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Functional Capacity Evaluation: Evidence and Issues

Doug Gross, Ph.D. dgross@ualberta.ca

1)  Overview to FCE – definition, rationale and approaches

2)  Review evidence regarding FCE as a

measure of:

a) Sincerity/ Malingering

b) Work Ability

3) General discussion

Objectives

•  Medical findings and impairment level are

not good indicators of ability and/or RTW

Why Guesswork?

•  Medical findings and impairment level are

not good indicators of ability and/or RTW

•  Often there are no signs of injury, only

symptoms

Why Guesswork?

•  Medical findings and impairment level are

not good indicators and/or RTW

•  Often there are no signs of injury, only

symptoms

•  Most doctors and health professionals get

little training on how to judge work ability

•  Little evidence informing best methods

Why Guesswork?

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Standardized protocols of performance tests used to determine an individuals’ ability for work-related activity and job placement, readiness to return to work, or need for modified work duties. Soer et al, JOR 2008

Functional Capacity Evaluation Def’n

Many Commercial Protocols

Key

Valpar/ Joule

BTE/ Hanoun

Isernhagen

WorkWell

Ergoscience (PWPE)

Matheson (Epic, PILE)

Arcon

Blankenship (Quest)

WorkAbility/ Ergo-Kit

How  Much  Do  Stakeholders    Value  FCE  Informa;on?  

 Results  from  a  Qualita/ve  Study  of  Pa/ents,  Clinicians,  

Employers  and  WCB-­‐Alberta  Case  Managers    

Hierarchy of Information Within the WCB-Alberta

Other  Medical  Specialists  (i.e.  Physiatrists,  Occupational  Medicine  Specialists,  etc.)  

-­‐  

Functional  Capacity  Evaluation  Reports  

Generalists/  Allied  Health  Professionals  (i.e.  family  doctors,  physios,  chiros    

Orthopedic  Surgeon/  Diagnostic  Imaging  

Increasing  Value  Placed  on  Information  from  the  

Various  Sources  

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•  Objective = reliable and valid from a

scientific perspective

•  Evidence must be linked to the purposes

of FCE which are:

1) Detecting sincerity of effort

2) Assessing work ability

Is FCE “Objective”?

“Catch the malingerer”

FCE Model 1: Sincerity

“(FCE) is a good way to find out if the person is playing games. It’s a good way to get fakers to maximum medical improvement. If the test

shows they are not fakers, well, now their complaints have been validated.”

- Article in recent ‘Lawyer’s News’

Can FCEs detect insincerity as claimed?

Detecting Sincere/Insincere Effort

Therapists can differentiate maximum from sub-max performance

Little evidence we can detect “malingering” or judge insincerity

Submax = depression, FCE done in non-native language, etc.

Behaviour is an idiom of pain, disability and/or distress

Frequent displays of strange/erratic/inconsistent behaviour during FCE

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Other Influences on FCE

Pain Depression

Perceived Ability/ Fear Self-efficacy (subject’s own ‘prediction’)

Assessment setting

Cross-cultural Comparison

Valens

28 13 16

16 11 13

34 17 20

24 15 17

Netherlands Alberta Switzerland

Netherlands Alberta Switzerland

Social Model Injury Models

Have to prove you are

ill or injured to qualify

for compensation

•  Don’t use FCE to judge lack of sincerity

•  View findings as a form of pain behaviour

with multiple potential explanations

•  Indicator for further investigation

Summary: Interpreting Sub-Maximal FCE Performance

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Load Capacity

Model 2: Work Ability

Several studies have shown that FCE is associated with self-rated work ability

FCE is correlated with ‘Occupational’ ratings more than recreational/personal functional activities

But…FCE is limited to Health/Functional Capacity foundation of Work Ability ‘House’

FCE as a Measure of Work Ability?

Do FCEs predict return to work?

Days FCE to TTD Suspension

4003002001000

Pro

porti

on o

f Sub

ject

s

1.0

.8

.6

.4

.2

0.0

Floor- to-Waist Lift

Fa il (n=18)

Pass (n=59)

FCE Prediction of RTW

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Modest Predictor

Streibelt et al, 2009

Lechner, Work 2008

Gross et al, 2004, 2005, 2006,

Matheson et al, 2002

FCE Prediction of RTW Short Form-FCE

Brief assessments are as or more

predictive than long FCE protocols

Does FCE Promote RTW?

Days to Suspension of T ime Loss Benefits

4003002001000

Prop

orti

on o

f Su

b je c

ts

1 .0

.8

.6

.4

.2

0.0

Typical recovery in chronic conditions

Recovery after FCE

Does FCE Promote RTW and/or job placment? Does  FCE  enhance  outcomes  following  

return  to  work  assessment?    

