assessing fitness for work (msds) · reliability of fce overall reliability of individual tests and...
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Assessing Fitness for Work (MSDs)
Using Functional Capacity Evaluation (FCE)
Putting the ACPOHE guidelines into practice
Nicola Hunter and Glyn Smyth
Chartered Physiotherapist & Registered Ergonomist
The problem
• Each week:
– one million workers take time off because of sickness and most return to work within days; but
– around 17 000 people reach their sixth week of – around 17 000 people reach their sixth week of statutory sick pay; and
– at this point, almost one in five people will stay off sick and eventually leave work.
• HSE Working together to prevent sickness absence becoming job loss (2005) www.hse.gov.uk
There is a need for objective
advice on a persons fitness for
work and rehab to restore it...
• MSD’s typically account for 25% of an organisations sickness absencesickness absence
• 20 % of people on Incapacity Benefit (IB) have MSD’s
• Most of these are common health problems that should not result in long term incapacity
• Main, Burton, Concepts Of Rehabilitation For The Management Of Common Health Problems 2004
• http://www.dwp.gov.uk/docs/hwwb-concepts-of-rehabilitation.pdf
ACPOHE Guidelines on the use of
FCE & Functional Measurement for
Assessment of Fitness for Work
• Occupational Health (OH) Physio’s advise on physical fitness
for work
• Functional Measurements and FCE is best for this purpose
• Functional Capacity Evaluation got bad press in UK several
years ago
• ACPOHE FCE Guidelines have been produced to help OH
Physio’s use and interpret Functional measurement and FCE
appropriately and safely
Self Report• Underestimate true capacity (by 15-30%)
Clinical examination
How good are we at assessing
functional / work capacity?
Clinical examination• Best guestimate(but poor prediction of work
capacity and poor inter-rater
reliability)
FCE• Least disabled( based on physical capability
only)Brouwer et al 2005
‘Be aware of the differences when assessing’
Is this chap physically fit to
return to work as a butcher?
How do we assess fitness
for work?
• Subjective history - Relevant medical history, HPC
• Clinical Examination – S&S, diagnosis, prognosis
• Investigations – MRI, X-ray, etc
• Psychosocial screening (yellow, orange, blue and black flags)
• Analysis work activities / demands
In my opinion ......
• We must take MEASUREMENTS of how much he can actually
do in terms of his job demands
If you can’t measure it you
can’t manage it
Assessing Fitness For Work
ACPOHE Guideline recommend that you assess ALL the Risk Factors associated with MSDs development, reporting, chronicity and sickness absence:
• Individual / lifestyle
• Clinical findings• Clinical findings
• Biomechanical / physical work demands
• Psychosocial ( yellow and blue flags)
• Work specific issues (black flags)
Assessing Fitness for Work –
ACPOHE guidelines
Physiotherapists undertaking fitness for work assessments / FCE
are advised to include the following elements:
• Informed consent
• Relevant medical history
• The client’s understanding of their health problem / disability, • The client’s understanding of their health problem / disability,
reported performance of ADL.
• Screening to identify orange, yellow, blue and black flags
• A detailed description / analysis of previous / future potential
work activities / demands
• Baseline evaluation of cardiac fitness
Assessing Fitness for Work –
ACPOHE guidelines
• Clinical Examination - Neuro-musculoskeletal evaluation as
appropriate (to exclude red flags) and to understand the
nature of the problem
• Functional Capacity Evaluation - using a range of measuring • Functional Capacity Evaluation - using a range of measuring
instruments which should be selected on the basis of their
relevance to potential job or lifestyle demands
• Observation of effort in manual handling test elements
• Provision of report and recommendations (including consent
and confidentiality)
Assessing Fitness for Work
Background - Medical History
and Referrer’s questions
Typical referral questions include:
• Is the employee fit for work?
• When is the likely date of return to work?
• Are they any duties the employee will be unable to do?• Are they any duties the employee will be unable to do?
• What adjustments could facilitate their return to work?
• Are these likely to be temporary or permanent?
• Will they require continued treatment?
• Will the employee’s service be regular and efficient?
