The Blankenship FCE System
The Blankenship Forensic FCE is a scientific search for the truth about the injured workers functional deficits. The software and hardware combine to allow computerized testing of spinal inclinometry, grip and pinch strength, computerized muscle testing, static strength testing, heart rate, palpation sensitivity, and functional lifting ability. The hardware accurately collects all of the testing data and the software helps organize it and integrate it into an easy to read finished report that saves time and identifies functional ability and impairments.
THE MOST IMPORTANT THING TO KNOW ABOUT THE BLANKENSHIP FCE SYSTEM is THAT IT WAS THE ONLY FCE SYSTEM IDENTIFIED in the GUIDES TO THE EVALUATION OF FUNCTIONAL ABILITY, as being a “GOOD METHOD FOR IDENTIFYING SINCERITY OF EFFORT” during functional testing. Now this book is the FCE Bible and identifies the gold standards in FCE practice.
The Blankenship FCE System is unique in that the system has two distinct components; functional testing and a behavioral profile.
The functional testing component utilizes a psychophysical approach which is the safest and the most researched decision making paradigm in functional testing. It is steeped in research and has been used by OSHA, NIOSH, and Liberty Mutual to establish population lifting guidelines. It has also been utilized in numerus studies examining material handling ability. It is the safest way, that is, the lowest risk of injury to the patient and therefore lowest liability to the tester, to evaluate material handling ability because it lets the patient decide if they want to lift more weight or not. In comparison, the kinesiophysical approach makes the evaluator the decision maker, placing all liability for re-injury or symptom aggravation on the evaluator.
The behavioral profile consists of assessment of symptom exaggeration, nonorganic signs, and a validity profile. Combining functional testing with a behavioral profile is consistent with the philosophy and standards established by the American Medical Association and the American Physical Therapy Association when testing function. Surprisingly, the Blankenship FCE System is the only FCE system on the market that currently incorporates all the components of a behavioral profile that allows us to determine if the functional information truly reflects the patient's actual functional ability, or if the patient is attempting to control the outcome of the test in order to appear more limited than they actually are.
The validity profile was studied in 2007 and the results published in the Journal of Orthopedic and Sports Physical Therapy. The study concluded that the Blankenship FCE Systems validity profile had a specificity of 84% and a sensitivity of 80% for identifying the level of effort given during functional testing.
In 2009, The Blankenship FCE System was identified in the American Medical Association publication, Guide to the Evaluation of Functional Ability, as a "good method for identifying sincerity of effort" during functional testing. This is a crucial point is comparing FCE Systems. All commercially available systems were contacted and their testing paradigms, philosophy and standards reviewed prior to publishing this book. The Blankenship FCE System was the Only one identified as being able to identify level of effort during functional testing.
The Blankenship FCE System advocates the use of the Functional Model as opposed to the Medical Model when testing function in injured workers with chronic symptoms. The Functional model requires evaluators to objectify assessments as much as possible and assess nonorganic signs, symptom exaggeration, and validity during functional testing. It requires patients to give their best effort during functional testing and not exaggerate their symptoms or disability. This model of testing is consistent with the philosophy of the AMA Guides to the Evaluation of Permanent Partial Impairment.
This approach to functional testing is unbiased and fair to all parties involved. It helps identify volitional attempts to exaggerate symptoms and disability, while also substantiating functional loss in individuals with chronic symptoms and functional loss associated with soft tissue injuries
Decision Making Paradigms
Two of the most common decision making paradigms utilized in Functional Capacity Evaluations are the psychophysical and the kinesiophysical.
The kinesiophysical decision making paradigm makes the evaluator the expert and puts them in the position of deciding if the patient can lift more weight or not. To understand the kinesophysical model, one must understand its two core constructs.
1. Pain intensity and functional ability are separate entities that can be evaluated separately and do not affect one another.
However, research shows that pain intensity and functional ability are in fact linked and inversely proportional (construct validity of a kinesiophysical functional capacity evaluation, Gross & Battie, 2003). This makes sense, the higher the level of pain a person has, the lower the functional ability they will possess. This is made obvious when watching NFL football games where you have 300 lbs tough guys who limp off the field. Why do they limp instead of run normally? Because the level of pain they are experiencing prevents them from displaying normal function.
