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Work Capacity Evaluation Professor Gorman

#1 User is offline   Alan Thomas 

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Posted 06 March 2007 - 02:43 PM

This is quite an important read so as to understand what a medical assessor is looking at.


Work capacity evaluation
Michael Menard, Senior Lecturer; Des Gorman, Head, Occupational Medicine, Department of Medicine, Faculty
of Medicine and Health Sciences, University of Auckland, Auckland.
NZ Med J 2000; 113: 335-7



Work capacity evaluation (WCE) is a systematic method of
measuring a worker’s ability to perform occupationallymeaningful
tasks safely and dependably, for the purpose of
evaluating their fitness and risk when starting to work or
when returning to work after an injury or illness. WCE is
also used to determine the presence (and, if present, the
level) of disability so that the patient’s case with a workers’
compensation carrier can be bureaucratically or judicially
concluded. General practitioners (GPs) in New Zealand
encounter WCEs as part of the Work Capacity Assessment
Procedure (WCAP) inaugurated by the Accident
Rehabilitation Compensation and Insurance Corporation
(ACC) in late 1997.1 In the WCAP, an Occupational
Assessor (OA) will have worked face-to-face with an injured
worker when they have reached their maximal medical
improvement and completed rehabilitation.
The nature of a WCE is to observe the evaluee as he or
she performs certain specified physical tasks, and rate
performance on a scale of named categories of physical
activity factors that address strength and dexterity. The
evaluator also records illness behaviour (clutching the lower
back, pain vocalisation etc) and explicitly solicits the
evaluee’s perception of difficulty experienced while
performing the task. Nominally, physical factors are not to
be considered in isolation from non-physical factors. In
practice, they tend to dominate discussion since they are the
least disputable aspect of the evaluation.
A stereotyped procedure should be followed, and includes
attention to the preparation (psychological and physiological)
of the evaluee, to the precise instruction given, and to making
a specific inquiry afterwards about ‘how it felt’ to perform the
evaluation activity. In light of the trend in human rights
legislation, it is usual to record explicitly that the evaluee
participates voluntarily in each task. Computerised systems
facilitate such systematic practice. They also tend to
incorporate both the features of good clinical measurement
practice2 and the rules of legal evidence.3 As in all clinical
situations, the interpersonal interaction between the patient/
evaluee and the evaluator can influence the performance. It is
a challenge to maintain inter-observer reliability.
We have found that similar ratings are produced by
gymnasium-based assessments, observation of simulated
shop tasks, and an elaborate computerised work simulator.4
The final ‘strength’ rating tended to be different with the
different methods, because of the design of the method. For
example the work simulator was programmed to award a
particular ‘strength’ rating only if all subtasks were
performed successfully at that level, while the physical
therapist usually would look at the evaluee’s general pattern
of performance in arriving at a rating. Overall, we found that
the work simulator’s computer program rated a person
slightly lower than the clinical observer, and the shop
evaluator rated them slightly higher, on the basis of
evaluations that were performed at the same time, but that
all methods correlated highly in their detailed results.4
The favourable technical and practical aspects of WCEs
reflect their development through a long and pragmatic

