Functional Capacity Evaluation 1

Functional Capacity
Evaluation
2007 june Shweta Bodkhe

Presentation Flow
Introduction
Functional capacity evaluation
Difficulties in FCE
Summary
Conclusion

• USA 1970s
• Physicians were asked to assess workability of injured
worker

• Therapists compiled existing and self developed
tests into a battery of tests, and named them FCEs

• Functional capacity is the ability of a person to perform
work-related activities
• It can be assessed in different ways:
– Self-report (questionnaire),
– Expert based (physician assessment),
– Performance based (functional capacity evaluation
(FCE)

• The need for functional evaluation was identified in the
1980s by workers' compensation systems that required
specific functional information to expedite the return-to-work
process

• Physical therapists, whose core competencies include
functional evaluation, began to develop relative functional
tests
• Functional examination/evaluation, combined with
diagnoses and prognoses by physical therapists has
become a more effective tool for safely returning
employees to employment

Functional Capacity Assessment
• Definition: Functional capacity assessment is the process

of measuring, recording, and analyzing a person’s ability to
safely perform a number of job-related functions, such as
lifting, lowering pushing pulling and carrying weights,
climbing ladders and stairs, sitting ,standing, bending,
stooping, crouching, kneeling, crawling, grasping.

USES OF FCA
• FCA results are used at appropriate points in the worker

care spectrum to determine a worker’s safe working levels
for the purpose of
– Job placement
– Injury prevention
– Rehabilitation
Components
• This measurement and analysis process involves:

– Physical capacity evaluation
– Work assessment
– Functional capacity evaluation
– Functional capacity assessment

Definitions
• Capacity
The ability of the client to work safely at maximal or sub-
maximal levels over a selected period of time.
• Evaluation
A dynamic process in which the physical therapist makes
clinical judgments based on data gathered during the
examination.

Definition
• Matheson has defined functional capacity evaluation as: A

systematic process of measuring and developing an
individuals capacity to dependably sustain performance in
response to broadly defined work demands
• He further states that a functional capacity evaluation
denotes a form of work evaluation that consists of a battery
of tests which focus on selected work tolerances
• Work tolerances are the observed and measured physical
capabilities of the evaluee that affect competence to
perform the physical demands of work tasks
• Summarily, an evaluation is a systematic approach to
monitoring and reporting performance and includes
observation, measurement, reasoning, and judgment
Physical Therapy Board of California on August 3, 2001

Functional Capacity Evaluation
• An FCE is a detailed examination and evaluation that

objectively measures the patient's/client's current level of
function, primarily within the context of the demands of
competitive employment

• Measurements of function from an FCE are compared to
the physical demands of a job or other functional activities,
and are used to make return-to-work/activity decisions,
disability determinations, or to generate a rehabilitation plan

• A FCE measures the ability of an individual to perform
functional or work-related tasks and predicts the potential to
sustain these tasks over a defined time frame
• A job-specific FCE is one that is required to evaluate a
client's ability to perform the physical demands of a specific,
identified job
• A series of test activities is usually administered to measure
whether an individual has the ability to meet the required
job demands
• Ideally, FCEs are used following an injury or illness to
assist with cost-effective vocational rehabilitation

Purpose
• To provide an objective measure of a patient's/client's safe
functional abilities compared to the physical demands of
work

• The FCE quantifies safe functional abilities, and is a pivotal
resource for:
– Return-to-work and job-placement decisions
– Disability evaluation
– Determination of work function with non-work-
related illness and injuries.

• Determination of function in non-occupational settings
• Intervention and treatment planning
• Case management and case closure

Use
• To determine a person's readiness to return to work after

injury,
• To perform pre employment and post-offer screening,
• Disability determinations,

• Setting goals and planning treatment for industrial
rehabilitation
• Monitoring progress throughout industrial rehabilitation,
• To determine case closure

Factors currently shaping the growth
and evolution of FCE
• Occupational Safety and Health Administration are

promoting the use of FCEs in an effort to ensure employee
health and safety in job placement
• Americans With Disabilities Act (ADA) places an emphasis
on identifying an individual's physical abilities and
limitations for employment and accommodation
consideration
• In litigation cases, FCEs have become critical for the
determination of whether a claimant has wage-earning
potential based on physical abilities
• State welfare reforms and the Social Security
Administration are opening new markets for
FCE providers as they seek a streamlined process for
disability determinations
Types of FCE

• Deals with issues such as
– Type of training for FCE administration,
– Degree of work simulation,
– Ability to alter the test design,
– Generic versus job-specific testing
• The classification into controlled and uncontrolled
categories focuses on different aspects of these issues, but
the classification is arbitrary and overlapping

