Testing Sustained Activities/Postures & Predicting to an 8-hour workday
Fri, 07/02/2010 - 10:55am
I was deposed in a plantiff and defense attorney earlier this week about a patient (workers' comp claim) that I had performed a FCE on several months ago.
She had a four level cervical fusion from her injury. She worked for the USDA as a food inspector in a chicken processing plant. Based on the FCE, she was capable of safely returning to work within a LIGHT to MEDIUM physical demand level range with some specific restrictions pertaining to awkward neck postures and overhead reaching. Her concerns about returning to her normal job duties were the sustained amount of time required looking down at the chickens and using her left hand (due to complaints of radicular symptoms).
EMG/NCV study was normal. Physical exam revealed no evidence of muscle atrophy or sensory impairment. She had normal grip strength based on standard Jamar testing. However, she demonstrated a significant impairment with cervical spine range of motion limited to about 50% of normal in all motions.
In my professional opinion, this patient was capable of safely returning to her normal job duties if provided with accommodation for her limitations as laid out in the FCE. A job analysis was not available for review at the time of the FCE>
The plantiff attorney posed several questions that have me thinking:
1. Do you think that three repetitions for each hand showing normal grip strength are a good predictor of her ability to use her hands for grasping at work without restrictions? (My response was yes with the qualification that she reported no change in pain with the testing, and the physical examination for her hands/upper extremities was completely normal).
2. Do you think that she can perform work requiring her to bend her neck forward to look down? (My response was yes. Her cervical spine flexion was limited to 30 degrees and considering her surgery, I recommended that she not perform work requiring repetitive cervical flexion or sustained cervical flexion, but occasional cervical flexion to her limit would be acceptable).
3. What does sustained mean? (My response was that there is no standardized operational definition for sustained. In general, it would mean more than a minute and could mean several hours depending on the activity and muscle groups being used.)
So, any recommendations for testing activities and postures such as grasping, cervical flexion (looking down), cervical extension (looking up), overhead reaching, stooping, etc.... I have used some standardized testing protocols for some of these postures -- but they generally range from 1 to 5 minutes in length.
Very good questions. Some thoughts:
1. Not knowing the thoroughness of your FCE protocol I will start at the beginning and work my way throught this case. If you have done each of these steps then they may benefit other readers who are newer to the process.
2. Starting with the Intake Interview, I would look at diagnosis, the demands of the job in question, her concerns about those demands, her reported abilities (important to do a complete Functional Tolerance Profile) and at least one of the two Sorts (Hand Function and Spinal Function). In the Functional Tolerance Profile I would be probe questions about hand and neck use with questions about dish washing, computer use, hobbies, etc.
3. Given step 2, you should now have a clear picture that she is concerned about the neck and hand issues in her job. BUT, you also now have at least an hour of hand and neck function observed during distraction based testing. (You could push validity further by doing all this in standing).
4. Next step is to do standardized tests that address hand and neck issues. It isn't just three squeezes on the Jamar. It is use of a pencil, turning pages in the Sorts, using the horizontal panel in the Matheson Panel System to evaluate neck and hand on a sustained, repetitivie basis, etc.
5. Once standardized testing is done, move to work sim or non-standardized testing. If you don't have the MPS use the Purdue several times; have her do the nail board (lay it flat on a table if possible), etc. Test her cognitive ability by having her do a crossword puzzle (hand and neck).
6. The defintion of Sustained matches your thoughts...there isn't a clear definition (I will check my resources when I get home tomorrow). I also wonder if he meant to ask about repetitive versus sustained? If he really wanted to know sustained then I might offer, "a movement or response to a task that requires energy or attention over time. Not necessarily repetitive in terms of frequency but noticeable terms of energy or focus required to successfully complete it". Repetitive has no exact definition: the ergo literature discusses repetitive in terms of number of reps per hour. I might explain it as a motion or activity noticeable in the number of cycles repeated in a specific time period.