1 Journal of Vocational Rehabilitation 28 (2008) IOS Press Utilization of the functional capacity evaluation in vocational rehabilitation 1 Ted Mitchell Texas Tech University Health Sciences Center, 4427 Royal Tern Court, Jacksonville, FL 32250, USA Tel.: ; Fax: ; Abstract. Identifying the functional capacities of the individual beset by a physical disability and the role physical limitations play in employment, are a primary concern of the rehabilitation counselor. Physicians and allied health professionals are qualified to identify current physical functional level and to clinically manage the injured worker. If a return of the individual to pre-injury employment is not possible, rehabilitation counselors provide vocational training to identify feasible occupational alternatives. Use of a functional capacity evaluation can aid the rehabilitation counselor in determining the physical capabilities of his/her client, and help identify potential barriers in the workplace. Defining the functional capacity evaluation with an examination of its strengths and weaknesses will help determine its use in the field of vocational rehabilitation. The specialized training of rehabilitation counselors that enables them to translate medical information into vocational information makes them the ideal professionals to define the worker s functional ability. 1. Introduction The functional capacity evaluation (FCE) has long been recognized as a valuable tool that enables the rehabilitation professional to obtain complete information regarding the impairment of an injured individual [2,13,23,26,29,35,39,40]. Employers, insurers, the Social Security Administration, and the legal community frequently use FCE s in making decisions regarding physical capacity and return to work readiness . The interpretation of the FCE with its recommendations and predictions contributes to the determination of the client s work capacity, employability, rehabilitation needs, and compensation that may be awarded . Approximately one third of all injuries in the United States occur on the job . According to the National Safety Council , 3.7 million American workers suffered disabling injuries in the workplace in With the insurance industry s interest in cost containment, it 1 Dr. Ted Mitchell has been practicing chiropractic rehabilitation in a multidisciplinary setting over 10 years. He is board certified in chiropractic medicine, and is currently pursuing his master s degree in rehabilitation counseling at Texas Tech University Health Sciences Center. is likely the rehabilitation counselor (RC) will be encouraged to return the injured worker to duty as quickly as possible. Functional capacity evaluations provide a safe effective method of determining the injured client s return to work readiness. The RC s ability to define the functional capacity of an injured client will become more important as a large portion of the population passes 45 years of age, which the World Health Organization defines as the start of physical decline and diminishing health status . Working knowledge of the methods used to quantify physical impairment of the injured individual will help the RC solve return to work issues within the budgetary demands of the insurer and the physical capacity of the client. 2. The need for an objective testing method Determining physical capacity has traditionally been performed by physicians, based on subjective information from the injured client and a physical examination . This may omit objective information however, leaving the opinion of the physician to scrutiny. Additionally, physical examination performed by the physician may fail to accurately assess critical aspects /08/$ IOS Press and the authors. All rights reserved
2 22 T. Mitchell / FCE in VOC REHAB of the job, such as aerobic and strength capacities, dexterity, and agility, thus limiting its ability to examine tasks beyond the sedentary or light level . The focus on cost containment challenges RC s to return the injured client to work as early as possible without delaying recovery or exposing the client to reinjury. The FCE helps determine the safe, tolerable levels of function and predict when a client is ready for return to work . Several authors have investigated the use of the FCE in the determination of work capacity. As the rehabilitation counseling profession approaches 90 years of contribution to the world of work, it has transformed from a profession owing its genesis to legislation to one of refinement by education. A thorough review of this information will help gain insight into the use of the FCE in determining the impairment of injured individuals, and its application in the field of vocational rehabilitation. 