interaction of controlled (scientific) and real-world
necessities. It is instructive to review this process. The
current approach to WCE developed from three main
sources: (i) Frederick W Taylor’s ‘laws of scientific
management’; (ii) the United States Dictionary of
Occupational Titles (DOT) listing of the factors that were
required in order to match workers to jobs, and in particular
the physical ones; and (iii) an ergonomic analysis of the most
common physical tasks of occupations.
FW Taylor pioneered the systematic analysis of the
physical demands of realistic work tasks. From the outset,
Taylor found he had to give considerable attention to
motivation: how to instruct the worker so he would be a
“first class man”.5 Two of his four principles of scientific
management dealt with this. The basic idea of matching the
measured demands of the job with the measured capacities
of the worker has endured. Thereafter, time and motion
studies were done of everything, and the term entered the
popular culture. Even the division of tasks in the surgical
suite that is so familiar to clinicians today resulted from such
an analysis of the (inefficient) previous system. Taylor’s
method of ‘work engineering’ evolved into one by which the
job could be formulated in such a way that the particular
worker could be first class at it.
Each job has unique features, but most job types can be
classified according to their usual demands, including their
physical demands, as in the DOT in the USA. The
Australian Classification of Occupations and the New
Zealand Standard Classification of Occupations are oriented
mainly to the skill level demanded of each job.
Hanman6 reports that in practice, the main effect of efforts
to identify the demands of a given job was to educate
employers to consider what was required to perform that
job, and not to reject out of hand any applicant with a
physical impairment:
“The idea behind the study was one of education, to
have foremen, in particular, realize that it didn’t take
supermen to perform each job in this plant, that most of
the jobs could be done by workers with all kinds of
disabilities.”
During the development of the third edition of the DOT,
employment experts selected the following components as
being the variables with the greatest potential relative to a
functional capacity scheme: aptitudes, interests,
temperaments, work performed, physical capacities, working
conditions, training time and industry. These experts
developed a series of rating scales and defined factors for the
purpose of compiling the attributes of each listed job. The
Physical Capacities component consisted of six categories
that were combinations of various factors in use at that time.
This is the origin of the ‘physical factors’ component of the
usual WCE.
Although ergonomists claim that in application,
ergonomics requires an eclectic philosophy and knowledge
from different disciplines rooted in the life, behavioural, and
engineering sciences, they also admit that occupational
applications have emphasized biomechanics as its primary



science.7 That is, although biomechanics is only one aspect
of a complex problem, it is a fundamental one. WCE
similarly focuses on physical activity factors related to work.
Nevertheless it has become the tradition to summarise
evidence about manual materials handling (MMH) under
four approaches: epidemiological, biomechanical,
physiological, and psychophysical.8-10 Ergonomics quite
clearly straddles medicine and occupation, and some basic
patterns of the modern health services approach can be seen
to have influenced its development.
The approach to the study of MMH during much of the
twentieth century has been like that of exposure to
potentially injurious agents in the course of work. This has
caused little dispute for physicochemical exposures in
general where damage to flesh is obvious. During the past
few decades, the approach has been extended fruitfully to
subtler exposures and to delayed manifestations of
physicochemical exposure. It was also used to trace a
putative causal chain back from an illness, disease, or injury,
to an occurrence at work. Under the assumption that the
same reasoning should apply, soft tissue injury came to be
attributed to exposure to physical activity, as an overexertion
injury.9 The problem was, there often was no biomedical
abnormality detectable in the sufferers, and a wide
diversity in the extent of work disability claimed by those
with similar initial ‘exposure’ and even by those with similar
initial clinical course.11 Consensus tends not to be broad
unless the situation is as obvious as amputation of a limb,
and even then there is room for dispute.12 In the absence of
consensus on causation, legitimate competing interests such
as labour and employer would have nothing to mitigate their
natural inclination to interpret a situation in a way
favourable to their own interests. As it has happened, the
history of this topic is characterised by dispute rather than
consensus. An ‘answer’ is demanded from the clinician.
When a clinician encounters a practice situation that is
novel and complicated, such as evaluating a person’s
fitness and risk relative to occupation, it is helpful if
information of high scientific quality is available, ideally
information based on evidence. The WCE process is
important in itself, but it illustrates an approach the
clinician can take in other such situations.
Most clinicians, as ‘treating clinicians’, evaluate a person
for determining the medical diagnoses, in order to treat
them. The role of ‘evaluating clinician’ differs in several
aspects: the evaluee (not ‘patient’) usually is not acutely ill
and is attending as a requirement for obtaining a specific
benefit (medical aid, compensation, or award for permanent
impairment); the nature of the evaluation is specified by the
referral source, even though an essential requirement is that
the clinician render a professional judgement about the
evaluee’s fitness and risk regarding some activity or
occupation (an aspect not covered in most medical training);
the clinicians primary responsibility is to report to the
carrier, not to the evaluee; and the clinician is paid by the
carrier. In a recent decision, the Court of Appeal in England
held that a doctor retained by a company to advise on
occupational health matters owed no duty of care to a job
applicant (Kapfunde v Abbey National & Daniel [1998]
IRLR 583 (CA)). Fortunately, the WCE provides the
clinician with the sort of information they need to maintain
focus in this complicated situation. The outcome of the
overall process, of which the clinician’s contribution is just
one part, is successful participation by the worker in
appropriate employment. Employment is a complex
outcome, and the clinician must focus only on the portion of
the process that is assigned to them by the terms of
reference, such as by the WCAP.3,13





