Articles

FUNCTIONAL CAPACITY EVALUATIONS
WHAT IS THE PURPOSE?

By Vincent Yip, RPT, B.Sc. (Life Sci.), B.Sc.PT

An FCE can be helpful to other assessors such as orthopaedic surgeons and physiatrists, who may have difficulty addressing an individual’s specific strength or endurance based solely on their physical examination.

Functional Capacity Evaluations (FCE) are standardized, objective, evidence-based assessments utilized to determine an individual’s safe level of physical abilities and tolerances. This is achieved by reviewing history of the individual and conducting clinical testing such as range of motion, strength, and neurological function. Additionally, job specific tests such as lifting, carrying, pushing/pulling, bending, squatting, stair climbing, and various dexterity tasks are conducted to determine whether they meet a particular job, household duty, or level of function.

In the workplace, an FCE can collect information regarding the risks associated with jobs, assesses personal factors affecting an employee's work, recommends strategies that assist in reducing the potential for injury, and assists with the implementation of key strategies and provide follow-up or re-evaluation as needed.

Following a traumatic injury such as a slip and fall or a motor vehicle accident, an FCE is useful in providing an objective measurement of disability, to assist in determining whether an individual is fit to return to their pre-injury occupation, housekeeping responsibilities, or looking after themselves. It can also help to provide direction in future treatment and rehabilitation. Additionally, an FCE can be helpful to other assessors such as orthopaedic surgeons and physiatrists, who may have difficulty addressing an individual’s specific strength or endurance based solely on their physical examination.

An FCE can be done over a span of a few hours, or it can be done over an entire day or multiple days, if fatigue or endurance is a major concern of the individual. Often individuals fail to realize that completion of a certain activity on day 1 may impact their ability on the second day, as pain and fatigue can play a role on their overall capacity. A qualified FCE assessor will be able to identify these issues and make appropriate recommendations.
When there is a question of whether an individual will benefit from a FCE, you should always consult with a qualified FCE assessor, who can provide you with guidance through this process. This is the most effective way to get the information that you want while being cost-conscious.

We can address them best by taking personal responsibility ourselves for dealing with our own issues and being actively supportive to others. Honesty and openness with unconditional positive regard and respect are the key for healthy intervention and ongoing support.

Mr. Vincent Yip, RPT, B.Sc. (Life Sci.), B.Sc.PT is a duly qualified physiotherapist with IME Plus Evaluations Ltd. working in the Provinces of Ontario and British Columbia. He graduated from Queen’s University with degrees in life sciences and physiotherapy. He has been practicing physiotherapy for over fourteen years, with knowledge of assessment and treatment of orthopaedic conditions. Mr. Yip’s experiences include acute care in the hospital setting, community care with complex injuries, and sports therapy with elite and Olympic athletes. Mr. Yip was the manager of rehabilitation services at York Central Hospital, and was part of the Toronto Written Item Generation Team for the Alliance of Physiotherapy Regulators. Mr. Yip is certified in the WorkWell Functional Capacity Evaluation protocol, Metriks FCE, ARCON computerized evaluation system, and has been performing functional capacity evaluation for over 10 years.

Addiction and Mental Health Problems: The role of Community

By Dr. Raju Hajela
CD,MD,MPH,CCSAM,CISAM,CMRO,FASAM,FCFP,DABAM

Community—personal and at work - is very important at identifying problems that need attention. Similarly when someone has been going for help, it is important for family members and co-workers to be open to honest communication rather than expecting everything to be fine.

The Canadian Mental Health Association and other agencies are trying to get people’s attention by saying that mental health illness affects one in five Canadians. This really applies to serious mental health problems. The true prevalence of Addiction and Mental Health problems in our society is closer to one in three or higher? This prevalence of Addiction and Mental Health problems means that all of us are affected directly or indirectly in our family and work circles. The problems though are not generally visible except the reflection in behaviours.

