Peoples Injury Network NW (PINN) PINN is an Industrial Rehabilitation therapy provider We have been in business for over 12 years Each PINN Clinic specializes in treating the Injured Worker through a multidiscipline approach with both Physical & Occupational Therapy PINN has a thorough understanding of the industrial rehabilitation needs of the Injured Worker Our PINN Clinics are at least 5,000 square feet in size

Peoples Injury Network NW (PINN) What services do we provide? Physical Therapy Work Conditioning Work Hardening Physical Capacity Evaluations (PCE’s) Ergonomic Assessments On-Site Services for Job Analysis & Job Modification Extended Evaluations Vibrasym Driving Evaluation (PINN Kent) Post-Operative Testing

PBPCE – Performance Based Physical Capacity Evaluation FCE Functional Capacity Evaluation Presented by: Peoples Injury Network Northwest, (PINN)

Physical Capacity Evaluation Is “a process of measuring an individual’s ability to dependably sustain performance in response to broadly defined physical work demands over time”

A Physical Capacity Evaluation can… Evaluate current work tolerances and potential work capacity Provide information to help determine if an individual can return to the usual occupation or perform the work demands of a new job being considered If no vocational goals are established provide guidelines related to the individual’s physical capacities to assist with the vocational exploration process Assist the Medical Professional in completing the Attending Physician Form (APF)

PCE’s should be performed with the following practice hierarchy: Safety Reliability Validity Practicality Utility Respect Safety: when used properly the test must not be expected to lead to injury Reliability: Test scores must be dependable across evaluators, evaluees, and the time of test administration. Effort testing is vital to ensure reliable results. Validity: The test must measure what it intended to be measured and must predict or reflect performance of a target task. Practicality: Requires reasonable direct and indirect costs of test procedures Utility: Testing procedures must meet the needs of the referrer, payer and evaluee Respect for the person being evaluated

Who can request a PCE? Doctors Chiropractors Claims Managers Attorneys Vocational Rehabilitation Counselors Nurse Case Managers

Initial Contact with the Client Explain the purpose of the evaluation Collect reliable information Current physical and functional abilities as that relates to vocational considerations Inform the client that they need to participate with: High level of effort Reliability of Pain and Disability Report Do not perform any activity that they perceive to be unsafe Explain the purpose of the evaluation Is to collect reliable information about current physical and functional abilities as that relates to vocational considerations Inform the client that they need to participate with 1. High level of effort, 2. Reliability of Pain and Disability Report and 3. But to not perform any activity that they perceive to be unsafe

Physical Capacity Evaluation’s Usually 1-2 days Determine level of physical effort and reliability of pain and disability report. Evaluator must be objective Should answer the referral sources questions

Oregon PCE Levels First Level PCE- Limited evaluation primarily to measure musculoskeletal components of a specific body part Active range of motion Motor Power Using the 5/5 scale Sensation No less than 45 minutes of actual patient contact OAR 436-009-0070(4)(a)

Oregon PCE Levels continued Second Level PCE This evaluation is to measure general residual function capacity to perform work or provide other general information. Musculoskeletal evaluation To establish Residual Functional Capacities for claim closure No less than two hours of patient contact OAR 436-009-0070(4)(b)

Oregon PCE Levels continued Third Level PCE (WCE)- This is a Residual Functional Capacities evaluation. Musculoskeletal evaluation for a single body part Endurance Assess ability to perform essential physical functions of the job based on a specific job analysis as related to the accepted condition Assess ability to sustain activity over time Assess reliability of the evaluation findings No less than 4 hours of patient contact OAR 436-009-0070(4)(c) When providing a PCE for a WA State WC Claim, our clinics always provide the Level 3 PCE which typically results in a 6 hour evaluation.

