Ormond Neuroscience undertake high-level insurance functional capacity evaluations (FCE) of clients who have lodged medical disability claims. This web page primarily targets Disability Claims Consultants from insurance companies. Are you a client who will be undergoing a neuropsychological examination? If you want to know what to expect, what to bring, and who should accompany you then please click here.

Typically, a functional capacity evaluation focuses on physical abilities and the person’s capacity to perform a given job. Consequently, it follows that occupational therapists most commonly undertake functional capacity evaluations.  Increasingly, however, mental prowess rather than physical competence is critical to functioning in the workplace. This is especially so when an insurance company is dealing with a client with a brain-related problem. In that case, the specialist opinion of a neuropsychologist is appropriate. Please use Ormond Neuroscience in such circumstances.

Neuro-Integrative Comprehensive Evaluations (NICE)

We prefer to call our assessments Neuro-Integrative Comprehensive Evaluations (NICE) rather than FCE’s. We do so because they really are New Age examinations. (A bit corny, I know! But read on and you’ll see why.) Significantly, our work goes beyond standard neuropsychological assessments in terms of breadth and the degree to which we integrate our findings with recent discoveries in the neurosciences. Additionally, we make coherent recommendations regarding reskilling clients. These recommendations take functional ability into account as indentified by neuropsychological testing. It’s not just about diagnosis but also about treating the problem!

Comprehensive Multi-Domain Functional Capacity Evaluations

We cover all domains of brain function relevant to occupational functioning, including:

• Sensory
• Motor
• Cognitive
• Affective
• Behavioural
• Social

We use well validated, psychometrically robust tests. For most procedures, we use local norms, although this is not possible with all tests. We take particular care to avoid misleading conclusions when interpreting results against norms (see below).

Person-Centred Functional Capacity Evaluations

Importantly, we use a person-centred approach to assessment, rather than a test-centred approach. This represents a paradigm shift in evaluating impairment. When it comes to evaluating impairment in the context of an insurance claim, the reference point needs to shift. The relevant comparison should be to the client’s premorbid level of functioning and not to their performance relative to a normative database. Insurance policies typically cover “own or similar occupation.” Therefore, the appropriate reference point is the level of functioning required to perform the job in question and not the population average. I cannot stress this point strongly enough. It is concerning that some major insurance companies insist on evaluating functioning relative to the norm.

Specifically, a disability claims consultant needs to evaluate the loss in the client’s functional capacity relative to how they were doing their job in the past. Comparing them to average functioning in a normative database is irrelevant. While norms provide a reference point, they may be misleading. A client may be above-average on psychometric tests but still have difficulties in occupational functioning.

Resilience and Affective Disorders

The person-centred approach to functional capacity evaluations also recognises the vital importance of the client’s personality and emotional well-being. These are powerful determinants of occupational competency. Moreover, psychological resilience plays a major role in the capacity to bounce back from a stroke, a brain injury, or other catastrophe that led to the claim. Therefore, we pay attention to resilience in our assessment of the client’s ability to return to work.

In addition, and closely related to resilience, is the extent to which the client may be experiencing depression, anxiety, or another mood disorder. Of course, emotional problems affect their capacity to return to work. Notably, clients with a premorbid history of psychiatric disorders often exhibit a greater degree of impairment. For example, someone who suffers a stroke on top of pre-existing depression is likely to experience a poorer recovery than usual. Furthermore, depression and anxiety may either result directly from the brain dysfunction itself. Alternatively, a mood disorder may arise as a secondary reaction to impairment.

Advances in the Neurosciences

Application of Connectomics to Functional Capacity Evaluations

Standard Imaging

CT brain scans and MRI brain scans are very helpful. When radiological information is available, then we are able to leverage the power of connectomics. This sheds further light on the client’s functioning. Connectomics refers to the scientific endeavour of delineating the network connectivity of the human brain. This is a fascinating field in which there has been massive progress in the last two decades. Nowadays we are able to apply those findings to clinical cases.

Have a look at the CT brain scan show in Figure 1. Notice the two haemorrhages, a small one in the dorsolateral thalamus (blue arrow) and a larger bleed in the region of the insula (yellow arrow). This is a standard radiological image. We’ve been using them for decades.

The Connectomics Advantage

Nowadays, we can use connectomics to map out the connectivity of the thalamic lesion. Doing so revealed a large region of the brain affected by the thalamic injury. The pale blue in the top right panel of Figure 2 shows the regions of brain connected to the thalamic lesion. This is connectomics in action!

Then, we mapped the connectivity to the lesion in the left insula, as shown in Figure 3. Intriguingly, mapping the connectivity from left insula lesion showed a much smaller region of affected brain tissue compared to the effect of the thalamic lesion. Thus, the smaller thalamic lesion on the CT brain scan actually connects to a much larger region of brain than the bigger lesion in the insula does. So, connectomics allows us to visualise information that is not apparent from the standard CT brain scan. Functionally, the thalamic lesion is more consequential, even though the visible extent is smaller on the CT brain scan.

