Traumatic Brain Injuries and FCEs

Lisa Fitzpatrick, OTR/CHT is the founder and president of Ergo Links, a company focused on creating an ergonomically healthy workplace, as well as helping injured workers return to work. Fitzpatrick also offers services to individuals who have suffered Traumatic Brain Injuries (TBI), and who require specific attention and tests that a normal FCE may not require.

Traumatic Brain InjuriesFitzpatrick has over 20 years of experience as a clinician, working with injured patients in a variety of settings. At the same time, she has researched and practiced ergonomics and injury prevention, and she has been performing FCEs for over 14 years.

Her career began in occupational therapy, where she garnered a working knowledge of the human body, and developed her clinical skills through hands on work with patients. Her passion led her to graduate work, centered on research into ergonomics, which in turn led to her founding Ergo Links.

JTECH spoke with Fitzpatrick about her FCE philosophy and experience, and here’s what she had to say.

What are the primary reasons you are asked to perform an FCE? Who is requesting them?

FCEs are disability evaluations to find out the patient's functional ability or their ability to perform specific tasks. The evaluations are mostly workers' compensation issues, and are usually geared at determining when a person can return to work.

Many people can request FCEs: employers, physicians, nurse case managers, vocational therapists, workers' compensation insurance companies, private insurance companies, referrals from attorneys, and more. Every now and then a physical or occupational therapist may also send a client if their clinic does not offer FCEs.

What type of skills and training are required to perform FCEs? Is licensure required?

Across the board, different professions are performing FCEs: chiropractors, physical therapists, occupational therapists, physicians, etc. But a lot of people are performing FCEs that shouldn’t be called FCEs.

Everyone who works in my clinic, for example, is a PT or OT, with an advanced degree. They all have—or are in the process of completing—FCE certification through JTECH. On top of that, we do internal training. So in the end, these are examiners with 8+ years of college, as well as internal training and official certification.

This type of training is fundamental for an FCE evaluator because these exams require knowledge of the human body, great attention to detail, and the ability to interpret and understand the results.

A lot of the "FCEs" out there are being performed by people without the proper training and lack the necessary attention to detail. For example, I have had patients come in and say they already did an FCE, but they describe a 15 minute exam. This obviously wasn’t a proper FCE, and it this has given FCEs a bad name.

Are there different types of FCEs? How are they performed differently?

There is no cookie-cutter approach to FCEs—each exam is different—but there are two main types: the General FCE and the Job Specific FCE. The general FCE results in a diagnosis of the patient's overall ability; whereas the job specific comes to us with a job description, and we determine whether or not the patient can meet the demands of the job.

I also perform FCEs for patients with Traumatic Brain Injuries (TBI), which can fall into either category. With TBI, we perform the same types of physical tests, but we also integrate "Executive Function Tests." These tests are standardized and are aimed at a person's cognitive abilities (memory loss, problem solving, and social interaction, to name a few), and are evaluated by comparing their results to peers of the same age.

TBI is a niche, untapped market for FCEs. These patients are generally the result of auto accidents or specific personal accidents (a fall off a roof, for example), and primarily come to us through a nurse case manager. DexterityThe military is also seeing a lot of head injuries, and these veterans are coming home with a need for good FCEs to determine cognitive and physical abilities, which will help place them in the proper job.

Another subsection of FCEs is the Hand FCE. This FCE is quite focused, testing for loss of ability, or general functional ability of the hand. It involves sensory tests, grip and pinch strength tests, and dexterity tests.

How important are tools for FCEs, and what are the most important features?

Objective tools with a valid and reliable calibration are a must. When you perform an FCE you need to explain how the tools are appropriate, but you also need to show how the manufacturer is calibrating the devices. Without proper calibration documentation, the FCE isn't valid. There needs to be inter-tester reliability for valid effort, and objective tools with a quantifiable calibration can provide this. If I have to testify in court, I can feel confident in my results.

When I review the FCEs that others have performed, I notice that they don't talk about the equipment or if and how the equipment was calibrated. But if you can't show this calibration, how can you say that the test results are objective?

So, yes, objective tools are required for a good FCE, but the therapist or clinician needs to know how to use and read the instruments and results to provide a valid and meaningful assessment. If someone uses a grip dynamometer, but cannot explain how it is being used, or understand the results, then the results won’t be of any use.

How long does an FCE take to perform?

Really, it's very difficult to do a good FCE in less than two hours. But at the same time, the patient's abilities and the requirements of the job determine the length of the exam. If a patient can only perform the tasks two hours at a time, but has four hours of testing, then it may be a two-day exam.

Some jobs may require more evaluation than others, which can result in a two-day FCE, with maybe four to five hours per day. That being said, I'd still say that two hours is the minimum for FCEs, and a longer FCE averages about three to four hours per session.

How can FCEs be incorporated into a practice, and what are some of the benefits to performing FCEs?

For starters, having the training and tools to perform FCEs correctly is paramount. It isn't something you can just decide to start doing. For instance, I began working as an OT at a clinic that performed FCEs. After learning the ins and outs, I branched out on my own to perform ergonomic work, and after some time, I added FCEs to my practice.

It is also necessary to spend a lot of time learning state and federal laws and regulations, as well as developing a network within your community. To receive clients, you really have to learn how to work with the nurse case managers, lawyers, and employers in your community. To help facilitate this, you could begin by performing job screens, and then move into offering FCEs.

There are many ancillary benefits to performing FCEs. Primarily, this isn't the traditional role for an OT or PT. I struggled with working with rehabilitating patients, but not seeing the end results: as a clinician, I simply discharged the patient and I never knew what happened. But by doing ergonomics and FCEs, I can "close the loop," so to speak. I no longer do treatments with patients, but I get to see them get back to work.

What do you think the current state of FCEs is, and what can be done to improve this?

As I mentioned, so often, FCEs are being performed that should not be considered an FCE. These incorrectly performed exams are giving FCEs a bad rep. There isn't really a set protocol, or a gold standard on how each FCE should be performed, and a lot of people are not properly trained, and are often not even clinicians. Without this background, people are performing exams that they shouldn't perform.

Insurance companies will continue to deny claims when bad exams are submitted. And with enough bad exams, the insurance companies begin to unfairly discriminate against the good exams, too. Because of this, the good exams have to fight an uphill battle for the injured worker and the disabled.

In my 20 years of experience working as a clinician, I can tell you that you need the clinical experience to do FCEs. Because you are deciphering a patient's abilities, you simply have to have this understanding of the human body and injuries. At the same time, the FCE has to be objective, valid, and reliable. If you can’t provide these things, how can you call it an FCE?

Anybody can take measurements, but you have to be able to know what these measurements mean. And for this, training is absolutely critical.

Grip Strength    Pinch Strength

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