ASSESSING OCCUPATIONAL DISABILITY FOLLOWING TRAUMA AND IMPAIRMENT

By Jasen M. Walker, Ed.D., Stacey A. Petersen, M.S., and Elizabeth McLaughlin, B.A.

Rehabilitation professionals have come to recognize the importance of comprehensive assessment in evaluating the employability of individuals who may have acquired occupational disability secondary to trauma.  Disability evaluation and rehabilitation professionals do not always agree on nomenclature and specific methodologies, and as a result, both the meaning and practice of assessing disability following trauma vary.  For many years, however, occupational disability assessment and vocational rehabilitation following trauma have been considered comprehensive, intra-disciplinary processes of evaluating an individual’s physical, mental, and emotional abilities; limitations from identifiable medical impairment; and residual functional capacities in order to help the injured person experience optimal restoration (Power, 1991).

The National Institute on Disability and Research (1992) summarizes the role of assessment and measurement in rehabilitation as follows: “Consumers are measured to establish their eligibility for benefits or services, to determine which services are appropriate, to assess their needs, to ascertain their current level of functioning, and to estimate their potential” (p. 1). Cushman and Scherer (1995) note that Anne Anastasi presented three definitions of assessment during her 1993 Master Lecture at the 100^th American Psychological Association Annual Meeting: (a) testing as a whole, (b) any information-gathering technique regarding individual behavior, and (c) the clinical and intensive study of an individual in which test scores are considered together with all of the relevant data and information.  Cushman and Scherer declare that they prefer the third definition, and we concur. 

Disability assessment integrates medical, psychological, social, educational, vocational, cultural, and psychometric data into a process that explains the effects of medical impairment on an individual’s occupational capabilities.  Despite the recognition that comprehensive assessment is fundamental to disability evaluation and occupational rehabilitation, the practice of disability evaluation following the onset of impairment remains highly eclectic.  Moreover, notwithstanding the growing appreciation for the difference between medical impairment and occupational disability (Holmes, 2007), many physicians are still asked to determine vocational capacity. 

In this article, we will define the lexicon of vocational/disability evaluation and occupational rehabilitation, trace its origin, briefly review relevant literature related to assessment of impairment and evaluation of disability following trauma, and proceed to describe a model of vocational disability assessment.  We will make our bias known.  That is, physicians diagnose disease and attempt to ameliorate the effects of disease and impairment.  Vocational evaluators trained in a variety of social and psychological disciplines, generally allied with but outside of medicine, assess disability. 

Accurate assessment of vocational disability following injury or trauma should be a concern for healthcare professionals, employers, public policymakers, and society in general.  If for no other reason, human injury is expensive.  Direct medical costs and indirect costs, such as lost productivity due to traumatic brain injury (TBI) alone, totaled an estimated $60 billion in the United States in 2000 (Finkelstein, Corso, & Miller, 2006).  The U.S. Bureau of the Census (2006) estimates that in 2003 medical costs for injured workers were $25.6 billion and compensation payments were in excess of $26.9 billion.  The National Safety Council (2007) reports that the economic impact of fatal and nonfatal unintentional injuries amounted to $625.5 billion in 2005. 

A multi-phased economic study has replicated findings that workplace disability costs the average American employer just over 8 percent of payroll (Berkowitz, Chelius, & Dean, 1992; Berkowitz, Chelius & O’Leary, 1994; Berkowitz & O’Leary, 1997).  If one were to consider a company with a modest $6 million payroll (100 employees averaging $60,000 in annual wages and benefits), annual disability costs at that company would average $480,000.

Traumatic injury and resultant disability are expensive.  Precision and accuracy in disability assessments can only benefit the individual being evaluated, employers, and society in general, as inaccurate assessments are likely to be the subject of scrutiny, further inquiry, misguided treatment, and additional expense.  Precise assessment begins with differentiating among the phenomena of trauma, impairment, and disability.

Trauma

People arrive at the disability evaluation process most often following trauma.  The term “trauma” originates from the Greek word meaning “wound.”  Bodily trauma can take place in many ways.  Slip and falls, motor vehicle collisions, work accidents, physical assaults, shootings, and surgeries can cause trauma.  Mild physical trauma does not always cause damage.  For example, striking one’s elbow on the arm of a chair (hitting the “funny bone”) is a mild form of trauma that seldom causes damage to the organism, and if it does, the damage is not necessarily permanent.  However, ulnar nerve injuries can cause permanent damage, and when irreversible damage occurs, the trauma has caused anatomic and/or physiologic change, which is described in this article as impairment. 

 Definitions of trauma are myriad and too diverse to adequately summarize here.  Classen and Koopman (1993) describe trauma as “an abrupt physical disruption in ordinary daily experience, often with loss of control over the body” (p. 178).  Courtois (2004) speaks to complex trauma as “a type of trauma that occurs repeatedly and cumulatively, usually over a period of time and within specific relationships and contexts” (p. 412).  The American Psychological Association’s Dictionary of Psychology (VandenBos, 2007) defines trauma as a physical injury or event in which a person witnesses or experiences a threat to his or her own life or physical safety or that of others, and as a consequence, also experiences fear, terror, or helplessness.  

Trauma can be the result of a single event or repetitive exposures to environmental forces.  Industrial explosions can cause trauma.  Repetitive assembly operations can cause trauma and injury.  Repetitive trauma often occurs because muscles are repeatedly stressed, tendons become inflamed, nerves get pinched, or blood flow becomes restricted (Van Fleet & Bates, 1995).  The effects of trauma can be numerous and physical and/or psychological in nature.

Psychological responses during and related to trauma include temporary psychophysiological reactions and development of permanent mental disorder.  Dissociative symptoms concomitant to traumatic experiences include stupor, derealization, depersonalization, numbing, and amnesia for the event (Classen & Koopman, 1993).  Survivors of automobile accidents often report a dulling of senses during the accident (Noyes, Hoenk, Kuperman & Slymen, 1977, as cited in Classen & Koopman, 1993).  Traumas that are seen as being caused by others (e.g., rape, assault, toxic accidents) generally have greater psychological effect on victims and their significant others than those caused by natural disasters (e.g., earthquakes) (VandenBos, 2007). 

Acute stress disorder (ASD) is a diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (2000), and by definition, ASD should resolve within four weeks after the conclusion of the traumatic event.  However, psychological responses to trauma can be more enduring and pervasive.  Post-traumatic stress disorder (PTSD) is a diagnosis that grew from the observations and formulations of researchers concerned with the devastating effects of war trauma on individual soldiers, but according to the DSM-IV-TR, PTSD can occur at any age, including childhood.  Survivors of rape, child abuse, domestic violence, and other traumatic experiences can also develop PTSD.  Moreover, chronic PTSD has been linked with diminished health and longevity of Vietnam War veterans (Boscarino, 2005).  As the result of severe, cumulative, or complex trauma, maladaptive psychological responses can be chronic and debilitating.

According to Herman (Herman, 1992a, 1992b, as cited in Courtois, 2004), symptoms associated with complex PTSD include alterations in the regulation of affective impulses, attention and consciousness, self-perceptions, perception of the perpetrators, relationships with others, position and/or medical problems, and alterations in systems of meaning. 

Not all traumatic injuries produce enduring psychological sequelae.  When it does occur as a result of trauma, dissociation, for example, does not necessarily persist (Esposito & Mellman, 2005).  Likewise, other psychological symptoms to trauma have been found to abate with time.  Grunert, Devine, Matlaub, Sanger, Yousef, Anderson, et al., (1992) discovered that the majority of workers with injured hands assessed five days post-injury reported flashbacks and nightmares.  At 3, 6, 12, and 18 month follow-ups, however, many of these non-exertional symptoms had diminished, although some, including flashbacks and avoidance behaviors, persisted.

Trauma may be described as being mild, moderate, or severe, but vague scales in the evaluation process are qualitative or descriptive at best and may provide little meaning in the assessment of impairment and disability.  What is clear is that trauma can produce physical and/or mental damage to the individual.  With time, the effects of trauma can abate, but the residuum from trauma may be permanent and can be measured in terms of impairment, physical and/or mental.

Impairment

Impairment is defined by the American Medical Association (Cocchiarella & Andersson, 2001) as the loss, loss of use, or derangement of any body part, system, or function.  Impairments may be exertional or non-exertional in nature.  The Social Security Administration (SSA) offers a Program Policy Statement (SSA, 1978) that clarifies the distinction between exertional and non-exertional impairments.  Exertional impairment affects the performance of work activities involving strength and endurance, such as standing, walking, lifting, and otherwise performing the essential requirements of sedentary, light, medium, heavy, or very heavy work.  A non-exertional impairment is one that is medically determinable and causes functional limitation generally unrelated to strength or environmental restriction.  For example, a speech impairment or a hearing disorder may be considered a non-exertional impairment.  Most mental disorders can be classified as non-exertional impairments.  One would expect licensed clinical social workers, psychologists, and psychiatrists to diagnose a mental impairment and hopefully assess its effects on mental and emotional functioning.