3. The functional capacity evaluation 3.1. Determining physical limitation Assessing the actual versus the perceived physical capacity of an individual requires more than a cursory medical examination. Functional capacity evaluations document activities the patient can perform safely and activities in which he has limited ability. According to the American Physical Therapy Association , the purpose of the FCE is to provide an objective measure of a patient s safe functional abilities compared to the physical demands of work. Objective limitations in range of motion, flexibility and strength are evaluated in terms of how these limitations relate to work activity . The FCE should be administered when the patient s injury or illness has received appropriate medical treatment and return to work is being considered . There are two common approaches to the FCE . The kinesiophysical approach focuses on the physiological responses and adaptations to workload. The evaluator determines the safe, maximal lifting capacity by observing adverse physiologic signs. The evaluator controls the test by assessing objective tests and observations. Because a set of standardized criteria for judging increased effort and maximal levels are used, the safety of the injured client is ensured as assessment is stopped before the client is overexerted . The Psychosocial approach to determining safe maximal lifting capacities is based on the psychosocial model, placing the participant in control by allowing him/her to stop performance when he/she determines maximal function has been reached . While there are many FCE methods or templates, the evaluation of an individual with unresolved illness or injury is common to all of them . If the FCE is to be accepted as a useful tool for measuring an individual s maximum ability, reliability and validity of the evaluation must be demonstrated . King et al.  reviewed ten computerized FCE systems widely used and accepted in the United States. The authors suggest that standardization, objectivity, reliability and validity must exist within any given FCE method in order for it to be considered a well-designed evaluation. Standardization is defined as the development of a clear set of procedures for administering and scoring tests . Objectivity indicates the measurement has a degree of reliability and is relatively free from examiner bias, and is performed within defined operations . According to King et al. the importance of reliability and validity cannot be overstated. Reliability refers to consistency in measurement . Interrater reliability refers to the ability to achieve similar results on an evaluation when administered by different evaluators . Test-retest reliability or intrarater reliability refers to the stability of a score derived form one administration of an FCE to another when administered by the same evaluator . Only two of the systems, Physical Work Performance Evaluation (PWPE) and the WEST-EPIC (lifting-capacity section only), reviewed by the authors have been examined for intrarater and interrater reliability. Validity refers to the test measuring what it says it is measuring and its ability to have the results used to make inferences . In FCE testing this means the score can be used to predict real world function. According to King et al.  validity is an essential requirement for all measurements. Only one system reviewed, the PWPE revealed study of its validity in a peer reviewed scientific journal. This lack of validity study questions whether FCE s are acceptable and credible . The accurate assessment of a patient s function is dependent on his willingness to exert maximal effort during the evaluation . In the study conducted by these authors 90 low back pain patients were evaluated for maximal effort during the FCE. Only five of 17 commonly used maximal effort tests were individually useful in differentiating between maximal effort and submaximal effort during the FCE . There is evidence that more research is needed in the use of the FCE in the disability examination process.
3 T. Mitchell / FCE in VOC REHAB 23 King et al.  suggest that the quality of the FCE process is dependent on the competence and training of the evaluator. Poor training and lack of competence can result in a lack of reliability and validity. It s important to note that King s study was an evaluation of FCE equipment and its quality rather than on the FCE process itself. Training in FCE protocols supported by empirical evidence of reliability and validity is imperative. To assure reliability and validity in the FCE process skill and training of the evaluator are more important than the equipment used. Rehabilitation counselors using FCE s in the return to work decision should have intimate familiarity with the protocols used and the research behind their design. Lechner, Jackson, Roth, & Straaton reviewed the PWPE in 1994 to determine the interrater reliability and concurrent validity of a newly developed FCE protocol. The PWPE is a test of a person s ability to perform physical work and consists of 36 tasks and 20 physical demands of work as defined by the United States Department of Labor in the Dictionary of Occupational Titles (DOT) . These authors note the PWPE is designed to maximize the objectivity of three major clinical judgments that must be made by the test administrator during testing of physical work performance: 1) the maximum ability of the subject in dynamic strength testing; 2) the quality of the body position or movement pattern in position tolerance or mobility testing; and 3) whether the subject is participating fully throughout all sections of the testing. The findings of this research indicate that the PWPE has a high degree of interrater reliability. Although the authors admit difficulty in establishing validity due to the lack of a perfect standard for comparison of PWPE predictors and actual work performance, the magnitude of positive correlation provides evidence in support of convergent validity. This research supports the intended design of the PWPE to predict a maximum safe level of physical work instead of an absolute level of work . Since FCE s are commonly used to determine return to work