People will often get physical symptoms for which they get medications. A common example is gastritis, which may be caused by smoking and drinking excessively but people will often get medications for heartburn rather than addressing Addiction involving tobacco and alcohol. Anxiety, panic attacks and depression are also common symptoms for which people may get medications but miss the underlying Addiction and Mental Health Problems that get worse over time. Moreover, the efficacy of anti-anxiety medications and anti-depressants over long periods of time is also questionable.

Behaviour problems that are noticeable at work usually involve absenteeism, presenteeism (being at work but not productive because of pre-occupations with personal issues resulting in problems with attention, memory and concentration) and neglect of responsibilities. The reliability may become variable such that co-workers are left guessing when the affected person is super responsible some of the time and unpredictably unreliable at other times.

Mood swings, social withdrawal or outbursts may be noticeable. Often co-workers and supervisors try to cover for the individual or try to guess at whether alcohol or drug problems exist. The better approach is to document the behaviour problems and approach the individual at a neutral time to share the concerns, with the view to pointing them in the direction of help. This can be done by co-workers informally or more formally by supervisors. The documentation serves as a record over time if the problems persist.

Similarly, family members can also bring concerns up in person, write a letter if the problems are persisting and/or write out the concerns in a communication book with date and time that will serve as a record over an extended period of time to remember and remind. This is a much better approach than avoidance or nagging. Community – personal and at work – is very important in identifying problems that need attention. Similarly, when someone has been going for help, it is important for family members and co-workers to be open to honest communication rather than expecting everything to be fine. Asking the person how best to support them works better than guessing or avoiding. We are all affected by our own and each others’ problems and issues.

We can address them best by taking personal responsibility ourselves for dealing with our own issues and being actively supportive to others. Honesty and openness with unconditional positive regard and respect are the key for healthy intervention and ongoing support.

Dr. Raju Hajela is a family physician and specialist with IME Plus Evaluations Ltd. He received his MD from Dalhousie University in 1982 and Master of Public Health (MPH) from the Harvard School of Public Health in 1988. He is licensed in both Ontario and in Alberta . He has had considerable training in Addiction Medicine over the years and completed a one year residency in Chemical Dependency at the Addiction Research Foundation (now Centre for Addiction and Mental Health) in Toronto. He is a Certificant of the College of Family Physicians of Canada , the American Society of Addiction Medicine , the Canadian Society of Addiction Medicine and the International Society of Addiction Medicine; and a Fellow of CFPC (FCFP) and ASAM (FASAM). He is a Diplomate of the American Board of Addiction Medicine (DABAM) and has held faculty appointments in Family Medicine and Psychiatry at Queen's University. He has taught residents and medical students at the University of Toronto, Queen’s University and the University of Calgary, where he continues to have a Community teaching and mentorship appointment. He is a certified Medical Review Officer (CMRO) and has been a Civilian Aviation Medical Examiner (CAME),a retired Major, having served in the Canadian Forces (Air), Consultant in Addiction Medicine at the National Defence Medical Centre and Director, Addiction Rehabilitation Centre in Kingston.

DO I NEED A NEUROPSYCHOLOGICAL ASSESSMENT?

By Dr. Mark Watson, Ph.D., C. Psych

Keep in mind, a head injury is typically necessary for a brain injury, but a head injury in and of itself is not a guarantee of a brain injury.

Many times it can be confusing to understand the difference(s) between all medical specialties. Keep this article handy as a reference to know if you may require a neuropsychological assessment. Just because someone did not have an open wound to the head does not mean that they did not sustain a brain injury. Likewise, just because someone required some stitches on their scalp does not mean that they have a brain injury that will affect them for the rest of their life. It would be hard to say exactly what circumstances need to be present to require a neuropsychological assessment, you should look at the file as a whole.

Things to consider:

· The accident – Was the claimant a pedestrian or was the impact enough so the claimant sustained fractures? If so, it could be that the brain was jolted within enough force to cause a concussion (which is a term synonymous with a Mild Traumatic Brain Injury). Does a concussion cause the claimant to suffer a substantial inability to perform the essential tasks of his/her employment or any Activities of Normal Living?

· Does the claimant complain of such things as: Headache; Dizziness; Memory issues; Concentration problems; or Problems focusing? Has another practitioner referenced the terms mild Traumatic Brain Injury, Concussion, or Post-Concussive Syndrome in any forms or reports?