 Impairment is evaluated in a variety of ways and is customarily the purview of healthcare providers with a particular expertise related to the type of injury, illness, or impairment.  Therefore, orthopedic surgeons are concerned with trauma to the musculoskeletal system, including bones, joints, and muscles.  Neurologists assess what is thought to be impairment of the central and peripheral nervous systems, and neuropsychologists generally assess cognitive deficits and other changes in brain behavior.  Psychiatrists and psychologists diagnose and assess mental and emotional disorders.  The American Psychiatric Association relies upon the DSM-IV-TR (2000) to categorize mental disorders and provide criteria for diagnosis.  In its introduction, the DSM-IV-TR reminds its readers that the term “mental disorder” implies an unfortunate distinction between “mental” and “physical,” as the compelling literature documents that the mind/body dualism is misleading: “...there is much ‘physical’ in ‘mental’ disorders and much ‘mental’ in ‘physical’ disorders” (p. xxx).

Each healthcare specialist possesses more or less reliable methodologies to assess the nature and degree of impairment.  When necessary, there may be attempts to determine the permanency of impairment.  Diagnoses and impairments, however, are insufficient to provide a basis for disability.  The critical link between impairment and disability is functional capacity.

Functional Capacity: The Critical Link

 The critical link or keystone between impairment and disability is functional capacity, and in disability evaluation, accurately determining functional capacity is of significant importance in evaluating disability and predicting employability.  Nonetheless, the evaluation of an individual’s residual functional capacities following trauma remains a challenge for rehabilitation professionals.  Among the primary issues are the validity and reliability of functional capacity assessments (King, 2004).  Although thought to be a substantial improvement over the practice of a physician simply filling out a physical capacity checklist, solid empirical data with respect to the validity and reliability of the functional capacity evaluation (FCE) are still lacking.  Randolph, Nguyen, and Osborne (as cited in Talmage & Melhorn, 2005) recommend that the FCE be used in conjunction with the practitioner’s thorough understanding of the examinee’s health problem and medical history.  Still, at its face, the FCE appears to be an improvement over the so-called “educated guess” offered by most physicians in response to questions regarding the injured person’s post-injury physical capacities.

Similarly, psychiatric and/or psychological statements regarding residual mental functional capacity may be deemed dubiously valid and reliable in terms of predicting an individual’s disability and employability.  The Global Assessment of Functioning (GAF) forms the fifth axis of the standardized diagnostic procedure followed in the DSM-IV-TR (2000) and seeks to quantify psychological, social, and occupational functioning on a continuum of mental illness.  Knowing the diagnosis and GAF of the individual with mental impairment is likely to be insufficient in accurately assessing the degree of motivation, self-control, functional skills, and tolerance for stress that individuals bring to prospective employment. 

Because trauma can result in permanent physical and/or mental impairment and functional capacity assessments are currently designed only to investigate the impaired person’s physical capacities, rehabilitation professionals must turn to other assessment tools and procedures to appreciate the examinee’s residual employability following trauma that may have resulted in mental impairment and associated dysfunction.  The SSA (2005) cites limitations in concentration, persistence, or pace as representative of disabling mental impairment.  Fortunately, significant attention has been paid to the validity and reliability of mental measurements, including standardized psychological and vocational tests that can measure an individual’s concentration, persistence, and pace.  Unfortunately, psychological and vocational testing in disability assessments is not always employed, and when utilized, psychometrics in vocational disability evaluation are not always administered with issues of ecological validity in mind.

Ecological validity refers to the real world meaningfulness of data-gathering activities.  The term “ecological validity” was coined by Egon Brunswik (Hammond, 1998), who was concerned with ergonomics, the application of human factors in the design of objects and systems in the environment.  How a person behaves at the time of an FCE or disability assessment may not necessarily predict how the person will function in a work setting, and that  reality may be the main challenge to rehabilitation assessment professionals, that is, how to design and standardize valid and reliable disability assessment protocols.

Disability

In describing the relationship of trauma and impairment to occupational disability, one must reiterate the important distinction between impairment and disability (Walker, 1993).  The AMA Guides (Cocchiarella & Andersson, 2001) notes the difference between impairment and disability.  As referenced above, impairment is defined as “a loss, loss of use, or derangement of any body part, organ system, or organ function” (p. 3) and is best evaluated by medical means.  On the other hand, disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands” (p. 3).  The World Health Organization (WHO) (2007) defines disability as an activity limitation that creates a difficulty in the performance, accomplishment, or completion of an activity in a manner that is within the range considered normal for a human being.  The Americans with Disabilities Act of 1990 (U.S. Department of Justice, 2007) speaks to disability as the individual having a physical or mental impairment that substantially limits one or more of life’s major activities, having a record of impairment, or being regarded as having an impairment.  In this article, we are concerned with the vocational consequences of medical impairment, and therefore, occupational disability and post-injury employability.

Occupational disability may be defined as an individual’s loss or limitations in employment capabilities secondary to physical and/or mental impairment.  Vocational disability can have a strong social component.  Observations and research have shown that vocational disability can be induced by social dynamics and that disability can be ameliorated or managed through psychological and social interventions, transition-to-work, ergonomic assistance, or career change, to name a few (Walker & Heffner, 2006).  Vocational or occupational disability is best assessed by qualified evaluators who possess an understanding of medical impairments and their effects on functionality.  Through comprehensive assessment, vocational disability evaluators can develop an accurate prediction of how the individual’s history of impairment will impact the essential functions of employment for which he or she is best qualified given the person’s residual physical capabilities, age, education, work skills, potentials to benefit from retraining, and return-to-work possibilities through job re-engineering.

Scheer (1991) pointed out that society is accustomed to putting physicians in decision-making roles for assessing work capacity or vocational disability and expecting them to make disability determinations, often without collaborating with other assessment professionals.  By training, however, physicians are ill-prepared to assess work disability, capability, and employability.  Nonetheless, the family physician in particular is commonly called upon to serve as an occupational health physician and to assess vocational capacity.  Walker (2007) and others (Growick, 2004) have described, in detail, the problems facing physicians and other healthcare professionals (i.e., physical and occupational therapists) in assessing an individual’s functional capacity following physical injury or illness, and yet, assessing functional capacity is only part of the tripartite analysis (i.e., impairment, functionality, and residual employability) of disability.  Following the occurrence of trauma, impairment and then functionality must be carefully investigated prior to determining the examinee’s occupational disability, and assessing his or her employability.

Rehabilitation professionals trained in vocational disability evaluation realize that assessment of occupational disability following trauma is a comprehensive, intra-disciplinary process of evaluating an injured individual’s physical, mental, and emotional capacities in an effort to identify an optimal vocational fit and, in most cases, a return to work (Power, 1991).  In forensic vocational disability assessments, those carried out for court purposes, rehabilitation is probably not the goal.  Nonetheless, assessment is the same and involves gathering and integration of data for purposes of making evaluations, decisions, or recommendations (VandenBos, 2007, p.751).  Assessing vocational disability following trauma for any purpose is logically multidisciplinary, integrating information from a variety of sources, as accurate assessment requires reliable data from more than one specialty. 

Assessing disability and employability following trauma begins with appreciating the functional effects of impairment, and the various assessment methodologies employed to determine functional capacity are dictated to some extent by the nature of the impairment(s).  Assessment of occupational disability following brain injury resulting in both exertional or strength deficits (e.g., hemiplegia) and non-exertional impairments (i.e., cognitive and emotional deficits) will likely require physical capacity testing, neuropsychological investigation, and ultimately, vocational evaluation, the latter to determine if the individual with multiple impairments can still carry out work-related activities on a competitive level. 

Assessment strategies for determining disability are therefore dictated to a large extent by the nature of the permanent impairments presented at the time of evaluation.  An individual with a permanent impairment of the lumbar spine following a work-related trauma involving lifting may not demonstrate post-accident psychological problems and may require no more than physical capacity testing after reaching maximum medical improvement through physiotherapy. 

Thorough assessment of disability following trauma, however, requires a comprehensive and detailed investigation of an individual’s medical history and residual functional capacities. The examinee’s social and family background, educational history, acquisition of vocational skills through experience, and potentials to acquire additional skills through post-injury training and/or job experience are critical areas of inquiry.

The more thorough the assessment, the more likely it is to carry ecological validity.  The prediction of vocational functioning from laboratory or clinical diagnoses alone remains a concern.  The rehabilitation professional wants to know how an examinee’s performance on an FCE and scores on various tests compare to what is expected in a job description or in relation to those performances of unimpaired cohorts with whom the examinee will compete in the labor market.

