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FCEs and pain the day after
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FCEs and pain the day after - November 12, 2006 12:20:00 PM
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VagusX
Posts: 215
Joined: March 26, 2003
From: Savannah, GA, USA
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For those PT's in this communiy that perform FCE's, How do you handle patient complaints of pain days following a FCE?
I perform a 1 day 4 hour FCE. I occasionally receive a call the day after reporting that their pain and symptoms had significantly increased. In a specific situation that I am working with right now, the patient is a multiple spinal fusion with heavy pain management (fentanyl, hydro.) He was able to complete the test in its entirety and only demonstrated a few limitations during the test. From the objective data gathered he would be classified in a medium to medium-heavy classification. HOwever, if his claim that he cannot move the day after is true (Let's just consider that he is being honest) how does one go about documenting? HOw would this affect the profile? Any comment would be appreciated.
Thanks
Dan
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Re: FCEs and pain the day after - November 13, 2006 2:48:00 AM
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ehanso
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From: Minnesota
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I am assuming that documentation of his pain behavior and response during the FCE would indicate how he tolerated the test. If there are significant subjective complaints that last more than a day or so,(if he as inactive for months prior to the FCE he was probably deconditioned) then symptom magnification or other psychological factors enter into the picture. Ask specific questions and document well. Describe the pain (ache, burn etc.) where is it, what helps, the usual. Vague nondescript answers will point you in the right direction.
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Re: FCEs and pain the day after - November 13, 2006 4:34:00 AM
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steve
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From: Canada
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Dan,
When I have been involved, we perform a pre FCE physiotherapy assessment and post assessment that day, which should help document any reports of soreness. This is followed by a second FCE the next day so we get to see what type of response the individual has to activity.
In this situation, I would simply keep everything objective and report "It should be noted that the patient called later and stated that he was sore for ....." Remember, the FCE is an attempt to evaluate somebodies true level of function. This stated, if the patient demonstrated maximal effort through the course of testing and reports this much difficulty the next day I would suggest to the payor that a two day FCE may be more insightful. If it is a matter of conditioning it may be an opportunity to provide some conditioning treatment.
You really see how screwed up the medical/compensation system is through FCE's - Ive had some doozies.
Steve
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Re: FCEs and pain the day after - November 13, 2006 5:40:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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One of the problems with FCEs is the issue of sensitisation of the patient's nervous system (most of them are chronic pain sufferers), their expectation of suffering from the FCE, the worry about being "believed" about their pain complaint etc etc. These aspects CAN greatly affect the pain experience of that individual, without it necessarily being a sign of non-organic causes.
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Mundi vult decipi
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Re: FCEs and pain the day after - November 13, 2006 8:00:00 AM
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steve
Posts: 470
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From: Canada
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Sebastian,
I agree but from a third party payer perspective, what should they do? Even if you are a chronic pain sufferer, certainly permanently disabling the patient from work is not the answer. Furthermore, like it or not, some third party payers do not compensate "Pain" and have no legal obligation to compensate pain.
From an assessing therapist point of view, you are given an opportunity to assess patients over a long period of time. Some communication can go along way and often your results can help justify future treatment - ie. CBT.
Steve
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Re: FCEs and pain the day after - November 13, 2006 8:55:00 AM
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Sebastian Asselbergs
Posts: 1204
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From: Barrie, Canada
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A third payor perspective is indeed a sticky position - I am not saying they should NOT have the patient evaluated, but they tend to be ignorant of the issues of a chronic pain patient. The fact that they do not "allow" chronic pain as a diagnosis makes it hard for any patient to get and find the type of therapy that they need. They usually hear that they need to "strengthen and stretch" and do work-hardening.....
I fully agree that complete disability from any work is not the answer, and that a good FCE can flag malingerers.
Not an easy situation by a long shot, and I am not saying that FCEs are bad - just that for a type of patient, they are not useful at all.