· Did the complaints start right after the accident? If so, it would appear that it could be accident related, however if memory issues start being reported months or years after, it could be something else entirely such as a stroke, age related issues, or lack of sleep.

In general:

· If someone has pins and needles sensation in the leg (such as when you sit on your foot too long) and has no complaints of memory issues, you probably do not require a neuropsychological assessment, but rather a neurology assessment to address the nerves.

· If someone has a scratch on their face from glass, and are no other residual issues, you do not require a neuropsychological assessment.

· However, if the impact jolted their head back and forth or they hit their head on the steering wheel, and are complaining of getting lost in conversations, having an inability to concentrate, and memory issues, then this would be a good time to get a neuropsychological assessment to address any ongoing issues and impairments in order to get them the treatment that they need to get them back to work.

· Keep in mind, a head injury is typically necessary for a brain injury, but a head injury in and of itself is not a guarantee of a brain injury.

Benefits of a Neuropsychological assessment vs other assessments:

· Unlike many other types of assessments, neuropsychological assessments include validity measures. These validity measure can be used to verify how much weight can be placed on what a claimant reports or if they are malingering (and are something that Judges and Arbitrators give credence to). This can be used, not only to address benefits under review, but can be a reflection if the claimant will present well on the stand.

· Neuropsychological Assessments are quite useful in address issues relating to benefits (i.e., Housekeeping, Attendant Care, and Income Replacement), Return to Work issues, and Catastrophic Impairment Designation when cognitive complaints are reported by the injured individual.

Rumours:

· Many people may have heard of “practice effects”, or have been told by a claimant’s lawyer that they cannot do a neuropsychological assessment until a year has passed since the previous assessment. This is actually INCORRECT. As of the date of writing this, there has been no clear scientific evidence to show that “practice effects” exist (and that will be a discussion for another day).

· The effects of a concussion can continue for years and years post accident (another interesting discussion for another day).

Dr. Mark Watson, Ph.D., C. Psych is a Clinical Psychologist with IME Plus Evaluations Ltd. practicing in the areas of Clinical Neuropsychology and Clinical Psychology. He has a Ph.D. in Clinical Psychology and Clinical Neuropsychology,York University in 2008; post-doctoral training in both areas, specializing in motor vehicle accidents and Independent Psychological/Neuropsychological Evaluations. Over the last decade, he has primarily developed expertise in generating psychological, neuropsychological and vocational assessments, and has acquired skill in determining the causes and consequences of disability and catastrophic impairment.

ACTIVE FUNCTIONAL REHABILITATION

By Dr. Phil Conway BPE DC FCCPOR(C)

AFR brings in a menu card of rehabilitation protocols and goals focused to the whole patient rather than repetitive isolated treatments with no functional goals.

For many years rehabilitation after an injury, particularly an injury due to a motor vehicle accident, has been a long drawn out affair. Typically patients are referred to a physiotherapist to start a ‘rehab program’, and at some point in the future the treatment may be completed and the patient is declared able to return to work or normal activity. Standard protocol is a series of passive treatments such as ultrasound, muscle stimulation and heat for example. This model of physical rehabilitation has proven to be very ineffective and very costly. The patient attends for what seems to be forever with no end in sight and the patient often becomes very frustrated. The patient returns to their physician who really does not want to deal with this patient and refers them back for more physiotherapy, and this cycle repeats and repeats.

A much more effective, less costly and timely physical rehabilitation protocol is Active Functional Rehabilitation (AFR). AFR brings in a menu card of rehabilitation protocols and goals focused to the whole patient rather than repetitive isolated treatments with no functional goals. For example if a patient had a shoulder injury due to a motor vehicle accident. A non-functional approach would typically use heat, ultrasound and electrical muscle stimulation. This approach could continue until the patient gets frustrated, goes elsewhere or self-discharges. Whereas AFR would set treatment goals that are measureable and obtainable, and could use treatment strategies that include scapulothoracic stability exercises, closed-chain exercises, single leg posterior chain training, soft tissue treatment and home based exercises. In addition, with AFR, the patient actively takes a role in their physical rehabilitation. They become an important part of the rehab team rather than a passive recipient of ineffective treatment.

