An Examination of the Perceptions of Functional Capacity Evaluations in Prince George, British Columbia: A Case Study Kimberley A. Thew BSc, University of Alberta, 1989 Thesis Submitted In Partial Fulfillment O f The Requirements for the Degree Of Master O f Arts in Disability Management The University of Northern British Columbia March 2007 © Kimberley A.Thew, 2007 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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Conformement a la loi canadienne sur la protection de la vie privee, quelques formulaires secondaires ont ete enleves de cette these. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. i*i Canada Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Abstract Functional Capacity Evaluations assist with work related decisions when limitations in a worker’s functional abilities have been identified. A literature review revealed concerns regarding the limitations of the information gathered during a Functional Capacity Evaluation, as well as, the subsequent interpretation and application of the information. This intrinsic case study explored the perceptions of four key stakeholders (evaluee, clinician, employer, and funder) regarding Functional Capacity Evaluations in Prince George, British Columbia. Primary Sources of information were derived through semi-structured interviews focusing on each stakeholder’s perceptions concerning Functional Capacity Evaluations, and a Sample Functional Capacity Evaluation Report. The key finding was that there are unreasonable expectations regarding the information that Functional Capacity Evaluations can provide and this influences the perceived utility o f the evaluation. The importance o f managing expectations throughout the Functional Capacity Evaluation process was identified and strategies that could be integrated into the evaluation process were suggested. Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation Table of Contents Abstract ii Table of Contents iii Acknowledgements v 1 Introduction Contextualization Historical Development of Functional Capacity Evaluation Statement o f the problem Research Questions Thesis Organization 1 1 2 3 4 5 2 Research Methods Rationale of the Qualitative Approach Site Sample Data Sources Interview Protocol and Structure Data Analysis and Interpretation Validity of the Study Bias Ethical Considerations Limitations 7 7 7 7 9 9 10 11 12 13 14 3 Literature review and data analysis Component 1: Definition Component 2: Nomenclature Component 3: Theoretical Framework for Functional Capacity Evaluation Component 4: Approaches Component 5: Assessment Protocol Component 6: Physical Abilities 27 Component 7: Cognitive Aspects Component 8: Psychosocial Considerations Component 9: Safe Level of Performance Component 10: Sincerity of Effort Component 11: Psychometrics Component 12: Qualitative and Quantitative Information in Functional Capacity Evaluation Reports 16 16 21 22 24 25 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 30 31 36 44 56 66 Functional Capacity Evaluation Component 13: Decontextualization of Work Component 14: Administration Component 15: Utilization 68 74 78 4 Conclusion Discussion Key Findings Personal Reflections Concluding Comments 82 82 85 88 88 References 90 Appendix A: Interview Protocols 98 Appendix B: Informed Consent 105 Appendix C: Transcriber’s Agreement 108 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation Acknowledgements I would like to thank the following individuals for their support throughout this process: • Dr. Henry Harder for his guidance; • The participants for the generous gift of their time and insights; • My co-workers for their words of encouragement; • Lydia Amold-Smith for our many discussions; • Mom and Dad for all your help when things were getting really crazy; • Brenden and Samara for your understanding while Mommy did her ‘homework’ and • Robert for his belief in me. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation Chapter 1 Introduction Contextualization An individual’s inability to work due to a disability can have a significant social, personal, and economic impact (Lechner, Roth, & Straaton, 1991). The individual can experience both a loss in work and income which affects their future security. The employer can experience a loss of skilled labour, lost production time, and increased costs o f benefits (Gardener & McKenna, 1999). Society can be affected by increased health care and social program costs (Gardener & McKenna, 1999; National Institute of Disability Management and Research, n.d.). In an effort to minimize the costs of disability to the individual, employer, and society; early intervention and return to work planning have become key components in disability management programs. The Functional Capacity Evaluation is viewed as a tool that can provide objective data to determine an individual’s functional abilities and assist with return to work planning (Lyth, 2001). Functional Capacity Evaluations are a collaboration of expertise from broad areas o f practice including Occupational Therapy, Vocational Rehabilitation, Physical Therapy, Psychology, Physics, Ergonomics, and Biomechanics (Tramposh, 1992). Despite the fact that the results of the Functional Capacity Evaluation could have significant implications for the individual’s vocational future, there have been a considerable number of limitations identified which could substantially affect the results of the Functional Capacity Evaluation. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 Functional Capacity Evaluation 2 Historical development o f Functional Capacity Evaluations Functional Capacity Evaluations were developed in order to determine objective functional status in relation to work, given that there was an identified need to supplement clinical information with performance based information (Strong, 2002). This need for objective information regarding functional status was identified by both the legal profession and the insurance industry (Lechner et al., 1991). The insurance industry required objective data to base decisions regarding benefits, however, there was also a need to contextualize an individual’s self-report regarding their functional abilities (Strong, 2002). In the 1970’s, the American Workers’ Compensation administration identified a concern regarding delays with return to work and the associated increased claim costs (Isemhagen, 1992; Schonstein & Kenny, 2001). It was determined that this delay was attributable to the difficulties experienced by physicians in assessing when an individual could return to work and the challenges of determining functional ability based on medical diagnoses and resultant limitations (Isemhagen, 1992; Schonstein & Kenny, 2001). The reliance on Functional Capacity Evaluations has increased primarily in response to the increased costs in healthcare and claims (King, Tuckwell, & Barrett, 1998; Strong, 2002). From a legal perspective, courts have traditionally relied on physician testimony regarding the medical or diagnostic findings focusing on impairment and based on range of motion or muscle strength measurements (Johnson & Miller, 2001). A lack of information regarding functional status was identified as a limitation of physician testimony (Johnson & Miller, 2001). Functional Capacity Evaluations were introduced in the legal system as a measure of functional abilities or limitations (Johnson & Miller, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 3 2001). However, Kennedy (2003) cautioned that acceptance of Functional Capacity Evaluation results within the legal system should not be interpreted as a positive reflection of the assessment tool’s reliability or validity. The terms Functional Capacity Evaluation (FCE), Physical Capacity Evaluation (PCE), Functional Assessment, Functional Assessment Evaluation (FAE), and Work Capacity Evaluation (WCE) are used interchangeably (Kyi, 2000; Strong et al., 2004). For the purposes o f this study, the term Functional Capacity Evaluation will be used. Statement o f the problem In my capacity as an Occupational Therapist, I am responsible for the development and implementation of return to work plans. One of the tools I have used to assist with return to work planning is the Functional Capacity Evaluation (FCE). Occupational Therapists are recognized as clinicians that can administer Functional Capacity Evaluations. However, within the scope of my job, I am responsible for contracting with secondary service providers to complete the evaluation. I have to use the information in the Functional Capacity Evaluation report to develop return to work recommendations. These recommendations are reviewed with the worker, union, employer, and funder. As a result of this experience, I began to question the utility and the value o f the Functional Capacity Evaluation. I was frustrated that the information that resulted from the Functional Capacity Evaluation was not as useful in the return to work planning process as I had thought. I found myself frequently requesting clarification o f the information and recommendations contained in the report. In addition, I was routinely seeking supplementary information from other sources. I developed a curiosity about the Functional Capacity Evaluation and realistic Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation expectations surrounding it. I also wondered about the perceptions various stakeholders, in the return to work process, had regarding Functional Capacity Evaluations. The purpose of this case study was to explore the literature and the perceptions of the identified key stakeholders to improve the understanding of Functional Capacity Evaluations. Research Questions This study was designed to further the understanding of Functional Capacity Evaluations as reflected in both the literature and the case study data. There were two primary questions that the study was designed to explore: (a) how are Functional Capacity Evaluations perceived by an evaluee, funder, employer and clinician in Prince George; and (b) how do these perceptions compare to the literature? Perception is the act of perceiving defined as coming to an understanding {New illustrated Webster's Dictionary o f the English Language, 1992). Therefore, this study explored the stakeholders’ understanding of Functional Capacity Evaluations. For the purpose o f this study, the perceptions regarding Functional Capacity Evaluations are defined as the benefits and limitations of the Functional Capacity Evaluation in broad terms and not related to a specific assessment tool. Perhaps this study can best be explained using an onion as a metaphor: The onion is used metaphorically to describe sequentially removable layers that conceal an important something. That is, when we use a metaphor involving an onion - such as “peeling away another layer” - we visualize a central concept (a heart or a core) that is buried beneath an organized series of increasingly central issues (Casnig, unknown). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4 Functional Capacity Evaluation This onion metaphor was applied to Functional Capacity Evaluations by the Funder during the interview: When you look at the [Functional Capacity Evaluation report] superficially it becomes something of value because there are numbers. What happens though is that underlying, it’s like the peels on an onion and you peel it one step further and then you see how [Functional Capacity Evaluations] can be very much affected by all that stuff we talked about. Given the complexity o f the Functional Capacity Evaluation, this study examines Functional Capacity Evaluations at both a macro and micro level. The macro level considers the evaluation as a whole, while the micro level explores the perceptions of specific components of the evaluation. A review o f the literature revealed fifteen areas of consideration specific to Functional Capacity Evaluations. These included definition/purpose, theoretical framework, approach, protocol, physical abilities component, cognitive aspects, psychosocial considerations, safe level of performance, sincerity o f effort, psychometrics, qualitative and quantitative information, decontextualization of work, administration, and utilization. Thesis Organization In determining the format for presenting this case study, a review in qualitative and case study research design was completed. The following comments were taken into consideration: (a) “for a qualitative dissertation, thesis, and journal article, the structure varies significantly” (Cresswell, 2005, p. 265); (b) “there is no standard format for reporting case study research” (Cresswell, 1998, p. 186); and (c) case studies “can be organized any way that contributes to the reader’s understanding of the case” (Stake, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 5 Functional Capacity Evaluation 1995, p. 122). To best present the information to the reader, I chose to present the literature review, case study findings, and discussion sequentially for each component analyzed. This provides the reader with the opportunity to review each component individually thus reducing the risk of the information being diluted with the information pertaining to the other components. Chapter 1 provides an introduction to the study. This includes contextualization and historical development of Functional Capacity Evaluations, statement of the problem, research questions, and thesis organization. Chapter 2 discusses the research methods inclusive o f the rationale of the qualitative approach, site information, data sources, interview protocol and structure, data analysis and interpretation, validity of the study, bias, ethical considerations, and limitations. Chapter 3 presents each of the fifteen components that were explored with regard to Functional Capacity Evaluations. Each component is presented in the context of the literature review, case study findings, and discussion. Chapter 4 provides conclusions of the study findings from a macro and micro perspective, key findings, and personal reflections. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6 Functional Capacity Evaluation Chapter 2 Research Methods Rationale o f the Qualitative Approach A case study involves “systematically gathering enough information about a particular person, social setting, event, or group to permit the researcher to effectively understand how the subject operates or functions” (Berg, 2004, p. 251). This was a single case study focusing on Functional Capacity Evaluations in Prince George. Specifically, this was an intrinsic case study as the focus was this particular case, Functional Capacity Evaluations in Prince George, rather than a broader theoretical question or problem (Berg, 2004). Further, the design was exploratory in nature with the researcher discovering what the stakeholders’ perceptions were regarding Functional Capacity Evaluations. The study also utilized an embedded case study design in that there was more than one area analyzed (Yin, 2003). This study was not guided by any specific ideological perspective as this study focused on the case and its issues. Site The case was bound by the geographic location, Prince George, British Columbia. In addition, the case was also bound by time, in that all interviews were completed in a two week period during December 2005. Sample Criterion based purposeful sampling was used and all research participants met the established criterion for inclusion. Participants provided informed consent regarding their participation in the study. Informed consent was achieved through ensuring that the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7 Functional Capacity Evaluation participants had reviewed, understood, and endorsed the information sheet and the consent form. The sample was comprised of one individual from each stakeholder group funder, employer, clinician, and evaluee. The following outlines the selection criteria for each stakeholder group. The criteria for the participant that was representing the funder’s viewpoint were: (a) must have responsibilities related to the funding for Functional Capacity Evaluations; and (b) must have experience with Functional Capacity Evaluations completed in Prince George. The criteria for the participant representing the employer’s viewpoint were: (a) must have experience with workers whose return to work planning involved a Functional Capacity Evaluation; and (b) the experience must include Functional Capacity Evaluations that were completed in Prince George. The criterion for the participant representing the clinician’s viewpoint was that the individual must have experience completing Functional Capacity Evaluations in Prince George. The criteria for the participant representing the evaluee’s viewpoint were: (a) must consider Prince George their primary community; and (b) must have completed a Functional Capacity Evaluation in Prince George. All participants in this study were approached by the researcher based on their identified participation in the Functional Capacity Evaluations as a key stakeholder. Two participants were identified based on the recommendation o f other individuals that were approached in regards to their participation in the study. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8 Functional Capacity Evaluation Data Sources In case studies, data sources are derived from documents, archival records, interviews, direct observation, participant observation, or physical artifacts (Yin, 2003). In this study, data was derived primarily from semi-structured interviews. In order to capture the various perspectives regarding the Functional Capacity Evaluation, interviews were conducted, using audio recordings, with each of the stakeholders associated with Functional Capacity Evaluations - funder, employer, clinician, and evaluee. In addition, the researcher inquired whether the participants had any documentation, supplementary to the interview data, that they would provide voluntarily. The research proposal noted that releasing written documentation may not be possible due to issues of confidentiality, consent, and ownership and as a result, interview data would be deemed sufficient in the absence of other documentation. Participants voluntarily provided additional information to the researcher including a Sample Functional Capacity Evaluation Report, clinician documentation outlining functional capacity test options, presentation notes regarding a specific test, and eight scoring sheets for various aspects of the Functional Capacity Evaluation protocol. All these written data documents were then analyzed and interpreted to further provide better understanding o f the perspectives on Functional Capacity Evaluations. Interview Protocol and Structure The interview protocol was developed based on the review of the literature. Since each participant represented a different perspective regarding the Functional Capacity Evaluation, the interview questions varied between stakeholders in an effort to collect data on the various aspects of Functional Capacity Evaluations. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 9 Functional Capacity Evaluation 10 The interview employed a semi-structured format designed to aid the researcher to ensure that the necessary data was gathered. (See Appendix A for the specific interview protocol.) Two broad questions were presented to all the participants initially in order to understand the participant’s perspectives of Functional Capacity Evaluations as a whole. Following the two broad questions, there were a series of more direct questions which enabled me to gather more specific information concerning the participant’s perceptions. An individual audio taped interview, ranging in duration from forty-five minutes to two hours, was completed with each participant. One interview was completed at University o f Northern British Columbia while the remaining interviews were completed at the worksite o f each participant as per the participant’s request. The audio tape recordings were then transcribed by an independent transcriber and reviewed by the researcher to ensure accuracy. All identifiers were removed from the transcriptions to ensure anonymity and when quoting participant’s responses, connecting, repetitive, and filler words were removed to improve readability. The researcher also clarified pronouns within the context o f direct quotes used in the data analysis. As the reference to funder, evaluee, clinician, and employer were used both in general terms and in specific reference to the participants, these terms were capitalized in this document when they were identifying a participant. Data Analysis and Interpretation The data analysis involved a series of processes undertaken with the goal of exploring the perceptions o f Functional Capacity Evaluations in Prince George and comparing these perceptions to the literature. The review of the literature identified Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 11 fifteen components specific to Functional Capacity Evaluations which subsequently formed the basis of this embedded case study. Embedded in reference to case study research means that it involves “more than one unit of analysis” (Yin, 2003, p. 42). The transcripts from each interview and the secondary data (a Sample Functional Capacity Evaluation Report; clinician documentation outlining functional capacity test options; presentation notes regarding a specific test; and eight scoring sheets for various aspects of the Functional Capacity Evaluation protocol) were reviewed in detail to identify key information. Data was