readiness, and their validity remains to be proven, the ability to predict the future work capacity of the individual based on this evaluation is suspect. Gross et al.  studied the validity of the Isernhagen Work Systems Evaluation in predicting timely return to work of patients with chronic low back pain. They noted that recommendations to return to work based on FCE results were made based on the patient s ability to perform at levels matching or exceeding all required job demands. In their study only 4% of the patients evaluated were deemed medically stable and rated as meeting all job demands. Gross et al.  noted a crude relationship between the suspension of temporary total disability benefits and the results of the FCE. It s interesting that while only 4% of the patients tested were deemed able to perform all demands of their job that 95% of all those tested were returned to work within 1 year. With this rather small indication of the ability of the FCE to predict work readiness, it is questionable as to whether the cost of the evaluation is reasonable . They further state that the floor-to-waist lift test has similar results to the full FCE protocol and may easily be added to a comprehensive physical examination of a patient with chronic low back pain. Incorporating this simple test in pre-existing examination protocols may prove more cost effective, and warrants further study. In addition to the skill and training of the FCE evaluator and the equipment used, there are other factors that affect the patient s performance on an FCE. Psychosocial factors have significant impact on functional activity . The authors go on to say that while several systems assess functional limitation, assessment of psychosocial factors has not been addressed. The authors of this study found that very few psychosocial factors directly impact functional measure, but many are related to measures of disability. Those factors that are related to the measure of functional ability are pain-related fear, self-efficacy, and illness behavior . These factors were shown to influence measures of sincerity of effort during the FCE Factors that influence the return to work decision Physical and psychosocial factors influence performance-based assessment. Clinically, these factors should be measured and acknowledged in performancebased testing . The RC with training in the psychosocial aspects of disability can utilize the objective information gained from testing and apply it in the world of work. Test performance is influenced by physical factors and self-perceptions of disability and pain. Functional capacity evaluations should be considered behavioral tests influenced by multiple factors, including physical ability, beliefs, and perceptions . Potential causes of magnified illness behavior include unrecognized physical severity of the medical impairment, psychological distress related to the duration, amount, and failure of treatment, or dislike of the job or employer, and voluntary exaggeration to influence legal proceedings . Functional capacity evaluations are measurement tools used in predicting readiness to return to work fol-
4 24 T. Mitchell / FCE in VOC REHAB lowing an injury. Rehabilitation counselors use FCE s in balancing recommendations for early return to work with concerns of delayed recovery or pain exacerbation. Reliability and validity must be demonstrated if this test is to be considered useful. Gross et al.  determined that better performance on evaluation was weakly associated with faster recovery, and that one task in the evaluation was as predictive as the entire protocol. A later study by these same researchers suggested the opposite was true. A lower number of failed tasks were consistently associated with higher risk of recurrence after controlling for potential confounding variables . These results suggest that more study is needed in this area. A major finding of one study was that a surgeon s recommendations had strong influence on the period of absenteeism and was not correlated with objective findings . It may be that the advice is not based on the physiology or the other parameters measured, but other more subjective information. It is possible, but unlikely that patient preferences influenced the surgeon s decision since the recommendations are written in the discharge summary usually without any face-to face discussion. Identifying predictors for ability to return to work is essential in order to direct correct individual rehabilitation. Identification of predictive factors could be a valuable instrument in prioritizing the provision of resources to the clients with the best chance of successful rehabilitation . Social and work factors have been demonstrated to be more accurate predictors of physical disability than physical factors  The physician s role in evaluating work ability In contrast to the clinical examination, the FCE is not important until the patient emerges from the acute stages of an injury and objective measurement of functional outcomes is necessary . Rehabilitation professionals can have significant influence on the improvement of the role of the physician in evaluating work ability. Pransky et al.  suggest this can be achieved through provider education, developing improved systems for communication with employers, and encouraging employers to provide more alternative duty assignments. These authors state the physicians are trained to focus on symptoms, with the