The AFR model has developed over time and has incorporated additional key rehabilitative components such as the restoration of faulty movement patterns to develop a neurological imprint or engram of healthy movement patterns, enhanced motor control activities and 3 dimensional resistive exercises. This involves the patient performing real world specific resistive exercises, realistic movement tasks, whole body exercises and taking part in an aerobic reconditioning program.

AFR programs may be completed at a multidisciplinary centre or at an individual practitioner’s clinic. AFR is a timely, effective, cost effective and patient centric rehabilitation protocol and should be used, rather than an ongoing ineffective passive program.

Dr. Phil Conway BPE DC FCCPOR(C) is a chiropractor with IME Plus Evaluations Ltd. He is Matheson Trained Functional Capacity Evaluator and incorporates Arcon FCE testing. He is a Board Certified Specialist in Physical and Occupational Rehabilitation, he certified in Low Speed Collision and Injury Analysis, and Biomechanical Injury Analysis.

MILD BRAIN INJURIES:

THE CHALLENGE OF PERSISTENT SYMPTOMS

By Dr. Lorie Saxby, Ph.D., C.Psych

Traumatic brain injuries (TBIs) range from minor to very severe, with the potential to be life-threatening. Largely due to high profile sports concussions, there has been a surge of interest in brain injuries and how these can affect health and functioning.   

Most TBIs are in the “mild” range. Usually these mild brain traumatic injuries (MTBIs) are referred to as concussions. A recent Canadian study calculated the incidence of MTBI in Ontario to be between 493/100,000 and 653/100,000.

Symptoms following an MTBI are common and may include fatigue, cognitive impairment (e.g., confusion, impaired memory), emotional and behavioural changes (e.g., emotional lability, irritability) and somatic or physical difficulties (e.g.,  headaches, sensitivity to noise, dizziness, sleep disturbance).

Clinical research shows that good to complete recovery normally occurs within several weeks or months following a single, uncomplicated MTBI. However, up to 15% of persons who have been diagnosed with MTBI report ongoing symptoms.  These symptoms can be associated with increased emotional distress, reduced function and delayed or limited return to work or school.

Why do most individuals with an MTBI recover within weeks of injury while others have lingering symptoms? One view is that a variety of interacting neuropathological and psychological contributors underlie and maintain postconcussive symptoms beyond the typical three month recovery period. When MTBI symptoms persist beyond three months, this is often referred to as “post-concussion syndrome” (PCS) or “post-concussional disorder”. There is controversy regarding the diagnosis of PCS because:

Symptoms that persist following MTBI are not specific to MTBI and overlap with other diagnoses that can occur as a consequence of a traumatic experience such as a motor vehicle accident, sports injury or fall (e.g., depression, anxiety, post traumatic stress disorder, sequelae   of   pain  related   to  headache   or   whiplash associated disorder)

Individuals with no history of a brain injury, but who have symptoms shared by non-brain injury disorders, are sometimes misdiagnosed with concussion. Symptoms that can occur following MTBI are observed to varying extents in healthy individuals but may be misinterpreted as “neuropathological”.

Iatrogenic factors (i.e., misdiagnosis, invalid cognitive test findings and other clinical misinformation provided to patients) can influence symptom development and persistence.

Expectations about symptoms and recovery affect symptom report. diagnosis and help identify post-injury conditions that should be addressed in order for optimal recovery to be achieved.

Regardless of the formal diagnosis (e.g., PCS versus depression versus pain), symptoms following injury have the potential to cause functional limitations

 A neuropsychological assessment can provide a differential diagnosis and help identify post-injury conditions that should be addressed in order for optimal recovery to be achieved.

