Functional Capacity Assessment Applications

By Gideon Ariel, Ph.D.
Fifth Annual Scientific Sessions and Symposium
American Academy of Disability Evaluating Physicians
Ritz-Carlton Hotel, Kansas City, MO
November 14-16, 1991

The Ariel Performance Analysis System is a computer-based system for the measurement and analysis of movement. The system models the human body as a series of moving �links� upon which muscular, gravitational, inertial and reaction forces are applied. The means of measuring human motion is based on the processing of video recordings of a subject�s performance. The advantages of such a system are that it is non-invasive, portable and the performing environment need not be modified. This allows for greater flexibility in the recording of an activity. The A.P.A.S. has been applied for some time in areas such as injury assessment, gait analysis and athletic performance.

Functional Capacity Assessments are a major application of the Ariel Performance Analysis System. Such assessments are utilized for determining whether or not someone is healthy enough to continue working or participating in a certain activity (i.e.: athletics). An example of the use of this system is for an injured baseball pitcher who claimed to feel ready to return to pitching whereas his trainer and coach disagreed despite medical exams and strength tests. Video pictures of the athlete before and after injury displayed the change in function of the pitcher�s elbow indicating an insufficient post-injury neuromuscular response under the dynamic conditions of pitching. Another example is a longshoreman, who sustained a job-related injury, and his physician contending that permanent disability and compensation ought to be awarded to the worker whereas the employer disagreed. The employer requested that his employee perform a number of sitting, standing, bending and light lifting maneuvers for performance analysis. The evaluation showed inconsistent motion patterns and changes in acceleration indicating that the worker was in fact exaggerating the extent of his injury. Actual injury is represented by consistent acceleration patterns, almost like a �signature�, that do not change in any significant manner.

The value of applying the principles of biomechanics to the assessment of functional capacity has been clearly demonstrated. Movement analysis provides the means to quantify human activity and to provide insight into the mechanisms that contribute either to superior or inferior levels of performance. Functional capacity assessment is only the first step in the capacity of this technology. Specific performance parameter measurements for various occupations, coupled with actual performance analysis of individual disability, will allow better rehabilitation programs to be established.

The System for Functional Restoration

By Earl F. Hoerner, M.D., Medical Director, Kinematic Consultants, Inc.
Abstract of �The System�
A Continuing Education Document

A Team Approach is instituted when a patient with Musculoskeletal injuries does not respond to traditional care. Traditional care would be medication, Physical and/or Occupational Therapy, Chiropractic care or alternative treatment methods. After six weeks without improvement the patient may be identified as failing to respond to his or her treatment plan. It is then that a Comprehensive Medical Evaluation-Assessment is initiated which includes examination and re-evaluation by a physician, trained in Occupational Medicine, or a Physiatrist.

Assessment procedures would include the application of three-dimensional motion analysis. A force-platform is used to evaluate/assess balance, equilibrium and gait patterns. Muscle function, strength, endurance, power, fatigue and rhythm are measured using surface electromyography. Motion analysis would facilitate the identification of circumstances, which are present in the patient�s failure to respond to traditional programs.

When appropriate, the Team, which consists of the �Gatekeeper�(physician), treating personnel, Managed Care personnel, Rehabilitation Nurses and specialists in the field of Evaluation/Assessment would establish an appropriate treatment program to modify and correct the patient�s present treatment program. The Treatment Program and the patient�s response to it would be recorded objectively. Such documentation would include the rate of which treatment was applied, patient active participation, resistance used and duration of participation. This way outcome results will be identified and documented at the initial six week re-assessment period, two to three weeks later and one month after completion of the Treatment Program.

The goals of The System are to minimize time spent out of work, prevent or postpone surgery, prevent recurrence of injury, increase the number of individuals returning to work and decrease litigation. The System would be most beneficial for Workers� Compensation injuries, Litigation-Tort related cases and Managed Care Programs.

REPRINT: November 1996 vol.7 No.11 issue Case Management Advisor

Speed lost time in workers� comp with proactive case management

Aggressive approach pays off in workers� compensation

Kaiser Permanente Northwest Region in Portland, OR, reduced average loss time per workers� compensation claim by $666. How did they do it? By setting up a system of proactive case management that experts interviewed by Case Management Advisor agree is the most effective way to prevent an injured employee from remaining on the disability rolls.