prevention of work disability not being central to the mission of the medical practice. Teaching of occupational medicine is on the decline, within limited curriculum to occupational medicine . According to this study, occupational medicine is taught as a half-day seminar in the third of 4 weeks of primary care teaching. This is the only formal teaching in occupational medicine the students receive. The student is left with the impression that the principles and concepts associated with occupational medicine are just common sense . Pransky et al.  go on to say that training about work disability for primary care physicians is minimal. They add that there is a general lack of knowledge regarding the assessment and treatment of work disability that leads to reluctance to address these issues. Despite this reluctance and lack of formal training, physicians are given a key role in evaluating and certifying the work implications of illness, recommending appropriate time out of work, and assisting patients in returning to work and maintaining employment . The physician s role is of central importance to patients, employers, insurers, and the government. Physician input is required by benefit programs, such as social security, private disability insurance and workers compensation . Pransky s study examined the physician s role in supporting the employment of their patients, and their perspectives on disability and return to work issues. While the physicians in this study recognized the importance of disability prevention and their role in the process, they had little training in managing time off from work, reporting work restrictions, and communicating with employers. This study suggests that increased access to disability case management services and consultation with rehabilitation experts would improve accommodations and communication with employers . Brodwin et al.  state the RC seeks to maximize the person s potential in the world of work. Improvement of the client s interaction with the work environment is accomplished by finding ways to minimize a person s functional limitations through accommodation. Combining the RC s knowledge of workplace restrictions and reasonable accommodation with the information revealed by the FCE can help safely return the client to full duty. 4. Using the FCE in vocational rehabilitation 4.1. Impairment v. Disability The RC may serve an important role in bridging the gap between impairment and disability. Confusion caused by the terms impairment and disability is
5 T. Mitchell / FCE in VOC REHAB 25 an area of concern. According to the AMA Guides to the Evaluation of Permanent Impairment, 5 th Edition, impairment is a loss, loss of use, or derangement of any body part, organ system, or organ function. This same textbook defines disability as an alteration of an individual s capacity to meet personal, social, or occupational demands because of impairment. An impaired individual may or may not have a disability. The physician s role is to determine impairment, and provide medical information to assist in disability determination. Impairment is used to describe a stable condition that has had sufficient time to allow complete tissue repair and is not likely to change with further medical treatment. The purpose of determining an individual s impairment is estimation of the loss of ability to perform activities of daily living (ADL). Self care such as grooming, making and eating meals, spoken/written communication, standing, sitting, maintaining your home and finances, walking and social activities are all examples of ADL s. An individual with an impairment that affects ADL s may or may not be able to meet the demands of their job. Evaluation of impairment is accomplished by thorough review of the patient s history and clinical information. This determination relies heavily on the judgment, skill, training, and experience of the physician. Currently the use of the FCE in conjunction with the physician qualifications has become common and is viewed as relatively objective. The FCE has been upheld in the legal arena as medical evidence that is reasonably supported, and as such sufficiently significant in either a qualitative or quantitative sense in determining worker ability . Evaluation of disability involves many factors that are not evaluated by the physician examination or the FCE. Disability refers to an individual s inability to complete a task or a duty. It is the inability of the injured individual to perform personal, social, or occupational demands because of impairment. In other words it is the relationship between the impairment suffered by the individual and its affect on tasks they must perform. It is in this relationship that the RC is most effective. Lydell et al.  state that the most important factors in determining the injured individual s return to work were an optimistic/pessimistic outlook on life, the degree of rigidity concerning work tasks, the degree of social assistance and self-image. In a follow-up study on patients with whiplash trauma and myofascial pain, Heikkila et al.  determined that a good social environment has been proven to be the most important factor for a positive result in a multidisciplinary rehabilitation program. Another study by Ratzon et al.  found that time to return to work following carpal tunnel release is directly related to the recommendation of the surgeon. Their study suggests that an important factor in predicting