This is an significant finding and brings out the importance of connectomics. It allows us to better understand the effects of a brain injury. Typically, this is not something on the radar of a claims assessor. Let’s change that!

Advanced Imaging for Functional Capacity Evaluations

In addition to using tools derived from connectomics, we also have access to advanced imaging technology. Naturally, this comes at an additional fee but can provide extremely valuable information and increases the value of our NICE functional capacity evaluations. (The fee is paid to the radiology department, not us.) Specifically, we are able to commission diffusion tensor images (DTI) that reveal the fibre tracts of the brain. DTI is especially valuable in cases of traumatic brain injury and multiple sclerosis.

For example, Figure 4 is a DTI image. Have a look and notice that there is a break in the patient’s corpus callosum (yellow arrow). That’s the fibre tract that connects the two cerebral hemispheres. DTI uses anisotropy to map fluid flow in neuronal membranes. The colours in the image indicate the direction of flow. Red/pink shows left-right fibre tracts. Green denotes anterior-posterior tracts. Blue shows superior-inferior fibre tracts. Importantly, this break in the corpus callosum was not apparent on a standard MRI. Thus, DTI provides important additional information. In this particular case, this observation was clinically significant and explained various findings on the psychometric tests.

More recently, we also have access to magnetic resonance (MR) perfusion imaging. These wonderful scans are great for showing restrictions in blood flow, particularly after stroke. Figure 5 shows a series of slices from an MR perfusion study. These are from a patient who had an infarct in the left middle cerebral artery. The stroke resulted in aphasia. These images explain why her speech impediment was so severe.

Symptom Validity

Unfortunately, some clients see a medical disability claim as a means to early retirement. To that end they exaggerate symptoms and feign impairment during functional capacity evaluations. At Ormond Neuroscience we have the tools to reliably and consistently detect malingering. We pick out deliberate underperformance on psychometric tests. Furthermore, we are the only profession with the tools to detect malingering and symptom exaggeration. These tests are psychometrically robust measures.

Catching out a disingenuous claimant usually results in repudiation of their claim. Predictably, the odds are high that they will deny malingering and approach the ombudsman. There is even a chance that the matter goes to court. In that scenario, you have the knowledge that our evidence regarding performance validity is robust. You can be confident that it will stand up to rigorous cross-examination in court.

Diagnostic Accumen

At Ormond Neuroscience, we pride ourselves on making the correct diagnosis. We verify the accuracy of existing diagnoses, because occasionally they are incorrect. This is especially true when dealing with patients with functional neurological disorders (FND). Despite the misleading name, these are not actually neurological conditions. Rather, FND is a psychosomatic manifestation of emotional problems of some kind. On average, it takes seven years before these symptoms are recognised for what that are. During that time, incorrect diagnoses and treatment has been made. FND is clinically problematic. It also creates problems in the insurance context.

We typically pin down diagnostically challenging cases. This is especially true when there are psychological “issues.” Also, in those rare cases when diagnostic uncertainty exists, we say as much. The insurer needs to know when the picture is fuzzy!

We report diagnoses as accurately as possible. For instance, we don’t just say “reading difficulty.” Instead we report “alexia without agraphia due to right homonymous hemianopia and a lesion of the splenium of the corpus callosum.” That’s quite a mouthful, but it is highly precise and conveys the exact cause.

Clientele

Clientele for Functional Capacity Evaluations by Profession

The functional capacity evaluations provided by Ormond Neuroscience are particularly important for clients whose decisions have an impact on the safety and well-being of others. This includes medical disability claims involving:

• Any claimant in a mission critical job (e.g. aircraft technicians, process controllers).
• Engineers (especially civil engineers).
• Financial professionals (bankers, accountants, actuaries, financial advisors etc).
• Healthcare professionals (doctors, surgeons, occupational therapists, veterinarians etc).
• Lawyers (attorneys, advocates, judges).
• Managers (junior and senior).
• Teachers, lecturers, and professors.
• High-level decision makers, such as CEOs, bankers, and architects.

Clientele for Functional Capacity Evaluations by Diagnosis

Patients with the following diagnoses are suitable for referral to Ormond Neuroscience.

Cerebral Autoimmune Conditions

Patients with autoimmune conditions that compromise brain function, such as

• Multiple sclerosis.
• Anti-NMDA Encephalitis.
• Guillain-Barré syndrome.
• Acute disseminated encephalomyelitis (ADEM).

Chronic Pain Disorders

• Complex regional pain disorder that impairs cognition and/or causes depression.

Psychosomatic Conditions

• Fibromyalgia.
• Irritable bowel syndrome.
• Functional neurological disorders.

Iatrogenic Complications

• Cardiac patients who have undergone coronary artery bypass graft (CABG).
• Nutritional deficiencies arising from short-bowel syndrome in bariatric surgery patients.
• Patients who developed septicaemia due to botched surgery.
• Patients who required prolonged mechanical ventilation and now present with cognitive fallout.
• Cancer patients who underwent chemotherapy and who developed “chemo-brain.”