then sorted for analysis based on the fifteen components. In some cases, data was applicable to more than one component and thus was assigned to multiple components. The data was reviewed repeatedly and triangulated to identify key data. Each participant was provided with a summary o f the key points, identified from their interview, for data verification to ensure that the interpretation of the interview data was consistent with their intentions. The information about the case, reflective of each component, was then compared to the literature. I made naturalistic generalizations through data analysis to identifying what was learned from the case and potentially its application to other cases (Creswell, 1998). Validity o f the Study In qualitative research, reliability and validity considerations have less emphasis than in quantitative research. However, strategies were implemented in this case study to assist in providing a context for validity. Construct validity is concerned with “establishing correct operational measures for the concepts being studied” (Yin, 2003, p. 34). The strategy used in this case study to address construct validity was the use of multiple sources of evidence (Yin, 2003). The Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 12 multiple sources o f evidence were the interviews with the various stakeholders, the Sample Functional Capacity Evaluation Report, and the supplementary Functional Capacity Evaluation protocol information provided by the Clinician. External validity is “establishing the domain to which a study’s findings can be generalized” (Yin, 2003, p. 34). One of the strategies used in this case study to establish external validity was the review of the literature to establish the specific components to be explored. Another strategy that was implemented was verification where a professional familiar with Functional Capacity Evaluations reviewed the data to confirm that the key information had been identified (Creswell, 1998). Bias As with most research, there is the potential of researcher bias affecting the results of the study. My experience and training as an Occupational Therapist provided a context for understanding the principles and terminology associated with Functional Capacity Evaluations which was invaluable as a foundation for this research. I do have past experience specific to Functional Capacity Evaluations which potentially could contribute to a researcher bias. This experience was related to coordinating the Functional Capacity Evaluation for a third party funder, obtaining a secondary service provider to complete the Functional Capacity Evaluation, and then applying the Functional Capacity Evaluation results. I did not conduct Functional Capacity Evaluations nor was I in a position of financial gain if a Functional Capacity Evaluation was recommended for a particular individual. I have not been involved in coordinating Functional Capacity Evaluations in Prince George in the last three years and none of the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 13 participants were ever directly involved with any Functional Capacity Evaluations that I coordinated. Based on my past experience, I had identified concerns regarding the utility of the Functional Capacity Evaluation. I was cognizant of this potential bias and throughout the research process made a conscious effort to consider all aspects of the Functional Capacity Evaluation. I also had an independent reviewer complete data verification to confirm that key points from the data had been identified. Ethical Considerations Consistent with University policy, the research proposal was submitted for approval to University of Northern British Columbia Research Ethics Board and approval to proceed with the research was granted by the committee in October 2005. Ethical considerations included autonomy, non-maleficence, confidentiality, and anonymity. Autonomy is the ethical principle that researchers “ought to respect the right to self-determination” (Mathers, Howe, & Hunn, 2002, p. 5). Specific to this study, an individual’s decision to not participate or to withdraw from the study was respected. In addition, the information sheet and consent form were reviewed with the participants to ensure that they had an opportunity to provide informed consent regarding their participation in the study. Non-maleficence is the ethical principle that researchers “ought not to inflict evil or harm” (Mathers et al., 2002, p. 6). There were no identified risks to participating in this study. There were no attempts to deceive participants regarding the nature of the study and the participants’ privacy was respected. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 14 It was critical that the confidentiality of all participants be maintained. The transcriber agreed with the requirements outlined in the Transcriber’s Agreement. The audiotapes were stored in a locked cabinet until completion o f the transcript. Additionally, the electronic data was stored on a memory stick and no copies of the information remained on the transcriber’s computer hard drive. The audiotapes and original transcribed data sheets were stored in a locked cabinet during the period of data analysis and then stored in a secure location at the University o f Northern British Columbia after data analysis was complete. The data will be destroyed a year after the successful defense of the thesis which includes shredding the original transcripts that contain the identifiers, and the memory stick and audio recordings will be physically destroyed. In compliance with the ethical concern of anonymity, all possible identifiers of the participants such as names, employer, and professional designation were removed from the transcripts. In addition, I removed any reference to a specific assessment tool or protocol if it could result in participant identification. This occurred several times in the presentation of the case study findings when direct quotes from the participants were included. In addition, I could not provide the list of the scoring sheets for specific assessments which were provided to me by a participant to supplement the data for this study, as this information could be used to identify the participant. Limitations There are a number of limitations associated with this research. As a result of using exploratory case study design, the results can be applied to this specific case and cannot be generalized to other cases. However, I have made some naturalistic Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 15 generalizations through data analysis to identify what was learned from the case and potentially its application to other cases (Creswell, 1998). The geographic boundary for this case study was Prince George so that there would be elements of a similar experience between the participants. Given this boundary for inclusion, the potential sample size was very limited, especially for some of the identified key stakeholders. This resulted in a limited sample size given that I wanted to have equal representation from each stakeholder so that the perceptions of each could be equally weighted. This limit regarding potential participants meant that completing a pilot interview to ensure that the interview protocol was sufficient was not possible. In case studies, data sources are derived from documents, archival records, interviews, direct observation, participant observation, or physical artifacts (Yin, 2003). There are limited sources of data for this case study given the difficulties of confidentiality, ownership, and consent. I was able to get several sources of data inclusive of interviews with four stakeholders, a Sample Functional Capacity Evaluation Report, and other documentation related to a specific Functional Capacity Evaluation protocol. Functional Capacity Evaluations have a significant number of variables to consider. Given that this study was exploratory in nature, this large number of variables should not be viewed as a significant limitation to this study but rather should be suggestive that future study designs could focus with more detail on specific components. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 16 Chapter 3 Literature review and data analysis Due to the unique nature of this study and the number o f considerations involved with the data and the literature, the information is organized based on the components. The reader is encouraged to read each component as an independent part of the overall case. An overview of the case as it relates to the components will be presented in Chapter 4. Component 1: Definition Despite Functional Capacity Evaluations being widely accepted as a rehabilitation tool, defining what a Functional Capacity Evaluation is remains difficult (Abdel-Moty et al., 1993). There is confusion regarding the variety of terms (Innes & Straker, 1998b) and definitions vary between authors. Lechner et al. (1991) indicated that the Functional Capacity Evaluation examines an individual’s functional physical abilities as related to work. Matheson (2003) defines Functional Capacity Evaluation as a “systemic method of measuring an individual’s ability to perform meaningful tasks on a safe and dependable basis” (p. 2). May III (1988) provides a broader definition that includes an individual’s work tolerances, aptitudes, and attitudes. It appears that additional variations in definitions are attributable to the variety of purposes for the evaluation. Functional Capacity Evaluations are reported to be used for the following purposes: (a) to predict return to work outcomes (Lechner et al., 1991; Lemstra, Olszynski, & Enright, 2004; Schonstein & Kenny, 2001) which include return to work to the current job, current occupation or any occupation (Lechner, 2002); (b) to determine maximum safe capacity for work (Gardener & McKenna, 1999; Gross, Battie, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 17 & Cassidy, 2004; King et al., 1998; Lemstra et al., 2004; Schonstein & Kenny, 2001); and (c) to determine the degree of work disability for the purposes of benefits (Matheson, 2003; Wind, Gouttebarge, Kuijer, Sluiter, & Frings-Dresen, 2006). The definitions broaden as additional adjectives are added to capture other aspects of the evaluation. Such adjectives include comprehensive (Harten, 1998; May III, 1988; Wind et al., 2006); profile (Lyth, 2001); standardized (Gross et al., 2004); protocol (Gross et al., 2004); systematic (Durand et al., 2004; Wind, 2006); multifaceted (Gouttebarge, Wind, Kuijer, Sluiter, & Frings-Dresen, 2005; Wind et al., 2006) and objective (Geisser, Robinson, Miller, & Bade, 2003; Gouttebarge et al., 2005). The complexity o f the Functional Capacity Evaluation is demonstrated with the difficulties encountered in trying to define specifically what the term