The relative quality of different types of scientific evidence
has been discussed extensively.14 The strength of a study is
generally improved by increasing the specificity of the
patient group, the intervention, and the measured outcome,
but to do so makes the study less relevant to the usual
circumstances of practice. The strength of the WCE
approach is that it separates out from a complicated situation
(employment), one aspect (physical demand) that is
susceptible to scientific inquiry, and for which a broad expert
consensus has been established. Although perhaps not the
ideal, this still is good information on which to base clinical
practice guidelines.15 The approach taken to legislation in
this complex area is to proclaim a contemporary provisional
regulation (ie something to use now) but also to require
ongoing research.
Clinicians are now expected to view health more broadly
than has been their tradition, and especially to consider any
limitation on the ability of the patient to function.16,17 It could
be argued that the healthiest people in society are those
engaged successfully in competitive employment. However,
employment is a social phenomenon, encompassing biological,
psychological and social considerations. It is not amenable to
the reductionist approach of traditional science. It will continue
to be an area of controversy involving trade-offs between
legitimate competing interests. Amidst such complexity, the
clinician’s traditional skills and expertise can provide clarity in
at least one domain. Clinicians are familiar with preparticipation
examinations, such as for sports or driving. It first
is determined whether there is substantive active disease, and if
so, whether it is being appropriately treated. If this question is
thought of as “What is wrong?”, in the usual biomedical sense,
the next question is “So what?” - what are the consequences for
the person’s function? In the WCAP, the medical assessor is
only asked the former question. If no important disease is
apparent by a conventional medical investigation, it is only
necessary for the clinician to say so.
‘Function’ is a concept with depth and breadth, spanning a
spectrum from caring for oneself to performing manual
tasks, walking, seeing, hearing, speaking, breathing, learning
and working.11 Clinicians in general are most familiar with
acute and critical care where the concern is with maintaining
the patient’s vital processes, identifying biomedical diagnoses
and establishing treatment. Post-acute care is concerned
with supervising biomedical treatment, monitoring to detect
recovery or relapse and starting rehabilitation. It is in
rehabilitation that the patient’s independence of function is
the main concern (“the ability of the patients to perform the
daily activities of their lives, how they feel, and their own
personal assessment of their health in general).18 The
clinician needs to be clear about which domain of clinical
practice they are working in, because the priorities are
different in each, for treatment objectives and hence for
treatment methods. In complex situations such as worker
fitness and risk evaluation, the clinician need not and should
not render a professional opinion that includes areas of the
overall problem that are beyond their area of expertise.19


Correspondence. Professor D Gorman, Occupational Medicine Unit,
Department of Medicine, Faculty of Medicine and Health Science, The
University of Auckand, Private Bag 92019, Auckland. Fax: (09) 308 2379;
Email: [email protected]



