Randomized control trial funded by WorkSafeBC

Performance  vs.  Self-­‐Report  •  Self-­‐reported  ability  levels  are  consistently  lower  than  those  determined  through  performance  

•  Typically  5-­‐8kg  lower  (poten/ally  places  them  in  a  different  NOC  category  affec/ng  job  placement)  

Study  Methods  Design:  Cluster  Randomized  Controlled  Trial    

Sample:  All  workers  assessed  at  Millard  Health  

Comparison:  FCE  vs.  Func/onal  Interview  

Context:  Pre-­‐rehabilita/on  and  at  claim  closure      

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•  FIT = Functional Interview Tool

•  Developed out of previous studies on self-efficacy beliefs and functional performance

•  Semi-structured functional interview using FCE assessment items

Alterna;ve  To  FCE:  FIT  Self-Efficacy Theory

•  Self-reports are enhanced when appraisals are specific and meaningful (Bandura)

Motivational Interviewing •  Counseling method

aimed at increasing motivation by resolving ambivalence (Shannon and Hillsdon, 2007)

Interview  Theory  

Results •  All baseline assessment results were similar

between groups (claimants interviewed for

case closure did not “underestimate”)

•  No significant differences on any outcome

•  Rehab outcomes comparable except pain

and disability were worse in FCE group Differences were not statistically significant (p = 0.74, n=203).

Pain Findings Confirmed in Qualitative Study

The assessment the first day, it went okay. There was a little minor ache right going to bed . . . at night, when I went to bed that second day, it kept me up most of the night so I dropped a sleeping pill. I thought, okay, stay in bed for a week and then maybe I’ll get better. Now I’m still sitting. That year span I healed a lot I thought. I thought I was ready to go back to work. I was running frequently and hitting the gym. Then that last assessment just, it just whacked everything out again.

- Claimants who underwent FCE

  Some evidence FCE is a valid measure of work ability and moderately predicts RTW

  Assessment process may facilitate RTW

  Brief FCE protocols or interviews are likely as useful as more burdensome FCEs

  FCE can exacerbate pain

Summary  2:  FCE  as  a    Measure  of  Work  Ability  

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Take  Home  Messages  

  FCE should not be used for ‘finding fakers’

  Functional assessment can help identify work

ability levels to guide job placement, return to

work and rehabilitation

  Optimal form of assessment still unknown

University  of  Alberta  Maxi  Miciak  

Michele  Crites  BaVé  Linda  Carroll  Peter  Rothe  Alex  Asante  

 

Collaborators  and  Funders  

WCB-­‐AB  Millard  Health  Rene  Huellstrung  Ambrose  Sun  Janet  Welch  

Mar/  Mikalsky  Riikka  Niemelainen  

Discussion STUDY  FLOW  CHART  

2-Day ‘Comprehensive’ FCE Results

•  All baseline assessment results and

outcomes were similar between groups

•  No statistically or clinically significant

differences on any outcome

Differences are not statistically significant (Mann-Whitney test p = 0.74, n=203).

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1-Day ‘Basic’ FCE Results

•  Claimants undergoing FCE had 15% higher functional levels recommended (p<0.01)

•  Smaller differences at follow-up times (0% to 8%) in favour of the interview though not significant

•  Program outcomes (95% PRTW) comparable except pain and disability which were worse at discharge in those undergoing FCE (p<0.05)

Rehabilitation Program Outcomes

FCE FIT Mean Change Scores

Pain VAS* 0.9 2.3 PDI%* 13.5 21.5 SF36 Bodily Pain* 8.5 24.9 SF36 Physical Comp 4.5 9.3

Follow-up Interview with Basics FCE FIT

Participated in Follow-up* 29.5% 45.0% 1-Month

Not Working 40.7% 34.7% Regular Duties Full time 29.6% 16.3% Med/Heavy work 62.5% 56.2% Not working due to injury/new * 58.8% 9.1%

3-Month Not Working 35.3% 16.2% Regular Duties Full time 47.1% 62.2% Med/Heavy work 54.6% 63.3% Not working due to injury/new 66.7% 66.7%

2-Day CFCE Outcomes FCE FIT

Return-to-work Recommendation 57.3% 53.0% No further rehabilitation 66.0% 71.0% Off all benefits by 180-days 90.3% 88.0% 1-Month Interview

Not Working 38.8% 44.7% Regular Duties Full time 18.4% 23.7% Med/Heavy work 36.7% 47.6% Not working due to injury/new 68.4% 64.7%

6-Month Work Ability Compared to Lifetime Best (out of 10) 4.1 5.2

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Pain Findings Confirmed in Qualitative Study

This is when we get into: "Yes I did that activity but for three days later it killed me. I can't move.” Okay, then really why do we want to get him injured again? Let's start lower and we'll move up a little bit slower but we will get to the level we need to without reinjuring hopefully.

- Employer Rep … if they come in really sore after doing the FCE, it wouldn't be appropriate to start them at that level.

- MH Clinician

In all, he was very professional. The bad part is he said the pain was not an indicator. I could be on a pain scale up to 10 where you are just biting your teeth or pulling the arms off your dental chair. They didn’t care about pain. Pain is no indicator to them. It’s what could you physically lift and… How do you feel about that when you hear that, what do you think? I think they are missing half the boat. Ya, you can keep on going but at what point should you have to endure or not endure pain? So if you are in pain… That’s a key indicator that you shouldn’t be doing the job.

-From an Interview with Injured Worker

FIT Customer Service?

…it was a positive experience. I was absolutely fine and comfortable sitting down with both those clinicians… To tell you the truth it didn’t feel like an evaluation. He wasn’t testing me to make sure…he was looking to see what level I was functioning at, to see where I was at….It wasn’t a race. There was no end point. His job was more or less him finding exactly where I’m at, not where I need to be.

-Claimants who underwent FIT