Expert review of an approach to functional capacity evaluation

Functional capacity evaluation (FCE) is a widely used tool in work rehabilitation, despite the limited examination of the soundness of its measurement properties. This paper outlines the development of a new approach to FCE, the GAPP FCE, and reports on the findings of an expert review of aspects of its content validity and technical adequacy and how it meets established test criteria. Five expert occupational therapists reviewed the materials of the GAPP FCE then completed a questionnaire related to the content validity, technical adequacy and safety, reliability, validity, practicality and utility of the GAPP FCE. The experts gave support to most aspects of these criteria. The main issue identified by the review was related to interpretation and extrapolation of the FCE results for return to work. This and other issues are discussed in relation to recent developments in FCE and plans for future development of the GAPP FCE.     

The power of outcomes: FOTO Industrial Outcomes Tool -- Initial assessment

OBJECTIVE: To demonstrate how outcomes assessment can assist in describing clients receiving rehabilitation in occupational health rehabilitation clinics and to describe the preliminary assessment of internal consistency reliability and construct validity of the FOTO Industrial Outcomes Tool. METHODS: 266 adults referred for acute work rehabilitation (AWR), work conditioning/hardening (WC/WH) or a Functional Capacity Evaluation (FCE) comprised the data set. Clients were treated between July 1998 and January 1999 in 15 clinics from 6 states by 46 clinicians participating in the Focus on Therapeutic Outcomes (FOTO) national rehabilitation database beta test. For AWR and WC/WH, clients completed a health status questionnaire on intake and discharge, and health status was assessed prior to the FCE. Comprehensive demographic data were collected describing the clinics, clinicians, clients and work status collected 2 weeks following discharge. RESULTS: Internal consistency reliability coefficients for the health status scores ranged from 0.57 to 0.89. Construct validity was supported. CONCLUSION: Results demonstrate the power of collecting outcomes from a variety of constructs for clients receiving industrial rehabilitation services. Initial reliability and construct validity findings were adequate and support continuing data analyses.     

Improving work programs' delivery of information and service to workers' compensation carriers

This paper presents the results of a telephone survey of workers' compensation carriers, addressing how occupational therapy work programs can best meet these carriers' needs. Fifty percent of the market share of workers' compensation carriers in Michigan participated in the survey. Survey results indicated that workers' compensation carriers found Functional Capacity Evaluations, job analyses, and work hardening to be important work rehabilitation services. A significant portion of the respondents (88%) stated that they recognized the need for clinically successful work rehabilitation programs and indicated that if they had return to work rates for different providers, they would utilize providers that had the most successful outcome data in a specific geographical area. Occupational therapists can use these survey results to improve their services and communication with insurance to ensure that injured workers will continue to have access to the efficacious interventions occupational therapists provide in work rehabilitation.     

Health professionals' attitudes and practices in relation to Functional Capacity Evaluations

Functional Capacity Evaluations (FCE's) are part of practice in work injury prevention and rehabilitation, and are designed to define an individual's functional abilities or limitations in the context of safe, productive work tasks. Qualitative research methodology was used to investigate the attitudes and behaviours of health professionals in relation to FCE use. The study aimed to identify why health professionals chose a particular FCE, and to identify what factors influence health professionals' clinical judgements when providing results and recommendations for the individual being assessed. Five health professionals from the Hunter Region of New South Wales, Australia, participated in semi-structured, individual interviews using a phenomenological approach. Following inductive analysis of the data, four themes reflecting participants' attitudes and behaviours of FCE use emerged: i) referrals and expectations, including why and when the assessment is completed ii) outcomes, -- what the results aim to provide iii) workplace/practice/usage issues and iv) skills of the assessor. The results indicate the need for further research on the clinical utility of FCE's. A large scale quantitative study would allow results to be generalised to a wider community of FCE users.     

Functional testing: Approaches and injury management integration

Functional Capacity Evaluations (FCEs) have become the standard for identifying an individual's physical abilities and/or limitations following injury or illness. While philosophies and approaches differ, the focus of most FCE systems is to identify the individual's maximum capabilities. This article will discuss the usefulness of the FCE information and how FCEs are impacted by multiple factors including APTA guidelines, machine based testing, therapist expertise, medical legal credibility and court testimony, IMEs and FCE, and return to work/return to function.     