In terms of assessing the occupational disability and residual employability of individuals experiencing psychiatric or psychological symptoms following trauma, the input from treating mental health professionals regarding the examinee’s diagnosis and capacities for non-exertional work demands can be helpful.  For example, whether the psychologically impaired person can communicate and cooperate with others in a workplace is essential in determining if a person is disabled from the essential function of teamwork.  Moos, Nichol, and Moos (2002) conducted research that led them to conclude that GAF ratings were only minimally associated with treatment outcomes and were of questionable value in a program for predicting the allocation and outcomes of mental healthcare.  No consistent relationship has been identified between psychiatric symptoms and vocational performance, making diagnostic categories poor predictors of future work performance (Anthony & Jansen, 1984).  On the other hand, a person’s functional capabilities and occupational adjustment exhibited in a clinical setting and in response to work-like tasks, such as problems on psychological tests and work samples, may still be important observational data in assessing disability and residual employability.  For example, whether the psychologically impaired person can communicate and cooperate effectively with others in an evaluation would seem to have merit in terms of predicting work behaviors.  Likewise, because standardized tests are designed to measure behaviors, a person’s performances on appropriately selected psychological and vocational measures would seem to have value in predicting work performance following the onset of impairment.

It is in light of the experience and research of others that we advocate multidisciplinary, comprehensive assessment to include: documentation regarding the examinee’s medical history and disabling impairment, careful observation during a detailed structured clinical interview, and analysis of relevant data from both functional capacity assessments and psychological/vocational testing.  Assessing occupational disability is greatly enhanced through “clinical and intensive study of an individual in which test scores are considered together with all other relevant data and information” (Cushman & Scherer, 1995, p. 3).  As stated above, we concur with Anastasi (as cited in Scherer, 1995) and propose a three-part model to disability assessment: 1) review of detailed documentation, 2) structured clinical interview data, and 3) results of ecologically valid psychovocational testing. 

Assessing Disability: Practical Applications

Although there are many elements of investigation that have the potential to contribute to disability assessment, beginning with determination of physical or mental impairment, the findings of impairment alone should not be considered equivalent to disability.  As stated, there is a sometimes considerable difference between impairment and disability.  Walker and Heffner (2006) note that the presence of impairment alone does not determine an individual’s capacity to meet social or occupational demands.  Disability is more complex than a change in mental or physical functioning secondary to impairment; it is a multifaceted combination of physical, social, and psychological factors.  Breeding (2005) recognizes that the impact of a medical impairment largely depends on the perception of the person affected, and he adds that the psychosocial impact on two people with identical impairments can be quite different.

A major objective of disability assessment is to determine an individual’s capacity to meet social and occupational demands.  The goal of the disability assessment process is to develop a detailed picture of the individual being evaluated, including, among other factors, medical impairments, residual functional capacities, post-injury aptitudes and skills, personality characteristics, the environments in which the individual might again live and work, and levels of functioning prior to impairment. The individual’s entire medical history is often important in disability assessment.  Disease entities and resultant limitations can be antecedent to and a consequence of trauma, and these co-morbidities, regardless of onset, may be occupationally significant.  Due to the encompassing nature of disability, the information needed to adequately assess disability is necessarily comprehensive. 

Although the methods for assessing disability in a forensic setting remain the same as for rehabilitation purposes, the goal of the former is often to answer a legal question.  Typically, it is a question of whether an individual has incurred reduced employment capacity and/or lost potential to earn wages occupationally.  Assessment for rehabilitation purposes generally produces recommendations, and forensic vocational disability evaluation aims to answer legal questions.  Ideally, the initial assessment processes and methodologies remain the same.

It is important to consider the question of who is qualified to conduct disability assessments.  Walker and Heffner (2006) indicate that it is a common misconception that members of the medical field are qualified to make determinations about disability.  There are several concerns associated with this misconception, particularly as the determination of disability is reliant on many factors apart from medical expertise alone, and are therefore beyond the purview of physicians (Scheer, 1991; Cocchiarella & Andersson, 2001; Talmage & Melhorn, 2005).  The assessment of disability also requires training in the nature and demands of multiple forms of work and what is required of individuals to successfully participate socially in a work setting.  Sleister (2000) correctly notes that the reliance on physicians and economists to provide assessment of an individual’s capacity to work following impairment is ineffective, as they do not have the expertise to speak to qualifications, physical requirements, or earnings for the more than 20,000 jobs in the U.S. labor market.

Often, in cases of personal injury where disability assessment is required, vocational experts are the most qualified.  Sleister (2000) provides a comprehensive discussion on the qualifications and abilities of vocational experts, which include knowledge of the psychosocial aspects of disability and a variety of occupational skills and characteristics.  Weed and Field (2001) discuss the role of vocational or rehabilitation experts as professionals who are knowledgeable in vocational, educational, and psychological assessment practices.  Weed and Field provide an overview of the forensic disability evaluation process.  Ultimately, the disability assessor needs to be able to synthesize information from a variety of sources while maintaining a focus on ecological validity. 

The Elements of a Disability Assessment

Although Thomas (1999) notes that some feel the present state of vocational evaluation has lost its utility and that the formal process associated with disability assessment should be altered to reflect more of a screening process driven by self-report, we argue that thorough and accurate assessment should consist of three main parts: a review of pertinent documentation, a clinical interview, and the administration of standardized testing.  Berven (as cited in Bolton, 2001) similarly describes assessment for rehabilitative purposes as being constructed of a review of client records, clinical interviews, observations, examinations by other professionals, and formal testing. 

Before presenting each of these data-gathering areas in some detail, it is noteworthy to mention that reliance on a clinical interview solely is fraught with potential for error.  Meyer, Finn, Eyde, Kay, Moreland, Dies, et al. (2001) highlight several possible errors, such as gathering data from poor or unreliable historians, using overly narrow interview formats, and having an inability to objectively determine exaggerated or biased self-reporting.  It is also worth noting that through the use of testing in conjunction with interviews, the evaluator is able to measure a variety of features at the same time, compare individual performances to relevant norm groups, and follow standardized scoring and administration procedures, which lessen possible legal and ethical conflicts and likely increase the validity of the findings. 

Sleister (2000) notes that throughout a disability assessment, a skilled evaluator must be able to observe and assess personal characteristics, educational potential, and related work histories, which would be difficult to complete accurately through reliance on self-report alone.  Additionally, Breeding (2005) points out that in the research on disability, no link exists between the physical severity of an injury or illness and the psychosocial effects it has on a given individual and, therefore, disability cannot adequately be assessed through medical examination alone.   

Many disability evaluators have traditionally relied on a transferability of skills analysis (TSA), a process of investigating the skills and traits a person has demonstrated during his or her working life in order to recommend alternative job placement or retraining options after the establishment of impairment.  Despite its broad acceptance in the field of disability evaluation, we suggest that a TSA is not comprehensive enough to adequately assess disability and has several inherent flaws that lend against its use.  In fact, findings suggest that little research, particularly empirical research, has been conducted to speak to the validity and usefulness of the practice (Dunn & Growick, 2000).     

A major criticism of the TSA is its rigidity, which often leads evaluators to overlook a range of alternate occupations available to a person simply because it falls outside of the description of his or her customary employment.  TSAs actually evaluate the essential functions of job descriptions that the person reportedly carried out and intend to predict what skills the individual should be capable of doing with functional limitations.  However, an individual’s self-report of work history, job titles held, and specific work responsibilities is not a reliable method of assuring that the individual had actually acquired skills delineated by government job descriptions, such as those promulgated by the U.S. Department of Labor (1991).  Job titles vary from workplace to workplace.  Even with a very careful inquiry regarding the individual’s training, tools, materials, and methodologies used, considerable variation can exist from one worker’s job responsibilities and experience to another’s and have little or no match to government job descriptions.

 Moreover, the disability assessment is the evaluation of a person’s employability and not a simple tally of demonstrated skills that might be utilized at another level of function.  Disability evaluation is a complete appreciation of an impaired individual’s residual employability.  To assume, for example, that a physically impaired longshoreman can only work with objects and things because that was his previously-demonstrated ability and interest profile is potentially fraught with error.  In 1951, Eric Hoffer, a Seattle longshoreman, wrote The True Believer, acclaimed by many as a literary classic, and two decades later, Harvey Jackins, also a longshoreman, created Re-evaluation Counseling, a peer counseling program that has been meaningful to millions throughout the world.  Obviously, assessing these two longshoremen with  TSA approaches would have fallen well short of accurately evaluating their vocational  potentials.

The TSA method of work disability assessment also assumes that an individual was well-suited to prior employment, which may be untrue, and therefore not only presumes acquisition of work adjustment skills but also ignores potential vocational interests outside of previous modes of work (Dunn & Growick, 2000).  Dunn and Cain (2001) note that often, a return to employment following the onset of impairment is dependent on extra-vocational circumstances and activities, and a disability assessment is likely to be incomplete and ineffective if these variables are not considered.  Dunn and Cain also conclude that many elements of TSA are not relevant to determining vocational outcome, and furthermore, TSA does not appear to be as sensitive in identifying alternate vocations when the individual in question has greater physical effects of impairment. 