Infectious Conditions

• Cerebral malaria.
• Encephalitis of any aetiology.
• Herpes simplex encephalitis.
• Neurocysticercosis.
• Neurosyphilis.

Mood Disorders

• Generalised anxiety disorder.
• Bipolar mood disorder.
• Major depressive disorder.
• Obsessive-compulsive disorder.
• Post-traumatic stress disorder
• Any mental condition associated with psychosis.

Neurodegenerative Conditions

• Alzheimer’s disease.
• Frontotemporal dementia
• HIV-associated neurocognitive disorder (HAND).
• Multiple system atrophy.
• Parkinson’s disease.
• Vascular dementia
• In fact, any type of dementia.

Organic Brain Dysfunction

• Brain tumours.
• Epilepsy.
• Strokes.
• Traumatic brain injuries.

Substance Abuse

• Chronic alcohol abuse disorder.
• Drug abuse disorder.

Systemic Illness

• Chronic kidney disease (CKD).
• Survivors of critical illness survivors (Critical illness myopathy – CIM. Critical illness polyneuropathy – CIP. Critical illness polyneuromyopathy – CIPNM).
• Poorly controlled diabetes.
• Insulinoma.
• Hepatic dysfunction.
• Multiple organ dysfunction syndrome (MODS).

Medical Disability

Functional Capacity Evaluations and Medical Boarding

Medical boarding is the process of granting medical disability status. This process begins only after someone lodges a claim. If the client has the relevant insurance cover and is genuinely ill, the insurance company usually grants temporary disability. After two years, if the client still cannot return to work, the insurance company evaluates them for permanent disability. At that stage, clients often visit Ormond Neuroscience for functional capacity evaluations.

 

Disability vs Functional Incapacity

Healthcare professionals make decisions regarding the degree of a client’s functional incapacity.  Insurance companies make decisions regarding the degree of a client’s disability.  Functional incapacity is a medical concept; disability is a legal concept.  The medical board at the insurance company make a legal decision regarding disability. They consider both the information contained in the functional capacity evaluations and the fine print of the insurance policy that covers the client.  Clients who are unhappy with the insurance company’s decision may seek arbitration. To that end, they may lodge a dispute with the insurance ombudsman.

Access to Information

The law makes provision for clients to see the report produced by Ormond Neuroscience. Since the insurance company pays Ormond Neuroscience to produce the report, they are the owners of the report.  If the client would like to see the report, they should approach the insurance company, and not Ormond Neuroscience.

Objectivity of Functional Capacity Evaluations

Ormond Neuroscience are independent of the insurance company.  The reports that we provide are impartial and objective.  We favour neither insurance company nor client.  The content of the report is the same irrespective of who pays our fees.

Treatment

Lastly, not only do we assess, but we also we provide treatment for brain -related conditions. This comes in a number of different guises, including:

Vagal Nerve Stimulation

Approved by the FDA, vagal nerve stimulation (VNS) has application in stroke rehabilitation, epilepsy, and depression. It induces neuroplasticity, which facilitates synaptogenesis. In turn, boosting synaptogenesis makes it is easier for the brain to form new connections. This facilitates the process of healthy nerves taking over the functioning of damaged nerves. This has obvious benefits for recovery after any type of brain injury. When accompanied by psychotherapy, VNS facilitates mental reframing of negative emotions. Doing so is important to diminishing the effects of depression.

VNS reduces sympathetic hyperactivation, ameliorating the effects of severe anxiety and PTSD. By virtue of its role in synaptogenesis, VNS improves cognitive functioning.

VNS also reduces systemic inflammation. This can be beneficial in multiple conditions. For example, patients with multiple sclerosis where standard treatments such as interferon is no longer beneficial. You can read more about VNS on our website.

Neuroharmonics

Ormond Neuroscience runs a brain optimisation programme that we call Neuroharmonics. The program focuses on the elementary physiological functions on which brain function depends. These include sleep, nutrition, and exercise. Enhancing emotional well-being is also an important part of Neuroharmonics.

We provide an individualised form of cognitive rehabilitation, styled as “mentored cognitive rehabilitation.” It is different to conventional cognitive rehabilitation exercises such as memory games, puzzles, and sudoku. We create tailor-made cognitive stimulation programs that dovetail with the patient’s interests. This injects real-life meaning into treatment, facilitating patient engagement, and piggybacking on the patient’s own semantic neural network. In addition, Neuroharmonics also includes a strong emphasis on the neuronal benefits of socialisation.

Critically, treatment programs of this kind reduce amyloid burden in patients suffering from Alzheimer’s disease! That is remarkable! As a matter of fact, we can actually demonstrate the benefits of this treatment using new objective biomarkers.

Above all, involving family member in Neuroharmonics makes the treatment more effective. Neuroharmonics is about lifestyle change. Consequently, much of the treatment unfolds in the patient’s home. Naturally, we also need to see the patient. We prefer face-to-face interaction, but when distance is a problem, we can use virtual consultations. Find out more about Neuroharmonics on our website.