A Functional Capacity Evaluation (FCE) is a test to determine a patient’s level of physical function as it relates to work. A comprehensive FCE should determine the worker’s overall physical ability to work at a Sedentary, Light, Medium, Heavy, or Very Heavy job as defined by the US Department of Labor in the Dictionary of Occupational Titles (DOT). This determination is made largely on the amount of weight/force the worker can handle. The test should also determine whether the employee can perform that level of work full-time or whether they are only capable of part-time work at that overall level.
The test also determines the percentage of the day (Constantly, Frequently, Occasionally, Never) that workers can perform specific tasks such as lifting, carrying, pushing, pulling, walking, standing, sitting, reaching, kneeling, stooping, climbing, and crouching.
Optional sections, depending on the patient’s diagnosis and job requirements, include testing balance, coordination, and fine motor (hand and finger) skills.
If the purpose of the FCE is to determine the patient’s functional ability to perform work and in some cases, compare the worker’s physical ability to the requirements of a specific job. If a comparison to the job is desired, then a table that provides a side-by-side comparison of worker ability vs. job requirement is usually provided. Most employers and workers’ comp insurance carriers will also need a statement regarding the level of cooperation with testing. It is important to know whether the worker gave a full effort on the test.
The subject of worker cooperation (also known as “sincerity of effort”) with testing is controversial. Many tests have been used to make this determination, but few have adequate research to support their use for measuring sincerity of effort. FCE reports should avoid terms that state or imply that the patient is malingering or exaggerating their symptoms. Comments should be limited to reports of inconsistent behavior, movements that do not match the pain scale, or stopping tasks of the test before a maximum effort is observed.
A well-designed FCE involves an objective, valid, and reliable scoring system for determining an accurate level of work and projecting client abilities for full-time work [link to reliability and validity article]. It’s important to ask the FCE provider about the research that supports their test’s reliability and validity, as many testing protocols lack the necessary research to withstand a legal challenge.
Physical and Occupational Therapists are the typical professionals who perform FCEs. However, in some states, PT and OT Assistants, Certified Athletic Trainers, and Exercise Science Professionals are also allowed to either perform or assist in conducting the tests. Workers’ compensation laws determine what is permissible in each state.
Although these clinicians are licensed in their respective states, few learn how to perform FCEs as part of their college/university-based education. Most learn this skill through continuing education after graduation. Most of the continuing education programs are sponsored by a commercial FCE vendor and clinicians are certified to do one particular commercial FCE.
Click here to learn more about ErgoScience's FCE training.
An impairment rating measures the permanent losses caused by a workplace injury and determines if an employee who has filed a workers’ compensation claim will receive monetary benefits in addition to the initial income payouts (usually paid at a rate of 2/3 of the worker’s full salary).
The American Medical Association (AMA) has developed a prescribed methodology/calculations for performing impairment ratings. This methodology is published in The AMA’s Guides to the Evaluation of Permanent Impairment. The “AMA Guide” covers the process of determining impairment in all body systems. However, impairments involving the musculoskeletal system (muscles, bones, joints, nerves, tendons, and ligaments) tend to be the most common.
The typical musculoskeletal impairment involves taking a medical history (including related surgical procedures), considering diagnostic imaging, and making goniometric range of motion measurements. Using tables and graphs in the “AMA Guide” the evaluator determines the percent impairment. In some conditions, muscle weakness or loss of sensation are also considered when making the impairment calculation. The rating is conducted after the worker reaches maximum medical improvement (i.e., the treating physician states that no further medical improvement is expected).
There are several editions of The AMA’s Guides to the Evaluation of Permanent Impairment. The specific edition that should be used varies by worker’s compensation state law. The Fourth, Fifth, and Sixth editions are the ones most commonly used.
Let’s take a simple example from the Fifth Edition of the AMA Guides — a significant elbow fracture restricting elbow bending (flexion) to 65 degrees and lacking 40 degrees from fully straightening out (extension) would result in an upper extremity impairment of 21% (according to page 472 of the Fifth Edition of the AMA Guides).
Then, the upper extremity impairment must be translated into a whole-body impairment to determine the final workers’ compensation payout. In this case, with no other joints or systems involved, the 21% upper extremity impairment translates into 13% whole-body impairment.
In sum, the system of determining whole-body impairment is fairly objective but involves a fairly complex set of calculations. It is based on strict scoring rules from the AMA Guide edition according to the state in which the test is performed.
Physicians are the professionals who most often perform an AMA Impairment Rating, and some physicians specialize in doing so. However, in some cases, physicians will request that a Physical or Occupational Therapist make the joint angle measurements and calculate an AMA Impairment Rating that the physician reviews and signs.