Power (1991) concludes that when assessing an impaired individual’s current level of functioning, the use of standardized tests, such as aptitude and achievement tests, is warranted because specific knowledge of how an impaired individual’s abilities or competencies compare with those of non-impaired individuals may be necessary for rehabilitation planning to be relevant. 

Review of Pertinent Documentation

The process of assessing occupational disability and residual employability can be greatly enhanced by the review of pertinent documents, which can provide a wealth of information not typically available to an evaluator.  It is not possible to gather all the needed information for a disability assessment through a clinical interview and testing alone, particularly given the limited time allotted for those tasks.  Through the review of relevant historical records, the evaluator often has better access to the social environment in which the individual has lived and worked.  By reviewing employment records, and more specifically past performance reviews, for example, it is possible to obtain information about how an individual typically carried out work.  In addition, disciplinary actions, workplace injury reports, and attendance logs can illuminate an individual’s prior work record.  Review of these documents as well as earnings records may help define how central a theme employment has been to this individual prior to the onset of impairment.  Work records can reflect attendance patterns and general work adjustment issues that may influence an individual’s behavioral responses to both assessment and rehabilitation interventions.   

Documented medical information is vital in a disability assessment.  Not simply materials related to the trauma that brought the examinee to assessment, but the examinee’s health history in general may represent a reflection of his or her pre-injury lifestyle and well being.  As mentioned earlier, some individuals can be unreliable historians or may intentionally distort or omit aspects of their health history that they feel will influence the outcome of a disability assessment.  Reviewing documentation of medical treatment, both prior to and after an injury or illness, has the potential to provide a more complete body of information than some individuals may wish to provide in an interview.  Reviewing medical records is especially important if the individual in question had been diagnosed with particular conditions that could have interfered with his or her ability to participate in work prior to the issue in question, such as advanced heart disease or diabetes.

In particular cases, academic records can provide relevant information about the individual’s pre-morbid or baseline performance on formal testing.  Classroom achievement can provide more information regarding motivation and pre-injury skill sets depending on how recent the records are.  At times, academic records identify a starting point in a long history of absenteeism or disciplinary issues and may reflect pre-morbid adjustment.  School records also have the potential to suggest post-injury avenues for someone who must consider alternate work following the onset of impairment.

Ultimately, the examinee’s school, earnings, military, and employment records can yield important information about how that person was functioning from day to day before the trauma in question.  Records provide a historical context to the disability assessment, a context that will be enhanced not only by the collection of accurate post-injury data but vis-à-vis the shared perspectives of other informed observers over the years prior to the onset of a disabling impairment.       

Clinical Interview

            The clinical interview is an essential element of a comprehensive disability assessment for several reasons.  For one, it offers the examiner an opportunity to directly observe and calculate the impact of trauma on the individual and also gives the individual being evaluated the opportunity to share his or her personal experiences before and after sustaining an impairment.  Breeding (2005) highlights the subjective nature of the impact of impairment and notes that information about an individual’s lived experience is typically not available in documentation, testing, or general intake interviews.  The clinical interview provides the examiner with the opportunity to ask an individual about a variety of areas in his or her life that may have been affected by impairment and also to gather information about the person’s lifestyle. 

Perhaps the most important reason to conduct a clinical interview, as opposed to simply reviewing records, is that more often than not, people are much different in person than they appear to be on paper.  This point comes into sharp relief when one considers the many different professional perspectives that build a body of records regarding an individual’s care.  The type of qualitative information generated in a clinical interview helps to construct a context for the assessment and resultant findings by exploring and incorporating the unique features of the individual. 

            There are numerous texts devoted to specific techniques, styles, and goals of interviewing, so only select points will be briefly discussed here.  Before conducting a clinical interview, the examiner should invest considerable time into practicing the required skills.  Namely, data gathered from clinical interviews are greatly enhanced when the interviewer is a trained listener who recognizes and follows important leads instead of relying solely on the rather clerical nature of filling in a structured interview format.  That is, though semi-structured, the interview should respond and adjust to the unique features each individual brings to an evaluation.  This is also essential to building rapport with the person being interviewed and demonstrates that the examiner is listening.  Berven (as cited in Bolton, 2001) suggests that during an interview, the communication of empathy, respect, and genuineness have the power to augment the relationship and encourage disclosure.  

During the interview, the evaluator’s main tool is that of questioning, so it is essential to practice phrasing questions tactfully though directly.  At times, individuals are resistant to being interviewed, and the evaluator must effectively confront the person in order to generate quality information.  One method is to simply point out the individual’s behavior, such as appearing uncomfortable, and then engage the person in a dialogue directed to resolve the resistance and resume the interview.  For example, it may be that the individual feels uncomfortable meeting new people and simply needs a few additional minutes to adjust to the task.  In forensic settings, some individuals come to evaluations with the knowledge that the opposing legal party sent them and therefore have pre-existing notions of what the experience will entail.  In any case, investing a few minutes to develop rapport with the individual and reduce resistance is worthwhile.   

            Another essential task of the clinical interviewer is to closely observe the person being interviewed.  As mentioned, interviewing should not be considered a static clerical task but rather an opportunity to gather important qualitative data about a person.  Observations might include noting the way an individual is dressed, monitoring body language or complaints of physical discomfort, surveying the person’s emotional responses to different questions, and noting any obvious abnormalities in thinking or information processing.  The evaluator may also want to observe the individual’s level of social appropriateness and sophistication, as the ability to be socially aware and accurately interpret social cues is essential to successful functioning in all but a select few vocational settings.  Goleman (2006) explores the topic of social intelligence in detail. 

The examiner should begin an interview by clearly stating the purpose of the evaluation.  This includes stating any limitations to confidentiality, the source of the referral, and who will have access to the findings of the evaluation.  The assessor should be prepared to answer any questions that the individual may have before beginning and should take care to ensure that the person has understood the purposes of the evaluation as stated.  

            When conducting a clinical interview as part of a disability assessment, it is important to structure the interview around the areas of the individual’s life that generally have an effect on his or her productivity.  This includes exploring the person’s perceptions of his or her own abilities or disabilities, the role of work in the person’s life as part of a detailed job history, and pre-morbid and unrelated post-morbid health issues.  Berven (as cited in Bolton, 2001) suggests conducting an interview with at least a semi-structured format so that other professionals assessing the individual are likely to reach similar conclusions, or at least to understand how the conclusions of an interview are determined.   During the clinical interview, the evaluator should take into account how the person spends a typical day, which, in some cases, has the potential to highlight new roles the individual has taken on that may reduce the likelihood of a return to full productivity.  An example of this is when a person becomes the primary caretaker of the family almost by default while the spouse works. 

            There are certain concrete areas of an individual’s experience that should be taken into account during a clinical interview as well, such as recording a list of any medications taken, including the dosage and frequency of use.  Some medications can affect the speed or clarity of cognitive processing, thus affecting performance both on standardized testing and on general measures of productivity.  It is also helpful to ask individuals to describe his or her educational attainment, hobbies, and family.  This information further builds the context for a disability assessment. 

            If possible, it is helpful to interview other people who are significant in the life of the individual who is the focus of the evaluation.  Often, significant others can offer valuable perspectives on the individual both prior to and after injury and can also speak to the person’s residual abilities, activities, and interests.  The need to interview significant others becomes evident when a child is the subject of evaluation, as it is essential to interview parents.  This can also be the case if the subject of the evaluation is unable to participate in interviewing due to his or her physical or mental limitations. 

 Standardized Testing

            The final area of the three-part model proposed for conducting a disability assessment is the administration of standardized testing.  A standardized test is a method of sampling behavior and describing it with categories or scores.  Standardization is achieved if the procedures for administering the test are uniform from one examiner and setting to another.  Standardized testing is frequently overlooked or is undertaken incompletely by many vocational disability examiners.  As mentioned earlier, Meyer, Finn, Eyde, Kay, Moreland, Dies, et al. (2001) point out the many benefits of using standardized testing as an integral part of an assessment and even demonstrate that many published standardized measures are as reliable as medical tests like x-rays and CT scans.  The use of standardized testing also provides unique information in that it can measure a person’s aptitudes for retraining in a new vocation, for example.  It is difficult to determine with any certainty a person’s learning potentials based on self-report or historical documentation alone (Walker, 2004). 

            When designing a test battery to employ during a disability assessment, it is important to keep the concept of ecological validity in mind.  That is, it is most logical to select measures that can provide information useful in the real world in which the person will be functioning.  There is not much value in administering a test of manual speed and dexterity to a person who has suffered a major injury to his or her dominant hand, unless attempting to demonstrate that, in fact, the hand is impaired.  It would be more informative, not to mention a better use of time, to select measures for the person that speak to the basic skill sets required in areas where he or she may be able to resume work or social activities.  The availability of various workplace accommodations, such as voice-activated dictation, highlight the need to measure the basic, underlying skills a person has even if the individual is impaired in using those skills via traditional methods.  An individual who possesses skills associated with office work should not be considered excluded from that category of work simply because he or she lacks the capacity to type on a keyboard in a way that others do.   

