2. Current Standards for Test Development, Selection and Application: Evaluation of Lifting and Lowering with the EPIC Lift Capacity Test Based on: Matheson, L. (2012). EPIC Lift Capacity Test Examiner’s Manual. St. Charles, MO EpicRehab. Matheson, L. (2003). Functional capacity evaluation. In G. Andersson & S. Demeter & G. Smith (Eds.), Disability Evaluation. Chicago, IL: American Medical Association and Mosby Yearbook.

3. Introduction: Functional Capacity Evaluation (FCE) Historical Background Traditional FCE has been based on “folk knowledge”. Modern FCE must have an “evidentiary” basis. Evidence is qualified and graded in terms of science. Evidence must be based on standardized scientific measures collected by trained personnel. 2

4. FCE Definition FCE is a systematic process of measuring and developing an individual's ability to perform meaningful tasks on a safe and dependable basis. 3

5. Types of FCE FCE LevelCompared to...Duration 1. Disability RatingNorms1-2 hours 2. Job AdequacyJob Demands3-6 hours 3. Occup AdequacyOccup Demands5-8 hrs 4. Max Depend AbilityEmployment Stds3-8 days 4

6. Focus of Typical FCE Employability Occupational Disability Functional Limitations Impairment Pathology Wherever the focus, all FCE must be conducted within professional and legal standards and guidelines. What standards were used for the ELC? 5

7. Testing in an Interdisciplinary Professional Context APA Standards for Testing AOTA Standards of Practice APTA Standards for Tests & Measurement ACSM Guidelines ACRM Measurement Standards These standards were used to develop the ELC. 6

8. Legal Contexts of Testing Federal Uniform Guidelines on Employee Selection Procedures (1978) Title VII of the Civil Rights Act (1964, 1972, 1978) Age Discrimination in Employment Act (1967) Rehabilitation Act (1973, 1978, 1987) Americans with Disabilities Act (1990) Daubert v. Merrell Dow Pharmaceuticals (1993) NIOSH Work Practices Guide (1982) These laws and guidelines were used to develop the ELC. 7

9. Professional & Legal Consequences Professional & Legal standards are used to invalidate the opinions of professionals who do not comply. A pleadings of ignorance of the standards is not defensible. Professionals must select instruments that will support their opinions when challenged. The ELC has never been successfully challenged in court. 8

10. Specific Legal Context for Testing Lift Capacity NIOSH Work Practices Guide for Manual Material Handling (1982) Requires that Safety be primary consideration in employment selection tests. Defines “Test Factors Hierarchy” for evaluation of employment selection tests. 9

11. General Test Criteria: Work Capacity Evaluation Test Factors Hierarchy 1. Safety 2. Reliability 3. Validity 4. Practicality 5. Utility 10

12. Reliability Validity Practicality Safety 11

13. Peer Reviewed Research Research underway since 1989 to develop the ELC. Numerous studies with ongoing publication in peer-reviewed scientific journals. Provides the basis for the ELC U. S. patent award. ELC is the only lift capacity test with normative data that are age-based and differentiated by gender. 12

14. Safety Questions To what level of demand is evaluee safely able to be tested: Target function? Supportive functions, such as cardiac? May other safety problems be precipitated? Has protocol been demonstrated to be safe in peer-reviewed research? 13

15. Specific Criteria - Safety Diagnostic procedures must be completed. Battery must provide evaluator with indicators of impending overload that he/she can interpret. Equipment at site-licensed facilities has been demonstrated to be safe. Protocol demonstrated to be safe: Matheson LN, Mooney V, Grant J, Affleck M, Hall H, Melles T, Lichter R, McIntosh G. A test to measure lift capacity of physically impaired adults: Part I - Development and reliability testing. SPINE, 1995;20(19): 2119-2129. 14

16. Reliability Questions Are data dependable / reproducible? Does equipment produce stable results? Is evaluator reliable, trained, certified? Did evaluee try his/her best? Has protocol been demonstrated to be reliable in peer-reviewed publications? 15

17. Specific Criteria - Reliability Procedures standardized. Instructions understandable. Full-effort checks built-in to test battery. Evaluator formally trained and tested. Protocol demonstrated to be reliable: Correlations range from r =.86 to r =.93. Matheson L. Relationships among age, body weight, resting heart rate, and performance in a new test of lift capacity. Journal of Occupational Rehabilitation. 1996;6(4): 225-237. 16

18. Validity Questions Did the question asked get answered? Does test correspond with actual experience? Does result coincide with real life performance? Has protocol been demonstrated to be valid in peer-reviewed publications? 17