References
Simon, R. H, & Sayre, J. T., (1987). Strategy in Head Injury Management. East Norwalk, Connecticut: Appleton & Lange.
McCrea, M. A. (2013) Mild Traumatic Brain Injury and Postconcussion Syndrome. New York: Oxford University Press.
Ontario Neurotrauma Foundation Guidelines for Concussion/mTBI 2nd ed. (2013)
http://onf.org/documents/guidelines-for-concussion-mtbi-persistent-symptoms-second-edition

Dr. Lorie Saxby, Ph.D., C.Psych., is a Registered Psychologist and Clinical Neuropsychologist at IME Plus Evaluations Ltd. She has authored published articles on brain functioning and brain injury. She is founder and co-developer of the first Concussion Baseline Screening Project for the Ontario Hockey League - Kitchener Rangers Hockey Club.                 

Disability vs. Impairment: What Is the Difference?

By Rick Zabrodski, MD, CCFP(EM), FCFP,
CCBOM, FAADEP

Two right-handed members of an orchestra are involved in a lawn-mower accident, and both suffer traumatic amputation of the entire left fifth (pinky) finger. Both people are impaired; that is, they lost the use of the fifth finger on the left hand, which (using the American Medical Association [AMA] criteria) translates into approximately 5% of whole-person impairment.   One individual is totally disabled from performing the essential duties of their own occupation while the other has minimal or no work related disability.
Why?

Impairment is a loss of, a loss of the use of or a  derangement of any body part, system or function. The loss or abnormality can be psychological, physio­logical, structural or functional. Impairment is the alteration of an individual’s health  status and is assessed  by traditional  medical means.

It can be measured in the clinical exam room. The condition must be such that it interferes with an individual's activities of daily living. Impairment does not indicate the impact on the person's capacity to meet social or occupational demands. Impairment only deals with a loss that affects basic activities of daily living.

When asking about disability, third parties are usually only concerned about the patient's ability to safely get to and from work, and his or her ability to perform the required job in a safe and acceptable manner. Third parties may also wish to have an opinion from the physician regarding the patient's capacity to work in a specific occupation or alterna­tively, any occupation. Clearly disability is not solely a medical issue!  Disability is the loss of capacity to meet personal,   social  or   occupational  demands,   or  to  meet statutory or regulatory requirements. Disability is any restric­tion or lack of ability (resulting from an impairment) to perform an  activity  within the  range considered  normal for  a  human being. Disability may be thought of as the gap between what a person can do and what a person needs or wants to do. Disability exceeds the physical limitations of impairment, and is subject to the established concepts of wellness. Disability is usually defined in a legal contract in the context of a series of tasks that make up a given role, such as a job description for a specific occupa­tion. Disability, therefore, is only partially a medical determination; it also involves the determination of impairment and non-medical factors, such as con­tractual definitions.  Finally, an individual may have a disability but may still be considered to be employable in another job role.

Impairment is a loss of, a loss of the use of, or a derangement of any body part, system or function.
Disability is a non-medical determination that defines task-specific limitations in performance of a defined role.

Case Answer : Both individuals have the same impair­ment (loss of fifth finger).  Both are violinists. The first individual is totally and permanent­ly unable to perform his previous job; the second is not dis­abled at all and  returns to  work  within a few weeks. Why? The first person is right handed and the second is left-handed.  If this were the conductor, there would be no long-term date of injury disability regardless of which hand was involved.

The exact opposite would occur with the piano player who needs all ten digits.  This case demonstrates that it is the specific nature of the job demands that determines whether the same impairment is disabling.

In summary, impairment is a loss of function that can be measured by the physician and documented objectively. In many cases, impairment is all that a physician can comment on with confidence. Disability is an administrative determination that uses both medical and non medical information. A physician should  not be  expected to com­ment on non-medical issues with certainty unless all the necessary information is available. In some cases the determination can only be made by a clinician with special (non medical) training or experience in the areas under consideration.

Dr. Rick Zabrodski, MD, CCFP(EM), FCFP, CCBOM, FAADEP of IME Plus Evaluations Ltd. is a duly qualified Family Physician with a special interest in Occupational Medicine. He has over 30 years of experience in various aspects of medicine, including the assessment of occupational fitness to work, impairment & disability for corporate and government clients. He is Clinical Assistant Professor at the University of Calgary medical school, a member of the Occupational & Environmental Association of Canada, Canadian Board of Occupational Medicine, a Transport Canada certified Civil Aviation Medical Examiner and contributing author of Perspectives on Disability and Accommodation.

