I have been a Physical Therapist for over 19 years, primarily in the orthopedic, out-patient side of the profession. Roughly 10 years ago I started working more in the Industrial Rehab side of musculoskeletal injuries, and primarily doing Functional Capacity Evaluations. Many of my colleagues asked why I would be interested in doing these long, arduous tests with people that weren’t interested in getting better. I will admit, I frequently took that position too as I worked with these clients. The individuals going through a Functional Capacity Evaluation often can look like the “malingerer”, “the faker”, and “you know the type, trying to not go back to work.” Often their pain symptoms seem more exaggerated than you would expect. Their pain and movement patterns don’t match the subjective symptoms they describe. The test itself, in my opinion, is designed to try to identify the “malingerer.” There are always several crosschecks included in the FCE to help the provider find the inconsistencies.
It wasn’t until I started working full-time with patients living with chronic pain that I started to realize my previous biases and mindset could affect how I approached doing a Functional Capacity Evaluation. I always worked hard to be as objective as possible with reporting. However, I am certain in the back of mind I was trying to figure out what the client’s angle was.
Working with individuals with chronic pain daily now has given me a different perspective. In my opinion, when providers are trained/certified to do FCEs that the training should include some level of Pain Science Education. If this was included I think we,as experts in the field, would look at this very biomechanical based test with a much more Biopsychosocial viewpoint. The providers doing these tests would be reminded who exactly these clients are. They are the person who have gone through a very traumatic time, going from being very productive member of society and their families to being out of work for an extended period of time. The psychological toll is real, and the longer they stay out of work the worse it is. They have gone through the process of waiting for their workers' compensation payments and the stress of not knowing how they will pay their bills. They will have gone through several providers, many with the mindset that they are “faking”. Through mental stress, the physical waiting at home and for the next test and procedure provide time for their brain to start being rewired. The longer the process goes on, the greater opportunity there is for the fear of returning to activity, the fear of reinjury and condition of Central Sensitization to settle in. Central Sensitization is the condition that despite musculoskeletal tissue healing, the brain continues to get the message there is a problem, and ultimately feel the sensation of pain
Central Sensitization, I am certain, is a contributor to many people who go through FCEs. Sure, there are still those out there who have alternative motives. I am convinced, however, a lot of patients I have evaluated came to me with fear avoidant behaviors, anxiety, and depression. These are the individuals, if we stay in the framework of the biomechanical based FCE will not truly get good objective reporting. We as providers, need to consider the “whole person”, following the Biopsychosocial Model in the FCE completion and reporting, allowing us to give a more accurate representation of the person where they are “today”.
In summary, I am not concluding that there aren’t frequently alternative motivations behind some of our clients reasoning for their malingering-like behaviors and presentation. What I am asking is that we take a very Biomechanical based test, with a historical bias towards a malingering clientele, and consider including a more objective view of the person and how they are presenting. The medical system in the United States is getting closer to fully practicing in the Biopsychosocial Model each day. We need to keep that perspective when completing the Functional Capacity Evaluation as well
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