19. Specific Criteria - Validity Age and gender performance norms. Protocol demonstrated to be valid: Alpert J, Matheson L, Beam W, Mooney V. The reliability and validity of two new tests of maximum lifting capacity. Journal of Occupational Rehabilitation, 1991;1(1):13-30. Matheson L, Mooney V, Caiozzo V, Jarvis G, Pottinger J, DeBerry C, Backlund K, Klein K, Antoni J. Effect of instructions on isokinetic trunk strength variability, reliability, absolute value, and predictive validity. SPINE, 1992;17(8):914-921. Matheson LN, Mooney V, Holmes D, Leggett S, Grant J, Negri S, Holmes B. A test to measure lift capacity of physically impaired adults: Part II - Reactivity in a patient sample. SPINE, 1995;20(19): 2130-2134. 18

20. Practicality Questions What does evaluation cost? How long does it take: Referral > Evaluation Evaluation > Report Has protocol been demonstrated to be practical in peer-reviewed publications? 19

21. Specific Criteria - Practicality ELC is highly structured to look at key issues, giving most reliable info for time spent. Test used in multiple batteries (stand-alone, Cal-FCP, CBI, etc). Equipment useful for other rehabilitation tasks, such as conditioning. Protocol demonstrated to be practical: Matheson LN, Mooney V, Grant J, Leggett S, Kenny K. Standardized evaluation of work capacity. Journal of Back and Musculoskeletal Rehabilitation. 1996;(6): 249-264. 20

22. Specific Criteria - Utility Must help evaluee, physician, allied health personnel, payor and employer determine evaluee’s current status. Must help the provider identify rehab needs, evaluee’s resources, and potential rehab targets. 21

23. Utility Questions Have the four senior criteria in the hierarchy been adequately addressed? Did we get a second referral from this source? If not, which criteria were violated? 22

24. Introduction: EPIC Lift Capacity Test U.S. Patent #5,848,594 Design Team Leonard N. Matheson, PhD Vert Mooney, MD Colleagues and Consultants Roland Lichter, MD Scott Leggett, MS Edmund M. Bernauer, PhD Michael Affleck, BSc Kines Hamilton Hall, MD Tony Melles, MS PT Janet Grant, BS RN Greg McIntosh, PhD Scott Negri, MD Bryan Holmes, RPT Debbie Holmes, RPT Vince Caiozzo, PhD Janet Pottinger, ATC Cindy DeBerry, RPT Kirsten Backlund, MS RPT Kristen Klein, MS RPT John Antoni, MS RPT Theodore Dreisinger, PhD 23

25. Significance of the Patent Award The ELC is the only performance test of this type awarded a United States patent. The patent award identified more than 30 aspects of the ELC test that the U.S. Patent Office found to be unique and significant. Most of these address how the ELC test maintains the safety of the evaluee. Safety begins by understanding what we evaluate. 24

26. What Do We Evaluate? Lifting Upward displacement of an object with a mass that is accelerated vertically through the application of force along the direction of the lift. Lowering Downward displacement of an object with a mass that is decelerated vertically through the application of force against the direction of the lower. ELC measures “maximum acceptable weight”. 25

27. How Does ELC Determine Maximum Acceptable Weight? Integration of three categories of lifting factors: Biomechanical Factors NIOSH Lifting Equation factors are controlled by the ELC. Physiological Factors ACSM Physiological Demand factors are controlled by the ELC. Psychophysical Factors Rating of Perceived Load factors are controlled by the ELC. Evaluator monitors performance in these to determine if it is safe to continue, and when evaluee has reached a safe “maximum acceptable weight”. Several “lift demand factors” are monitored simultaneously. 26

28. Lift Demand Factor #1 Horizontal displacement of the center of gravity of the load from the center of the spine at the sacrum. Measure from center of hands horizontally to mid-point between the malleoli. 27

29. Lift Demand Factor #2 Location of the hands at the origin of the lift. Measure from center of hands vertically to floor. 28

30. Lift Demand Factor #3 Vertical displacement of the lift. Measure from center of hands vertically from start to end of lift / lower task. 29

31. Lift Demand Factor #4 Frequency of the task. This is based on: Approximation of max capacity; Duration of the individual task; Rest period after each individual task; Duration of the task set. 30

32. The speed of one lifting cycle should approach 30s + Allows timing to ask questions Doesn’t negatively impact HR or recovery Lift Demand Factor #4 b

33. Lift Demand Factor #5 Biomechanical couplings. Based on hand-holds. Rate as “good, fair, or poor” 32

34. Lift Demand Factor #6 Asymmetry of the task. Based on angular displacement of load from the sagittal plane. 33

35. Additional Factors that will influence an individuals outcomes in testing 1) Motivation – task target primary or secondary gain 2) Anaerobic Capacity – hi intensity / low duration activity 3) Aerobic Capacity – tasks up to 60 min. in duration 4) Metabolic Capacity – tasks in excess of 60 min. duration 5) Biomechanical Integrity of the system - The weak link concept