Working with industry: Matching the work and worker

The benefits of matching the work to the worker include injury prevention, decreased re-injury rates, decreased turnover, and improved production. This article will discuss three components of an employer safety and health program that allows employers to realize these goals. The program involves partnering with trained health professionals who provide Functional Capacity Evaluation, Functional Job Analysis, and Prework Screening services onsite as means to achieving appropriate matches of the workers to the work.     

A survey of occupational therapy in Australian work practice

While the prevention and management of work-related injuries are major areas of practice for Australian occupational therapists, there has been little research on occupational therapy's contribution in these areas. This study examined the characteristics of current Australian occupational therapy practice in the work arena. A postal questionnaire was sent to 355 occupational therapists employed in work practice from six of the eight state or territory Occupational Therapy Associations. The questionnaire enquired about demographic details, service provision in the prevention, assessment and rehabilitation areas and further education needs in these areas. The responses of 125 (35%) therapists were analysed and show the services commonly offered in prevention, assessment and rehabilitation. The most commonly offered services included job analyses, workplace assessment and suitable duties programs. The results also indicate high levels of service provision in the workplace. In presenting the findings of the survey, current trends in international and Australian occupational therapy work practice are discussed along with suggestions for directions in future education, practice and research.     

The functional capacity of healthcare workers with history of severe acute respiratory distress syndrome (SARS) complicated with avascular necrosis--case report

Two years after the SARS outbreak in Hong Kong, 128 healthcare workers continued to present with musculoskeletal complaints and 38 workers were diagnosed with avascular necrosis (AVN) in different joints. 13 healthcare workers were referred to six designated Physiotherapy Departments of the Hospital Authority for a tailor-made standardized Functional Capacity Evaluation (FCE) from 2004 to 2005 on a voluntary basis. Job analysis, workers' self-perceived disability and functional capacity, non-material handling tests, and the cardiopulmonary fitness test were performed. Retrospective review of the FCE data showed that there were 17 AVN of hips, 16 AVN of knees, 3 AVN of shoulders. All patients had AVN of lower limb joints. Nearly full ranges of movement (ROM) were observed in the knees involved, but the hip range was decreased for most subjects suffering from hip AVNs. Most workers (n=12) could not complete the cardiopulmonary test due to intolerable joint pain. Six workers' self-perceived physical demands level (PDC) matched with the physical demands level identified by the FCE. 12 healthcare workers attained a sedentary physical demands level and were unable to match with their previous job demands. One staff was classified as light physical demands and managed his original duty. Four workers had returned to work at the time FCE was performed. The tailor-made FCE added information to facilitate the return-to-work planning for the staff. Four more workers returned to work with modified duties one year after the FCE.     

Work rehabilitation programs: a 1997 survey

By adapting to the changing health care environment, legislative reforms, and consumer needs, work rehabilitation programs have experienced a metamorphosis. This study surveyed occupational therapists currently employed in work programs to ascertain a current demographic profile of work rehabilitation programs. Respondents indicated the delivery of services in the areas of prevention, assessment and rehabilitation. The majority of work rehabilitation programs in this study provide services in the form of ergonomics, education and training, and job analyses at the worksite. The area of work injury prevention services is forecasted for increased growth among work rehabilitation programs.     

Test-retest reliability of a WRULD functional capacity evaluation in healthy adults

The aim of this study was to determine test-retest reliability of a Functional Capacity Evaluation for patients with non-specific Work Related Upper Limb Disorders (WRULD FCE). The study sample included 33 healthy adults, consisting of 14 males and 19 females with a mean age of 29.2 years. The WRULD FCE consisted of 8 different tests including 26 items measuring repetitive movements, duration, working in awkward positions, forceful movements and static postures. Two FCE sessions were held with a 10-day interval. Means, 95% confidence intervals, one-way random Intraclass Correlation Coefficients (ICCs), 95% limits of agreement and repeated measures were calculated. An ICC between 0.75 and 0.90 was considered as good and an ICC above 0.90 was considered as an excellent reliability. The results showed that 14 of 26 items (54%) had excellent reliability, 9 of 26 items (35%) had good reliability and 3 of 26 items (11%) had moderate reliability based on ICC values. Significant learning effects were present in the Purdue Pegboard Task and in the Complete Minnesota Dexterity Test. It is concluded that the WRULD FCE is reliable in healthy adults.     