Functional Capacity Evaluation refers to. Matheson (2003) suggested that there are five types of Functional Capacity Evaluations based on the purpose of the assessment and resultantly, each type varies in complexity, time, and expense. The following provides an overview of each type of Functional Capacity Evaluation as identified by Matheson (2003). Functional goal setting examines the evaluee’s ability to perform a key task (Matheson, 2003). This assessment is used to assist with setting rehabilitation goals or to monitor the progress of therapy (Matheson, 2003). This assessment is usually 30 minutes in duration (Matheson, 2003). Disability ratings examine an evaluee’s loss of work capacity (Matheson, 2003). This assessment measures an evaluee’s functional status as a result of impairment (Matheson, 1996). It is frequently used to determine percentages of impairment and the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 18 resultant impact on an evaluee’s lifetime earning capacity (Matheson, 2003). The duration of this assessment is usually 90 minutes (Matheson, 2003). Job matching examines an evaluee’s ability to perform key tasks of the evaluee’s specific job (Matheson, 1996). This assessment requires the clinician to complete a job analysis and compare it to the evaluee’s medical status and functional performance (Matheson, 2003). This type of evaluation is usually three to six hours in duration (Matheson, 2003). Occupational matching examines an evaluee’s ability to perform tasks related to a general occupational classification (Matheson, 1996). Information concerning the job demands is obtained from the Dictionary of Occupational Titles (DOT) or Occupational Information Network (0*Net) (Matheson, 2003). In Canada, the clinician would refer to the information obtained in the National Occupational Classification (NOC) (Strong et al., 2004). There are more variables to consider with this assessment as all occupations within the occupational classification are considered (Matheson, 2003). It usually takes four to eight hours to complete this evaluation (Matheson, 2003). Work capacity evaluation considers an evaluee’s functional capacity and the demands o f competitive employment (Matheson, 1996). This assessment is the most comprehensive as there is no specific occupational goal (Matheson, 1996). Structured work simulations are often incorporated into this evaluation (Matheson, 2003). It usually is two to eight days in duration (Matheson, 2003). Given the nature of this study, it was expected that the definition of a Functional Capacity Evaluation may vary reflective of the purpose for which they have experienced Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 19 Functional Capacity Evaluations. Despite the variation in definitions, all the key stakeholders referred to the assessments as Functional Capacity Evaluations. The Evaluee identified that the purpose of a Functional Capacity Evaluation was to “find out if somebody can do their jo b .. .if they’re physically capable of doing it.” The Evaluee also noted that “it’s something we looked into having our new hirees do.” The Employer noted that the Functional Capacity Evaluation “should provide comparison o f their [evaluee’s] abilities to the job requirements.” The Employer continued to explain that Functional Capacity Evaluations assist “to understand somebody's restrictions.. .gives clarification for us [employer] so that we are not putting any employee at risk.” The Employer also noted that they do pre-employment physical ability assessments. The Clinician identified that Functional Capacity Evaluations “provide the employer [or] whoever is asking for it, current functional status of a worker whether they’re injured, whether they have depression, or whatever; it gives them a good current ability.” The Clinician also identified that Functional Capacity Evaluations can determine “how true they [evaluees] are to what they’re saying they can do.” The Clinician noted that Functional Capacity Evaluations would be recommended “when you’re trying to decide what's next in terms of a treatment plan.” The Funder identified that Functional Capacity Evaluations are beneficial “when we do not know what their [evaluee’s] level of functioning is.” The Funder continued noting that a Functional Capacity Evaluation: Assists m e... when there is a lack of objective clinical finding in terms of the [evaluee’s] level o f function - what they can do and what they cannot do. It gives Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 20 us [funder] something measurable.. .even though we recognize it is more of a subjective demonstrated ability, it gives us the next best thing to an objective measure. In addition, the Funder also identified that a Functional Capacity Evaluation “becomes a starting point for developing the return to work plan.” The Sample Functional Capacity Evaluation Report identified the assessment as a “Physical Abilities Assessment” and identified the following purposes of the assessment: (a) outline the employee’s physical capabilities; (b) outline if there are any physical limitations that would affect the employee's ability to perform essential work tasks; (c) provide baseline data pertaining to the employee’s functional abilities; and (d) perform a musculoskeletal examination and outline the employees past medical history Consistent with the literature review, this study has identified a multitude of purposes for which Functional Capacity Evaluations are completed in Prince George. These include: (a) determining safe return to work to current employment; (b) pre­ employment physical ability assessments; (c) determining current functional abilities or level of functioning or physical abilities; (d) comparing functional abilities to job demands; (e) developing a rehabilitation treatment plan; (f) assisting with return to work planning either to current occupation or alternative occupation; and (g) determining if evaluees are accurately reporting their abilities. Upon reviewing the types of Functional Capacity Evaluations, it is apparent that the term Functional Capacity Evaluation encompasses a broad range o f assessment goals. Given this broad scope of purpose coupled with the difficulties in defining Functional Capacity Evaluation, the potential challenge for clinicians, funders, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 21 employers, and researchers is to ensure that the parameters surrounding the Functional Capacity Evaluation are effectively communicated to all stakeholders. Component 2: Nomenclature In addition to the challenges regarding the definition of Functional Capacity Evaluations, there is also the challenge of understanding the terms associated with the evaluation due to confusion with the terminology (Innes & Straker, 1998b; Vasudevan, 1996). The concern has been identified that many of the terms are used interchangeably creating confusion for understanding specifically what was assessed (Abdel-Moty et al. 1996; Vasudevan, 1996). A taxonomy was developed for the Social Security Administration Disability Determination System (Gaudino, Matheson, & Mael, 2001). This taxonomy “provides a method to classify and organize constructs that are used to assess the functional abilities of people with medical impairments to determine work disability” (Gaudino et al., 2001, p. 155). It is based on the work disability model which was also developed for the Social Security Administration Disability Determination System (Gaudino et al., 2001). This model links structural impairment through to occupational disability (Gaudino et al., 2001). The researchers involved in this project speculated that this taxonomy could be used to improve the organization of research and intervention (Gaudino et al., 2001). However, the generalization of this taxonomy outside of the Social Security Administration Disability Determination System remains unknown (Gaudino et al., 2001) and thus its application to Functional Capacity Evaluations also remains unknown. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 22 The other issue around nomenclature specific to Functional Capacity Evaluations is the concern regarding the inclusion of ‘jargon’ in reports. The clinician must ensure that the language used in the report is familiar to the report’s intended audience (Roy, 2003). In this study, the Employer identified concerns regarding the nomenclature associated with Functional Capacity Evaluations. The Employer identified the importance of “plain English” in the reports. The Employer noted that clinicians “need to do all [their] technical background but how [they] present it or [the] summary, I think is key as well.” The implication for Functional Capacity Evaluations regarding nomenclature reiterates the importance of effective communication. It is the clinician’s responsibility to ensure that the language contained within the assessment report is appropriate for the intended audience. The clinician must also ensure that terms used in the report are defined so that the opportunity for misinterpretation of the information is limited. Component 3: Theoretical Framework for Functional Capacity Evaluations There is limited discussion in the literature pertaining to the theoretical framework that forms the basis for the Functional Capacity Evaluation. Gross (2004) and Rudy, Lieber, and Boston (1996) suggested that Functional Capacity Evaluations be considered as a behavioural assessment which incorporates an evaluee’s performance. Gross and Battie (2005) also noted that it should it be acknowledged that Functional Capacity Evaluations are influenced by an evaluee’s physical abilities, beliefs, and perceptions. This is supported by recent suggestions that the International Classification of Functioning, Disability, and Health (ICF) could be applied to Functional Capacity Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 23 Evaluations (Baum, 2002; Gibson & Strong, 2003; Gross, 2004). The ICF is a biopsychosocial model (Wittink, 2005). The ICF considers three major areas: body functions and body structures; activities related to an individual’s specific tasks and actions and their ability to participate; and contextual factors which consider both environmental factors and personal factors which impact on participation in activities (Baum, 2002; Dahl, 2002). According to the ICF, “functioning refers to all body functions, activities, and participation” (Wittink, 2005, p. 197). This theoretical approach would support the need for Functional Capacity Evaluations to expand beyond assessing the physical aspect (Gross et al., 2004). In this study, the Clinician, upon inquiry regarding the theoretical framework used for Functional Capacity Evaluations, identified that “I don't know about theoretical, but we use the [name o f a Functional Capacity Evaluation protocol] approach.” For the purposes o f this research, the reference would better reflect the protocol used for Functional Capacity Evaluation rather than the theoretical framework. Given the lack of discussion in the literature regarding the theoretical framework o f Functional Capacity Evaluations as well as the inability to identify the theoretical framework within the scope of this study, there is a need for further research in this area. The key factor inherent to a theoretical framework for Functional Capacity Evaluations is the definition of function (Gibson & Strong, 2003). The theoretical framework guiding a Functional Capacity Evaluation should incorporate an operational definition of function consistent with occupational performance. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 24 Component 4: Approaches There are three approaches to Functional Capacity Evaluations. The metabolic approach (also referred to as the cardiovascular or physiological [Gibson & Strong, 1997]) evaluates the physiological stress on the evaluee during the assessment process (Gardener & McKenna, 1999; Gibson & Strong, 1997). The biomechanical approach assesses an evaluee’s limitations based on their neuromuscular and musculoskeletal systems (Gardener & McKenna, 1999; Gibson & Strong, 1997). The concern with the biomechanical approach is that it has limited predictive value as it does not include psychosocial factors (Gibson, Strong, & Wallace, 2005). The psychophysical approach examines an evaluee’s abilities within the context of their perceptions, beliefs, and expectations (Gardener & McKenna, 1999; Gibson & Strong, 1997). The assessment approach utilized varies with assessment protocols. Gibson and Strong (2002) suggested that Functional Capacity Evaluations should include all three approaches, however, there may be situations when different approaches could be counter to each other. In this study, review of the Sample Report revealed that all three approaches (metabolic, biomechanical, and psychophysical) were utilized. The Sample Report referenced blood pressure and heart rate monitoring, which is consistent with a metabolic approach. The biomechanical approach was referenced in the Sample Report with statements like “the client demonstrated no signs of physical dysfunction during the test.” Although it was more difficult to identify the utilization of the psychophysical approach in the Sample Report, there was a reference to “no significant functional limitations reported” which suggested that feedback from the evaluee was sought during the testing procedures. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 25 A review o f the information provided by the Clinician also demonstrated a utilization of the three approaches. The Clinician referenced heart rate monitoring which is consistent with the metabolic approach. The Clinician noted the “observation of lifting and general movement patterns” during the Functional Capacity Evaluation, which is consistent with a biomechanical approach. The psychophysical approach is demonstrated when the Clinician discussed that “.. .You just listen to them [evaluees] .. .1 tend to believe people, unless there is obvious signs that they’re not comparable between what they said and what they actually do.” As recommended in the literature, this case study revealed that all three approaches to Functional Capacity Evaluations are integrated within the assessment. The issue regarding potential situations where the three approaches may run counter to each other, was not explored in this study. Component 5: Assessment Protocol There are a number of commercial Functional Capacity Evaluations available. Some of the Functional Capacity Evaluations that offer global test batteries include the Blankenship Functional Capacity Evaluation; BTE Work Simulator; California Functional Capacity Protocol (Cal-FCP); DOT Residual Functional Capacity Battery; ERGOS Work Simulator; Isemhagen Functional Capacity Assessment; LIDO WorkSET Work Simulator; Matheson Work Capacity Evaluation; Physical Work Performance Evaluation; Valpar Component Work Sample System; WorkAbility Mark III; and WorkHab (Matheson, 2003). Strong et al. (2004) determined through their study of practices specific to Functional Capacity Evaluations in Ontario Canada that the following commercially available evaluations were being used: Arcon, Ergos, Hanoun, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 26 Key System, and Isemhagen. Each test has a unique testing protocol and may measure different dimensions (King et al., 1998; Schonstein & Kenny, 2001). There is limited published scientific research conducted on commercial protocols (Gibson & Strong, 1997). One of the issues affecting review and research of standardized commercial Functional Capacity Evaluations is the proprietary nature of these tools (Jones & Kumar, 2003). It does not appear that there is a specific commercial Functional Capacity Evaluation that is superior in its approach (Gibson & Strong, 1997) nor does there appear to be a standardized functional capacity battery (Abdel-Moty et al., 1993). A functional assessment data base was developed that identified 812 measurements that are used to evaluate adults and work disability (Matheson, Kaskutas, McCowan, Shaw, & Webb, 2001). O f the 812 measurements identified, 633 were located and studied (Matheson et al., 2001). These measurements included “structured performance protocols using test equipment, simulated activities to measure functional performance, and structured behavior rating scales to rate observations or self perceptions” (Matheson, 2003, p. 5). One of the conclusions of the research was that there was no “truly global measure of function” (Matheson et al., 2001, p. 180). The number of available assessment measures presents a challenge to clinicians in respect to assessment selection. It also presents as a challenge to researchers with respect to the potential number of variables to consider. Within the context of this case study, the following commercial protocols were identified Arcon, Matheson, and Isnerhagen. The following measurements were identified as being used in the completion of Functional Capacity Evaluations: Bench Step test, Bolt Box test, Epic Hand Function Sort, Epic lifting, Jamar Hand Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 27 Dynamometer testing, Maximum Isoinertial Lifting evaluation, Minnesota Manual Dexterity test, National Back Fitness test, Oswestry Low Back pain questionnaire, Neck Pain and Disability Index (Vemon-Mior), PACT Spinal Function Sort, Progressive Isoinertial Lifting evaluation, Purdue Pegboard, and Spinal Function Sort. Consistent with the literature, this case study has identified a number of Functional Capacity Evaluation protocols that are used for Functional Capacity Evaluations in Prince George. The list of measurements identified in the case study is probably not comprehensive but still demonstrates the challenge of selecting measurement tools given the variety available to clinicians and the research implications regarding the quantity of variables that need to be considered by the researchers. Component 6: Physical Abilities Component The physical task components are based on the U.S. Department of Labor’s list of twenty physical demands (Allen, Rainwater, Newbold, Deacon, & Slatter, 2004; Gibson & Strong, 2002; Gibson et al., 2005; Isemhagen, 1992; King et al., 1998; Schonstein & Kenny, 2001). The Dictionary of Occupational Titles describes each occupation based on this list of physical demands (Innes & Straker, 1998b). These tasks include lifting, standing, walking, sitting, carrying, pushing, pulling, climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, feeling, talking, hearing, and seeing (Fishbain et al., 1999b; Lechner et al., 1991). There have been concerns identified specifically in regards to basing the physical assessment on the Dictionary o f Occupational Titles. Dusik, Menard, Cooke, Fairbum, and Beach (1993) commented that the validity of the Dictionary of Occupational Titles physical characteristics were unknown. Ten years later, Frings-Dresen and Sluiter (2003) noted Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 28 that the reliability and validity o f the Dictionary of Occupational Titles physical characteristics remains questionable and related this concern directly to its impact on the validity of the Functional Capacity Evaluations. Further, Rustenburg, Kuijer, and Frings-Dresen (2004) commented that if the Dictionary of Occupational Titles is used as a reference for basing return to work recommendations, there is concern regarding its comprehensiveness. Rustenburg et al. (2004) noted that a review o f the literature indicated that it was unclear as to whether Dictionary of Occupational Titles is an accurate description of the physical components of work. Another limitation of using the Dictionary of Occupational Titles is that it is developed for use in the United States of America and the information is not directly transferable to the Canadian National Occupational Classification (Innes & Straker, 1998b). There was a new system developed by the US Department of Labor that describes work (Gibson & Strong, 2002). This system is called the Occupational Information Network (0*NET). Gibson and Strong (2002) suggested that the Occupational Information Network may provide a resource for the development of new assessments while Pransky and Dempsey (2004) suggested that neither the Dictionary of Occupational Titles nor the Occupational Information Network were designed to assess function and cited concerns that the job demands are generalizations that have not been empirically tested. There have also been challenges identified with determining the physical demands of a specific job. An individual frequently adapts how a job is performed and complex job tasks can be performed in a variety of ways (Pransky & Dempsey, 2004). An evaluee’s self-report regarding job demands may not be accurate and standard job Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 29 descriptions provided by employers are also subject to inaccuracies (Pransky & Dempsey, 2004). In reviewing the Sample Functional Capacity Evaluation Report, the following physical abilities were assessed: dynamic standing, static standing, walking, frequent lifting, occasional lifting, carrying, pushing, pulling, stairs, bending, crouching, spinal rotation, grasp, and reaching. In addition, documentation from the Clinician identified kneeling, neck flexion, sitting, and cardiovascular. Interviews with the Clinician, Employer, Evaluee, and Funder identified similar inclusion of physical abilities, however, the list was not as comprehensive. The Funder identified a limitation in regards to the use of the National Occupational Classification (NOC): When we do a referral, we often identify in the NOC code. We ask the clinician to evaluate whether or not the [evaluee] can return; for example - Heavy Duty Mechanic. They [clinician] use the NOC to decide whether or not the [evaluee] can be a heavy duty mechanic. That isn't always a true reflection of a Heavy Duty Mechanic job because it’s so much based in a controlled environment. A lot are the times, we’ll say ‘no they cannot do the Heavy Mechanic job’ or ‘yes they can do the Heavy Mechanic job’ but the answer is so broad. It’s so much based on the NOC which is not a true reflection of what perhaps the Heavy Duty Mechanic does within the Saw Mill or what a Heavy Duty Mechanic does at Costco. There is so much variation within those occupations that I don’t always agree that the Functional Capacity Evaluation gives you a true answer on whether or not the [evaluee] can work within that classification. In comparing the case study information to the literature, there appears to be consistency regarding the physical demands that are assessed. However, it is possible that not all physical demands are assessed for each evaluee and that the clinician may individualize the assessment based on the needs of the particular file, ultimately affecting the reliability and validity of the Functional Capacity Evaluation protocol. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 30 The Funder identified the concern regarding the value of the conclusions of the Functional Capacity Evaluation focused on an evaluee’s ability to return to work when a general description o f the type of work is used as a reference. The more specific information that the clinician has regarding the specific job demands, the more useful the conclusions of the Functional Capacity Evaluation will be. As Innes and Straker (2003) noted, the Functional Capacity Evaluations with no specific job were the most generalizable and the least specific; therefore, the utility or usefulness of the assessment is less than Functional Capacity Evaluations completed for evaluees with reference to a specific job. For situations where there is a Functional Capacity Evaluation regarding a specific job, the assessment results will be more useful if there is a job demands analysis to reference for the Functional Capacity Evaluation. In addition, clinicians need to ensure that the funders, employers, and evaluees are aware of the limitations of the recommendations specific to return to work when broad vocational categories are used versus specific job requirements. Component 7: Cognitive Aspects Gibson and Strong (1997) identified the need for more attention to the cognitive aspects o f work in Functional Capacity Evaluations. Innes and Straker (1998b) identified the lack of attention to the cognitive aspect of work as a design problem of Functional Capacity Evaluations. When developing return to work strategies, focusing only on the physical aspects of work will not provide all the necessary information to develop recommendations to enhance return to work planning strategies or predict successful return to work (Innes & Straker, 1998b). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 31 The Sample Functional Capacity Evaluation Report did not include information pertaining to cognitive functioning. The Clinician noted that in respect to cognitive functioning that “we [clinicians] made sure that they’re [evaluee] obviously in full capacity so that they can provide informed consent.. .but nothing else in terms of [assessment] components.” The Funder indicated that cognitive aspects are not typically part o f the Functional Capacity Evaluation with the focus rather being on the physical components. The Funder did express support for the inclusion of such information: That would be more useful from a vocational perspective if we had some measurement of that because we don’t know a lot of the times.. .Part of the question we also have to answer in our role as the funder is does the [evaluee] maintain the knowledge to perform that particular job. While we don’t seek the answer within the Functional Capacity Evaluation, we do it through actually meeting with the [evaluee] and asking them questions. We make that determination very much on our own but certainly if the Functional Capacity Evaluation could measure that then it’s a truer reflection of whether or not the [evaluee] maintains the knowledge, skills, and abilities to do the job and that would be o f more value to our work. There was no evidence supporting cognitive function as an assessment component in the case study. The Funder agreed with the information obtained in the literature review that cites the importance of cognitive functioning in regards to return to work planning. The Funder indicated that inclusion of cognitive functioning assessment would improve the utility of the assessment findings. The Occupational Information Network (0*NET) is a taxonomy for work that includes work-related cognitive function that may provide a basis for future cognitive assessments that could be incorporated into the Functional Capacity Evaluation (Gibson & Strong, 2002). Component 8: Psychosocial Considerations Psychosocial components that are related to work include perceived disability, an evaluee’s expectation regarding return to work, self-efficacy, perceived effort, pain Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation location, and pain behaviour (Allen et al., 2004; Gibson & Strong, 2002). These components have been found to have a significant impact on an evaluee’s functional abilities (Geisser et al., 2003). Research has suggested that an evaluee’s subjective interpretations and appraisal may be a powerful predictor of post injury recovery (Hunt et al., 2002). It has been suggested that there needs to be greater consideration of psychosocial factors rather than just focusing on physical factors in regards to return to work planning (Gibson & Strong, 2002; Velozo, 1993). Limited consideration to psychosocial factors has been identified as a design problem with Functional Capacity Evaluations (Geisser et al., 2003; Gibson & Strong, 2002; Innes & Straker, 1998a; Pransky & Dempsey, 2004; Ruby, Lieber, & Boston, 1996; Velozo, 1993). As social and work factors appear to be stronger predictors of return to work outcomes than physical factors, Jones and Kumar (2003) suggested that analysis o f psychosocial factors is a necessary component for Functional Capacity Evaluations. Baum (2002) suggested that for evaluees with chronic low back pain, extensive physical Functional Capacity Evaluations may not be necessary due to the strong relationship between performance and psychosocial variables (depression, poor coping skills, and perceived disability). Furthermore, Baum (2002) reflected that without an examination of the psychosocial factors, Functional Capacity Evaluations may not be measuring or interpreting the physical parameters accurately. The relationship between the psychosocial factors and return to work has been cited as being complex (Geisser et al., 2003). This complexity translates into research limitations (Geisser et al., 2003). To demonstrate the complexity o f the related factors, consider the factors that influence return to work for evaluees that have chronic pain Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 32 Functional Capacity Evaluation 33 (Feldman, 1998). Physical considerations include nature of injury; prior injuries, surgeries, and treatments; other medical conditions; nicotine use; deconditioning; and alcoholism or other addictions (Feldman, 1998). Job related factors were identified as time out of work, job demands, salary, wage replacement, job satisfaction, relationship with supervisor, relationships with co-workers, employer’s commitment and flexibility, employment options, benefits, and stress (Feldman, 1998). Personal factors to be considered include age, education, transferable skills, personality variables, coping skills, personal values, history of trauma and abuse, beliefs and understanding about injury and pain, fear of re-injury, anxiety, depression, and marital and family situation. Feldman (1998) also identified some factors as ‘other’ which include perceived treatment by insurance company, rehabilitation nurse, employer and physician; perceived adequacy of treatment, physician warnings and advice; attorney warnings and advice; union status; and economic climate. This multi-factorial consideration specific to return to work outcomes should be reflected in the Functional Capacity Evaluation if it is to be predictive specific to return to work. To further expand on the complexity of the situation, Vasudevan (1996) noted that the relationship between objective data regarding impairment and the resulting effect on function is not a 1:1 relationship. Again, this adds to the challenge inherent to Functional Capacity Evaluations. In this case study, the Evaluee reported that there were no discussions during the Functional Capacity Evaluation process regarding his/her motivation to return to work or the identification of potential concerns regarding co-workers or administration. The Evaluee noted that the Functional Capacity Evaluation focused on the physical Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 34 components only. The Sample Functional Capacity Evaluation Report did not include any information regarding psychosocial functioning. The Clinician responded that in the event that the diagnosis is depression or anxiety, “we can comment on their fears of returning to work and stress.” Regarding work place relationships, the Clinician commented that “concerns about returning to work from a personal nature.. .1 haven’t really seen it [so] I can’t really comment conclusively.” The Employer reported that psychosocial factors are alluded to in documents and require follow up with the Clinician. The Employer provided the following commentary regarding the inclusion o f psychosocial information in Functional Capacity Evaluations: It may allude to some things in the written document you get. But I guess it depends on what kind of relationship you have with your assessors as well. I mean there’s information that they’ve provided me but it’s not in the written document.. .it will say whether this person is motivated to return to their position and it’s all correctly worded and then usually those things will be flags for us. Then I’ll make the call and I’ll say what is going on here or what did you observe. You tend to get more detail and that’s useful in terms of working with the employee to get them back as well. The Employer also noted that for Functional Capacity Evaluations that involve more occupational therapy testing that the report was: .. .very specific to the individual and it talked about what [the