FCE Protocols
• A standard protocol includes tests and measures

consistently applied to all patient's/clients undergoing a
functional capacity evaluation
• A job-specific protocol includes tests and measures
consistently applied to a patient/client undergoing a
functional capacity evaluation with reference to a specific,
identified job
• Functional Capacity Evaluation Provider
A physical therapist licensed in the jurisdiction in which the
services are performed, who is able to demonstrate
evidence of education, training, and competencies specific
to the delivery of FCEs.
• Job Modification
Change in a task to allow the demands of the job to match
the abilities of the patient/client
Medically stable

• Medical stability is defined as that state in which primary
healing is complete, or the progression of primary healing is
not compromised.
• Clinically, medical stability refers to the consistent presence
of a set of signs and symptoms.

• Consistent means that the location of the symptoms and
the presence of the signs has reached a plateau
• The intensity of the symptoms may vary with activity or
intervention/treatment, but the location or pattern of change
of symptoms remains consistent

• Physical Demand Characteristic Levels as listed in the
Selected Characteristics of Occupations
• Categories of work demands are:
– Sedentary
– Light
– Medium
– Heavy
– Very heavy
Revised Dictionary of Occupational Titles1
– The frequency of work demands1 are:
– Never
– Occasional
– Frequent
– Constant
– Physical Demands of the Workplace

Those physical abilities required to perform work tasks
successfully.
Physical demands include
– work postures (positions),
– body movements,
– forces applied to the worker,
– repetition of the work tasks, and other work stressors
and hazards
Occupational Safety and Health Administration

Knowledge Base
• For safe FCE administration and useful interpretation, the

FCE provider should have adequate knowledge in the
following areas:
• Examination (includes history, systems review, and tests
and measures) of the following systems:
• Cardiovascular/pulmonary
• Integumentary
• Musculoskeletal

• Neuromuscular
• Administration of FCEs and interpretation of tests results.
• Evaluation of physical demands of the workplace.
• Identification of patient/client behaviors that interfere with

physical performance.
• Biomechanical components of safe work practices

• Relevant laws and regulations, including, but not limited to:
• Americans with Disabilities Act
• Code of Federal Regulations6
• Occupational Safety and Health Administration
• Social Security Disability Administration
• Workers' Compensation
Admission Criteria
• The purpose(s) for performing an FCE should be defined.
• Admission criteria require that both of the following be

present.
• The patient/client must be medically stable.
• The patient/client must consent to participate

Indications for FCE
• Situations in which objective functional information is

required
φ Patient/client reaches a point where he/she is not
making functional gains with intervention/treatment
φ Patient/client has not returned to full or modified duty

φ Patient/client is working, but difficulty in maintaining
job/activity function is reported or demonstrated
φ Patient/client demonstrates physical deconditioning, with
a resultant decrease in job-related functional abilities

φ Patient/client displays discrepancy between subjective
complaints and objective findings
φ Patient/client requires data prior to disability
determination, determination of loss of earning capacity,
litigation or case resolution

φ Patient/client requires future rehabilitation or vocational
planning
φ Patient/client requires a job-placement decision
φ Patient/client requires an opportunity to demonstrate
safe performance of functional tasks

Contraindications
Ǿ The patient/client is not medically stable
Ǿ Performance of the test would compromise
patient/client safety or medical condition

Ǿ Communication barriers preclude understanding
instructions, communicating concerns, and interpreting
reactions during the FCE

Test Administration
• A physical therapist providing an FCE has the responsibility
to ensure that a FCE is appropriate for the patient/client,
and that the tasks of an FCE can be performed safely

• Appropriate and accurate performance and
documentation
A Communication of risks/contraindications
B History
– Medical history and diagnosis
– Patient's/client's report of pain and functional
abilities/limitations
– Work/activity history

C Examination
– C.1 Cardiovascular/pulmonary tests and
measures
– C.2 Integumentary tests and measures
– C.3 Musculoskeletal tests and measures
– C.4 Neuromuscular tests and measures

D Conduct functional tests/work simulation
E Observation of patient/client
– E.1 Level of participation
– E.2 Consistency and level of effort
– E.3 Behaviors that interfere with physical
performance
– E.4 Body mechanics
– E.5 Safety

F Evaluation of results of observed functional activity
examination and work simulation
G Comparison of functional abilities of the patient/client with

the physical demands of a job when identified, standardized
categories of work demands,or other task demands