Interviewing Strategies Give brief explanation of what to expect in the evaluation Privacy Communicate Respect Establish Rapport Have tissues and extra pens available Other areas considered: Sit with client having an escape route Sit “open” to the client to their side Avoid phone calls and interruptions Reinforce client’s sense of control Focus on function Listen to the client’s reported symptoms and dysfunction but redirect when appropriate

Interview Process Mechanism of Injury DOI/Onset & Diagnosis Physician/ Physician restrictions Diagnostic Testing Medications Age Other Items reviewed: Claim # Rehabilitation Specialists Mechanism of Injury Physician restrictions Diagnosis Previous medical treatment Physician Insurance Diagnostic Testing Referral Source Medications Attorney Pain Clinics Age Assistive Devices DOI/Onset Hand Dominance Occupation Surgery Employer Treatment Vocational Counselor Other medical conditions Claims manager Present complaints (what makes sx worse or better)

Interview continued Assistive Devices Previous medical treatment & Other medical conditions Current sleep duration ADL’s Subjective Tolerance Levels Examples of ADL’s: Self Care Household Chores Yard Work Car Maintenance Shopping Recreation/Hobbies Exercise Rest Periods Subjective Tolerance Level Examples: Sitting Standing Walking Full Time Tolerance Lifting/Carrying/Push/Pull/Squat/Crouch/Bend/Stoop/Kneel/Crawl/Climb/Balance/Twist/Reach and Hand use/Foot Controls

Objective Data Height Weight Blood Pressure Pulse Smoker Alcohol Usage Medication Usage

A PCE Summary should include Sitting, Standing, Walking Tolerance Total hours alternating sit/stand/walk at one time Total hours alternating stand/walk (being on feet) Lifting capability frequency and levels Carry capability frequency and levels Push/Pull capability frequency and levels Sitting, Standing, Walking Tolerance at a time and total hours in an 8 hour day Total hours alternating sit/stand/walk at one time and total hours in an 8 hour day Total hours alternating stand/walk (being on feet) hours at a time and total hours in an 8 hour day Lifting capability frequency and levels Carry capability frequency and levels Push/Pull capability frequency and levels

PCE summary continued Reaching Fine Manipulation, pinching Grasping, gripping, forceful grasp Operate foot controls Operate hand controls Twisting Squatting Kneeling Bend/Stoop Crouch Climb Stairs Climb Ladders Crawling

Job Analysis Definition A Job Site Analysis is a detailed description of the essential and non-essential job tasks/functions and the relevant physical demands to perform the essential and non- essential job tasks. PCE should address the client’s demonstrated physical and functional tolerances in relation to essential job tasks and required physical demands.

THE PHYSICAL DEMAND LEVELS OF WORK PHYSCIAL DEMAND LEVEL OCCASIONAL* 0 – 33% OF TIME FREQUENT* 34 – 66% OF TIME CONSTANT* 67 – 100% OF TIME SEDENTARY 10 lbs. Negligible LIGHT 20 lbs. (walk/stand and/or push/pull of arm-leg controls) Negligible (push/pull of arm-leg controls while sitting) MEDIUM 50 lbs. HEAVY 100 lbs. VERY HEAVY Over 100 lbs. Over 50 lbs. Over 20 lbs. *Occasional, Frequent, and Constant are terms defined by the Dictionary of Occupational Titles that refer to the frequency of “exerting a force,” including lifting, carrying, pushing, pulling, or any other physical activity.

Physical Effort “Physical Effort Testing concerns to an individuals levels of physical exertion during encountered testing procedures. This type of testing is best evaluated via a multi-facted approach under distraction based clinical conditions. Results of such testing are not intended to imply intent” (Kyi, 1997-2009)

Three categories of physical effort testing Isometric – Jamar Grip Cardiovascular – EPIC and NIOSH heart rate guidelines Behavioral

Jamar Grip Strength Rapid Exchange Bell Curve & SD Jamar Dynamometer Evaluates: Strength Consistency of effort Rapid Exchange Bell Curve & SD Coefficient variation cut points

Cardiovascular NIOSH 65-70% of age predicted maximum EPIC - >150% of Standing Resting Heart Rate

Behavioral (Competitive Test Performance) “The musculoskeletal and/or behavioral tendency to maximize one’s test score and performance under evaluation conditions. CTP is best evaluated in a distraction-based testing environment (Kyi, 1997-2009 RMA)

