MEDICAL VS FUNCTIONAL MODEL

 

The American medical system functions under the “Medical Model”. The Medical Model states that if a patient reports pain there must be a corresponding medical impairment causing the pain. Subsequently, if the right evaluation procedures are performed, the medical impairment will be found and can be appropriately treated. Consequently, tremendous resources are utilized in trying to “find the problem”. The focus and responsibility is on the medical provider being competent enough to identify the pathology and outline the effective treatment options. This model works well with patients who are being honest and are motivated to recuperate and return to a normal health status.

 

Unfortunately, when benefits and litigation are involved we know that this model is not effective in resolving medical pathology for a portion of the injured population. Studies show that in every aspect of medical care, recovery is slower and less complete in the workers’ compensation arena compared to private insurance outcomes. It has been shown that no-fault insurance systems decrease disability significantly. Analysis of multiple studies suggests between 30-50% of chronic disability workers’ compensation cases involve deception.

 

The problem has been long recognized and was addressed initially by Gordon Waddell in the 1980’s with the origination of nonorganic signs as a tool to identify those patients who have “other issues” delaying recovery over and above medical pathology.  At the time, the concept of nonorganic signs was revolutionary. Clinicians have long known outcomes in workers’ compensation patients was less predictable than for private insurance patients, but now there was a way to identify and differentiate patients who could be successfully treated with the traditional medical model and those patients who could not be effectively treated with the traditional medical model. However, nonorganic signs screening was incomplete in that it identifies patients with heightened distress and illness behavior as well. Many of these patients are not involved in conscious manipulation of the system. A way to identify patients who demonstrate positive nonorganic signs who are also involved in conscious manipulation of the system is needed.

 

The Functional Model provides this type of screening. The Functional Model is based on the premise that patients as well as medical providers have a responsibility for optimizing the patients’ medical and functional recovery.

 

Medical providers must:

1)perform objective evaluations with established validity criteria to ensure results are accurate 

2)treat organic problems with appropriate evidence based methods

3) resist treating “behavior problems” with medical treatments (conservative and surgical) 

4) help patient confront the real issues

5) base all decisions on objective data 

 

The Patient has the responsibility to:

1) not exhibit symptom exaggeration

2) not exhibit nonorganic signs

3) pass validity testing, indicating good effort.

 

The Blankenship FCE System operates under the above standards. Objectively identifying musculoskeletal impairments and functional loss, but also scrutinizing the loss to make sure it is an actual representation of the patient's true current ability. The Blankenship FCE System software and equipment allows for the accurate identification of functional loss and serial testing allows for an objective determination of functional progression as with a work conditioning program. This approach is fair to all parties involved including the patient, physicians, employer, and insurance company. It follows the philosophy outlined in the Guides to the Evaluation of Permanent Impairment for determining permanent anatomic and functional loss. In fact, the American Medical Association in 2009 published The Guides to the Evaluation of Functional Ability which stated "The Blankenship FCE seems to be a good method for identifying sincerity of effort". 

 

No other FCE System has all the essential components combining Functional Testing with a thorogh Behavioral Profile. 

 

 

                                                                               Functional Strength Deficit (FSD)

 

Keyserling developed six standard isometric strength test positions, they are often referred to as the NIOSH Standard Static Strength Tests. He then tested over 1000 healthy industrial workers to create a data base of test results for each of the standardized test positions. A patient’s test results can be compared to the data base to determine a percentile ranking, 0 to 100% for each test. When determining a FSD, the percentile ranking of the Static Strength Test which most directly stresses the injured area is considered the “impairment test”. This percentile ranking is then compared to the percentile rankings of the Static Strength Tests which do not directly stress the injured body area, which are considered the “non-impairment tests”. The difference between the results is considered the FSD. An FSD of 0-10% is considered within normal limits. An FSD of 11-25% is considered a minimal deficit. An FSD of 26-50% is considered a moderate deficit. An FSD of 51-100% is considered a significant deficit. This ability to compare the results of the injured body area to the non-injured body areas provides a unique ability to identify “functional loss” which may be present even if range of motion and isolated strength testing does not demonstrate an abnormality. Additionally, serial testing can demonstrate “functional improvement” more accurately than by evaluating material handling ability improvements alone. Often times with soft tissue injuries, there are no “objective” imaging test results that correlate with impairment. The FSD calculation provides a standardized and reproducible way to identify a deficit. The six standardized test positions are: 1) Arm Test, 2) High Near, 3) High Far, 4) Torso, 5) Leg, 6) Floor Lift.