Job Evaluation
• Job description and Analysis of overall demands of job
• Detailed task analysis of the work:
Dynamic strength Postural tolerance Mobility Other
Floor-to-waist lifting Sitting tolerance Steps / stairs Power GripFloor-to-waist lifting
Waist-to-eye lifting
Bilateral carrying
Unilateral carrying
Pushing
Pulling
Sitting tolerance
Standing tolerance
Elevated work
Stooping / bending
Kneeling
Squatting
Reclining reach
Steps / stairs
Repeated bending /
squatting
Walking
Crawling
Ladder climbing
Repetitive trunk
rotation – sitting /
standing
Power Grip
Pinch Grip
Key Grip
Hand dexterity
Balance
Tools
Function – Linked to DOT* job demands and interpreted in terms of the USDOL physical demand level chart *http://www.occupationalinfo.org/front_148.html
Job Evaluation - Physical Demands
Assessment (DOT) descriptions
Job Demand Classification
Lifting /
Activity
Sedentary Light Medium Heavy Very Heavy
Occasional < 4.5kg < 9kg < 23kg < 45kg > 45kgOccasional
0 - 33%
< 4.5kg < 9kg < 23kg < 45kg > 45kg
Frequent
34 - 66%
Negligible < 4.5kg < 11kg < 23kg > 23kg
Constant
> 66%
Nil Negligible < 4.5kg < 9kg > 9kg
Activity Sit Stand /
Walk
Stand /
Walk
Stand /
Walk
Stand /
Walk
Psychosocial Screening
• Established evidence for physical and psychosocial factors in
aetiology and reporting of MSDs
• Development of chronic problem depends more on
psychosocial factors than the underlying pathology (Waddell
2002, Burton 2003)2002, Burton 2003)
• Also evidence that physical, psychosocial and
organisation/employment factors can act as barriers to
recovery and RTW
• Assessing and reducing / managing barriers is the most
successful return to work strategy (Burton 2009)
Screening questionnaires
/ questions
To understand the client’s understanding of their health problem
or disability, reported performance of ADL.
–EQ5D5L
–An outcome measure relevant to their condition eg – DASH (quick),
Roland Morris or Oswestry Disability Index, Neck Disability Index, LEFS etcRoland Morris or Oswestry Disability Index, Neck Disability Index, LEFS etc
Relevant Psychosocial issues
– Yellow Flags and Blue Flags
– SEE ACPOHE Functional Capacity Evaluations and Psychosocial
Screening Tools by Dr Julie Denning
Black Flags - Ergonomics evaluation, work organization
Clinical Assessment
Exclusion of red flags
Relevant Clinical findings
• Restriction in range of movement (ROM and pain)
• Reduced muscle power
Reduced endurance / tolerance• Reduced endurance / tolerance
• Altered sensation / sensory loss
• Specific tests
Mechanical Diagnosis and Prognosis
Other
• Blood pressure
• Resting heart rate
Functional measurement or
Functional Capacity Evaluations
FCE uses objective measures to assess and report on the
discrepancy between the person’s physical capability and their
job demands
“FCEs are evaluations of capacity of activities that are used to “FCEs are evaluations of capacity of activities that are used to
make recommendations for participation in work while
considering the person’s body function and structures,
environmental factors, personal factors and health status”
(Soer et al. 2008)
FCE cannot identify that a patient is malingering or how much
less disabled then they present themselves to be
Functional measurement or
Functional Capacity Evaluations
The main emphasis of a FCE is to measure function in relation to
work capability or job demands
• Physical demands in relation to job demands are often
assessed following the Dictionary of Occupational Titles (DOT)
descriptions or Job Demands: descriptions or Job Demands:
• Sedentary, Light, Medium, Heavy, Very heavy
• As well as including specific tasks
• Floor-to-waist lifting, waist-to-eye lifting, carrying, pushing,
pulling
• And postural and mobility activities
• Standing, sitting, walking, climbing, reaching, etc
Physical Demands Assessment
(DOT) descriptions
Job Demand Classification
Lifting /
Activity
Sedentary Light Medium Heavy Very Heavy
Measured RequiredMeasured Required
Occasional
0 - 33%
< 4.5kg < 9kg < 23kg < 45kg > 45kg
Frequent
34 - 66%
Negligible < 4.5kg < 11kg < 23kg > 23kg
Constant
> 66%
Nil Negligible < 4.5kg < 9kg > 9kg
Activity Sit Stand /
Walk
Stand /
Walk
Stand /
Walk
Stand /
Walk
What do FCE’s comprise?