• Characteristics of test administration (4 - 8 hours over a 1 -
2 day period) include:
– Identifying those patients/clients with conditions that

prohibit or limit participation in functional testing
– Evaluating the patient's/client's functional abilities as

related to accomplishing work-related/non-work tasks

A Well-Designed FCE
• Functional capacity testing requires the evaluator to use

tests that are most appropriate for a given client
• There is no single most appropriate test for any one client
or for any one assessment situation because no one
assessment can provide 100 %of all the answers
concerning work injury and return to Work

• A clear understanding from the referral source regarding
the purpose of the FCE is essential in choosing an
FCE
• In evaluations where return to work is the major
focus, a job analysis should be performed to determine
the tasks required for the job
• The results of the FCE can then be compared with the job's
physical requirements

• In cases where an individual is being placed in a new job
we believe that a more comprehensive and generic
assessment is needed
• A range of physical demands must be tested to yield as

much information as possible in order to consider a variety
of job possibilities

• There is lack of data however, to suggest how much
information is necessary to infer from an FCE whether a
person can safely function on the job.
• If disability assessment is the purpose of the FCE, then the
evaluation often can be more limited in scope and
correspond to the information requested by whoever is
determining the level of disability

• Although the application of FCE testing is dependent on the
purpose and setting, every attempt should be made to
follow standardized procedures when available
• Jobs may differ from one FCE to another, but
consistency should be adhered to in the methods for

designing and conducting the assessment

Consider the following questions
• Is the test safe to administer?
• Does the test give reliable results?
• Is the test valid specific to job requirements for
• predicting a safe level of work?

• Is the test valid specific to work-related abilities?
• Is the test practical to administer?
• Does the test predict the risk of future injury or
illness?

Standardization
• Standardization refers to the development of a clear set of

procedures for administering and scoring tests.
• These procedures should be written in an easy-to-use
instruction manual that describes the general approach and
philosophy for the development and administration of
the test and the specific methods for administering all
items in the evaluation

Objectivity
• The term "objective" is used to indicate a measurement

that has a degree of reliability and is relatively free from
examiner bias
• Objectivity in testing can be promoted when the
procedures, variables for observation, and scoring system
are operationally defined
• Visual observations can be objective if operational
definitions and scoring criteria are applied

Reliability
• The importance of reliability and validity of FCE

measurements cannot be overstated
• If an FCE measurement does not have established
reliability, test results could be different with each
administration
• Without validity testing, there is no way of knowing whether
the results are accurate

Validity
• A score is considered valid if it measures the properties that

it supports to measure and can be used to make inferences
• In FCE testing, this means that the score predicts real-

world function

Components of FCEs
Record review
Self administered questionnaire
• Data Gathering interview
• Physical Examination Musculoskeletal examination

Screening

• Physiological Muscular ,
cardiovascular endurance
Measurement Test protocols
Term and task

• Functional Isometric ,isokinetic
Performance and isoinertial
Psychophysical method
obeservetion

Report making
• Logical clear easy to understand and free of jargon

• Clear picture of abilities and limitations
• The source of information on the job demand should
always be documented
• Clients cooperation, consistency, and safety of movement,
body mechanics should be documented
• Job modification and recommendation
Issues in FCE Development
• Qualifications of the Evaluator
• The issue of who is qualified to administer FCEs is being
addressed by determining the competencies required to
perform a safe, reliable, and valid FCE

• Once determined, these competencies guide mandatory
training sessions in which clinicians eventually demonstrate
competence through written and practical skills as well as
testing procedures

• Training
• Given the difference in skill levels among the
disciplines,evaluator training should, become an important
means of ensuring quality and consistency in evaluation,
scoring, and report writing related to FCEs

• "Train-the-trainer“approach
• Certifying each individual desiring to administer FCE
• Research has yet to provide data as to how much training
is needed to obtain valid and reliable measurements

Length of Assessment
• 2HRS -2 DAYS
• Shorter FCEs (1-2 hours) seem to provide less reliable data
and appear to be less comprehensive,
• The shorter FCEs are less likely to include all 20 physical
demand items identified by the DOT

• There are no data to support the selection of a specific
length of time for FCE testing
• Functional capacity evaluations that do not take long to

administer may compromise content validity because
addressing all of the physical demands of the job may not
be possible

• Validity may be affected in the performance of a 2-day
evaluation if soreness is acquired from testing on the first
day

Projection to an 8-Hour Workday
• Because work typically relates to a full day and week
(approximately 8 hours a day, 5 days a week), an FCE
needs to relate to these time periods
• It is important that endurance and tasks be evaluated so
that tolerance for an 8-hour workday can be determined

• Documentation of heart rate, endurance factors, change in
body mechanics, and fatigue can assist with this projection

