The Injured Employee

When an employee is injured on the job, there are a variety of treatment options available. Typically, an emergency room physician or company physician will examine the injured employee initially and then, if needed, refer the employee to the appropriate specialist, such as an orthopaedist.

If a musculoskeletal injury is sustained, the orthopaedist can schedule tests such as x-rays, and magnetic resonance imaging (MRI) (a test that shows the bones, muscles, tendons, and ligaments). Based on the findings, the orthopaedist will decide if the employee needs to be treated conservatively (without surgery) or if there is a need for surgery. An employee can be treated conservatively with a brace, splint, anti-inflammatory medication, such as aspirin or ibuprofen, and rehabilitation (physical or occupational therapy). Usually, when treated conservatively, the employee can continue to work, but at light or modified duty. If surgery is determined to be appropriate, the employee will go through a rehabilitation program before returning to work.

Rehabilitation
After an employee plateaus (stops improving) with rehabilitation, he or she may still be unable to return to work because of functional deficits and/or because of being physically deconditioned. If the physician feels that the client can benefit from additional rehabilitation with a more aggressive approach, the employee may be referred to a work-simulation program for example work hardening or work conditioning. Work-simulation programs are designed specifically for each employee and address the body as a whole versus addressing the injured body part only. For example, the employee is treated with a combination of flexibility, cardiovascular endurance, core- strengthening, circuit training, and job-specific functional activities. The frequency and duration of the work- simulation program typically lasts for 3 hours a day, 5 days a week, for 4 to 6 weeks.

Functional Capacity Evaluation
Normally, after completion of the work-simulation program the physician refers the employee for a functional capacity evaluation (FCE) or an impairment rating or both.

An FCE is a test that determines the maximum function of an employee based on the performance of musculoskeletal tests and work-related activities. According to Isernhagen,1 maximum function is defined as the greatest safe ability of an employee, either in repetitions or weight capacities. Maximum function is determined by observing physical efforts at low levels, medium levels, and high levels of activity.

An FCE consists of a history, musculoskeletal assessment, and functional testing. The history should be comprehensive and accurate. It should include a very thorough chart review, a functional job description, and a consultation with the employee's rehabilitation case manager or rehabilitation nurse to find out what are the options for case resolution.

The musculoskeletal assessment should include, but not be limited to, vital signs (blood pressure and pulse), gait, posture, coordination, movement characteristics, range-of-motion measurements, muscle strength testing, atrophy or edema, girth measurements, muscle tone or spasms, neurological testing and sensation, reflexes, and balance.

Testing
Tests are given over either one day or two days, depending on the body part to be tested. One-day, or modified, tests are for the upper extremity, i.e., finger, hand, wrist, elbow, and shoulder. A one-day test assesses lifts (Fig.1), push-pull (Fig.2), carries, elevated work, and hand activities (Fig. 3). Two-day, or standard, tests are for the lower extremities and spine, i.e., neck, back, hip, knee, ankle, foot, and toe. Two-day tests include the above mentioned one-day activities with the addition of positional activities, walking, stair and ladder climbing (Fig. 4), balance, and repeat of lifts on day two. On the second day the examiner assesses consistency and the response to that of day-one testing.

FCE reports include the physical examination, FCE grid, consistency checklist, and summary report. The summary report includes, but is not limited to, effort, cooperation, pain report, safety, quality of movement, significant abilities, significant deficits, and recommendations. In order for the FCE to be purposeful, the examiner must have a functional job description (FJD) of the client's job, which includes a physical demand level and specific critical demands. It is imperative that the physical therapist or occupational therapist receive an FJD when performing an FCE, so that the appropriate recommendations or job modifications can be made.

In conclusion, when and why do you perform an FCE? An FCE should be performed when an employee has suffered a work-related injury, after completion of rehabilitation, and when beginning or ending a work simulation program. The reasons an FCE should be performed are as follows: to define what an employee can do, to set job modifications (limitations or restrictions) if needed, and ultimately, for case resolution--that is for the employee to return to work.

J. Benjamin Belle, PT
Columbus, Georgia

References
1. Isernhagen S. Functional Capacity Evaluation. In: Isernhagen SJ, editor, Work Injury Management: Management and Prevention.Maryland:Aspen;1988.
2. Matheson R. et al. Work Hardening and Work Conditioning. Keene, NH; 1988.