2. Maximum physical effort can be identified by an observer using visible cues like slowed movement patterns, accessory muscle recruitment, and altered lifting mechanics. Unfortunately, this construct has been shown to have limited value when utilized in a population that has pain. Research has shown that a kinesiophysical approach to identifying maximal effort during material handling tasks in patients with chronic low back pain is not possible. (Testing lifting capacity: validity of determining effort level by means of observation, Reneman, 2005). This makes sense because the indicators of musculoskeletal overload that are visible in people without pain during material handling will all be absent in a population that has pain as a limiting factor, making the kinesiophysical approach of limited value in functional testing with a patient population. In other words, musculoskeletal overload never occurs, because pain prevents continuation of the task prior to musculoskeletal overload being present.
Now, advocates of kinesiophysical testing will say that letting patients “pick their own level of functional ability” leads to abuse and inflated levels of disability. They would be correct, if the FCE does not also have a behavioral profile responsible for assessing the patient’s level of effort during the functional testing. It is important to note that the approach of the kinesiophysical testing paradigm essentially places all the responsibility of determining if a patient is performing at their maximal level on the evaluator. There is no other mechanism built into the FCE to assist in answering this question for a kinesiophysical FCE. Some systems will include grip strength testing and base the validity of the functional data on whether the patient passes the grip testing validity or not. This approach is neither sensitive or specific in identifying patients performing with voluntary submaximal effort during functional testing.
The psychophysical approach allows the patient to determine if they should lift more weights or continue with a functional task. This approach has been researched extensively and has been utilized by NIOSH, OSHA and Liberty Mutual in establishing population norms for material handling. It has also been used effectively in monitoring cardiovascular loading during activity with the BORG exertional scale, essentially replacing the need to take heart rates in many cases. Clearly, the psychophysical approach is very successful in determining people’s functional ability. The problem is when dealing with a patient population where benefits and financial rewards are present, we can’t always trust people to tell us the truth. Therefore, the Blankenship Behavioral Profile helps us determine if the functional data is indeed a true reflection of the patient’s current work ability or they are attempting to voluntarily demonstrate greater disability than is actually present.
The problem is not finding a way to accurately determine someone functional ability, the problem is finding an accurate way to determine if someone is giving their best effort during an FCE or not. Thankfully, as noted by the above research and the AMA publication, THE BLANKENSHIP FCE SYSTEM has successfully identified “a good method for determining sincerity of effort” during functional testing!
The Evolution of Behavioral Testing in FCEs
Gordon Waddell was one of the first people to develop a test to distinguish between injured workers with back pain who could be successfully managed with the Medical Model from those who needed a multidisciplinary approach. He developed the NonOrganic Signs Testing Protocol. At the time, this concept was revolutionary and by utilizing the approach, injured workers could be identified that would have outcomes to surgical and conservative medical management similar to the private insurance patient population. However, unfortunately, this screen was very successful in identifying people who were demonstrating significant illness behavior or anxiety. Positive findings were used to discredit these individuals and suggest their pain and functional loss was either an attempt to defraud the system or due to metal illness. This was not Dr. Waddell’s intent and his screen was misused. An evolution of Waddell’s signs was Greg Korbon’s attempt to make the test more objective. He successfully modified the test and was able to demonstrate greater reproducibility. However, the test was still unable to distinguish those individuals who were volitionally demonstrating greater disability than was actually present from those individuals who were simply demonstrating anxiety and illness behavior in a response to their work related injury.
Apart from the nonorganic signs testing, there has been a long history of isolated validity tests or test that look at improvement with distraction in the medical community. These tests have been used by physicians in isolation to “decide” if the patient is telling the truth or making up their symptoms and disability. Some of these tests actually have physiological reasoning behind them. For example, comparing a supine SLR angle to a sitting slump test. Symptom provocation and angle of symptom provocation could be used to compare the two similar tests when the patient was unaware that the two tests should have the same outcome. Another tool for determining the level of effort during functional testing is validity testing. Most tests compare repeat trial consistency. There are current FCE systems that base their entire opinion on “best effort” during an FCE on the results of grip strength testing, regardless of the injured body area. However, most experts agree that tests in isolation should not be utilized in determining intent and that a broad group of tests throughout functional testing would be more reliable.
Blankenship understood that a broad behavioral profile had to be used to answer the complex question of identifying barriers to return to work. The components of the Blankenship FCE System are symptom exaggeration, nonorganic signs, and a validity profile. Each component answers a different question and gives a different insight into the patient’s presentation.