�Our reporting system identifies workers who fall outside established parameters for expected return to work,� says Betsy Kahnoski, RN, BSN, MS, COHN, occupational health nurse case manager for Kaiser-on-the-job for the Kaiser Permanente Northwest Region. �I receive reports every two weeks. Unresolved cases come to my attention quickly and can also be referred directly to me. We have established criteria thresholds that help identify excessive time loss or extended time on modified duty. Review can begin on those cases to identify problem areas.�

When an employee suffers from a soft-tissue injury, it�s sometimes difficult to pinpoint the exact source of pain and prescribe a proper treatment plan, says John M. Marshall, MD, a physiatrist with Appalachian Rehabilitation Professionals in Kingsport, TN. �To avoid secondary gain factors, such as psychological resistance to treatment and return-to-work, it helps when the time between injury and aggressive treatment is minimized.�

Marshall suggests case managers be on the alert for the following secondary gain issues that may cause an employee to malinger:
� Is the case in litigation?
� Has the employee applied for Social Security benefits?
� Is the employee going through a divorce?
� Does the employee have a history of substance abuse issues?
�
To track injuries and keep ahead of secondary gains, Eastman Chemical Company in Kingsport, has a strict reporting policy for all workplace injuries, says Stephen G. Jacobson, MD, assistant medical director of Eastman Chemical in Kingsport and medical director for Eastman's Batesville, AR, location. "All injuries are reported to the medical department, and the information is put into a computer database and tracked from the first day of injury," he says. "If an injury prevents an employee from performing normal job duties, accommodations are often made to allow the employee to remain safely on the job. By modifying work duties, many of our employees remain safely on the job even when injured through a combination of work accommodation, an aggressive return-to-work program, and proactive medical management."

The key to keeping employees moving in a forward direction is to place the focus of treatment on function and to help employees deal emotionally and physically with issues in their lives that may affect recovery, says Jacobson. For example, Eastman orders appropriate medical tests early on rather than delaying them. "If a test is clinically indicated, we order it, rather than take a wait-and-see approach in order to save short term costs," he says. "Even a negative test can be very reassuring to a scared patient and helps speed return to work."

Early tests establish reference information

Ordering tests early also can establish reference baseline information for use in future claims, adds Jacobson. "Electromyography [EMG], for example, done early not only helps medically define an employee's condition in order to diagnose and treat it properly, but it also establishes a baseline for the future. If the results are negative, and two years later the employee complains of back pain, and a second EMG is abnormal, we have proof that the back pain is not related to the original injury"

However, if a physician orders a test for an injured employee, case managers should insist that the test results, negative or positive, lead to an action, says Marshall. "There are physicians who get test results and then sit on them. The results may be negative. Yet, if the employee still complains of pain, the physician will prescribe another three months of bed rest.

"If expensive tests are going to be ordered, case managers should emphasize that the results be shared honestly and completely with the employee and lead to a specific action. Physicians can actually create a situation where a person languishes in pain and never returns to work. Order tests in a timely manner, but don't waste the results," Marshall stresses. "Case managers should check in with employees to make sure they have been informed about their current status," he adds.

A controversial diagnosis that often keeps employees on the disability roles for months or even years is reflex sympathetic dystrophy (RSD). RSD is characterized by pain out of proportion to the degree of injury and autonomic nervous system malfunction. "The first step in keeping RSD cases from getting out of control is for the case manager to begin considering the possibility of RSD the minute an employee complains of pain of unknown etiology," says Marshall.

New tool helps Identify fraud

A useful new tool in the case manager's arsenal against workers' compensation fraud is a kinematic analysis. "We can clearly identify abnormal body movement and mechanical-based pain," explains Robert W. Wainwright, PT, physical therapy director, president, and chief executive officer of Kinematic Consultants in Point Pleasant, NJ. (For further discussion of kinematic evaluation, see the related story, �Article # 2�)

"With this information, we can recommend specific therapy to correct poor biomechanics, which is often the cause of pain symptoms. The most effective time for a kinematic analysis is four to six weeks post injury," notes Wainwright. "That's the time when patients with soft-tissue injuries get into trouble. If the patient isn't responding along normal rehabilitation guidelines at that point, case managers should consider a functional capacity evaluation (FCE), EMG, or kinematic analysis."