Behavior Management and
Assessment
• 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
– Voluntary exaggeration to influence legal proceeding

Are functional capacity evaluations affected
by the patient’s pain?
Current Pain and Headache Reports Volume 10, Number 2 / April, 2006
• Many people undergoing FCE have painful musculoskeletal

conditions limiting their work ability, pain becomes a critical
factor in the assessment of function
• This paper considers the available literature related to the
influence of pain on FCE, which clearly indicates FCEs are
behavioral assessments influenced by pain intensity and
other pain-related constructs

• Increasing pain levels are consistently associated with
reduced FCE performance levels
• For purposes of claims adjudication, FCE should not be
considered a purely "objective" indicator of functional
impairment independent of subject or evaluator perceptions

• FCE may have some value for facilitating return-to-work or
re-integrating chronically disabled workers into the
workforce, although pain factors must be taken into
consideration when making predictions about future work
status
• Shorter FCEs could potentially be as effective as more
lengthy protocols
Current Pain and Headache Reports Volume 10, Number 2 / April, 2006

Factors Influencing Results of Functional Capacity
Evaluations in Workers’ Compensation Claimants
With Low Back Pain
Physical Therapy . Volume 85 . Number 4 . April 2005
• Purpose: To evaluate the association between performance

on the Isernhagen Work System Functional Capacity
Evaluation (IWS-FCE) and various clinical and
psychosocial factors
• Subjects:170 workers’ compensation claimants who were
undergoing functional capacity evaluations (FCEs) for low
back injuries
• METHODS:CROSS-SECTIONAL study, claimants
completed IWS-FCE, the Pain Disability Index (PDI), a
workplace organizational policies and practices scale, and
a recovery expectations questionnaire. Functional capacity
evaluation performance indicators were the number of
tasks in which subjects did not meet work demands and
weight lifted on the floor-to waist lift
• Analysis included multivariable regression

• The results indicate that performance on FCEs is
influenced by physical factors, perceptions of disability, and
pain intensity
• However, perceptions of workplace organizational policies
and procedures were not associated with FCE results for
workers’ compensation claimants with chronic back pain
disability
• Functional capacity evaluations should be considered
behavioral tests influenced by multiple factors, including
physical ability, beliefs, and perceptions
Phys Ther. 2005;85:315–322

Functional Self-Efficacy Beliefs Influence
Functional Capacity Evaluation
Asante, Alexander; Brintnell, E.; Gross, Douglas
Journal of Occupational Rehabilitation, Volume 17, Number 1, March 2007
• Objectives: The relationship between functional self-

efficacy and Functional Capacity Evaluation (FCE) lift
performance was examined in workers' compensation
claimants' with low back pain

• Methods: A cross-sectional design was used.
• Sample size: Forty-two claimants with back pain
and 38 subjects without back pain were enrolled.
• Subjects completed a measure of functional self-
efficacy related specifically to lifting. Subjects also
underwent FCE floor-to-waist, waist-to-overhead
and horizontal lift testing
• Potential confounders were also assessed including
perceived disability, pain intensity, and self-rated
health.
• Analysis included Pearson correlation and
multivariable linear regression

• Results: Higher functional self-efficacy beliefs were highly
associated with better FCE performance on each of the lift
items tested (r = 0.50-0.73).
• In multivariable analysis, the measure of functional self-
efficacy remained independently associated with lift
performance after controlling for potential confounders

• Conclusion: Functional self-efficacy beliefs appear to
influence FCE lift performance
• Strategies for altering functional self-efficacy beliefs
and their resulting impact on patient functional
performance and outcomes should be examined
JOOR Volume 17, Number 1, March 2007

The Prognostic Value of Functional Capacity
Evaluation in Patients With Chronic Low Back
Pain:Part2
Spine 2004;29:920-924
• Objectives. To investigate the ability of the Isernhagen

Work Systems' Functional Capacity Evaluation to predict
sustained recovery
• Study Design. Historical cohort study

• Methods: Workers' compensatjon claimants who underwent
Functional Capacity Evaluation following low back injury
and subsequently demonstrated recovery in the form of
suspension of total temporary disability benefits or claim
closure were studied
• The number of failed tasks and performance on the floor.
to-waist lift task in the protocol were used as indicators
• Indicators of sustained recovery included whether or not
total temporary disability benefits restarted, the claim was
reopened, or a new back claim was filed
• Logistic regression was used to determine the prognostic
effect of Functional Capacity Evaluation alone and after
controlling for suspected confounding variables

