that would, the Fourth Circuit, you would knock out three of those six. I know, it's- Right there. It's unbelievable, these liberal courts right now. And that was the full Florida appeals. So you've got to be very careful how you use the FCE, right? Yeah. I mean, it was determined to be illegal, but- I know, and it's ridiculous because it's also the way it's performed. It kind of goes through different levels and it's provided almost a discredit to our profession when we have people performing FCEs that don't know what they're doing. And this is the case where an occupational therapist performed it on a nurse in a hospital and said she couldn't live based on the FCE, 35 pounds. And the court said the FCE is the illegal medical examination under the ADA. That's the Fourth Circuit holding. Yeah, and that's- Yeah. Was the FCE ordered by a physician? Yes, by the hospital, by the occupational health at the hospital. And was it like said, it was legal or illegal? Illegal. It was a legal medical exam under the ADA. Now, this is valid in the Fourth Circuit. Okay. Now, what if the physician had written the report utilizing the data from the FCE? They went so far as to say the FCE was the legal exam under the ADA. That's how far. For using it for disability determination for, and she wasn't working. So you've got to be very careful. If you ordered FCE, I wouldn't even order one in the Fourth Circuit. But if you use it, then they're not saying they can't go to work. You wouldn't use it for restrictions. Use it for your accommodations. Find those. Right. And use it for accommodation. Yes. I'm ordering an FCE to determine what accommodations my worker needs. Yes. Correct. You'll give an answer, and they can use it otherwise. But this was a return to work case. So that'll have to be our last comment and question. Perhaps Dr. Fitzpatrick can linger for a minute or two to- Continue an informal conversation.

Dr. Lisa Fitzpatrick

injury management

international involvement

FCE Research Symposium

Department of Labor

Functional Capacity Evaluations

biopsychosocial models

insurance companies

work capability