Functional Assessments

What are the details? Which ones enhance the ability of a claims professional to gain strong decision support to effectively manage the claims process?

Functional testing measures and provides information on the objective physical abilities of a claimant. The results of an assessment act as a bridge between the stage of recovery and return to work and/or pre-injury activities. The results/opinions formulated following the assessment are based on actual performance (i. e. claimant can lift 50lbs) vs. self reports (i. e. I don’t think I can lift more than 10lbs). This objective information is essential in supporting medical decisions, particularly related to the presence of a disability or not and whether return to work is safe and appropriate.

Assessment products

The type of equipment, testing philosophy and evaluator qualities, has an impact on the safety, reliability, validity, practicality and utility of the results of the assessment.

Manual vs. computerized functional testing systems

Many providers complete manual testing, which requires the evaluator to use tools with dials or digital readouts and manually document the results. Calculations are done by hand. Depending on the type of measurement tools used, the frequency of calibration is often an issue. From a legal defensibility stand-point, the ability of the clinical provider to maintain a record of calibration is important.

Report writing software is available, wherein the evaluator manually enters the data into the software. These reports are typically well organized and easy to read, but the method by which the functional testing data is collected is potentially an issue.

A computerized system is one where the data is captured by the computer from the testing tools (load cell, range of motion device etc). Computerized systems are becoming more and more popular for both evaluators and payers for the following reasons:

• Accurate: The system requires calibration to ensure the values recorded are accurate. There is no risk for recording errors since the computer is capturing the data versus writing the data down on paper.

• No bias: The computer captures the data and there is no risk that the data will be changed intentionally or unintentionally (dependent on system manufacturer).

• Real time strength graphing: This allows for the evaluator to see muscle fatiguing or unusual muscle recruitment.

• Real time heart rate graphing: This allows for the assessment of cardiovascular endurance and ensures the claimant is performing safely throughout the assessment.

• Safety parameters built into software: Dependent on the system manufacturer, safety parameters are programmed so that testing does not start unless the resting heart rate and blood pressure are within safe limits and the testing will stop if the heart rate increases to unsafe levels for the claimant.

• Reliable and valid: Trail length, rest periods, repetitions and the test process are all standardized in computerized systems. Test protocols programmed are based on peer reviewed research or they match the requirements of the job tasks.

Standard vs. custom testing protocol

A number of functional assessment manufacturers and clinic chains use standardized testing protocols. This means that no matter what, the same test components are completed for each claimant. Other providers/evaluators customize the assessment based on the injury, job tasks and referral questions. Each assessment will be slightly different and tends to provide more relevant/valid results.

Length of assessment

Assessment length will vary based on the referral questions. If the adjuster only needs to know whether or not a claimant can perform the lift- ing requird at their job, then an assessment would take approximately an hour to complete. A full functional assessment is generally between two-and- a-half and four hours long. Research has found that multiple day assessments are not much value and that the shorter functional assessment can provide the same reliable and valid information.

Finding a healthcare provider

Evaluator

Functional assessment evaluators should have a knowledge base in anatomy, physiology, biomechanics, and psychology. Generally the health-care professionals involved with this type of assessment include kinesiologists, physiotherapists, occupational therapists, chiropractors, athletic therapists and occupational health nurses. It is essential these professionals have post graduate training in functional assessment as university programs do not have specific courses in this area. Due to the large number of complaints that are received related to this type of assessment, malpractice insurance and membership to a professional certification or regulatory body is essential.

Use a reputable company

As a claims adjuster, there is an obligation to the claimant to send them to the best provider/evaluator available, where the service and report meet high standards. Here are some questions to ask when contacting a provider:

• Who does their assessments? (education, post graduate FCE training)

• Do they have a quality assurance program? (i. e. senior clinician assisting with selecting test components and reviewing reports)

• What type of equipment do they use?

• What is the referral process for ordering an assessment (i. e. what are their timelines for booking and sending the report)

Referral process

A quality functional assessment will address the specific claims questions with objective measurement and sound clinical judgment. The following outlines the primary and secondary triggers for making a referral.

Primary triggers for assessment

• Lack of progressive improvement with consistent treatment.

• Physician requests functional assessment as a tool for determining clinical direction.

• Fraud is suspected.

• Documented activities contradict expected activities level.

• Days out of work exceeds maximum published days to recover for type of injury. Assessment can be used to verify physical recovery.

Secondary triggers for assessment

• Subjective complaints do not match physician’s objective findings.

• Treating provider will not determine work capacity.

• Return to Work (RTW) restrictions needed for case settlement.

• Claimant is frequently unable to sustain work at specified work restrictions.

• Lost time injury where light or restricted duty placement is difficult.

• Determine functional abilities and levels of effort of suspicious claims.

What to send the evaluator

When making a referral for functional testing it is important to send some key information to the evaluator prior to the appointment.

• Physical Demands Analysis if job match is required;

• Details on mechanism of injury;

• Information on diagnosis;

• Medical reports if there is a need to know if treatment was appropriate or if further treatment is required;

• Information on pre-existing medical conditions;

• Referral questions so the evaluator knows what information is needed to move the claim forward.

End result

It is important that each functional assessment report be to a standard that would withstand legal scrutiny. Key factors to ensure this include:

• Peer reviewed and published protocols are used.

• Unbiased computerized
technology.

• Test components and functional assessment design are valid.

• Cross validation of tests to ensure consistency of effort.

• Equipment accuracy with calibration reports available.

• Well qualified assessor.

Once the functional assessment has been completed, the potential actions that can be taken include:

Case management perspective

• Support physician’s opinion on return to work; facilitate early RTW.

• Specificity of actual residual deficit as compared to job requirements.

• Consult with physician to determine other options for residual deficits.

• Obtain an objective opinion of consistency of effort to demonstrate work ability.

• Evaluating the need for retraining /vocational rehabilitation

Claims perspective

• Objective test to support evidence and/or to dispute other objective findings.

• Use results of functional assessment in comparison with surveillance.

• Use results as objective, defensible documentation in settlement negotiations.

A well completed functional assessment should provide adjusters with the details they require to move a claim towards resolution. An informed adjuster can make a referral to a provider/evaluator who has the necessary experience and equipment to perform these assessments and provide objective data to answer referral questions.

Elizabeth Chapman B. Sc. Kin., CK, is the clinical specialist/business development manager at BTE Technologies Inc.