Musculoskeletal Evaluation Posture and Alignment Flexibility/mobility Strength Neurological Examination Gait Special Tests Waddell and Placebo Tests Movement patterns, quality of movement, comparison of movement and pain Palpation

Special Tests Finklestein’s Test Phalen’s Test Tinel’s Sign Femoral Nerve Test Straight-Leg Raise Test Patrick’s test (FABERE) Thomas Test Cubital Tunnel Syndrome Yergasson’s Test Waddell’s Non-Organic Physical Signs and Placebo test Finklestein’s Test – DeQuervain’s tenosynovitis Phalen’s Test – CTS Tinel’s Sign – CTS Femoral Nerve Test – presence of femoral nerve root compression Straight-Leg Raise Test – sciatic nerve root tension or compression Patrick’s test (FABERE) – arthritis in the hip joint Thomas Test – flexion contracture of the hip joint Cubital Tunnel Syndrome – Yergasson’s Test – determine integrity of the transverse humeral ligament Waddell’s Non-Organic Physical Signs and Placebo test– To determine Reliability of Pain and Disability Report

Objective Data Posture Range of Motion Gait PCE should determine if these objective findings are or are not reliable and consistent as the client did/did not self limit secondary to reported pain

When to stop/terminate testing Biomechanical Cardiovascular – Metabolic Psychophysical Blood Pressure exceeds 160/100 Heart rate exceeds the target zone of 85% of MAAHR Client develops chest pain, nausea, vomiting, dizziness, blurred vision, pale Client is unsafe or is unable to perform activity or movement patterns Request to stop

Types of Testing MET/Endurance Testing Risk Factors Single Stage Treadmill Protocol Modified Bruce Treadmill Test Balke Substandard Treadmill Test Bench Step Test Circuit Testing (Material Handling or non-material handling) MET/Endurance Testing Risk Factors Have you had a heart attack? Have you ever had heart surgery? Have you had an abnormal electrocardiogram Do you have heart disease? Have you been told by a physician you have had angina? Have you been told by a physician you have had palpitations? Have you had a stroke? Is the blood pressure 160/100 or higher Are you pregnant?

Lifting Purpose is to assess safe maximum occasional lifting capacity Instructions for specific test protocol and safety Termination of the Tests: 1. biomechanical failure 2. heart rate 3. client request

Dynamic Lifting, Carrying, Pushing or Pulling Isoinertial Lifting PILE test, Lumbar PILE and the Cervical PILE WEST II Lifting Evaluation EPIC Normative data for maximum acceptable weights and forces Stover H.Snook and V.M.Ciriello Ergonomics,1991 vol. 34, No.9,1197-1213 Isoinertial Lifting – floor to knuckle, knuckle to shoulder, shoulder to overhead, carry task 30’, push, pull PILE test – standardized lifting test, Lumbar PILE and the Cervical PILE WEST II Lifting Evaluation EPIC – researched based lifting protocol

Repetitive or sustained material handling or work postures Endurance circuit to determine Frequent Material Handling or Frequent tolerances for work postures Work simulation to determine Frequent or Constant tolerances for work postures Performed in 30-60 minute increments

Standardized Testing Method-Time Measurement “is a procedure which analyzes any manual operation or method into the basic motions required to perform it and assigns to each motion a predetermined time standard which is determined by the nature of the motion and the conditions under which the motion is made” In practice, 100% MTM refers to an objectively-derived entry-level production standard on a given work sample to which the evaluees’ performance can be compared

MTM vs. Normative MTM - Based on Industry standards which are more reliable in determining suitability to a job Normative - Based on a sample population may be biased by race, gender Percentile scores do not necessarily predict whether or not someone meets industry standards

Introduction to Standardized Tests Reliability and Validity Assess the various diagnoses of the clients to be seen Can used assess the type of industry near the clinic and the type of work performed Can be used for evaluation or work simulation

Valpar 9 (Whole Body ROM) and West 7 Bus Bench Evaluates physical tolerances for prolonged standing, repetitive and sustained horizontal reaching, stooping , prolonged light strength work, hand and finger dexterity

Mobility Valpar 9 (Whole Body ROM) WEST 7 Bus Bench Balancing Crawling Stairs Ladder Flexibility Squatting Crouching

Purdue Pegboard Used to evaluate a person’s ability to manipulate very fine objects.