clinician] believed [the evaluee’s] efforts were and [the clinician’s] recommendations were...It Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 35 went into [the] interview findings.. .getting more into sort of the person and understanding a little bit better where they are at. The Funder did not support the inclusion of psychosocial considerations in Functional Capacity Evaluations: I think that our intention is really to get some objective measurements. There is the issue o f psychosocial information and I think we can get into trouble from a systems perspective regarding what is [related to the claim]. I think that’s a part o f our job. We put together the psychosocial things that are happening in the [evaluee’s] life, what their claim issues are, and the Functional Capacity Evaluation...we have to look at the level of functioning so we use it as a piece of evidence. Despite the fact that the literature review supports the inclusion of psychosocial information in Functional Capacity Evaluations, specific to this case study, it was revealed that this information is not routinely included in Functional Capacity Evaluations. The Employer noted that the information may be alluded to in the report but that it was the reader’s responsibility to identify the reference and contact the clinician for further clarification. This approach results in an increased likelihood that significant psychosocial factors may go unacknowledged and, therefore, present as a significant barrier to successfully implementing the report recommendations and achieving identified goals. The Funder did not support the inclusion of this information in the Functional Capacity Evaluation. This may be reflective of the intended use of the information gathered. The Funder referred to Functional Capacity Evaluations providing objective Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 36 measures in terms of functional abilities with the parameter that the Functional Capacity Evaluation is not used in isolation but rather is viewed as a piece of evidence. The Funder did not disregard the importance of the psychosocial factors but rather viewed the gathering o f this information as a purview of the Funder’s job. Component 9: Safe Level o f Performance Safety has been identified as the primary attribute when reviewing Functional Capacity Evaluations (Gibson & Strong, 2005; Gross, 2004; Innes & Straker, 2003; Pransky & Dempsey, 2004). Given that the evaluee has either an injury or a disability and that physical exertion is required, the importance of safety cannot be overlooked, however, there has been very little investigation regarding this attribute (Gibson & Strong, 2005). It is important to determine that there are no contra-indications that would prevent the evaulee’s participation in the Functional Capacity Evaluation based on a concern for the evaluee’s safety (Gibson & Strong, 2005). It is also important to identify any precautions that the clinician needs to be mindful of during the assessment (Gibson & Strong, 2005). It is recommended that the clinician obtain medical clearance for an evaluee’s participation in the Functional Capacity Evaluation (Gibson & Strong, 2005). During Functional Capacity Evaluations, clinicians need to ensure that no injuries occur during the testing procedure and at the same time, determine an evaluee’s maximum level of functioning (Isemhagen, 1992). This is also referred to as maximal end point of performance (Innes & Straker, 1998c). There are two approaches employed to ensure a safe level of performance - psychophysical and kinesiophysical (biomechanical). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 37 With the psychophysical method, an evaluee determines his or her own safe maximum level o f performance (Isemhagen, 1992; Johnson & Miller, 2001; King et al., 1998; Schonstein & Kenny, 2001). Critics of this method cite concerns that the results may not be reliable (King et al., 1998). Isemhagen (1992) suggested that this method may be appropriate for uninjured and highly motivated individuals who have no reason to be fearful o f the evaluation. Isemhagen (1992) continued by noting injured evaluees are not accurately able to determine their own physical limitations. Some of the factors that inhibit the injured evaluee’s ability to determine their own physical limitations include fear, pain, lack of willingness or overzealousness specific to return to work, or strong attitudes towards the return to work process (Isemhagen, 1992). Johnson and Miller (2001) suggested that the psychophysical approach is appropriate for evaluees that understand their abilities, are not fearful of the evaluation, are highly motivated, and are willing to work at their full potential. Piela, Hallenberg, Geoghegan, Monsein, and Lindgren (1996) completed a study that examined the hypothesis that evaluees with a low back injury can estimate their own functional abilities for specific lifting tasks waist level lifting, lifting from the floor and standing tolerance. The study concluded that evaluees cannot accurately predict their own functional abilities and therefore, an evaluee’s self-report is not reliable (Piela et al., 1996). Kuijer, Gerrits, and Reneman (2004) completed a study with healthy subjects with the objective to investigate to what extent self-reporting could replace performance based testing. The study concluded that correlation coefficients between self-reporting and performance testing were too low to be relevant to the clinical setting and therefore, self-reporting cannot replace performance testing (Kuijer et al., 2004). The study also concluded that the Rating of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 38 Perceived Exertion Scale (RPE) should not be used to determine maximum performance (Kuijer et al., 2004). The kinesiophysical approach is based on the theory that the clinician administering the evaluation can determine an evaluee’s safe maximum performance This approach relies on observation of physiological and biomechanical signs of effort to determine safe, maximum performance levels (Gross & Battie, 2003). Isemhagen (1992) suggested that this is accomplished by observing the evaluee’s physical efforts at low, medium, and high levels of demand with the evaluee reaching maximum abilities gradually. The clinician would observe for early signs of fatigue such as increased heart rate, increased deliberateness of movement patterns, recruitment o f accessory muscles, or changes in body mechanics (Isemhagen, 1992). Isemhagen (1992) suggested that safe movement translates to safe work. However, Pransky and Dempsey (2004) noted that there is no scientific support that the results of safe body mechanics in a testing setting can be transferred to the job setting. Some authors have noted that general testing regarding safe level of performance has little value when applied to a specific job (Abdel-Moty et al., 1993; Pransky & Dempsey, 2004). Isemhagen, Hart, and Matheson (1999) published a study that evaluated three kinesiophysical lifting tasks from the Isemhagen Work Systems Functional Capacity Evaluation to determine the level of agreement between clinicians regarding the assessment of an evaluee’s safe maximum performance. The conclusion of the study was that for the tasks, floor to waist lifting and waist to crown lifting, there was excellent intra-tester and inter-tester reliability (Isemhagen et al., 1999). It was noted Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 39 that successful rating using the kinesiophysical approach relies on professional training and the strict use of operational definitions (Isemhagen et al., 1999). In the kinesiophysical approach, the clinician may instruct the evaluee on correct body mechanics (Innes & Straker, 1998c). Proponents of the psychophysical approach believe that such feedback from the clinician invalidates the assessment because it is no longer representative o f the techniques that the evaluee would employee at work (Innes & Straker, 1998c). Proponents of the kinesiophysical approach counter that safety should be the primary concern and to not correct unsafe lifting techniques would be unethical (Innes & Straker, 1998c). Specific to medical clearance, the Evaluee in this case study reported that she/he did not obtain physician support to participate in the Functional Capacity Evaluation, however, physician support to return to work was obtained prior to the Functional Capacity Evaluation. The Sample Functional Capacity Evaluation Report noted that one o f the purposes o f the assessment was to outline the employee’s past medical history. However, the medical information was contained in the section o f the report entitled Interview and was attributed to the evaluee’s self-report. In the same section, the report noted “Her doctor had given her the okay to go ahead with testing.” It would appear from this statement that the evaluee obtained physician support to participate in the assessment, however, it is not known if written documentation was submitted to the clinician as verification of the Evaluee’s self-report. The Clinician identified that at the beginning of the Functional Capacity Evaluation, a physiotherapy assessment is completed but the interview did not reveal if this was a safety screen or if it was to gather functional performance data. The Clinician also referenced receiving a medical Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 40 package prior to the Functional Capacity Evaluation, however, the interview did not reveal what was included in the medical package and whether physician clearance for the evaluee’s participation in the Functional Capacity Evaluation was included. The Sample Report also references a physiotherapy screen but it is unclear to the reader as to the purpose o f the screen. The information in this section includes evaluee’s self-report, musculoskeletal evaluation, and physiotherapy impression. The physiotherapy impression was that “the physiotherapist screen revealed no physical limitation to Employee performing the physical requirements of a [specific job] at [specific worksite].” This is not reflective of a pre-assessment screen for safety to participate in the evaluation. The Evaluee reflected that the safe maximal level of performance was determined by WCB guidelines. However, the Evaluee also referenced that “they definitely watched to make sure you were lifting proper.. .they checked your heart rate on a regular basis and just watched to see if you were physically capable of doing it.” The Clinician explained that safe maximum level of performance is determined: .. .through observation of lifting and general movement patterns.. .it’s really easy to monitor safe lifting, carrying, pulling, and pushing because people do really wonky things when things get too heavy. It’s