36. ELC Pre-Test Requirements Medical Stability Pathology and impairment must be understood and stable. Review records, contact treating physician, and / or conduct screening exam. Screen for major problems with the Cornell Medical Index or EPIC Health Questionnaire. 35

37. Pre-Test Screening Consider each evaluee in terms of: Available range of motion; Changes in sensibility; Swelling; Understanding of instructions. Be aware of medications that artificially limit the HR response (Beta Blockers ) Cannot use EPIC 36

38. EPIC Parameters Male or Female, between ages of 18 and 60 years 4’10” to 6’5” in frame size Can be overweight as long as horizontal displacement can be meaningfully used

39. Impairments Affecting ELC Safety Accommodate for: Visual impairment; Deafness or cognitive other impairment affecting the understanding of instructions; Upper extremity weakness and instability; Lower extremity weakness and instability. 38

40. Impairments Affecting ELC Safety Cardiac impairment requires real time monitoring plus the immediate availability of emergency assistance. Do not use the ELC without these safeguards. 39

41. Resting Heart Rate and Blood Pressure Limits Improves safety by prohibiting testing of individuals at increased cardiac risk, unless they are properly monitored and emergency response capability is immediately present. 40

42. Resting Heart Rate and Blood Pressure Limits Without proper monitoring and emergency response capability, do not test individuals whose resting blood pressure exceeds 159/100 or whose resting pulse rate exceeds 90 beats per minute. 41

43. Standardized 10-Pound Load Increments May not be exceeded. It is permissible to increment in 5-pound loads if the 10-pound increment is too great for the evaluee, but do not compare to normative data. 42

44. ELC Load Limits When present, must not be exceeded without doctor consultation: Doctor’s prophylactic restrictions. Job task target. 43

45. ELC Load Guidelines May be exceeded only with clear rationale and adherence to other limits. Biomechanical guideline based on frame size taken from the Evaluation Record. 44

46. ELC Safety Factor #1 Progression & integration of testing over 3 vertical ranges with 2 frequencies and 12 biomechanical limits. 45

47. Progression of Testing 1. Knuckle to ShoulderOcc10 lbs 2. Floor to KnuckleOcc10 lbs 3. Floor to ShoulderOcc70% of 1 or 2 4. Knuckle to ShoulderFreq40% of 1 5. Floor to KnuckleFreq40% of 2 6. Floor to ShoulderFreq40% of 3 RangeFrequencyStart Weight 46

48. Integrated Test Battery Improves practicality by utilizing previous performance data to determine subsequent test parameters. 47

49. Integrated Test Battery Do not perform a frequent test without performing the infrequent test at that range of motion. Do not perform a floor to shoulder test without performing both of the previous tests at that frequency. 48

50. Progression of Testing 1. Knuckle to ShoulderOcc10 lbs 2. Floor to KnuckleOcc10 lbs 3. Floor to ShoulderOcc70% of 1 or 2 4. Knuckle to ShoulderFreq40% of 1 5. Floor to KnuckleFreq40% of 2 6. Floor to ShoulderFreq40% of 3 RangeFrequencyStart Weight 49

51. ELC Safety Factor #2 Wrist-Neutral Knurled Handholds Allow either overhand (pronated) or underhand (supinated) grasp. Allow change to accommodate load. Improves Safety and Reliability. 50

52. Wrist-Neutral Handholds Improves safety by allowing secure grasp of crate. Improves reliability by standardizing position of crate and eliminating psychophysical limit due to hand discomfort. 51

53. ELC Safety Factor #3 Age-Referenced Heart Rate Window Do not begin any test if above 70% of PMHR, and... Do not continue test if 85% of PMHR is achieved (PMHR = 220 - Age) Improves Safety and Validity. 52

54. Progression of Testing 1. Knuckle to ShoulderOcc10 lbs 2. Floor to KnuckleOcc10 lbs 3. Floor to ShoulderOcc70% of 1 or 2 4. Knuckle to ShoulderFreq40% of 1 5. Floor to KnuckleFreq40% of 2 6. Floor to ShoulderFreq40% of 3 RangeFrequencyStart Weight 53

55. Performance Heart Rate Limits Improves safety by restricting activities that may place the evaluee at an unnecessarily increased risk. Improves validity by restricting the evaluee’s activity within a sustainable range. 54

56. ELC Safety Factor #4 High Risk Work Style Limits Horizontal Displacement Stance Must not intervene with a “1,” and... must intervene with a “3”. Improves Safety and Reliability. 55

57. High Risk Workstyle Guidelines Improves Safety by requiring the evaluator to constantly monitor body mechanics. Standardizes the means of intervention (NIOSH) Improves reliability by controlling intervention. 56

58. High Risk Workstyle Watch the feet during lift segment. Interrupt the evaluee and correct performance if either rating = “3”. Stop test if evaluee persists at “3”. 57

59. Two tape lines 3” from the shelf and 6” from the shelf Horizontal Displacement “3”“2”“1”

60. Must intervene with a rating of 3 Rating of 1 or 2 - acceptable Horizontal Displacement

61. Consider the stance based on client’s shoulder width Stance “3”“2”“1”“2”

62. Must intervene with a rating of 3 Rating of 1 or 2 - acceptable Stance

63. High Risk Workstyle Improves Safety by requiring the evaluator to constantly monitor body mechanics. Improves reliability by controlling intervention.