1. ACC Dec 1997. Work Capacity Assessment Procedure (WCAP). Final Version, Wellington:
October 1997.
2. Rothstein JM. Measurement and clinical practice: theory and application. In: Rothstein JM,
editor. Measurement in physical therapy. New York: Chuchill-Livingstone; 1985. pl-46.
3. Wilner KM. The physician as a witness. In: Demeter SL, Andersson GBJ, Smith GM,
editors. Disability evaluation. St. Louis, Missouri: American Medical Association / Mosby;
1996. p63-67.
4. Dusik LA, Menard MR, Cooke C et al. Concurrent validity of the ERGOS work simulator
versus conventional functional capacity evaluation techniques in a workers’ compensation
population. J Occup Med 1993; 35: 759-67.
5. Taylor FW. Scientific management. New York: Harper and Brothers; 1929.
6. Hanman B. Physical capacities and job placement. New York: Harper and Brothers; 1929.
11 August 2000 New Zealand Medical Journal 337
7. Goguen L. The general aptitude test battery. [Paper presented at the Atlantic Region
convention of the Canadian Guidance and Counselling Association, Halifax, Nova Scotia in
May of 1976, and available from the ERIC Document Reproduction Service].
8. Chaffin D. Egonomic basis for job-related strength testing. In: Demeter SL, Anderson GBJ,
Smith GM, editors. Disability evaluation. St. Louis, Missouri: American Medical Association
/Mosby; 1996. p159-67.
9. Troup JDG, Edwards FC. Manual handling and lifting. London: Her Majesty’s Stationery
Office; 1985.
10. Badger DW, Habes DJ, editors. Work practices guide for manual lifting. Cincinatti, Ohio:
National Institute for Occupational Safety and Health; 1983.
11. Demeter SL, Anderson GBJ, Smith GM, editors. Disability evaluation. St. Louis, Missouri:
American Medical Association/Mosby; 1996. p2-4.
12. Menard MR. Comparison of disability behavior after different sites and types of injury in a
workers’ compensation population. J Occup Envion Med 1996; 38: 1161-70.
13. Butler RJ, Johnson WG, Baldwin ML. Managing work disability: why first return to work is
not a measure of success. Ind Labor Relat Rev 1995; 48: 452-69.
14. Chalmers I. Unbiased, relevant, and reliable assessments in health care. BMJ 1998; 317: 1167-8.
15. US Department of Human Services Guideline Panel. Acute low bck problems in adults.
Rockville, Maryland: US Department of Health and Human Services; 1994. p13.
16. Ware JE. Measures for a new era of health asssessment. In: Stewart AL, Ware JE, editors.
Measuring function and well-being, the Medical Outcomes Study approach. Durham and
London: Duke Univeraity Press; 1996. p3-11.
17. National Advisory Committee on Health and Disability. The social, cultural and economic
determinants of New Zealand health. Wellington: National Advisory Committee on Health
and Disability. 1998.
18. Stewart AL, Ware JE, editors. Measuring function and well-being, the Medical Outcomes
Study approach. Durham and London: Duke University Press; 1996.
19. Davies W. Assessing fitness for work. BMJ 1996; 313: 934-8.
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#2 Guest_mini_*

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Posted 07 March 2007 - 09:13 AM

Hi Alan

Thanks for posting that very interesting information.

Have just had IMA at lower level, will have report back in two or three weeks. It maybe on to this level as you have posted. I am not sure. But have had a great interest on how the whole process works as cannot Review it, if we don't know how the come to the conclusion they do.

Can you post the actual document to download, or should I e-mail the University to get a copy sent.

Cheers
Mini
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#3 User is offline   Alan Thomas 

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Posted 07 March 2007 - 12:48 PM

Mini do a word search on the Internet.

Professor Gorman has framed his language to suit his international presentations.

You should download the Ramsay decision and another publication called Vocational Independence Outcomes for ACC Claimants published February 2007. If.

If you are concerned about your assessments you should prevent the assessment going to the ACC utilising the privacy act to prevent wrong information falling into the hands of the ACC. You will then need to challenge the assessor to correct the information about you. For example if the assessor states that you have qualifications of a certain type which you don't have then they have produced a document that is capable of pecuniary advantage (fraud) and you can certainly such information about you entering into the system.
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Posted 07 March 2007 - 02:59 PM

hey Alan Thanks for that.

I don't think I can sit here any longer today.

I am starting to feel that invisible skull cap sitting on my head and that is not a good sign.

I can just hope that the IMA went OK. Have too much to do to worry about it until it happens.

I often get acused of jumping the gun, or longing too far into the future, worrying about things before they happen.

I actually think pre-armed is pre-warned. Makes me feel better at the end of the day. But one can suffer from overload of information.

Thanks for the interesting read.

Mini
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