American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
Fitness for Duty Evaluations
American Osteopathic College of Occupational and
Preventive Medicine
Mid year meeting
Clement Hanson DO, MPH (COL, RET.)
March 15, 2012
Vinoy Renaissance, St. Petersburg
Purpose of Fitness for Duty (FFD) Eval:
FFD Components
 Individualized
 Identify worker’s maximum job capabilities
 Job specific
 Applicable to worker’s job
 Interview: health history, questionnaires
 Match functional capability to physical demand
requirements
 Musculoskeletal exam
 Provide information regarding worker’s limitations and
 Movement tests
abilities
 What can worker do safely and repetitiously?
 Medical basis: Scientific reliability and validity
Employer Responsibilities
Who Refers Worker for FFD?
 Physician
 Written policies and procedures
 Other health provider
 Staff training to identify “triggers”
 Case manager
 Employer
 Protocol: disclosure of employee health information
 Supervisor
 Outcomes following FFD evaluation
 Insurer
 Attorney
 Coordination with Federal, state, local agencies, ADA
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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
Physician
“Consultants”
 Integrates the data
 What triggered the FFD?
 Review the job description
 Drug screening protocol
 Work restrictions/job accommodations
Medical Reasons for FFD
Environmental Safety and Health Professionals
 Develop effective controls to minimize hazards
 Injury prevention
 Pre or Post Job offer
 Personal health is predictor of workplace safety risks
 Periodic screening
 Ergonomic job site “walkthroughs”
 Job transfer
 Return to work
 Involvement of union representatives
 Work related injury/illness management
 Early return to work evaluation
Chronic Illness or Injury Management
Pre-Offer FFD
 Non-medical personnel may perform
 Usually at Maximum Medical Improvement (MMI)
 No medical history or physical exam
 Job placement functional abilities
 ADA prohibits discriminatory testing
 Dispositional FFD as adjunct to Independent Medical
Evaluation.
 Special circumstance
 Early return to work evaluation
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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
Other FFDs
Post Offer FFD
 Performed by medical personnel
 Dispositional FFD with IME

Case closure/claim settlement
 Personal health risk factors: smoking,
deconditioning, sleep disorders
 “Special Purpose FCE”

Can worker return to current or alternate position?
 Drug and alcohol testing
 Can applicant perform essential job functions?
FFD Precautions
Prior to Testing
 Informed, written consent
 Medical conditions that could be exacerbated during
 How hard is the test? Worker “trust”
testing
 Risk, expectations, opportunity to ask questions
 Test end points:
 Pain vs. function
 Physiologic (heart rate, BP)
 Kinesophysical: Functional movement criteria and safe body
mechanics to determine endpoint
 Adjunct questionnaires
 Pain drawings
 Visual analog scale
 Note exam findings before testing
Methods
Job Specific FFD for Injury Management
 Computerized extremity and trunk tests
 Identify return to work barriers
 Static tests: force applied to stationary object
 Employee internal transfer to more demanding job
 Movement and positional tolerance
 Investigate worker symptoms and difficulty performing job
 Aerobic capacity

 Worker return to specific job following illness/injury
Estimated V02 max
 Assess effort: symptom magnification present in 25-30% of work comp
 Identify transitional work options
 Impairment not directly correlated to function
 Continuation in company transitional program or outpatient PT
 Psychological factors
 Determine need for work restrictions
cases
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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
ADA
Employer Functional Job Analysis
 Employer manages workers on observed performance
• More than “job/position description”
and not health related issues
• Helps evaluate injured worker’s capabilities
 Disability: physical or mental impairment that
substantially limits one or more major life activities
• “Marginal functions”
 Not covered: transitory health conditions; mental or
• Tools, equipment, frequency of repetitive motion,
health disorders that can be controlled by medicine or
transitory devices; “excessive weight” is not covered
 www.ada.gov/cguide.htm
modified duty options
Chronic Pain
Upper Extremity Assessment
 5-15% of patients
 Disabilities of the Arm, Shoulder and Hand (DASH and
 Deconditioning syndrome

 Common in low back and CTD patients

included in the Sixth Edition Guides
 Unclear pain generator



measures dexterity, strength, endurance
Quick DASH) questionnaires:
 Depression, anxiety, substance abuse, financial issues