return to work is the doctor s recommendation, and standardization of these recommendations may address the variability of sick-leave amongst patients. With disability-related absences costing major corporations billions of dollars per year, reduction of lost work time is of prime importance . The expertise of the RC can address this reduction of lost time from work and the complex factors of disability that are beyond evaluation by the physician or FCE. 5. Vocational rehabilitation counseling 5.1. History of the profession After World War I, wounded soldiers returning from Europe needed help finding jobs. Passage of the Soldier Rehabilitation Act in 1918 authorized vocational training and placement for veterans with disabilities . A sequence of legislation, with its culmination in the 1998 Amendments to the Rehabilitation Act of 1973, has expanded the services, disabilities, and programs provided by RC s . Empowering the individual to exercise control over their own life is the goal of the RC. Skills that help coordinate available services and resources include counseling, job analysis, job accommodation, and coaching clients in their job search. These functions require the RC to talk about the concerns, and answer questions that arise from an episode of disability. Knowledge of health and disability benefits is essential as the RC helps the client with their return to work. In the 1970 s, the Commission on Rehabilitation Counselor Certification (CRCC) was established to prepare rehabilitation professionals to assist people with disabilities . This agency offers credentialing as a Certified Rehabilitation Counselor (CRC) for candidates that have completed an accredited master s degree program and approved internship. The CRCC  states the focus of rehabilitation counseling is helping people with disabilities to live as independently as possible and integrating them into society. This is achieved by the assessment of individuals needs, career counseling, and removal of environmental, employment and attitudinal barriers . In order to meet the goal of eliminating barriers to employment, and integrating them into the world of work, clients must be evaluated in order to determine their functional ability.
6 26 T. Mitchell / FCE in VOC REHAB 5.2. Education Rehabilitation counselors have the training and experience to translate the evaluation of medical fitness into the determination of work capacity. The Council on Rehabilitation Education (CORE) accredits rehabilitation counseling programs in the United States. Certain standards must be met in order to be CORE certified. In addition to counseling theories and case management, students in these programs are exposed to the medical and psychosocial aspects of disability. The approaches, techniques, and instruments of vocational assessment are taught with a strong emphasis on interpretation and integration of this information. The education of future RC s includes hundreds of hours of classroom training and internship participation in order to develop the skills necessary in their profession Transitioning from injured to employed The recommendations given by the treating physician directly impacts the injured client s return to work. The information obtained from an FCE can help the RC determine if the client can perform the essential or critical job functional areas . Combining physical ability with the other factors including client motivation enables the RC to assist with this transition. This unique knowledge of the specific job tasks required of the individual in the work place allows the RC to effectively return the injured worker to gainful employment. The Revised Handbook for Analyzing Jobs (RHAJ) defines a task as one or more elements and is one of the distinct activities that constitute logical and necessary steps in the performance of work by the worker. RC s have the ability to match workers abilities with specific job tasks. This process begins by analyzing the job to identify the nature and physical requirements of the job tasks. The FCE is then utilized to identify whether the client maintains the physical capacities to perform these tasks, and if not, helps the counselor identify what job modifications are needed. This places the RC in the unique position to match a job s tasks with an injured client s abilities. Occupation is defined as a group of jobs, found at more than one establishment, in which a common set of tasks are performed or are related in terms of similar objectives, methodologies, materials, products, worker actions, or worker characteristics . Matching a client s functional capacity to the demands of an occupation is within the scope of practice of the RC. The physical demands of an occupation are available from resources such as the DOT, published by the United States Department of Labor, or O*NET, which is a system that defines occupational groups . The physical demand levels of different occupations are described as sedentary, light, medium, heavy, and very heavy. Although the DOT has been replaced by O*NET, it still remains one of the most commonly used resource by RC s. The DOT uses a nine-digit occupational code to classify occupations, with each digit having a specific meaning. Because no two occupations have the same nine-digit code the listings are quite extensive, containing 12, 741 occupations . O*NET is a database that contains only 1,122 occupations . In contrast to the DOT, O*NET uses an eight-digit code