            Typically, a test battery used for the purpose of disability assessment includes measures of achievement, intelligence, aptitudes, interests, personality dynamics, and, at times, measures of effort (Walker, 2004).  Standardized testing should always include objective measures of personality or temperament as opposed to only including subjective self-report measures.  The use of self-report measures raises the potential for biased responding and offers no means of objectively determining when biased responses are given.  Although not directly related to vocational skill, personality measures offer valuable information about an individual’s suitability for a certain vocation.  Even if an individual had the requisite skills for a career in sales, the person would likely not be successful if extremely introverted or socially timid.  Personality measures not only provide objective information on how suitable a person is for a specific job but also how likely the individual is to be satisfied with that particular work. 

            In addition to administering an objective measure of personality, a test battery for disability assessment should also include measures of achievement to include basic academic skills, such as reading comprehension and mathematics.  It is advisable to administer achievement testing early in a battery to ensure that later measures are appropriate for the individual’s mathematic and reading abilities.  There are also a variety of standardized measures that assess a range of work aptitudes that may be helpful, such as the Career Ability Placement Survey, the Differential Aptitude Test, and the Employee Aptitude Survey. 

When conducting disability assessment, it is important to incorporate the individual’s personal and vocational interests, as an examinee should not be expected to undertake an activity that he or she finds repellent and, in fact, it is likely that the individual would not sustain unappealing activity even if able to.  Evaluators should devote special attention to the interest inventory they employ in order to ensure that it adequately covers a large range of occupational interests, including more modern vocations such as computer-related activities if possible.

Another aspect of the test battery for disability assessment is testing designed to measure effort.  There are several available measures for assessing the validity of an individual’s effort and response style during testing that are informative to the process, as sometimes individuals purposefully distort performance, particularly when secondary gain dynamics are present.  Lynch (2004) offers some suggestions for identifying behaviors that indicate when validity testing is warranted, such as large discrepancies between subjective complaints and objective findings or a lack of cooperation during assessment efforts.  

            As with interviewing, test administration is a clinical process rather than a clerical task.  The test administrator should make careful observations throughout the administration of standardized testing in order to gather qualitative data about how the person approached and organized each task.  These observations should also include the individual’s emotional response to particular activities, willingness to follow instructions, affect, and any signs of thought disorder.  The examiner must be prepared to answer questions about not only the purpose of testing but also specific questions about each test and, therefore, must be quite familiar with the measures.  Frequently, it will fall to the examiner to help reduce anxiety associated with taking tests. 

            It is of great importance that the test battery and the examiner are responsive to the strengths, weaknesses, and needs of the individual being assessed.  As data are gathered during the interview and test administration, it is the examiner’s responsibility to integrate the information and adjust the assessment so that the most useful information is being collected.      

            The goal of medical and vocational rehabilitation is to maximize an individual’s functioning following trauma and the onset of impairment and, when possible, restore that person’s productivity.  The comprehensive assessment initiates the disability evaluation and vocational rehabilitation processes, both of which are enhanced when practitioners fully appreciate the difference between impairment and disability and go about employing a tripartite analysis of occupational disability and post-injury employability.

Summary

The primary objective of an occupational disability evaluation following trauma is to identify the impaired individual’s vocational potential through a systematic assessment process.  Through that process, the vocational assessment professional is able to observe, measure, and document occupationally relevant behaviors to determine an individual’s potential to successfully perform particular forms of work.

A portion of the data gathering done in vocational evaluation is based on documentation.  Relevant documentation regarding an individual’s work history, earnings record, and educational background may be quite pertinent to the assessment data gathered. In addition, vocational rehabilitation professionals rely on the exertional or mental recommendations of physicians and therapists with respect to an individual’s functional capacities for work.  A significant issue affecting the vocational evaluation process is the basic difference between the concept of “impairment” and “disability.”  Defining impairment is, of course, within the scope of the physician’s expertise, whereas determining disability is not (Cocchiarella & Andersson, 2001).  In terms of a work disability, the examiner making the assessment needs to understand the physical and mental requirements of the specific job tasks to decide whether the impairment will, with or without a work accommodation, impact the injured worker’s ability to carry out that work.  This expertise on occupational capacity belongs to the qualified vocational professional (Sleister, 2000).

 Through well-planned standardized testing, a complete picture of an individual’s actual abilities and work potentials can be obtained.  Without comprehensive test data, determining an appropriate occupational match for an individual could be incomplete and perhaps speculative.

There are several components that should be considered when developing criteria for vocational testing, including academic achievement levels, vocational aptitudes, personality characteristics, and occupational interests.  Through gathering data in each of these areas, along with understanding the history of the injured worker, one would be well equipped to successfully match a person to a particular job.

Comprehensive vocational assessment can be accomplished by utilizing the following methods (as cited in Bolton, 2001):

§         reviewing various documentation, including medical, employment, and wage data

§         utilizing direct observation

§         obtaining physician input

§         conducting a client interview

§         administering standardized testing

§         assessing and inventorying worker traits

However, despite the importance that standardized testing might play in accurately assessing an individual’s characteristics and abilities, one of the most frequently asked question regarding vocational evaluations is, “What is the purpose of vocational testing?”  Many times, persons requesting a vocational assessment question the efficacy of administering a battery of tests.  In general, it is assumed that a person’s ability to perform a job can be determined by nothing more than examining what type of work that individual performed in the past and understanding the medically-determined restrictions or limitations in functional capacity.  In fact, to the well-trained vocational disability evaluation professional, work experience plays only a part in assessing a person’s ability to function effectively in a particular job.  Because of the wide variations in job descriptions and job demands, the work history alone does not ensure that the individual being evaluated has acquired specific skills.  Moreover, it has been the experience of well-trained vocational evaluators that individuals with particular work histories can possess dramatically different skill sets and worker characteristics.

 One could simply perform a “transferability of skills” analysis on the basis of a person’s work history (Dunn & Growick, 2000).  However, to repeat the illustration, one cannot assume that the longshoreman is simply interested in objects and things because he has manually and mechanically unloaded ships and nothing more in his employment.  What is more, one cannot conclude that a longshoreman possesses no more than the mental abilities of the “typical” longshoreman.

Conclusion

The vocational disability assessment process is of substantial concern to rehabilitation professionals, employers, and society in general.  In this chapter, we provide specific definitions of vocational disability assessment and its key concepts, look at relevant economic impact data, and continue by discussing the explicit methods used in disability assessment to evaluate the work potentials of individuals who are impaired physically and/or mentally.  After defining trauma, we make the crucial distinction between “impairment” and “disability.”  We describe the vital role of the functional capacity evaluation in the assessment process.   

Vocational disability assessment is discussed in depth in terms of practical applications, the elements of an assessment, and the “three-part model” of assessment.  The three-part model, the heart of the assessment process, identifies the essential steps as:

1. a document review
2. the clinical interview
3. standardized testing

The essence of this chapter is that the goal of vocational assessment is to develop a precise picture of the individual’s capacity to function occupationally so that additional decisions regarding the examinee’s potentials and productivity can be made. 

References

1.      American Psychiatric Association. (2000).  Diagnostic and statistical manual of mental disorders (4^th ed. – text revision).  Washington, D.C.: American Psychiatric Publishing. 

2.      Anthony, W. A., & Jansen, M. A.  (1984).  Predicting the vocational capacity of the chronically mentally ill.  American Psychologist, 39(5), 537-544.

3.      Berkowitz, M., Chelius, J., & Dean, D. (1992).  The full cost of disability:  Phase I.  Unpublished manuscript.

4.      Berkowitz, M., Chelius, J., & O’Leary, P. (1994).  The full cost of disability:  Phase II. Unpublished manuscript.

5.      Berkowitz, M., & O’Leary, P. (1997).  The full cost of disability:  Phase III.  Unpublished manuscript.

6.      Berven, N. L.  (2001).  Assessment interviewing.  In B. F. Bolton (Ed.), Handbook of measurement and evaluation in rehabilitation (pp. 197-213).  Austin, TX:  Pro-ed.

7.      Boscarino, J.A.  (2005).  Post-traumatic stress disorder and mortality among U.S. army veterans 30 years after military service.  Annals of Epidemiology.  16, 1-9.

8.      Breeding, R. R. (2005).  Vocational rehabilitation and sudden onset disability:  Advancing proprietary consumer involvement through improved vocational assessment.  Journal of Vocational Rehabilitation, 22, 131-141.

9.      Classen, C. & Koopman, C.  (1993).  Trauma and dissociation.  Bulletin of the Menninger Clinic, 57(2), 178-194.  

10.  Cocchiarella, L., & Andersson, G. B. J. (Eds.). (2001).  Guides to the evaluation of permanent impairment.  Fifth Edition.  Chicago: AMA Press.

11.  Courtois, C.A. (2004). Complex trauma, complex reactions: Assessment and treatment.  Psychotherapy:  Theory, Research, Practice, Training, 41(4), 412-425.