Psychological Testing:

RELIABLY ASSISTING THE COURTS
WITH INTEGRATED
MENTAL HEALTH OPINIONS

By Dr. Joe Garber, C. Psych

Psychological testing provides an objective and statistically reliable representation of an individual’s level of emotional, cognitive and behavioral functioning in addition to the severity and intensity of any identified psychological-based disturbance.

The Court has become progressively more demanding of independent examiners in general and   Psychological and/or Psychiatric assessors in particular. The need to provide an Acknowledgment of Expert’s Duty points to raising the proverbial bar. Our value to the Court is measured by our ability to offer independent, objective, scientifically driven and reliable information, not by our ability to “sell or spin” an idea. Unlike the harder sciences, independent psychological and/or psychiatric examinations findings  are  often  challenged  as  biased.   The challenge may be influenced by the assessor’s reliance on the type of subjective information collected through an interview process. However, until we have we have more objectively based assessment methods, this interviewing process remains the “best if not only practice method” in such matters. While a formal clinical interview will probably remain a pivotal underpinning of any psycho-legal examination process, there are ways in which this data can be better explained and understood. In other words, clinical interview information can be more fully considered within the context of scientifically validated objective data derived from psychological testing.

The Court is demanding both unbiased, independent clinical opinion and the scientific basis for such opinion. The days of unsubstantiated, unsupported and unscientific pronouncements   are  coming  to  an   end.   Sophistication in the Judiciary and in both the defense and plaintiff bars should no longer tolerate baseless unscientific theories designed to obscure objective data in order to support a particular finding. 

Here is where the role of Clinical Psychological testing can be of assistance. Both Psychovocational and Neuropsychological testing have a well-respected place in psycho-legal matters.   Scientific studies   point to the value of incorporating clinical interview findings with the type of additional data that can be obtained through the administration of psychological tests. Appropriate professional use of the psychological tests as administered by clinical Psychologists  can add another perhaps more complete perspective to that database which is ultimately collected to assist the Court. While some may consider such testing as being predominantly useful in assessing matters involving symptom validity, there is far more that psychological testing can offer. Specific psychological tests are known to be of assistance in identifying the presence of clinical psychopathology and its intensity. There are tests which can also provide us with a perspective of an individual’s underlying personality makeup.
 
Psychological testing provides an objective and statistically reliable representation of an individual’s level of emotional, cognitive and behavioral functioning in addition to the severity and intensity of any identified psychological-based disturbance. It can serve to bolster and/or challenge the impressions formulated by other mental health clinicians through less objectively driven interactive processes such as clinical interviews.

Psychological    testing   can    also    assist    with   differential diagnoses. It  is  important  to  keep  in  mind  that  the  reliability and validity of the obtained results is based not on a clinician’s opinion, but on the science that supports the psychometric underpinnings of those particular tests. In other words what the testing identifies and measures is likely meaningful and real.
 
There is persuasive scientific evidence that psychological testing can be reliable and valid; that psychological test soundness is comparable to medical test validity; that specific types of psychological testing can provide unique sources of information and that the findings of clinical interviews can at times be substantively enhanced by the availability and incorporation of psychological test data.
 
In mental health assessments clinicians can benefit from collecting as much relevant data as reasonably possible.   Psychological testing is a source of such rich, meaningful and useful information that has a well-established place in psycho-legal examinations. Including relevant scientifically-validated objective psychological test findings in your reports will improve your ability to offer reliable and valid assistance to the Court in its deliberations.

Dr. Joe Garber, C. Psych is a Psychologist with IME Plus Evaluations Ltd. He is a Clinical, Rehabilitation and Consulting Psychologist who practices in Toronto. He is a Court-qualified clinician who has provided Psychological IMEs, psychological input to psychiatry IMEs, records reviews and trial-preparation consultations within the context of his ongoing clinical practice for over 20 years