Safe Return to Productive Work After COVID-19: Is a Functional Capacity Evaluation Needed?
Response timing and objectivity are critical when workers experience job performance difficulty after a serious health condition like COVID-19. Studies indicate that physicians under-estimate work-related abilities after performing a clinical evaluation, especially when chronic pain and other symptoms limit performance. Underestimating a worker’s abilities contributes to unnecessary work disability and lost productivity. There is useful evidence to consider from Current Concepts in Occupational Health Physical Therapy for managing injuries or illnesses that limit work participation.
After a COVID-19 illness, an aerobic fitness test should be routinely included when workers report return to work barriers due to cardiorespiratory impairments. The Chester Step Test (CST) is a versatile and mobile test to consider this purpose because step height is adjustable and it may be administered in an incremental manner in a small area until the subject achieves the highest acceptable workload based on criteria for perceived exertion, heart rate, and pulse O2. A recent literature review by Renfro et al. identified CST applications for patients with severe cardiopulmonary conditions, and recommended modifications to the standard protocol to enhance clinical evaluation and physical activity prescription of patients recovering from a broad range of cardiorespiratory and musculoskeletal heath conditions.
There is strong evidence that disability duration is reduced with an integrated care process that considers temporary workplace modifications (accommodations) for workers with physical and mental health conditions. This necessitates early identification of job demands and validation of worker restrictions with objective functional capacity evaluation measures. A helpful first step to address return to work barriers after disabling health conditions such as COVID-19 is to accurately communicate specific job demands and accommodation options to workers and healthcare providers. To expedite this communication, a Certified WorkAbility Therapist may conduct a virtual WorkerFIT Job Survey consult with the worker or job supervisor. This supports cost-effective employment decisions in the following disability scenarios:
- Certification of disability leave exceeds optimal RTW benchmarks
- Release to work restrictions are not based on objective findings
- Worker has difficulty with job duties or requests accommodation
Scenario #1: Certification of disability leave exceeds optimal RTW benchmarks
Established guidelines exist to determine when disability duration exceeds optimal or normative bench marks for a given combination of worker conditions or job strength demands. The WorkerFIT platform offers a worker survey option and an Examiner Report of WorkerFIT report option to present physical or cognitive demands with a yes/no check box beside each demand. This prompts the worker or attending health provider to indicate which job demands the worker is able or unable to meet. Usually it is best to ask the worker to identify what job demands they are unable to meet, as this provides an opportunity to engage the worker in a discussion of possible accommodations to support return to modified duty. The WorkerFIT report used to present the list of demands to the health care provider is called the Examiner Report of WorkerFIT. After the health care provider selects a NO (unable) for a specific demand factor, they are prompted to identify an appropriate work restriction on that factor that may be used to create a suitable modified duty offer.
Scenario #2: Release to work restrictions are not based on objective findings
Attending health providers are highly influenced by requests from their patients. Release to full duty after an excessive period of work disability leave is cause for reasonable suspicion if there are no objective findings to substantiate functional recovery. If the worker is afraid to return to work, they may ask the provider to continue to certify disability or write restrictions that excessively limit the worker’s physical or cognitive demands. Either of these circumstances would justify a referral request by the employer for a functional capacity evaluation (FCE) to determine what residual functional limitations or impairments are objectively present.
Scenario #3: Worker has difficulty with job duties or requests accommodation
This is a special circumstance that merits investigation at the job site as a priority goal in the physical or occupational therapy plan of care, or through an independent consult called an Ergonomic FCE. An Ergonomic FCE is a completely mobile FCE exam that is administered at the job-site to facilitate an interactive process between the worker and employer to resolve work performance difficulties. It includes:
- Review of past job performance barriers, medical history/records, and lifestyle impact
- Validation of reported job task demands, safety equipment used, and work methods
- Neuro-musculoskeletal exam to identify physical impairments that may limit function
- Job-relevant functional capacity performance tests (keyboarding, finger dexterity, vision, push/pull strength, agility, aerobic capacity, posture tolerances, and materials handling)
- WorkAbility Summary addressing validity (performance consistency), limiting conditions, functional job restrictions, job modification options, and medical management
- Option to include a physician consult to address medical management issues, functional recovery status (MMI), or determine an impairment rating to facilitate case resolution
The cost-benefits of integrated care have been estimated to result in a 26 to 1 return on investment for every dollar invested in integrated care in sick listed patients with chronic low back pain. Applying a similar integrated care approach to serious health conditions such as COVID-19 is expected to have a positive effect by lowering lost productivity costs.
- Brokaw JP, Walker WC, Cifu DX, Gardner M. Sitting and standing tolerance in patients with chronic back pain: comparison between physician prediction and covert observation. Arch Phys Med Rehabil. 2004 May;85(5):837-9.
- Brouwer S, Dijkstra PU, Stewart RE, Göeken LN, Groothoff JW, Geertzen JH. Comparing self-report, clinical examination and functional testing in the assessment of work-related limitations in patients with chronic low back pain. Disabil Rehabil. 2005 Sep 2;27(17):999-1005.
- Peppers D, Figoni SF, Carroll BW, Chen MM, Song S, Mathiyakom W. Influence of Functional Capacity Evaluation on Physician’s Assessment of Physical Capacity of Veterans With Chronic Pain: A Retrospective Analysis. PM R. 2017 Jul;9(7):652-659.
- Perry T, Cheung A, Asumbrado A, McBee K. Current concepts in occupational health: managing an acute injury that limits work participation. Orthop Phys Ther Pract. 2019;31(2):101-105.
- Renfro MO, Wickstrom R, Angeles E, et al. The Chester step test: a graded performance measure of aerobic capacity for physical therapy. Orthop Phys Ther Practice. 2019;31(3):172-178.
- Cullen KL, Irvin E, Collie A, et al. Effectiveness of Workplace Interventions in Return-to-Work for Musculoskeletal, Pain-Related and Mental Health Conditions: An Update of the Evidence and Messages for Practitioners. J Occup Rehabil. 2018;28(1):1-15.
- Lambeek LC, Bosmans JE, Van Royen BJ, Van Tulder MW, Van Mechelen W, Anema JR. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomized controlled trial. BMJ. 2010 Nov 30;341:c6414.