 Poor coping, anger
Deconditioning
monitors worker progress
worker responses compared to findings on FFD
testing
Test Anxiety
 Joint stiffness
 Observe and annotate
 Muscle atrophy
 Determine when to stop FFD
 Psychosocial status/education
 “Do the best you can”
 FFD Benefit: identify true muscle weakness
 Report: “minimum is able to do”
 Minimal performance on FFD
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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
During the FFD
Pain Behaviors
 Disproportionate compared to pre-FFD exam
 Assess effort
 Patient wants to “tell their story”
 Inability to follow directions
 Compare to pre-FFD exam observations
 Inconsistent behavior
 Disproportionate pain behaviors
 Testing at different percentiles of “normal”
 Declines to perform specific test due to employer-assigned work
restrictions
 Poor performance throughout FFD
Other FFD Indications
 “Shortened FFD”
 Work incapacity and SSDI
 FFD as initial injured worker treatment
 Guides treatment, resolves fear avoidance and physical
inhibition
 Determine minimum safe capacities
FFD Outcomes:
Final Pearls
 Health issue with no impact; refer to private doctor
 Talk to your therapist
 Health issue that may be aggravated. Work
restrictions
Job rotation
 Let your conscience be your guide
 Request further medical information
 Take care of the patient
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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
References
 Elizabeth Genovese MD; Jill S. Galper PT. “Guide to the Evaluation of
Functional Disability: How to Request, Interpret, and Apply Functional
Capacity Evaluations.” American Medical Association. 2009.
 Robert C. Blink. Jerome Schreibstein. Article: “Fitness-for-duty evaluation:
Walking the medical-legal tightrope.” Journal of Chemical Health and
Safety. March/April 2007.
Questions?
Are you ready to take the “Test?”
 Case discussions?
The Test
 Five question quiz
Question 1
Question 1: FFD purpose
 1. The purpose of a Fitness for Duty testing includes




 Answer: d:
A method for employers to discipline or
terminate employees who cannot perform essential
assigned duties
all of the following except:
a. Identify a worker’s maximum job capabilities
b. Match functional capacity to physical demand
requirements
c. Provide information regarding the worker’s
limitations and abilities
d. A method for employers to discipline or
terminated employees who cannot perform essential
assigned duties
 “illegal”
 Reference: www.ada.gov/cguide.htm
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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
Question 2: Employer responsibilities
Question 2: Answer
 Employer responsibilities in FFD testing include all
 c: Integrate FFD test results and explain results to
of the following except:
the employee.
 This is the physician’s responsibility
 a. Staff training to identify “triggers.”
 b. Written policies and procedures.
 Source: “Fitness for duty evaluation: Walking the
medical-legal tightrope,” Robert Blink, Jerome
Schreibstein; Journal of Chemical Health and
Safety, March/April 2007
 c. Integrate FFD test results and explain results to
the employee.
 d. Coordination with state, federal, and local
agencies.
Question 3: Referral for FFD testing
Question 3: Who refers
 Who refers a worker/employee for FFD testing?
 Answer: all the above
 a. Physician
 Source: “Guide to Evaluation of Functional Ability,”
Genovese and Galper, AMA, 2009, pp. 12-14
 b. Case manager
 c. Supervisor.
 d. Insurer.
 e. All the above
Question 4: DASH
Question 4: DASH/Quick DASH
Regarding the “DASH” (Disabilities of the Arm,
Shoulder, and Hand) questionnaire, which one of the
following is not true:
 Answer: d
 DASH and Quick DASH are both used to study
clinical outcomes
a. A shorter version of DASH is Quick DASH
b. Either version may be used to monitor employee
progress during therapy
c. It includes a question regarding “sleep”
d. It is not used to study clinical outcomes
 Reference: “Guide to Evaluation of Functional
Ability,” Genovese and Galper, AMA, 2009, p.80
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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St Petersburg, Florida
Question 5:
Question 5: Chronic Pain
Workers with chronic pain may display all of the
following during a FFD except:
 Answer: b
 Source/reference: “Guide to Evaluation Ability,”
 a. Deconditioning syndrome
Genovese and Galper, AMA, 2009, p. 292
 b. A specific pain generator
 c. Fear avoidance behavior
 d. Poor coping behavior
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