A pioneer in the field of Functional Capacity Evaluations (FCEs), Keith Blankenship, P.T., has explored the unique and subtle art of evaluating the abilities of the injured human body for over 30 years. During his impressive career, Blankenship has become one of the foremost practitioners and teachers in the field of FCEs.
Blankenship began his career as a physical therapist, working his way to becoming the Director of Physical Therapy at The King’s Daughters Hospital in Ashland, Kentucky. But after 11 years in the field, he found himself wanting to branch out and explore new areas. As luck would have it, a neurosurgeon in Georgia approached him about developing a clinic that would bring injured individuals into the facility and evaluate their ability to work right there onsite. In 1983, Blankenship began to develop this program from scratch, and it proved to be the start of his influential and often groundbreaking career in the field of FCEs. Keith Blankenship is now the Director of Clinical Operations and co-owner, with Lisa Blankenship, of the Blankenship Center in Macon, Georgia. Blankenship continues to perform FCEs both at his clinic and on the road. At the same time, he conducts training seminars aimed at licensed clinicians that provide the foundation from which they can begin to offer FCEs in their own practices.
JTECH had the opportunity to chat with Keith Blankenship about his area of expertise, and gain some insight into the world of FCEs.
What is a Functional Capacity Evaluation (FCE)?
An FCE includes two major ingredients: you are evaluating the injured person’s ability to function and perform work tasks, but you are also determining their willingness to go back to work.
In order to better understand these two incredibly complex areas, it is important to have an in-depth knowledge of how the human body functions. A strong background in rehabilitation or orthopedic medicine equips evaluators with the necessary understanding of injured joints, and clinical work with patients provides the experience necessary to understand how people exhibit and respond to pain.
Also, there are two basic decision philosophies on the market as to how to perform FCEs: kineseophysical and psychophysical. The kineseophysical philosophy places the emphasis of the decision on the evaluator: is the patient giving good effort? How much can they lift for this given task? And so forth. The psychophysical philosophy exposes the patient to stresses and allows them to decide. So, for instance, the patient decides when they have reached their best effort, or what their ability for a certain task is. I believe that a good FCE should incorporate both of these methods.
What does it take to begin performing FCEs?
A licensed clinician can take a seminar that will teach them how to begin performing FCEs, but it takes about five years to become good, and another five years to become extremely good. In his book Blink, Malcom Gladwell claims that it takes roughly 20,000 hours for us to become experts in something, and FCEs are no different.
We offer several different FCE seminars at the Blankenship Center: the WorkEval™ Seminar, which trains clinicians in the Blankenship WorkEval™ process; and a joint FCE seminar with JTECH Medical. These seminars train clinicians to begin offering FCEs in their own practice, and introduce them to the objective tools and software that they can incorporate into their evaluations.
What are the values of performing FCEs, and what can someone gain by incorporating them into their practice?
For starters, FCEs provide an additional profit center for the practitioner and facility. When someone becomes trained to perform FCEs, they add value to their credentials and elevate their facility by becoming a specialist in an area that often goes untaught at most graduate-level programs.
Just as a physician would recommend someone to a specialist for an MRI or X-Ray, they recommend their patients to an FCE specialist for their expertise. Rather than operating as an ancillary service used by physicians, the clinician who performs FCEs becomes a trusted expert, upon whom the physician relies for information that determines a patient’s treatment, or could even be used in a deposition.
By learning to perform FCEs, clinicians can also gain a new career. Perhaps they are in a difficult place financially, or they are just looking to learn new skills. I have worked with a number of physical therapists for whom FCEs have saved either their careers, clinics, or both.
And finally, FCEs are simply fun to perform. You are usually only asked to evaluate a patient once, so every time someone walks through your door, it is a new experience.
Who are FCEs for, and who gets the results?
FCEs are primarily performed on individuals who have been injured at work and are covered under some sort of workers’ compensation plan. A smaller subset is individuals who have had a personal injury, say in a car accident, and they are determining the level of injury for insurance purposes. And a third group is individuals coming in for pre-placement (or pre-employment) screening. This tends to be a more focused FCE, in which we are given a job description, and are asked to determine whether or not the individual will be able to meet the demands.
In the first instance, there are a number of involved parties that get the results: the referring/treating physician, the insurance company, the employer, the medical case manager, and the patient’s attorney. With personal injuries, it is usually the two attorneys for either side that receive the results. For the pre-placement screening FCEs, the employer receives the results to determine whether or not the person can perform the job, and the workers’ compensation insurance company often receives the results, to help them keep their insurance rates low.
How do you know that FCEs are reliable and valid? Are there any objective tools you can rely upon to help improve these areas?
The primary method for determining validity for an FCE is a validity profile for the patient, which includes tests for the patient’s willingness to cooperate with the FCE and exert a sincere level of effort. It also looks at whether or not the patient is exhibiting symptoms of disability exaggeration behavior, and whether or not they are demonstrating any non-organic signs. I developed this in 1983, and have continued to use and improve it since. Today, everything is based on published research, using evidence-based results, making these profiles that much more reliable.
Objective tools, such as JTECH Medical’s wireless evaluation tools, provide specificity and precise measurements which are invaluable in determining a patient’s abilities. For instance, you don’t just evaluate a person and say that there is a weakness; you are able to say that there is a 50% degree of weakness. This specificity is just invaluable. Without these tools, you are simply making judgments by feeling, which is distressing because it lacks any sort of precision or objectivity. Yet, these devices are still just tools. If the FCE isn’t a good FCE, then the data won’t be good. It is important that these tools are in the hands of a qualified, educated, and experienced FCE evaluator.
What are some of the difficulties or problems you might run into if you were to perform an FCE without objective tools?
If you perform FCEs without objective tools, you are shooting in the dark and making professional decisions without good information to back up those decisions. Just as a surgeon needs a scalpel, an FCE evaluator needs a force gauge.
When I evaluate someone’s ability to perform a job function, I can take these tools out to the job site and see what force is required to perform a specific job function. With this level of specificity, I can then bring the person into my facility, and know, without any doubt, whether or not they will be able to perform that function. Without an accurate force gauge, you just can’t compare an office to a worksite, and this is an integral part of performing an FCE.
The objective tools also offer you a precise and quantifiable value, which you can then compare to published norms. But to compare results to normal values, you must have your patient’s exact ability accurately quantified, which FCE tools and a good FCE process will provide.
What do you see in the future for FCEs? Will they retain their importance?
The need for a high-value FCE will become greater, not lessen, so FCEs will continue to grow as an advanced specialty that will demand advanced evaluation skills and experience with all orthopedic—and many neurological—conditions. This growth in FCEs will further remove the treating physician from the return to work decision making process, establishing the FCE evaluator firmly in this role. This also will be further advanced with physical therapists now achieving the DPT (Doctor of Physical Therapy) status.
That being said, much more research needs to be performed on many of the basic work activities to allow FCE evaluators to become more specific with our testing. For example, the “Best Floor Lifting Technique” has never been established. Everyone thinks they know what it is, but when a group of FCE evaluators from around the world are asked, opposing philosophies and biases always emerge. So, basic research regarding one of the most basic work activities needs to be accomplished. If that is done, then FCEs 10-20 years from now will be performed quite differently.
For more information about Blankenship's WorkEval™, please visit the Blankenship website at www.blankenshipworkeval.com.