12.  Cushman, L. A., & Scherer, M. J. (Eds.). (1995). Psychological assessment in medical rehabilitation.  Washington, DC:  American Psychological Association.

13.  Dunn, P. L., & Growick, B. S. (2000). Transferable skills analysis in vocational rehabilitation: historical foundations, current status, and future trends. Journal of Vocational Rehabilitation, 14, 79-87. 

14.  Dunn, P., & Cain, H.M. (2001)  Comparisons of pre-injury characteristics of injured workers across levels of post-injury occupational congruence:  Potential applications for Transferable Skills Analysis.  Journal of Forensic Vocational Analysis, 4, 13-20.

15.  Esposito, K., & Mellman, T.  (2005).  Stress disorder after traumatic injury.  The American Journal of Psychiatry, 162, 629-630.

16.  Finkelstein, E., Corso, P., & Miller, T. (2006). The incidence and economic burden of injuries in the United States.  New York: Oxford University Press.

17.  Goleman, D. (2006). Social Intelligence: The New Science of Human Relationships.  New York, NY: Bantam Books.

18.  Growick, B. (Ed.). (2004). Journal of Forensic Vocational Analysis.  7(2).

19.  Grunert, B. K., Devine, C. A., Matloub, H. S., Sanger, J. R., Yousef, N. J., Anderson, R. C., et al. (1992). Psychological adjustment following work-related hand injury:  18-month follow-up.  Annals of Plastic Surgery, 29, 537-542.

Application of the FCE by Vocational Experts

By: Jasen M. Walker, Ed.D. C.R.C., C.C.M.

Vocational Experts are those rehabilitation professionals who testify in court matters regarding an individual’s capacities to perform competitive employment following the onset of injury or illness.  Vocational Experts inform the court as to how an injury or disease causes changes in a person’s occupational potentials and earning capacity.  A rehabilitation professional serving as a Vocational Expert (VE) is generally trained as a counselor or psychologist, is skilled in vocational assessment and/or job analysis and placement, and is customarily certified by one or more relevant professional associations, (1) such as the American Board of Vocational Experts. VEs are the only rehabilitation professionals who are specifically trained to evaluate an injured person’s post-accident occupational disability and employability.

Forensic vocational/disability evaluation does not involve a helping relationship between the vocational evaluator and the injured party.  It consists of the VE executing an independent review of pertinent medical information (including an appreciation of the impaired individual’s functionality), a clinical interview, preferably vocational testing (i.e., aptitudes and interests), and a resultant assessment of the injured person’s transferable skills and residual employability.

In formulating an analysis of residual employability, the VE relies upon medical documentation regarding the injured person’s impairment(s) and residual functional capacity (RFC), or what the impaired person is able to do physically and/or mentally despite the medically-defined impairment(s).  In vocational disability evaluation, the RFC report bridges the gap between the existence of medical impairment and the assessment of occupational disability/residual employability.  The RFC for those individuals who have physical or exertional impairment(s) has customarily been established by healthcare providers and is an evolving methodology.

For many years, members of the legal system and employers relied upon a physician to make statements as to whether an injured individual could work.  Concerned parties would actually ask physicians whether an injured employee, for example, could work without considering issues of what the person might be qualified to do or what the demands of the job might be.  All too frequently, exclusive of laboratory methods, the physician responded to items on a checklist and provided only a “guesstimate,” or best clinical judgment, in terms of the patient’s physical abilities to perform work-related tasks.  Unfortunately, this fairly subjective process of delineating RFC continues in some instances.

Talmage and Melhorn edit a text that instructs physicians to assess, negotiate, and promote a patient’s return to work by considering multiple factors in the patient’s history, including functional capacity evaluations (FCEs).  (2)  Talmage and Melhorn write, however, “The term functional capacity evaluation is a misnomer in that it tells the physician whether or not, on the day of testing, the patient was or was not willing to demonstrate the ‘current ability’ to do a job or job tasks.” (3)  By making FCEs the focus of its entire December 2004 Journal of Forensic Vocational Analysis, the American Board of Vocational Experts, too, has recognized the need to improve state-of-the-art functional testing for a variety of reasons.  (4-8)

Rehabilitation professionals have long known that vocational disability is a “relational outcome, reflecting the individual’s capacity to perform a specific task or activity, contingent upon the environmental conditions in which they are to be performed,” as presented by the Institute of Medicine Report in 1997 and cited by Cocchiarella and Andersson.  (9)

In its Guides to the Evaluation of Permanent Impairment (10), the American Medical Association speaks to the difference between impairment and disability.  According to the Guides, impairment is defined as “a loss, loss of use, or derangement of any body part, organ system or organ function.”  On the other hand, disability is “an alteration of an individual’s capacity to meet personal, social, or occupational demands,” which is best evaluated by non-medical means.  Still, vestiges of expecting or charging medical personnel with determining vocational disability remain in the healthcare, legal, and disability systems.  Time and experience have shown that confusion of medical impairment with vocational disability has been waning.

As disability determinations, particularly within the Social Security Administration, have become more refined, a growing awareness has emerged that physicians are not formally trained to define an individual’s occupational capabilities and, therefore, are unable to accurately declare an individual as totally disabled from working or, conversely, capable of gainful employment.  For many practitioners, a patient’s RFC is most accurately assessed with a formal FCE.  In determining the vocational impact of medically-determined physical impairment, the VE relies upon functional capacity data detailing the impaired individual’s safe physical capabilities in terms of lifting, carrying, reaching, handling, bending, and other exertional work-like behaviors.  The FCE is regarded by many as the state-of-the-art method of determining an individual’s exertional capabilities within the work classifications of sedentary, light, medium, etc.  VEs determine an individual’s employability from measured functional capacities.

VEs are required by ethical standards and case law to provide opinions regarding an individual’s employability on the basis of reliable methodologies.  In a current editorial to the American Board of Vocational Expert newsletter, the Ethics Committee Chairperson writes, “…our opinions must be based upon reliable and defensible data and it is our responsibility to investigate whether those assessment tools fit that description.  Given that condition and the body of research questioning the validity, reliability, and efficacy of functional capacity evaluations (FCE), is there sufficient evidence to support their use in their current state as a foundation upon which to base one’s opinions regarding sustained functional capacity and, therefore, employability and labor market access?” (11) 

VEs have expressed concern regarding the validity and reliability of FCEs as well as their application in both forensic matters and return-to-work programs.  Refinement of FCEs may be dependent on developing a meaningful dialogue between those measuring RFC and those charged with the responsibilities of defining residual employability and helping patients return to work.

Rehabilitation counselors and psychologists with expertise in vocational matters may be asked to provide return-to-work assistance and, thereby, have an ongoing therapeutic relationship with an individual including days and weeks of observation.  VEs rendering independent opinions in court matters, however, are typically divorced from the provision of vocational rehabilitation services to the individual being examined.  As a result, forensic VEs generally do not have the opportunity to observe the injured person’s work behavior over an extended period of time and, therefore, are unable to document what an individual can physically do in a work setting, either by trial and error or through work adjustment processes.  Therefore, VEs must rely on data gathered from other sources, including FCEs, regarding the individual’s physical capacities.

Dakos (4) states, “The role of the VE in considering the findings of a functional capacity evaluation is that of interpreter/translator.”  With reliable information regarding an individual’s RFCs, the VE can predict with professional certainty the examinee’s specific employment options and occupational potentials with or without job accommodation.

VEs, as well as other forensic experts, are required to present “scientific evidence” that helps a judge or jury determine if occupational disability and economic damages follow personal injury. This requirement is codified in the Federal Rules of Evidence. (12)  The Rules help to define what evidence is admissible.  Rule 702 specifically states:

“If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise….”

All forensic experts are further challenged by court rulings, such as Daubert, Joiner, and Kumho, (13) demanding greater relevance and reliability in their assessment methods.  Increasingly, all forensic experts are being compelled to establish with the court that their evaluation methods are valid and reliable and, most significantly, are based on “scientific” and “reproducible methodologies.”

As the interpreter/translator, the VE relies on others, including those who carry out well-designed FCEs, for accurate data.  The importance of FCEs is increasing as both vocational and medical experts realize the inadequacy of medical personnel reporting functional limitations based on office examinations, an injured worker’s self-reports, and other subjective means.  The continuing refinement of how an impaired individual’s physical capacities for competitive employment are defined includes the advancement of the FCE.

As stated, however, the development of valid and reliable tools for measuring the impaired individual’s physical capacity remains a concern for VEs.  The December 2004 issue of The Journal of Forensic Vocational Analysis focuses exclusively on the use of FCEs in vocational forensics.  According to contributors to that particular issue of The Journal, troublesome issues in state-of-the-art FCEs include:

§         validity and reliability, (5)

§         generalizing performance from a four-hour assessment to an entire workday, (6,7)

§         sincerity of effort, (6,4) and

§         whether FCEs meet legal standards of relevance and reliability.  (8)

No effort is being made here to revisit the concepts of test validity and reliability in any detail, as those concepts are more than adequately covered elsewhere.  However, qualified VEs are cognizant of the basic concepts of validity and reliability and are ethically bound to consider these factors as well as test standardization or uniformity of testing procedures in formulating their forensic findings and opinions.