• Conclusions: Contrary to Functional Capacity Evaluation
theory, better Functional Capacity Evaluation performance
as indicated by a lower number of failed tasks was
associated with higher risk of recurrence
• The validity of Functional Capacity Evaluation's purported
ability to identify claimants who are "safe" to return to work
is suspect
Standards of Practice Policies
• Therapists should be aware that they are legally

responsible for the consequences of performing FCEs
• Policies and procedures of testing must be documented
• Client safety is often an issue, and the amount of

documentation regarding client safety in test performance is
an important part of any defense
Safety
• The issue of safety in FCEs focuses on the prevention of
further injury during the testing process

• 2 schools of thought regarding therapist intervention during
testing to ensure client safety:
• Intervention decreases validity and reliability no intervention

places the client at an unacceptable risk of injury
• No data are available to support either contention

• Isernhagen stated that therapists should allow only safe,
controlled body mechanics in testing situations
• Unsafe procedures are potentially harmful to the worker,
and it is clearly inappropriate if an evaluator notices unsafe
procedures and allows the behavior to continue
Ogden-Niemeyers et al
Medico legal implications
• Functional capacity evaluations are increasingly being used
in the legal arena
• FCEs often leads to scrutiny of test standardization, and
particularly to scrutiny of the qualifications of the evaluator

• Using his or her background in showing how the client was
evaluated, the clinician can serve as an expert witness
• Medico legal credibility must be compatible with the
development of more efficient, clearer, and safer FCEs

ICF Model for back pain
• Adults with chronic back pain may have some limitation

or impairment in pain, anxiety, range of motion, strength,
endurance, cognition, attention, memory, sleep, or
depression
Wittink8 et al, Clinical Journal of Pain in 2004

• They may also have difficulty in carrying out activities of
daily living including sitting, standing, walking, or using
stairs
• Some may be able to sit and stand during the day, others
may be able to walk only 2 blocks before they are limited by
their neurogenic claudication

• Participation, Personal Factors, and External Factors are
not easily measurable and can play pivotal roles in a
patient’s ability to function within society
• These are exactly the missing links that indicate why a

Functional Capacity Evaluation is not able to provide high
predictive value of disability

ICF Models Conclusion
In many senses, there are several dimensions that one

needs to understand to train understand a complex
problem such as chronic pain
There will obviously continue to be a need for physicians

trained in the proper treatment of chronic pain

There will be a need for physical therapists who are
skilled in the measurement of functional abilities,
although it may not need to be with a full-scale functional
capacity evaluation.
The missing links like vocational rehabilitation, social
work, and psychology can add to improve a person’s
performance up to his or her capacity

By understanding these concepts we can provide our
patients with excellent care and enable them to optimize
their performance and capacity in fulfilling their societal
roles

Missing links

Summary
• Functional capacity evaluations are most accurately
considered behavioral tests influenced by many factors,
including physical ability, beliefs, and perceptions
Therefore, these results should be interpreted within the
subject’s broad personal and environmental context

• The ability of an FCE to identify claimants who are safe
to return to work is suspect
• Perhaps the FCE process and its administration are only
as good as the examiner

• “Performance on functional capacity evaluations is
influenced by physical factors, perceptions of disability,
and pain intensity.
• Therefore, FCEs should be considered behavioral tests

influenced by multiple factors including physical ability,
beliefs, and perceptions.”

Summary
Impairment Participationn
Activity limitation
Dynamometry FCE Job trial RTW

References
• Use of the ICF Model as a Clinical

Problem-Solving Tool in Physical
Therapy and Rehabilitation Medicine
Phys Ther. 2002;82:1098 –1107

• GUIDELINES: OCCUPATIONAL HEALTH
PHYSICAL THERAPY: EVALUATING
FUNCTIONAL CAPACITY
• BOD G11-01-07-11 (Program 32) [Retitled:
Occupational Health Guidelines: Evaluating
Functional Capacity, Amended BOD 03-01-
16-54; BOD 03-00-25-60; BOD 11-97-16-53]
[Guideline

• Factors Influencing Results of
Functional Capacity Evaluations in
Workers’ Compensation Claimants
With Low Back Pain Physical Therapy .
Volume 85 . Number 4 . April 2005

• The Prognostic Value of Functional
Capacity
Evaluation in Patients With Chronic
Low Back Pain:Part2 Sustained
Recovery SPINE Volume 29, Number 8,
pp 920-924

• A Critical Review of Functional
Capacity Evaluations Physical Therapy
. Volume 78 . Number 8 . August 1998
• Functional capacity evaluation &
disability Department of Orthopaedics
RehabilitationUniversity of Iowa
Hospitals and Clinics vol 27

Thank you

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Functional Capacity

2007 june Shweta Bodkhe