The equipment required for musculoskeletal Impairment Ratings includes a goniometer for measuring joint motion, a reflex hammer for testing tendon reflexes, the test kits for testing sensation, access to medical records, including X-ray and MRI reports, and access to Impairment Rating software or a copy of the AMA Guides. In terms of space, a simple examination room is all that is needed.
Independent Medical Exams (IMEs)are medical examinations used to resolve disputes between workers and their employer's insurance company about:
IMEs are conducted by physicians, psychologists, nurse practitioners, physician assistants, and other licensed healthcare professionals in essentially all medical disciplines, depending on the purpose of the exam and the claimed injuries. However, they are most commonly performed by cardiologists, neurologists, neurosurgeons, occupational medicine physicians, ophthalmologists, orthopedists, pain specialists, physiatrists, chiropractors, psychologists, and neuropsychologists.
They are typically performed by a physician who has not been involved with the worker’s treatment and who is neutral regarding the exam's outcome. Rules about who chooses the doctor to perform the IME vary by state. In some states, physicians are chosen by the employer’s insurance carriers. In other states, the physician is randomly selected from a list of IME providers or selected by the judge presiding over the case.
IMEs are often used in legal proceedings at the request of the party opposing the patient's request for benefits. They are commonly performed in workers’ compensation cases, disability claims, or personal injury litigation. An insurance company may request the IME because it disagrees with the treating physician about a proposed course of medical treatment or disability status. Sometimes, a judge or hearing officer requests an IME to resolve a dispute. Insurance carriers, employers, and workers have a legal right to request an IME. If the doctor/therapist performing the IME decides that a patient's medical condition is unrelated to a compensable event, the insurer or self-insured employer may deny the claim.Bottom of Form
IMEs vary by state, but they often significantly affect the benefits received in workers’ compensation. To conduct the IME, the physician reviews the worker’s relevant medical history and records. In some cases, but not always, the physician also examines the worker and creates a report. Workers' comp carriers perceive IME doctors as "experts" and give significant weight to their reports. If workers disagree with the IME findings, they can challenge them and, in some states, request a second IME, performed by a physician of their choice.
Sometimes, the insurance carrier will request that the examining physician answer a set of questions the carrier has regarding the case, such as:
After the IME, the doctor will write a report with his or her conclusions and opinions, particularly in response to the disputed issues or questions raised by the insurance company. Judges tend to view IME doctors as more objective than treating physicians. For these reasons, it can be difficult to discredit an IME doctor's opinion. If the report is logical and supported by medical evidence, it is considered credible. Any inconsistencies will undermine the credibility of the evaluation.
| FCE | IR | IME | |
| Reason for conducting | Determine the worker’s physical function as it relates to work. | To determine the percent whole body permanent impairment. | To determine the legitimacy of an insurance claim. |
| Typically performed by | Physical or Occupational Therapists | Physicians or Physical or Occupational Therapists | Physicians |
| Test provides | Information about the physical abilities of the worker (lift, carry, push, pull, sit, stand reach, etc.) | Percent permanent partial Impairment | Diagnosis, course of treatment, disability |
| Typical Length of Evaluation | 3-5 hours | 1-2 hours | 15-30 minutes |
| Test is Conducted | In a physical or occupational therapy/rehab clinic | In a physical or occupational therapy/rehab clinic or physician’s office | In a physician’s office |
| Standardization | Some FCEs have standardized protocols and scoring that are supported through research; others do not. | Impairment ratings are conducted according to guidelines from the American Medical Association | Not standardized, but guidelines that suggest best practices exist. |
The type of evaluation chosen depends on the questions being asked. If the insurer/employer is asking:
In some cases, the insurance carrier or self-insured employer will ask all of these questions, and a patient or worker will undergo all three types of evaluations. The way that the information from each evaluation is combined to resolve the case will vary from state to state according to each state’s workers’ compensation laws.
We hope this blog has clarified the differences between these evaluations related to workers’ compensation and disability determination. ErgoScience has 30+ years of experience delivering a research-based FCE through its network of thousands of clinicians in all 50 states. We likely have a provider near your claimant.
We provide a shorter version of the FCE for pre-hire/post-offer Physical Abilities Testing– providing testing nationwide.
ErgoScience also spent 30+ years perfecting clinician training in conducting FCEs and Impairment Ratings (Fourth, Fifth, and Sixth Editions). Our training is now available online, and our web-based software is easy to use and cost-effective.
If you are an insurance adjuster, case manager, attorney, or employer wanting to schedule an FCE or Impairment Rating, CLICK HERE.
If you are a physical or occupational therapist wanting software and training to conduct a validated FCE or AMA Impairment Rating, CLICK HERE.
If you want additional information on the ErgoScience FCE, The Physical Work Performance Evaluation, CLICK HERE.
Deborah Lechner, ErgoScience President, combines an extensive research background with 25-plus years of clinical experience. Under her leadership, ErgoScience continues to use the science of work to improve workplace safety, productivity and profitability.