Symptom exaggeration determines if the patient’s rating of their pain level is consistent with the medical pathology present and the patient’s movement patterns. The presence of symptom exaggeration does not necessarily mean the patient is making up their symptoms or disability. However, often symptom exaggeration is concurrent with volitional manipulation of functional testing.
Similarly, the next component, nonorganic signs testing, measures the level of distress and illness behavior in the patient. Again, positive nonorganic signs does not necessarily indicate the patient is lying about their symptoms and functional loss. A patient presenting with positive nonorganic signs tells us there are other barriers to recovery and the patient cannot be managed successfully with the traditional Medical Model. However, as with symptom exaggeration, positive nonorganic signs are also commonly present in patients who are volitionally attempting to control the outcome of functional testing.
Lastly, the validity profile tells us if the patient is consciously attempting to manipulate the outcome of the functional testing. A patient who fails the validity profile can accurately be identified as someone who is consciously attempting to portray a greater level of disability than is actually present, regardless of the results of the symptom exaggeration and nonorganic signs evaluations. The result of the validity profile, more than any other component of the Behavioral profile tells us the motivational intent of the patient. The validity profile of the Blankenship FCE System has been examined in a research article that was published in the Journal of Sports and Physical Therapy and noted to have a sensitivity of 80% and a specificity of 84%. A receiver operating characteristic (ROC) curve demonstrated the 70% cut-off value for scoring the FCE was optimal. Furthermore, this information was reviewed for the text book, Guides to the Evaluation of Functional Ability, AMA, 2009, and the Blankenship FCE System was deemed a “good method for determining the level of sincerity of effort” during functional testing! This level of examination, scrutiny and verification is unparalleled in any other FCE system on the market today. This is why I believe that the Blankesnship FCE System Behavioral Profile is the maturation of the evolution of behavioral testing in FCE’s. We finally have a researched and tested way to identify patients who are cooperating with functional testing and those who are attempting to manipulate it for their own gain.
Why Static Strength Testing continues to be Relevant
Over the decades of functional testing, there have been many technological advancements that we have all hoped would be the silver bullet in making functional testing more precise and allow us to detect patient manipulation more easily. Static Strength Testing and Isokinetic Testing are two examples of such technological advancements. Unfortunately, both technologies had their day and fell short of being able to replace real world functional testing to determine a patient’s safe work abilities. However, having said that, Static Strength testing continues to offer significant benefits that are not available with any other method of strength testing.
First, Static Strength testing is extremely safe, especially when testing patients with musculoskeletal pain. The presence of mechanical musculoskeletal pain provides a sensory safety net that prevents musculoskeletal overload. Performed correctly, the slow ramp up of muscular force during Static Strength Testing will allow ample protective feedback. The Boeing Study done by Battie and Zeh experienced only 3 “injuries” after performing 495 tests. Only one of the “injuries” required medical observation and none of the workers lost time with full symptomatic recovery. This was testing industrial workers who were performing at their maximal effort level. This gives us a safe way to assess the injured body area on a serial basis or initially and compare to a data base or previous exertions in an effort to gauge the level of loss or progression with treatment.
Second, it allows for a relative comparison of the injured body areas performance compared to the non-injured body parts. The Blankenship FCE System calls this a Functional Strength Deficit (FSD). This is exceptionally helpful with work hardening/conditioning patients. Serial testing can document functional progression very accurately, satisfying the requirement to document progression for the insurance company, physician, and employer. Additionally, it allows a general evaluation of the level of effort given during Static Strength Testing. A negative or minimal FSD in a patient with significant symptoms lets us know the patient is not giving their best effort during testing.
Lastly, it provides a safe mechanism of validity testing during an FCE to ensure the patient is giving their best effort without exposing the patient to an undue level of re-injury risk. Repeat testing comparison, force curve analysis, and distraction testing such as the Pain Replication Test (PRT) provide valuable information into the level of effort the patient is providing during FCE testing.
Quest Medical Group
The Quest Medical Group is the ONLY authorized dealer of Blankenship FCE equipment/software. Richard Beveridge is the CEO of the Quest Medical Group and is dedicated to ensuring the continued and unparalleled value that the Blankenship FCE system provides. All the equipment, software, and training required to develop and grow an industrial rehabilitation program can be obtianed through the Quest Medical Group. Call Richard Beveridge for further information and details.