If a test of an individual’s performances are to yield data that allow for comparisons with others or predictions of the same individual’s behaviors in different settings or on different occasions, the testing should be administered in a uniform fashion. That is, the test problems, conditions for test administration, scoring procedures, and interpretations need to be consistent and carried out in a standardized manner. (14)

In research, validity and reliability are essential aspects of an experiment that has merit.  Validity is the ability of the experiment or test to accurately reflect what it purports to measure and ecological validity is a subset of test validity. (15)

FCEs must be capable of accurately providing a foundation from which to infer appropriate, meaningful, and useful behavior regarding physical functioning in the workplace.  That is, FCEs must be ecologically valid or capable of reflecting the examinee’s real-world performance. 

Every VE knows that the value of a standardized measure is determined by its reliability as well as its validity.  The assessment of reliability invariably boils down to a simple summary statistic, the reliability coefficient, but practically speaking, reliability speaks to consistency.  If FCEs are to be of value to VEs, injured people, the court system, physicians, and employers, they must be consistent not only from test to re-test, but also when administered by two or more different examiners and in between parts of an assessment.  As King (5) states, “To the clinician, reliability means that changes in a client’s performance can be attributed to real change in function rather than to measurement error.” 

FCE data are often interpreted in an accompanying narrative report authored by the evaluator.  The language contained in FCE reports can be difficult to interpret as suggested by the following: “Results obtained indicate this client performed with determined, consistent effort and demonstrated appropriate pain behaviors.”  It is difficult to appreciate the meaning of these words exactly in terms of what the FCE measures or what it purports to measure (i.e., the individual’s physical capacities), and whether, if re-tested at another time or by another examiner, this language would appear again in the narrative report.  However, the primary concern must be whether the functional capacity examinee’s measured behaviors have application to the workplace.

 Some proprietary FCEs present inconsistent information regarding standard physical classifications of strenuousness defined by the U.S. Department of Labor.  (16)  Those classifications are sedentary, light, medium, heavy, and very heavy.  Some FCE reports combine these definitions (as in sedentary-light) and by doing so, confuse the issue of whether the examinee is capable of one exertional level or both levels.  This could represent a substantial difference in RFC, resultant employability, and ultimately earning power.

VEs rely heavily upon this terminology to make accurate and reliable assessments of an individual’s residual employability.  FCE report language such as, “Based on results obtained, the client is able to perform Sedentary-Light PDC (physical demand component) work with occasional lifting below waist height to 25 pounds, and the client lifted 35 pounds to shoulder and 20 pounds overhead,” potentially confuses the VE’s assessment.  By definition, the capacity to lift 25 and 35 pounds places the individual above the light work domain and into the medium category of work as defined by the U.S. Department of Labor. (16)  In offering quantitative data regarding lifting and then mislabeling that data with the incorrect physical work classification, the FCE report can lead to a potentially inaccurate vocational evaluation and/or an incorrect forensic conclusion.

A standardization of language must be basic to the FCE and congruent with accepted definitions of physical strenuousness.  Efforts to consistently employ the federal definitions of work in FCEs would prove helpful to the subsequent process of conducting accurate vocational assessments.  Otherwise, it should be left to the VE to match the examinee’s measured physical capabilities with the Department of Labor definitions or a specific known job description.  Uniformity of language regarding physical strenuousness would improve the interpretation of FCE outcomes.

Among the different FCEs utilized in determining how an individual’s exertional impairments translate into RFC, one of the more significant variables is whether the FCE relates to a full day and/or a full week of work.  The VE may consider this distinction as the difference between part-time and full-time employment.  VEs generally remain at a loss as to how FCEs can predict part- or full-time employment or endurance in general.

As an actual example, an FCE report contained this language: “In a valid representation of physical capabilities based upon consistencies and inconsistencies when interfacing grip dynamometer graphing, resistance dynamometer graphing, pulse variations, weights achieved, and selectivity of pain reports and pain behaviors,” the individual manifested a “sitting tolerance of 23 minutes demonstrated during keyboard activity and history review.”  In this case, the functional capacity assessment specialist “recommended” a workday “tolerance” of only two hours.  Within weeks of these FCE findings, when examined for vocational evaluation, the same individual was able to remain seated for more than two hours without interruption while completing paper-and-pencil vocational tests.  More discrepancies between FCE “recommendations” and actual vocational assessment behaviors were observed.

In still another FCE utilizing a different protocol than that referenced above, the document reporting the FCE data contained a “functional capacity summary” that described the examinee’s sitting job demands as frequent (34-66% of the time).  However, additional comments read, “It is recommended that he take short standing/stretch breaks during periods of prolonged sitting (e.g., greater than one hour).”  No reason was given for this added comment, but the vocational ramifications are potentially significant.  The examinee was a tractor-trailer truck driver, and even though he could perform medium work with frequent sitting, it was “recommended” that he not sit for greater than one hour without taking a “short” standing/stretching break, undoubtedly incompatible with his job demands and not at all explained in the FCE report.

Sincerity of effort remains one of the most controversial and unresolved issues associated with the efficacy of FCEs, according to Lechner (6) and others. (17,4)  According to Lechner, (6) “The standardization, reliability, and validity of some of the methods used to determine sincerity of effort are questionable.”  As an example, Lechner notes that Waddell’s non-organic signs are frequently used in FCEs.  Scoring positively on the Waddell’s should not allow one to conclude that the client is withholding full effort, and conversely, demonstrating less than the necessary 3 out of 8 positive scores on the Waddell’s is not necessarily indicative of “appropriate pain behavior,” by which one could conclude that sincere effort has taken place.

Dakos (4) speaks of multiple factors that should be considered in assessing genuine performance or effort and recommends that skilled functional capacity evaluators observe and report, but not analyze, performance-limiting behaviors.  Analyzing performance-limiting data avoids the potential error in logic that an individual who has conceivably set forth “genuine effort” during an FCE is necessarily a sincere and reliable examinee under all circumstances, including when returned to work, where conditions might be quite different than the controlled atmosphere of an FCE.

With respect to pain-related deficits, the results of FCEs are frequently described in reports with rather confusing language.  Too frequently, the evaluation can be affected by a subjective complaint and, in some cases, less than maximal effort by the examinee.  In cases involving litigation, the injured worker’s effort in testing is often an issue, particularly if the person being evaluated anticipates financial gain by demonstrating weakness and/or dysfunction.

FCEs are also limited in their potential to discern between the results produced by pre-existing impairment (e.g., osteoarthritis and degenerative joint disease) and traumatically-induced, accident-related impairment.  VEs may be charged with the responsibility of determining residual employability and earning power following the accident, but based on the medical history, the individual may have had a pre-existing exertional impairment affecting strength and, of course, FCE outcomes.

Consider, for example, a 56-year-old truck driver with a history of spinal complaints and radiographically documented severe spondylosis and degenerative disc disease.  Nonetheless, he was working as a truck driver prior to a work-related accident in which he sustained a shoulder injury lifting.  After undergoing physical therapy, he is examined with an FCE and found capable of lifting no more than 20 pounds, and therefore, restricted to light work as defined by the U.S. Department of Labor. (16)  The government classification of his job is medium work, which is more demanding than his measured capacity for light work.  However, the question is: “Which impairment limits his measured functional capacity?”  Is it his accident-related shoulder pathology or his pre-existing spinal disease?  FCEs have yet to reach a level of sophistication to answer this question.

Still, the question of discerning in this particular case which impairment caused exertional limitations could have particular importance to a vocational-legal argument that the examinee could have worked and earned money indefinitely as a truck driver, for example, had the accident-related shoulder injury not occurred.  Alternatively, the FCE might be used in a setting that concerned itself with apportionment.  All too often individuals come to functional capacity evaluations with strength-limiting co-morbidities, perhaps only one of which is related to trauma resulting in a lawsuit.  Future FCE research and design might focus on these issues of differentiation and apportionment.

Functional testing has become an increasingly important aspect of the VE’s analysis of residual employability, but it is not beyond challenge.  With the fabled U.S. Supreme Court decision in Daubert v. Merrell Dow Pharmaceuticals, (13) the American court system has increased the standards and refined its definition of what constitutes relevance and reliability for expert testimony.  According to Dominick, (8) with the standards of expert testimony increasing, VEs should be prepared to deal with cross examination regarding measurement theories, reliability, validity, test selection, testing methods, outside entity standards, and FCE vulnerability. 