The cases I have had experience with, ended up going into court where specialists argued about chronic pain as a diagnosis.....and the lawyers got rich....
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Re: FCEs and pain the day after - November 13, 2006 9:17:00 AM
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steve
Posts: 470
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From: Canada
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Sebastion,
Ever the Simpsons episode where Lionel Hutz (The lawyer) says "What kind of a world would we have without lawyers?" and an image pops up with everyone rejoicing and holding hands? Again, a problem with a very complex system that tends to cause echronic pain entrapment for the individual who is injured. I dont know if there is a great answer but usually by the time I see an FCE (I just do a physio assessment and this is rare) patients have had lots of intervention, entitlement based beliefs, depression, no longer have a job to return to and established identity as a "Disabled non worker", chronic pain, litigation and previous enabling medical care.
This might sound awful to some (And I mean some) but sometimes having the cord cut so to speak is the best answer - Necessity is the motherhood of invention and people find a way to get on with their lives.
Steve
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Re: FCEs and pain the day after - November 13, 2006 11:20:00 AM
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Sebastian Asselbergs
Posts: 1204
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From: Barrie, Canada
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Steve, , you are 100% right for some indeed. And a lot will go on - and adapt/adjust/improve.
My apologies for taking this thread to something other than intended by VagusX:
Pain the day after a FCE - Steve's first response: "a second FCE" seems to offer the most logical solution.
However, IF you don't have that option, making a specific note of the feedback is essential. It may well get interpreted as irrelevant, since it is subjective feedback, but that seems all you can do in this case.
It can't really affect your test outcomes, since next-day symtoms are not part of single day FCEs.
So, in this case, your profile stands as tested, with a footnote.....
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Re: FCEs and pain the day after - November 13, 2006 10:41:00 PM
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Randy Dixon
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I think that it has been covered but a second day evaluation is the standard that I think should be used. Having given a lot of FCE's, although not for a long time, I don't find it to be a very useful tool for identifying malingerers, symptom magnifiers or the euphemism of the month. I've seen too many people able to do things they shouldn't be able to, and too many be able to NOT do things I think they should, even when I'm sure they are given an honest effort. (Such as myself). It is good for knowing what a person can and can't do, and assuming the job requires more than one appearance, a two-day FCE makes more sense.
Should you document the pain the next day? I would say not on the FCE, you didn't observe it during the completion of the FCE, therefore it doesn't belong. Depending on the situation though, hopefully you have good communication with the client that referred the candidate and you can communicate it.
FCE's are tricky for this reason. You are used to being a patient advocate and sometimes you are placed in a position where you are almost in an almost adversarial relationship with the patient, at least from their view. That is one of the difficult things to navigate. The best system would minimize this confrontational aspect, but for the most part, most current systems encourage it.
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Re: FCEs and pain the day after - November 14, 2006 9:28:00 AM
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VagusX
Posts: 215
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From: Savannah, GA, USA
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I thank everybody for posting. I do agree with the 2-day FCE, but my current FCE is designed 1 day, and I am not sure how splitting it up over a two day would affect its validity. I have yet to end up in the middle of any litigation, but I'm not sure how I would fare if I decided to mess with the design without having the research to back it. So for now, I'll stay a 1 day.
I ended up calling the person and getting some more specific info of the pain and I put it in as a footnote. I kept everything objective and did not let the complaint sway my outcomes.
Randy
I a lot of times feel like the adversary which is unfortunate. I hate FCE's when I end up being in that position. I have screwed up a few FCE's for pointing out a person's inconsistancies on the spot. Things spun out of control and they ended up leaving a lot faster than they walked in (I made sure that documented the speed of their departure ;) )
So with these tough cases, chronic pain and bs'ers I end up being much more passive and giving into the patient's pain complaints easier than I used to. I just document the best I can. I, just as much as the the patient don't need to put myself through a bunch of stress while going through an FCE.
Dan
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