 

 

 

 

 

 

 

 

Arm Test

Leg Test

Torso Test

High Near

Floor Test

High Far

Below is an example of a patient who has sustained a shoulder injury and continues to be symptomatic when torque force is produced through the shoulder. You can see that the other standard static test postures that do not directly place torque force through the shoulder (the test positions noted in green) are performing much higher than the High Far Test (noted in red). Comparing the non-impairment test exertions to the impairment test exertion results in a 32% FSD, a moderate FSD. This tells us that activities that require the patient to work at/above shoulder height or with the arm out away from the body will be limited. This deficit can be used to justify continue physical therapy care and serial testing used to track improvement. If the patient has plateaued, the results provide an indication of permanent functional loss.

 

 

The FSD calculation is most useful when only one injured body area is present. Multiple injured areas make it difficult to get an accurate normal strength value for comparison.

 

 

Blankenship System Procedure Manual, 1994.

Keyserling, Herrin, Chaffin: An analysis of selected work muscle strength. Proceedings of the Human Factors Society 22 nd Annual Meeting, Detroit. 1978.

                                               Pain Replication Test (PRT)

 

Most industrial injuries are soft tissue in nature. Medical imaging has improved significantly over the years, but continues to be unable to determine symptomatic individuals from asymptomatic individuals. That is where the Pain Replication Test (PRT) comes in. The PRT uses the standard NIOSH Static Strength Test (with Blankenship modification) positions identified by Keyserling and Chaffin. Blankenship created the PRT test to identify  two things: 1) If the patient is being honest about their pain provocation during static strength testing, 2) how much their pain is affecting their ability to generate force. The PRT is completed in standard NIOSH static strength Arm Test Position. The patient is instructed to generate as much force as they can without increasing their level of pain during the first and third exertions. During the second and fourth exertions the patient is instructed to continue past the initial pain change and to generate as much force as they feel is safe.

 

The screen shot below demonstrates a patient with two distinctly different levels of force generation. A patient with a PRT result like this identifies a patient who is being honest about their pain and gives an objective level of force generation that provokes their soft tissue pain.

 

The PRT test below indicates a patient who most likely has no soft tissue pain to base their exertions on and therefore, is unable to demonstrate two distinct levels of static strength test force. The results demonstrated below would lead us to believe this patient is not being honest about their level of pain and functional loss.

The PRT test is a useful tool in validating pain limiting functional ability in patients where diagnostic imaging is unable to demonstrate obvious pathology. The obvious benefit of identifying patients who are being honest about pain limiting function is for case settlement purposes. When you can prove your client is giving their best effort and has measurable functional loss, this can be leveraged during the settlement process. Converesly, if it can be proved that the patient is not giving their best effort and not being honest about their pain level, it can be used to minimize case settlement cost. 

 

The fact that the Blankenship FCE System has been identified in the Guides to the Evaluation of Functional Ability, AMA, 2009 as "a good method for identifying sincerity of effort" during functional testing validates the systems ability to determine accurate functional loss when it is present as well as identifying those patients who are attempting to control the test data for personal gain. 

 

 

Blankenship System Procedure Manual, 1994.

Keyserling, Herrin, Chaffin: An analysis of selected work muscle strength. Proceedings of the Human Factors Society 22 nd Annual Meeting, Detroit. 1978.

CONTACT US

 

Contact Richard Beveridge for further information

Quest Medical Group

 

6217 South Vinecrest Drive

Murray UT 84121

(800) 248-8846

ADDRESS

 

Quest Medical Group

Administrative Office

6217 South Vinecrest Drive

Murray, UT, 84121

(800) 248-8846

Richard Beveridge CEO

 

© 2023 by  THE PUB. Proudly created with Wix.com