Standardized FCEs would seem to hold substantial promise in providing accurate and reliable data regarding an individual’s physical capacities for work.  This is particularly true when compared to the conjecture of a healthcare professional who has been asked to simply fill out a checklist or provide a generic statement (e.g., “light duty”) of what he/she thinks or feels a patient might be able to do in the workplace.  In this respect, FCE standardization seems far off.  Lechner (6) identifies ten different FCE protocols, all proprietary, and noted an apparent lack of research supporting the validity and reliability of the methodologies.  King (5) encourages and challenges FCE developers to conduct research and improve their assessments to levels of reliability and validity that are scientifically sound and legally defensible.

Although FCEs hold the potential to be an invaluable tool for the VE, there is a need to continue to refine the process and especially the precision and standardization of the report language.  VEs remain concerned regarding the efficacy of FCEs.  When the purpose of the FCE is to provide the VE with the basis for case testimony, FCE validity, reliability, and language are critical.  Functional capacity evaluators and VEs will, for the foreseeable future, need to continue a refinement dialogue.

References: 

1.      Weed RO, Field TF.  Rehabilitation Consultant’s Handbook.  Revised Edition.  Athens, GA: Elliott & Fitzpatrick, Inc.; 2001:31-32.

2.      Talmage, JB, Melhorn, JM. (Eds.).  A Physician’s Guide to Return to Work. American Medical Association; 2005.

3.      Talmage, JB, Melhorn, JM.  How to think about work ability and work restrictions:  Risk, capacity, and tolerance.  In A Physician’s Guide to Return to Work.  American Medical Association; 2005:10.

4.      Dakos MS.  The application of functional capacity evaluations in the provision of vocational expert services.  The Journal of Forensic Vocational Analysis.  2004;7:105-117.

5.      King PM.  Analysis of the reliability and validity supporting functional capacity evaluations.  The Journal of Forensic Vocational Analysis.  2004;7:75-82.

6.      Lechner DE.  The well-designed functional capacity evaluation: application in forensic vocational analysis.  The Journal of Forensic Vocational Analysis.  2004;7:83-96.

7.      McDaniel RS, Tilton J, & Philadelphia, A.  Use of the functional capacities evaluation in the vocational expert practice: help or hindrance.  The Journal of Forensic Vocational Analysis.   2004;7:97-104.

8.      Dominick BK.  Daubert & ADA decisions: will functional capacity evaluations hold up in court?  The Journal of Forensic Vocational Analysis.  2004;7:119-126.

9.      Brandt EN Jr, Pope AM. Enabling America: Assessing the Role of Rehabilitation Science and Engineering. In: Guides to the Evaluation of Permanent Impairment. 5^th Ed.  AMA Press; 2005:8.    

10.  Cocchiarella, L, Andersson, G.  Guides to the Evaluation of Permanent Impairment.  5^th Ed.  AMA Press; 2005:2-3.

11.  Hale, BL.  From the Editor’s Laptop [editorial].  The Vocational Expert.  2007:3.

12.  Federal Rules of Evidence.  No. 8, Washington: U.S. Government Printing Office; 2004.

13.  Field TF, Choppa T, Dillman EG, et al. A Resource for the Rehabilitation Consultant on the Daubert and Kumho Rulings. Athens, GA: Elliott & Fitzpatrick, Inc.; 2000:61-104.

14.  Anastasi, A.  Psychological Testing.  7^th Ed.  Prentice Hall; 1997.

A Lexicon for Vocational Rehabilitation Personnel and Professionals in All Related Fields

by Jasen Walker, Ed.D., C.R.C., C.C.M.

Vocational rehabilitation in the private sector is an established profession.  It has been a process used by well-managed companies for well more than three decades to retain trained and valued employees, and provide alternative job placement.  Other specialized fields related to vocational rehabilitation include disability management, case management, physical therapy and work hardening, forensic evaluation and expert testimony, and legal representation in workplace issues.

A comprehensive vocational rehabilitation program is made up of specific components that have evolved from empirical investigations, creative developments, and practical experience.  These components have been refined as progressive companies have created new approaches to rehabilitation and disability management and tested their value in real world applications.  Over time, the best of these component practices have been accumulated into what are called “exemplary” disability management programs.

All rehabilitation and allied professions can be structured around their organizing concepts.  These concepts can, in turn, be broken down into individual terms.  A compilation of these individual terms constitute a lexicon specific to the professions. 

CEC Associates, Inc., (located in Valley Forge, PA and Miami, FL) has, for many years, contributed to the development and testing of vocational rehabilitation and disability management components (disability proneness, worker learned helplessness, transition-to-work, etc.).  More recently, we have begun to accumulate and publish a lexicon of the terms basic to the rehabilitation and disability management professions.  The lexicon is a crucial aspect in identifying, defining, and documenting the individual approaches that make up vocational rehabilitation and disability management programs.

The Workipedia Lexicon

Ability:  In terms of a work environment, “ability” means being able to perform the essential functions of a job. 

ADA:  Acronym for the Americans with Disabilities Act.

Ageism:  Ageism commonly refers to negative discriminatory practices regardless of the age towards which it is applied. 

§         Adultism – A predisposition towards adults, which is seen as biased against children, youth, and young people.

§         Jeunism – A predisposition towards young people.

Americans with Disabilities Act: A federal program enacted in 1990 intended to make American society more accessible to people with disabilities. 

The Act is divided into five Titles:

            Title I: Employment

            Title II: Public Services

            Title III: Public Accommodation

            Title IV: Telecommunications

            Title V: Miscellaneous

Title I may be summarized by saying businesses must provide reasonable accommodations to protect the rights of individuals with disabilities in all aspects of employment.  Changes employers may be required to make include restructuring jobs, altering/modifying workstations, or modifying equipment.  Also addressed specifically are the application process, the hiring process, wages, benefits, and all other aspects of employment.  Medical examinations of employees are regulated.

An individual is deemed to be “disabled” if he or she meets at least one of the following tests:

§         He or she has a physical or mental impairment that substantially limits one or more of his/her major life activities

§         He or she has a record of such an impairment

§         He or she is regarded as having such an impairment

Key provisions of the ADA are that an employee can, with or without accommodation, perform the essential functions of a job as determined by a job analysis.

Title I applies to employers of fifteen employees or more.  All other provisions apply to all sizes of business regardless of the number of employees.  State and local governments are covered regardless of size.

Amputation:  The removal of an extremity by trauma or surgery.  As a surgical measure, it is used to control pain or remove a diseased limb that cannot otherwise be cured.

Armed Services Vocational Aptitude Battery:  A multiple-choice test administered by the United States Military Entrance Processing Command used to determine qualification for enlistment in the United States armed forces.  It consists of nine sections:

§         General Science

§         Arithmetic Reasoning

§         Word Knowledge

§         Paragraph Comprehension

§         Mathematics Knowledge

§         Electronics Information

§         Auto & Shop

§         Mechanical Comprehension

§         Assembling Objects

Assessment:  Assessment is the process of documenting (in measurable terms) knowledge, skills, attitudes, and beliefs.  Validity and reliability are essential elements for determining the quality of any assessment.  Assessment can be formal (by way of a written document, such as a test) or informal (by way of observation, peer and self evaluation, or discussion).

Atrophy:  The partial or complete wasting away of a part of the body.  Causes of atrophy include malnourishment, poor circulation, loss of nerve supply, or a lack of exercise.  Most forms of atrophy can be reversed through physical therapy and proper nutrition.  However, cases of atrophy that are caused by nerve damage (such as a spinal cord injury) can be permanent and progressive.

Attribution Theory (sometimes called “causal attributions of occupational disability”):  Attribution theory is the cause-and-effect analysis of personal behavior made by ordinary individuals.  The attribution is a mechanism by which people construe the causes of and arrival at their beliefs about success and failure.  Attribution theory helps explain not only how individuals perceive their own successes and failures, but how they causally ascribe the achievement and failure of themselves and others.

Avocation:  An activity carried out in addition to a primary occupation or profession, such as a hobby.

Behavior Management:  All of the actions and conscious inactions enhancing the probability that people, both individually and collectively, choose behaviors that are personally fulfilling, productive, and socially acceptable.

Belief-Bias Effect:  A situation that occurs when a person’s prior knowledge, attitudes, or values distort the reasoning process by influencing the person to accept invalid arguments (i.e., “I’m disabled because the Social Security Administration says I am.”).

Botoxin:  A neurotoxin made by the Clostridium botulinum bacteria.  It can cause food poisoning.  Although many types of Botulinium toxin exist, only types A (Botox Cosmetic) and B (Myobloc) are used as medical treatments.  Botoxin has been effective in the treatment of many illnesses, including urinary bladder retention, dysphonia, and voice tremors.

Brachial Plexopathy:  Decreased movement or sensation in the arm and shoulder caused by impaired function of the brachial plexus (a bundle of nerves that controls sensation and movement of the arm).  Brachial plexus dysfunction is a form of peripheral neuropathy.  Damage of the brachial plexus is usually related to direct trauma to the nerve, stretch injury, pressure from tumors, or damage that results from radiation therapy.