Use of Functional Capacity Evaluations by rehabilitation providers in NSW

Returning the disabled worker to maximum productivity is a shared responsibility between the treating health practitioners and employers, with the insurer as an overseer of the injury management plan. Allied health professionals have responded to the need for standardized tools to assess work capacity by developing Functional Capacity Evaluations (FCEs). Literature exists outlining the limitations of FCEs in injury management systems; however, little is known about their uses and perceived usefulness. Questionnaires were posted to managers and therapists of accredited rehabilitation providers. The questionnaires consisted of both open and closed format questions. The response rate for the managers' questionnaire was 53%, while the therapists' questionnaire was 27%. The majority of rehabilitation providers use an assessment of their Own Design. Eight commercial FCEs were identified as being used. The majority of therapists use only one type of FCE. Therapists rated FCEs highly on their flexibility with Own Design assessment rated as significantly more flexible than the most frequently used commercial FCEs. From the data collected, it appears that cost is the main factor influencing choice of assessment. Level of evidence supporting capabilities of particular assessments does not appear to influence use. It seems that, despite there being poor research evidence to support the use of many brands of FCEs, they are still commonly used by rehabilitation providers. To achieve optimal use of FCEs, further research is required on the types of adaptations therapists make to commercial assessments and properties of Own Design assessments, including reliability and validity studies.     

Item validity of the physical demands from the Dictionary of Occupational Titles for functional capacity evaluation of clients with chronic back pain

This study assessed the item validity of 15 of the physical demands from the Dictionary of Occupational Titles (DOT), as evaluated in a new approach to functional capacity evaluation (FCE) for clients with chronic back pain, the Gibson Approach to FCE (GAPP FCE). Fifty-two occupational therapists were sent the specifications of the items in the GAPP FCE procedures and were asked to rate the items in terms of item-objective congruence, relevance and difficulty. A response rate of 59.2% was obtained. The majority of the therapists agreed that most of the items were congruent with the objectives based on the definition of the physical demands from the DOT. The items evaluating Balancing and Pushing and Pulling had the lowest item-objective congruence. The evaluation of Balancing and the Lifting, Carrying and Pushing and Pulling of loads greater than light-medium weight (10-16 kg) were not considered significantly relevant. Concerns were raised about the difficulty and safety of the evaluation of Lifting, Carrying and Pushing and Pulling with clients with chronic back pain, particularly if the therapist evaluates the manual handling of medium to heavy loads. These results may have implications for other FCEs, particularly those which are based on the DOT, or when assessing clients with chronic back pain.     

Disability management and functional capacity evaluations: A dynamic resource

Functional capacity evaluation (FCE), as an objective resource for disability managers, is an invaluable tool in the return to work process. Effective communication of expectations between the employee, employer, medical providers, disability management team, and the FCE provider contributes to enhancing the benefits of the FCE to all participants. Careful review of the results of the FCE as compared to the employee's other pertinent medical/functional information provides clarity for that person's rehabilitation goals and RTW potential. Finally, future opportunities and proactive uses for the FCE are shared.     

Approaches to worker rehabilitation by occupational and physical therapists in the United States: factors impacting practice

Work-related rehabilitation services have changed in nature and scope since their inception in the late 1970s. A review of the literature reveals a large body of published data concerning the various approaches used by therapists in this practice area, but a limited number of comparison studies documenting the value of one approach over the other. This national survey of physical and occupational therapists in the US was conducted in 2002, and examined the prevailing trends in service provision, and factors that determine the nature of services provided to clients. Results indicate that services continue the move to onsite service provision and an emphasis on prevention, but that select services, such as onsite job analysis and comprehensive, inter-disciplinary programs are being used to a limited degree. Research that examines the relative contributions of selected work-related services to successful and efficient return to work outcomes is necessary to identify best practice approaches. Therapists and insurance providers should work more closely in exchange of data that will ensure optimal program design and funding.     

Cognitive and behavioural assessment of people with traumatic brain injury in the work place: occupational therapists' perceptions

Cognitive and behavioural impairments, in the absence of severe physical disability, are commonly related to poor return to work outcomes for people with traumatic brain injury (TBI). Along with other health professionals, occupational therapists make judgements about cognitive and behavioural dimensions of work capacity of clients with TBI during the return to work process. Unlike many physical functional capacity evaluations, there is no standard method that therapists use to assess the ability of people with TBI to perform cognitive operations required for work. Little is known about what information occupational therapists use in their assessment of cognitive and behavioural aspects of client performance within the work place. This study employed qualitative research methods to determine what information is utilised by 20 therapists who assess the work capacity of people with TBI in the workplace. Results indicated that the process of making judgements about cognitive and behavioural competence within the work place is a multifaceted process. Therapists triangulate client information from multiple sources and types of data to produce an accurate view of client work capacity. Central to this process is the relationship between the client, the job and the work environment.     