64. High Risk Workstyle Watch the feet during lift segment. Interrupt the evaluee and correct performance if either rating = “3”. Stop test if evaluee persists at “3”.

65. These changes are what the client will typically do as they reach their maximum capacity WHY? High Risk Workstyle

66. BMI: Body Mechanics Interrupts Interrupt the test and correct the evaluee when these body mechanics are demonstrated by the evaluee. Do not allow the test to continue if they recur. Conclude the test with a report of “non- cooperation”. 65

67. Prevent These BMIs: Twisting the spine. Throwing the load. Dropping the load. Lower extremity nudging. 66

68. ELC Safety Factor #5 Rating of Perceived Load (RPL) Stop test if RPL =>8 If RPL = 9 or 10, last functional lift is considered at trial prior to that rating. Improves Safety and Validity. 67

69. Rating of Perceived Load Improves safety by providing the evaluator with frequent psychophysical feedback. Improves validity by providing ongoing psychophysical reference to improve evaluee’s judgment of what can be tolerated “8 to 12 times per day”. 68

70. ELC Safety Factor #6 EPIC Certification Workshop Attendance Pass Written Examination Complete 5 Test-Retest Subjects Technician certified for use under professional's supervision. 69

71. EPIC Certification Allows a professional to test, and to supervise certified technicians, within the professional’s area of expertise. Allows a technician to test under the supervision of a certified professional. “Professional” is defined as one who is able to provide this type of service independently in one’s jurisdiction. 70

72. Additional Safety Factor Client reports new symptoms Stop the test and seek medical assistance or clearance For us that would be having reassessment by Screening therapist or re-assessing yourself

73. ELC Reliability Factor #1 Masked Weights Improves reliability by allowing a blind re-test of an evaluee who may be providing less than full effort Facilitates cross-validation of RPL X heart rate max X vertical range X frequency X load. 72

74. ELC Reliability Factor #2 Height-Linked Vertical Range Improves reliability by equalizing the vertical range of motion between evaluees of various heights. Avoids gender-based test versions that are illegal. 73

75. ELC Validity Factor #1 Masked Weights Improves validity by simulating the cognitive circumstances of a “real world” lift. Evaluees do not know the starting weight nor the weight progressions, just as is normally the case in daily experiences. 74

76. ELC Validity Factor #2 Content-Validity Can be used to simulate the job task and sample actual job demands. Screen first with the standard ELC. Design work simulation using job analysis if ELC screening indicates adequate safety. 75

77. ELC Validity Factor #3 Age-Based Normative Data Allows comparison across age and gender groups and with both age and gender groups combined. Provides actuarial estimate of pre-injury capacity: Compared to norms for age and gender, what percent of expected lift capacity does evaluee demonstrate? How do they compare to the uninjured matching group? None of the other lift capacity tests offer age and gender-based normative data. 76

78. Global Effort Rating ELC is very useful to identify individuals providing insincere (non maximal) effort Gauged by reviewing HR changes, Biomechanical changes and HR progressions If effort is good (+) in the comments If effort is poor (-) in the comments Improves both the safety and reliability of the ELC

79. How does the ELC compare? PILE use of different loads for females causes more work to get to the same maximum lift. PILE, Isernhagen & WEST use un-masked weights. PILE & Isernhagen do not appraise psychophysical limit (RPL). PILE & Isernhagen do not use frequency and vertical range to gradually increase demand. 78

80. How established is the ELC? Since 1993… More than 5,000 professionals have been trained. More than 1300 professionals have been certified as ELC evaluators and technicians. Data have been collected on more than 5,000 healthy normal subjects. ELC results have never been successfully challenged in court in the U.S. or Canada. There has not been a single report of injury while using the ELC. 79

81. ELC Workshop Summary Research shows that the ELC is a safe, reliable, valid and practical test protocol. Site licensing of equipment provides quality control. ELC evaluator certification program provides quality control. 80

82. Thank you! Correspondence about technical issues can be directed to Dr. Matheson at Len@EpicRehab.com. Correspondence about certification issues can be directed to Karen Markley at Karen@EpicRehab.com. Karen@EpicRehab.com Contact me Aman Bains at abains@cbi.ca orabains@cbi.ca Chris Dobson, at cdobson@cbi.ca for assistance with accreditation questionscdobson@cbi.ca 81