• 2 hours to 2 days NB Short protocols are as reliable as the
longer ones
• Both standardised and non-standardised systems
• Assessing functional capacity against the elements of the
work:work:
Dynamic strength Postural tolerance Mobility Other
Floor-to-waist lifting
Waist-to-eye lifting
Bilateral carrying
Unilateral carrying
Pushing
Pulling
Sitting tolerance
Standing tolerance
Elevated work
Stooping / bending
Kneeling
Squatting
Reclining reach
Steps / stairs
Repeated bending /
squatting
Walking
Crawling
Ladder climbing
Repetitive trunk
rotation – sitting /
standing
Power Grip
Pinch Grip
Key Grip
Hand dexterity
Balance
Tools
Short protocols Gross and Battie 2007
Trunk
• 15-min stand
• Lift floor-to-waist
• 1-min crouch
Lower extremity
• 15-min stand
• Lift floor-to-waist
Upper extremity
• Waist-to-overhead lift
• Elevated work
• Crawling • 1-min crouch
• 2-min kneel
• 5-min rotation
• Lift floor-to-waist
• 1-min crouch
• 2-min kneel
• Stepladder/stairs
• Crawling
• Handgrip
• Hand coordination
Developments in FCE protocols
• Development and testing of job specific protocols (Frings-Dresden 2003)
• Development of FCE protocols for neck and upper limb based on identified risk factors for neck pain (Reesink 2007) and ULD (Reneman 2005)(Reesink 2007) and ULD (Reneman 2005)
– Development is underpinned by research to understand the factors that determine work disability for the body region
• Development of a 3 step procedure to improve the efficiency and practicality of FCE’s (Goutterbarge 2010)
• ACPOHE needs to keep abreast of developments
Safety of FCE
Adequate screening procedures to detect any precautions
or contraindicated conditions for the FCE
1. Biological (e.g. current or co-morbid conditions including red
flags)
2. Physiological (e.g. heart rate and blood pressure)2. Physiological (e.g. heart rate and blood pressure)
3. Biomechanical (e.g. signs of muscle fatigue or weakness,
manual handling risk assessment)
4. Psychophysical (e.g. pain or fear of (re)-injury, orange flags)
FCE can be painful (inc DOMS) but no evidence of harm
Gibson and Strong 2005, Soer 2008
Reliability of FCE
Overall reliability of individual tests and FCE systems is
reportedly good but inter-rater reliability is poor on testing.
No normative data for the UK population (Dutch and USA)
ACPOHE Guidance:
Select and use individual impairment and functional tests that
have proven reliability.
Where multiple tests are used, they should be administered in
the same sequence if repeated to measure progress or change
in a rehabilitation
Reliability of FCE’s: Consider
how you use tests in your clinic
• Reliability in terms of the test itself
• Test retest, inter and intra tester
Reneman 2002, 2004, Gouttebarge and Wind 2004, Reneman 2004,
Durand 2004, Soer 2006, Taylor 2010
Validity of FCE
1. Face Validity – does the measure actually measure the
construct it is intended to measure.
2. Content Validity - represents all facets of a construct.
FCE alone is unlikely to adequately measure all the factors
that influence sustainable return to work.that influence sustainable return to work.
3. Criterion-related validity - FCE should predict whether a
person is safe and able to return to work (but it probably
doesn’t)
4. Construct Validity – in the absence of a gold standard there
is some construct validity for FCE with pain and impairment
Hart 1998, Reneman 2002, 2004 Gross & Battie 2003, Lackner 1996, 2002 Gouttebarge
and Wind et al 2004
Validity of FCE: Can it detect not
trying or malingering?
• Guidance: FCE alone is unlikely to adequately measure all the
factors that influence sustainable return to work.
• Functional tests are extremely useful as part of the tool kit of
an occupational health physiotherapist. an occupational health physiotherapist.
• Functional measurement and FCE show the physiotherapist
how a person performs in test activities that simulate real
work tasks giving valuable information to inform fitness for
work advice and rehabilitation recommendations
• Evidence suggests hat without objective measurement
professional frequently underestimate a person’s work
capability.
ACPOHE guidance:
• Physiotherapists providing functional
measurement and FCE must ensure tests are
reliably performed and must understand the
validity of the tests and instruments they are validity of the tests and instruments they are
using.
• They must report accurately and in line with
the measurement capability of the tests /
instruments they use.
Last but not least - Reports
Report must give recommendations re a person’s ability
work (and rehabilitation requirements)to their current jobto current job with modifications/ adaptations to another job – demand level / capabilities definedMust be professional ( ie layout grammar spelling etc)Must be professional ( ie layout grammar spelling etc)Must answer the questions asked by the referrer
ACPOHE - Specialist Interest
Group in FCE
• Terms of reference including its aims and objectives
• The efficacy for using functional measurement tools when
assessing fitness for work
• Assessing consistency of effort
• The use of FCE tools in occupational health
• FCE tools commonly used by ACPOHE members and the
possibility of producing an 'FCE toolbox' for ACOPHE members
• Training needs for ACPOHE members in FCE
• Future researchIf you use functional measurement /FCE or want to
find out more, Join the workshop this afternoon and
help us form an ACPOHE special interest group in
FCE to move this agenda forwards
Further information and references
Guidelines for Occupational Health
Physiotherapists on the use of Functional
Capacity Evaluation and Functional
Measurement for the Assessment of
Fitness for Work
Edition 1
Nicola Hunter
May 2014