Minnesota Rate of Manipulation Evaluates a person’s ability to manipulate small objects

Valpar 202 Four tests that require proper selection, placement and use of hand tools.

Bennett Hand Tool Dexterity Test Evaluates manipulative skill independent of intellectual factors such as understanding of mechanical principles or the ability to plan a task or follow directions

Crawford Small Parts Dexterity Test Measures dexterity or hand function

Pinch Grip Measures strength and dexterity 3 point or palmer pinch Tip pinch or finger pinch Lateral pinch

Jamar Grip Strength Evaluates: Strength Consistency of effort Jamar Dynamometer Evaluates: Strength Consistency of effort Rapid Exchange Bell Curve & SD Coefficient variation cut points

Reliability of Pain and Disability Reports RPDR “involves completion of a battery of tests designed to asses the dependability and accuracy of a client’s subjective reports of pain and associated disability. The battery includes test which evaluate the presence or absence of non-organic findings as well as tests which compare a client’s subjective report to their demonstrate ability through distraction- based clinical observations.”

SORTS Use to obtain a subjective rating of perceived ability to perform various household, work and daily activities Use for evaluation of client’s with a wide variety of physical limitations Evaluates “work function themes” Evaluates “ unrealistic self-perception of ability”

SORT Tools WEST Tool Sort/Loma Linda Activities Sort PACT Spinal Function Sort EPIC Hand Function Sort

Functional Pain Scale 0 = no pain 1-2 = pain is present but not limiting 3-4 = pain is starting to affect your ability to perform current activity 5 = pain causes you to be unable to complete current activity 7 = you cannot use or move the painful area, can’t talk, are tearful, need to lie down 10 = requires immediate hospitalization

Waddell and Placebo test Performed during assessment of range of motion, strength and movement patterns

Repetitive Movement Testing Performed Pre and Post testing Look for change in movement patterns in comparison to reported pain and disability Look for change in performance time in comparison to reported pain and disability

Feasibility “The acceptability of the worker in the general sense i.e. worker traits and behaviors” The person being evaluated perceives themselves in the “worker role” and not in the “patient” role.

Red Flags for Feasibility Lack of attention to the evaluator Resistance to testing - voiced refusal or fearful of testing Signs of Anger Descriptions are too explicit or vague No future goals or goals are simple with no detail Want a better doctor to “fix them” Lack of active control of symptoms

Red Flags continued Regional symptoms that do not make anatomical sense Inactive lifestyle or “couch potato” Has others perform ADL’s/chores Reinforcement of behaviors by others Noncompliance Length of time off work is extensive

Resolving Feasibility Evaluate Physical effort and RPDR Intervene and confront the evaluee in a respectful manner to attempt to foster physical effort and RPDR Document the PCE to provide functional validity. It is the skilled evaluators job to evaluate the client in regards to 1. Physical effort and 2. RPDR It is the skilled evaluators job to intervene and confront the client in a respectful manner to attempt to foster physical effort and RPDR It is the skill evaluators job to document the PCE to provide functional validity.

Questions?

Bibliography U.S. Department of Labor Dictionary of Occupational Titles, fourth Edition www.lni.wa.gov Washington State Labor and Industries Roy Matheson and Associates www.oregon.gov Department of Consumer and Business Services Workers Compensation Division

The End

Peoples Injury Network Northwest, (PINN) Thank you Peoples Injury Network Northwest, (PINN)

Peoples Injury Network NW PINN Kent 20640 84th Ave S Kent, WA 98032 253-395-1131 PINN Olympia 2120 Mottman Rd Tumwater, WA 98512 360-357-7466 PINN Tacoma 6704 Tacoma Mall Blvd Tacoma, WA 98409 253-475-7466 PINN Vancouver 2501 SE Columbia Way Suite 120 Vancouver, WA 98661 360-260-7466