The cost of kinematic analysis and FCEs is more than justified when case managers use the information to get employees back to work, says Jackie Margadano, CCM, vice president of claims for Berkley Risk Managers, a workers' compensation third-party administrator in Mays Landing, NJ. "As an added incentive to employees to not only get well but to prevent future injury, we also offer a three-month enrollment in a fitness plan when the employee completes the prescribed physical therapy."
When an employee complains of long-term chronic pain past the time of expected recovery, Kahnoski often suggests that the attending physician request a panel review. �We call in appropriate team members depending on the case and the areas of expertise needed,� she notes. �The review might include a physical exam of the employee or a review of the medical records, or both.�

Marshall agrees that calling in a physician�s peers is a good approach for case managers to try. �Case managers have to approach physicians carefully, if they want quick results,� he notes. �Physicians are an egotistical bunch. They will rear their backs up like a cat if a case manager pushes them too hard,� he adds. �Calling in another physician to approach them at a peer level is much more likely to understand and accept recommendations from another physician. They�re also more likely to act quickly on those recommendations.�

Article #2
Kinematic/kinetic testing increases
accuracy of FCEs

Technology turns the subjective into the objective

Workers' compensation case managers often rely on a functional capacity evaluation (FCE) performed by a physician, physical therapist, or occupational therapist to assess an injured employee's impairment ratings and fitness for work. But FCEs rely on the professional's visual estimation, or observation, of movements that can vary greatly from one observer to another.

Kinematic analysis uses instrumentation combined with sophisticated computer technology to turn FCEs from subjective observation to reproducible clinical data. The data has proved successful in resolving legal battles and improving return-to-work outcomes in worker's compensation cases, say proponents of the method.

"We use video technology, force plates, and electromyography (EMG) to eliminate the need for subjective opinions and to mathematically quantify an employee's injury, or lack of injury," says Robert W. Wainwright, PT, physical therapy director, president, and chief executive officer of Kinematic Consultants in Pt. Pleasant, NJ. "We can do a full analysis in about 90 minutes, compared to several hours for a traditional FCE, and the cost is comparable," he notes, adding that traditional FCEs usually run about $500, and a kinematic evaluation costs between $500 and $700.

The value of the kinematic system is that the employee's injury can be documented and measured, explains Wainwright. (See sample report last page.) "We have a reliable measure of the employee's dysfunction and whether it is repeatable. It also helps therapists develop a care plan to correct poor body mechanics and makes for a more targeted, faster recovery."

Case managers who regularly refer injured employees to Kinematic Consultants agree. "Kinematic Consultants has been instrumental in resolving some difficult old files. In one case, the kinematic evaluation saved a second surgery on a shoulder injury. I find the evaluations are an extremely fair assessment of the individual employee's true clinical condition," says Jackie Margadano, CCM, assistant vice president of claims for Berkley Risk Managers, a workers' compensation third-party administrator in Mays Landing, NJ.

How It's done

Kinematic measurement uses three-dimensional force platforms, or scales, to measure the various forces of human motion, explains Wainwright. The system analyzes ground reaction forces and torques around geometric coordinates of x, y, and z axes. The information gathered is used to calculate displacements, velocities, and forces, he notes.

EMGs are a common measure of normal and abnormal electrical response in muscles. The motion specialist uses the EMG to measure activation of skeletal muscles in timing response, frequency analysis, fatigue, and pain response analysis. (For more discussion on the use of EMGs for workers� compensation cases, see cover story.) Kinematic Consultants uses EMGs to correlate the findings of kinematic measurements and to provide insight into possible neuromuscular impairments, says Wainwright.

Kinematic Consultants uses the Ariel Performance Analysis System developed by Gideon Ariel, a scientist and two-time Olympic athlete, who developed the system to analyze the body mechanics of athletes and to help them enhance their athletic performance. The system merges three-dimensional data gathered from digitized video footage from up to nine cameras with data collected from force plates and EMG.
While other facilities nationwide currently use the system to analyze and enhance athletic performance, Kinematic Consultants is unaware of other facilities who use the system for workers' compensation cases, Wainwright notes.

The final product is a comprehensive measurement and description of all movements and forces used in the performance of a work task, says Wainwright. Reflective markers are attached to employees, and the system measures the displacements, velocities, and forces used while the employee performs various work tasks, he explains.

"I wish I could send every injured employee to Kinematic, but not all employees are willing to travel to the lab, and they have the right to refuse. In some locations, we can also have Kinematic bring in portable equipment," notes Margadano. The analysis they provide is so much more sophisticated in comparison to a traditional FCE. The report makes the injury appear almost physical to you. It actually shows the true physical state of how a person is doing,� she says.