to classify occupations, and does not include what it considers obscure or obsolete occupations, or those that employ only a few individuals. The main difference between these two systems is that the DOT focuses on tasks and the O*NET focuses on skills . RC s can use the FCE to match objective data with these descriptions in an attempt to predict the client s ability to perform. The complexity of matching all the job tasks required in a particular occupation requires the expertise of a RC familiar with the full range of job demands in an occupational classification. Rehabilitation counselors analyze jobs by two major areas of job information: work performed, and worker characteristics . Work performed includes physical worker actions, and worker characteristics include the physical demands of the specific job-worker situation . Functional capacity evaluations provide information on the client s physical ability to perform work, allowing the RC to evaluate information that encompasses the most frequently encountered tasks and work behaviors, without regard to occupation . This allows the RC to match the client s functional ability with the demands of competitive employment. 6. The return to work decision 6.1. Opportunities Assisting the client in returning to work following an injury is a central role of the RC. His/her specialized knowledge of disabilities and the work environment, combined with his/her counseling skills, makes the rehabilitation counselor uniquely qualified in assisting the injured client to reenter the work force. Opportunities abound for those properly trained to objectively translate medically assessed impairment of structural
7 T. Mitchell / FCE in VOC REHAB 27 and functional limitations. Given the wide variety of functional assessment measures available, it is unlikely that many new measures will be developed . The FCE process supported by the rehabilitation expert will help answer the questions posed by requesting entities Determining the employment outlook for the injured client Functional capacity evaluations can assist the RC in determining whether a person is disabled from vocational activity or whether work activities should be restricted . Pain related fear, self-efficacy, and illness behavior have all been shown to be related to measures of function and test performance. Self-reported limitations are considerably higher than from those derived from clinical examination or FCE . There is strong evidence that depression and post traumatic stress disorder can limit performance on evaluation . The role that job factors such as job stress or secondary gain may play on the FCE is unclear. A study by Frings-Dresen and Sluiter  concluded that it is possible to develop a job-specific protocol, using on-site observations as the input. These researchers determined this would cut the testing time by 75%. Rehabilitation counselors can implement the use of a job-specific protocol to support the preparation of a client s vocational rehabilitation plan after the first few weeks of sick leave. This can be used as a starting point between employers and employees in developing a return-to-work plan . A report by Allen et al.  indicates that 29% of FCE reports provide no comment on the suitability of the client s future employment options. Future economic loss is one of the major foci of claims compensation in personal injury cases. The professional opinion of a RC regarding the client s strengths and weaknesses in relation to work capacity and employability on the open labor market extends the value of FCE s in the litigation process. 7. Conclusion Allen et al.  noted that demand for opinions on the functional implications of injuries in terms of work capacity and independent living, for litigation, compensation and insurance purposes has increased. A properly trained RC s report on a client s functional abilities at home, work and leisure, together with those of other experts, contributes to decisions about the economic losses, or damages, for which the person receives compensation. A well-trained rehabilitation expert who understands the relationship between an injured person s medical condition, functional abilities, psychosocial status and work demands can provide a wide range of consultation services. These services could include on site supervision for people on return to work programs, on site job analysis, vocational exploration, vocational retraining, and job placement. The FCE helps objectively determine whether a person may return to work, what work restrictions or accommodations may be needed, and whether a person has reached maximum medical improvement. Combining this information with the specialized knowledge of the RC can be an effective way to return the injured client to gainful employment without the risk of re-injury, while meeting the needs of our current healthcare system. References  S. Allen, G. Carlson, T. Ownsworth and J. Strong, A framework for systematically improving occupational therapy expert opinions on work capacity, Australian Occupational Therapy Journal 53 (2006),  S. Allen, A. Rainwater, A. Newbold, N. Deacon and K. Slatter, Functional capacity evaluation reports for clients with personal injury claims: A content analysis, Occupational Therapy International 11(2) (2004),  American Physical Therapy Association, Guidelines: Occupational Health Physical Therapy: Evaluating Functional Capacity. 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