A meta-evaluation, or quality assessment, of the evaluations in this issue, based on the African Evaluation Guidelines: 2002

Fourteen evaluations of UNICEF and UNAIDS HIV/AIDS programmes underwent a quality control process called ‘meta-evaluation’, which is an evaluation of the quality of the evaluation. This process of evaluating an evaluation is considered professional good practice by African Evaluation Associations and Networks, as well as the American, Canadian, German, Korean, Swiss and other national professional associations of evaluators. The quality control criteria used were the African Evaluation Guidelines—a list of 30 quality-enhancing standards that can be used as a checklist by evaluators to ensure that evaluation studies are performed well. These quality control criteria can also be applied retrospectively as a quality control method, to assess completed evaluation studies. The results of this quality control review process, for the 14 papers in this issue of Evaluation and Program Planning, are presented and discussed. An indication of a possible area of weakness in HIV/AIDS programme evaluation emerges from this analysis.     

Functional capacity evaluation: Ecological validity of three static endurance tests

Functional Capacity Evaluation's (FCE's) are designed to measure the functional capacity of injured workers. Static endurance tests are integrated aspects of FCE's. Little is known about the validity of the tests. In this study, three static endurance tests (overhead work, crouching and kneeling) of the Isernhagen Work Systems FCE are studied for ecological validity. By manipulating the environment in an experiment using three different conditions (normal, loud noise, high production requirement), the ecological validity of the tests was investigated. Results: the different conditions did not seem to influence the holding times, the perceived exertion and the productivity of the subjects. The results are discussed and it is concluded that the three static endurance tests meet conditions of ecological validity. In order to be able to state that the tests of the IWS FCE are ecologically valid, more research is needed to enable a generalization.     

The work ability web: A tool for job matching

A rural community in the Eastern Cape, South Africa, requested assistance in finding a solution for the dilemma of unemployment for persons with disabilities (PWD). The researcher was involved in a multi disciplinary development programme in the community and investigated the possibilities of integrating the PWD in the income generating projects planned for the community at large. This article reports on one of the objectives of this participatory research study: exploring possible ways of job placement in the projects by community workers. The challenge was to find a simplified process by which uncomplicated placements could be handled by community workers, and complex cases identified and referred to the regional occupational therapists. The researcher used a functional assessment kit to assess the level of dependence/independence of each PWD as well as an interview on employment history and personal aspirations and needs. A job analysis was done on five planned projects for the community that would generate income. The data of the functional analysis of each person and the job requirements were then plotted on one web, the work ability web (WAW) to illustrate compatibility. One of the cases from the sample is described to demonstrate the process.     

Predictive validity of a functional capacity evaluation: the physical work performance evaluation

The predictive validity of a Functional Capacity Evaluation, the Physical Work Performance Evaluation (PWPE), was examined in 30 workers compensation patients with musculoskeletal dysfunction who participated in an industrial rehabilitation program. Return-to-work recommendations were made by comparing the discharge PWPE to the physical requirements of the job. Kappa coefficients were used to compare PWPE recommendations to actual work at discharge, 3 months and 6 months. Substantial agreement was found between PWPE recommendations at all three follow-up points. This study provides preliminary evidence in support of the predictive validity of the PWPE for making return-to-work recommendations at the conclusion of an industrial rehabilitation program.     

Using an action research approach to involving service users in the assessment of professional competence

This paper reports on a piece of action research that has involved people who use mental health services in systematically providing feedback from a user perspective on participants’ assessed work completed for one module of a masters’ training programme in mental health. In an attempt to improve professional practice and include people who were accessing mental health services in so doing, it outlines how users were trained to provide feedback and the training methods employed. The findings summarise the kind of issues users raised in their feedback to participants about the evidence professionals provided to demonstrate their learning from the training programme. A focus group interview with professionals provides a contrasting insight into the participants’ experience of having their work commented upon from a user perspective. The paper draws on the experience of a five-year external evaluation of an interdisciplinary programme in community mental health at Birmingham University in the UK which has highlighted the involvement of people who use mental health services as a particular innovation in the design, delivery and evaluation of the curriculum.