Resumen de Functional capacity evaluation using applied biomechanics in occupational and legal settings. Situation in spain
Functional Capacity Evaluation (FCE) has become an important tool in impairment and compensation calculation. It is considered to be a means to objective measurements, as precise machines and engineering tools are used. To date, FCE in the occupational field has four major applications:
1. Measuring the ability of a person to perform at a future workplace (FCE-P); 2. Guiding and controlling a clinical treatment process (FCE-RHB); 3. Defining and managing the point of "Return-to-work/(Return-to -sport)" (FCE-RtW); 4. Establishing functional deficits for evaluating legal claims (FCE-Legal).
A relatively new use of FCE is the prevention of accidents, which is mostly related to sports science, as non-contact lesions are very problematic in this field. It is not yet much used in the occupational field, although the first application in the above list might result in greater implementation.
Whilst technology for FCE has been developed within the last 200 years, the concept of evaluation and compensation is far older. From the times of the Pharaohs, through the era of the pirates and up to the present day, compensation of loss of limbs and limitation of functions of the musculoskeletal system has been claimed and often established on a legal basis. In earlier times, evaluation was performed optically; either you had or you lost an extremity. Since then, this situation has changed drastically and is far more complex on both medical and legal grounds. Additionally, the prevention of accidents at the workplace, including medical checks prior to beginning at a new workplace, has become very important in modern society. A short introduction of this history will be given.
The basis for decisions is established within the national laws in each country and supported by initiatives such as those provided by the World Health Organisation (WHO). Thereafter, final decisions are made at the legal level. However, as the subject of interest is the function of the human body, final evaluation can only be made at the clinical level. The difficulties in combining both sets of criteria will be detailed in this project.
For many years clinical decisions were based on the experience of the professional, resulting in very mixed success in diagnosing and treating patients. In recent times, a first step in improving this subjective analysis was the introduction of evidence-based medicine. Evidence was given when a certain technique was presented in a controlled study and statistical improvements were shown to the scientific community. As a wide range of aspects needed to be considered when performing a study, presented results also varied widely. In 1972, Archie Cochrane published his article "Effectiveness and Efficiency: random reflections on health services" leading to the establishment of the Cochrane Database, where the quality of studies and their potential medical impact were provided. Whilst these initiatives have improved the modern general health service, final clinical decisions are still based on the personal experience of the clinical professional. In order to improve the objectivity of each case, the idea of measuring human function has become very important. Currently, several different and controversial methodologies and systems are available for performing FCE. But as there are aspects of the human body that are still impossible to measure with any exactitude, such as pain and its effect on function, the level of objectivity of these tests is still questionable. This project intends to analyse the current situation and provide a starting point for the discussion of future developments and the cooperation between the legal and clinical fields using a biomechanical approach.
This thesis consists of the following parts: - General Introduction into the subject; - The evaluation of current concepts in practice and their possibilities and limitations, including the different methods and approaches relating to these concepts; - The presentation of a biomechanical full body model for behaviour studies.
The main focus of this project is the analysis of FCE following an accident at work and the subsequent clinical and legal consequences. Whilst the concepts presented in this thesis are valid generally, particular focus will concern the current situation in Spain. This is based on nearly 11 years of experience in a motion laboratory in a "Mutua de accidentes", an insurance company for work-related accidents with its own clinical department.
This thesis will incorporate a wide range of concepts of the different fields necessary to perform FCE on an evidence-based scientific level. These concepts are explained on a basic level with regards to the relation to FCE. However, it is not intended to describe these concepts in detail, as this can be easily found in specialised handbooks, but it will list ambiguous terms which directly affect FCE and demonstrate possible influences.
As it is important to differentiate between objective and subjective information in the legal field, this work will show that, besides the interpretation of clinical results by a medical consultant, the engineering aspect of biomechanical measurements can be as subjective as the interpretation of data, but might be better in terms of the variability of error.
Although it is impossible to provide solutions to the problems illustrated, the intention is to produce a basis for inter-professional discussion in order to proceed from the current situation in FCE to a situation where the methodologies applied are more generally valid and accepted. Problems will be highlighted when the historical development of definitions has not been standardised, resulting in potential misinterpretation.
The CoM projects presented are examples of situations where practitioners are faced with certain problems and solutions have to be found on a practical level. Progression has been achieved with inter-professional consultation and participation, but even though this work has been presented and discussed at several congresses, it is still only a proposal and in order to be useful on a general level, rigorous scientific testing is essential.