really easy to figure out when somebody’s safe to do it and when somebody’s not safe to do it and that goes across the board, it’s pretty hard to fake. The Clinician also noted that: It’s all progressive; so you [clinician] start with no weight and you work your way up to wherever they [evaluee] don’t feel comfortable or you stop them Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 41 because they’re demonstrating max effort - they’re getting a lot of counter balancing or shoulders and stuff. Just looking like its too heavy... You ask them a whole bunch o f different questions and it gives you a lot of really good information and you always monitor their heart rate so you can see if they’re really working in their max. The Clinician also identified that the evaluee’s feedback is also considered when determining safe maximum level of performance: You [clinician] just listen to them [evaluee] too. I tend to believe people, unless there’s really obvious signs that they’re not comparable between what they say and they actually do. I’ll tend to believe them in terms of what they’re saying is their lim it... because ultimately we can’t force them to keep going. The Clinician also referenced the use of specific pain rating scales. After every weight the evaluee lifts, the clinician inquired as to the pain rating. The Sample Functional Capacity Evaluation Report referenced “no significant functional limitations reported” which leads the reader to conclude that the evaluee’s feedback regarding maximum safe performance levels were sought. There was also evidence in the report that heart rate monitoring was completed throughout the assessment. Specific to education regarding proper lifting techniques, the Evaluee identified “they [clinicians] definitely watched to make sure you [evaluee] were lifting proper and if you weren't then they suggested the proper way.” Upon inquiry, the Evaluee did think that the education regarding proper lifting techniques would be transferred to the workplace. The Clinician noted that: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 42 ... in the protocol, you [clinician] have an opportunity correct them [evaluee] once. If they choose not to do it that way, the approved way, or show an effort towards that; the test is done and you move on to the next [test item]. Specific to the transferability of the education regarding lifting to the workplace, the Clinician commented “I would hope so.” The Clinician also explained that the feedback regarding proper lifting techniques is provided within the context of work as demonstrated by the following comment. “I [Clinician] always give pointers in the form that I know at work there is obstacles but that there are ways around that and you [evaluee] should always keep these things in mind when you’re doing the lifts.” Medical clearance for the evaluee’s participation in the Functional Capacity Evaluation does not appear to be a standard part of the protocol in this case study despite the recommendation in the literature for medical clearance to be in place prior to commencing the Functional Capacity Evaluation. The Sample Report makes reference to physician support for the evaluee’s participation in the Functional Capacity Evaluation but it is not clear whether written documentation was provided to support the evaluee’s self-report. The Clinician referenced a medical package but it was not clear from the data whether physician support for participating in the Functional Capacity Evaluation was a component. The Clinician and Sample Report referenced either a physiotherapy screen or assessment but the purpose of the screen or assessment is unknown. As safety is ranked as the most important factor in assessing Functional Capacity Evaluation protocols, the inconsistencies regarding the determination of medical support for the evaluee’s participation in the Functional Capacity Evaluation is concerning. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 43 From the information gathered in this case study, there is evidence that both the psychophysical and kinesiophysical approaches are used in determining safe maximum performance. The use o f evaluee self-report to determine safe maximum performance is the basis of the psychophysical approach. The Sample Report, the Evaluee, and Clinician all referenced feedback from the evaluee regarding performance. The psychophysical approach includes heart rate monitoring and observation of lifting techniques (assessment of biomechanical performance). The Sample Report, the Evaluee and the Clinician all made reference to heart rate monitoring during the Function Capacity Evaluation. The Sample Report also made reference to blood pressure monitoring. The Evaluee and Clinician both cited observation of the evaluee’s lifting technique. The Clinician identified that the evaluee’s self-report is the primary guiding factor for determining safe maximum level of performance unless the Clinician identifies that there are significant inconsistencies between the evaluee’s self-report and the evaluee’s actual functional abilities. This finding is surprising as the discrepancies between self-report and actual abilities could be identified through the determination of safe maximal level o f performance and the resulting comparison to self-report. If the maximum safe level o f performance is subject to the evaluee’s perception then the determination o f safe maximum level of performance is also dependent on the factors that impact the evaluee’s perception such as fear, pain, motivation, and work place related factors as cited in the literature. There appears to be limited information in the literature regarding the combination of the two approaches - psychophysical and kinesiophysical. Based on the information provided by the Clinician, the focus is Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 44 primarily on the psychophysical approach for safe maximum level of performance in the absence o f data obtained from the kinesiophysical approach that would indicate that there is potential safety concern thus safe maximum level of performance has been achieved. Based on this case study, safety concerns regarding proper lifting techniques take precedence over the concerns regarding the clinician interfering with the testing results through the introduction o f education regarding proper lifting techniques. Both the Clinician and the Evaluee identified education regarding proper lifting techniques as a component o f the Functional Capacity Evaluation and speculated that there is transference o f the education regarding proper lifting techniques from the assessment to the workplace. Component 10: Sincerity o f Effort Functional Capacity Evaluation results are dependent on the evaluee providing maximum effort in order for the results to be considered to accurately reflect an evaluee’s ability (Kaplan, Wurtele, & Gillis, 1996; Wind et al., 2006). O f course, the concern is that due to secondary gain, which is not necessarily financial, an evaluee may choose to provide submaximal performance during the Functional Capacity Evaluation which will adversely affect the evaluation results (Lechner, 2002; Lechner et al., 1991; Roy, 2003). Most Functional Capacity Evaluation protocols include a mechanism to address concerns related to sincerity of the effort (King et al., 1998). Innes and Straker (1998b) cautioned that psychosocial factors that are related to successful return to work can be confused with sincerity o f effort. Examples of psychosocial factors that may influence effort include fear of pain, fear of re-injury, or a lack o f understanding Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 45 concerning the importance of the evaluation (Lemstra et al., 2004). Matheson (2003) identified the following causes for less than full effort performance- “malingering system; factitious disorder; learned illness behaviour; conversion disorder; pain disorders; test anxiety; fear of symptom exacerbation or injury; fatigue; medication and psychoactive substance effects; lower self-efficacy expectations; and need to gain recognition o f symptoms” (p. 7 and 8). It was also acknowledged that a lack of sincerity of effort may be attributable to an evaluee’s misunderstanding the instructions, poor test administration, or poorly calibrated equipment (Matheson, 2003). It has been noted that identifying malingering is not necessary in regards to return to work planning but is considered important related to the determination of benefits (Innes & Straker, 1998c). Lemstra et al. (2004) commented that determining sincerity of effort is complex. There are a number o f approaches employed to determine sincerity of effort - Waddell’s nonorganic signs, coefficient of variation, bell shaped curve, rapid exchange grip, correlation between musculoskeletal and Functional Capacity Evaluation, documentation o f pain behaviour, documentation of symptom magnification, and ratio of heart rate and pain intensity (Lechner, Bradbury, & Bradley, 1998). Waddell’s Nonorganic Signs (NOS) was initially developed to help identify individuals who would benefit from detailed psychological assessment (Lechner, 2002; Scalzitti, 1997). Unfortunately, it was not developed to determine sincerity of effort but it is being used for this application (Lechner, 2002; Pransky & Dempsey, 2004). Also, the Waddell’s Nonorganic Signs assessment lack standardization which contributes to unreliable findings (Lechner, 2002). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 46 Another method for measuring the sincerity of effort employs the Coefficient of Variation (Lechner, 2002). In this method, an evaluee performs three repetitions of an isometric contraction. It has been suggested that increasing the number of repetitions to five would increase the stability of the measurement (Robinson, Sadler, O'Connor, & Riley, 1997). The Coefficient of Variation is calculated by dividing the standard deviation by the mean o f the measures (Lechner, 2002). The assumption is that a greater variability or higher coefficient of variation will be present for evaluees that provide submaximal effort (Lechner, 2002), however, norms have not been established (Simonsen, 1995). This approach to measuring sincerity of effort has been noted to have poor reliability and have a high incidence of false negative results (Lechner, 2002; Robinson, Geisser, Hanson, & O'Connor, 1993). Simonsen (1995) noted that results could be affected depending on the type of muscle contraction used, the medical status of the evaluee, the presence of pain, or the specific test used. Schetman (2000) noted that Coefficient of Variation may be inflated for those individuals that experienced compromised muscular strength. It has also been noted that the Coefficient of Variation can vary throughout the day (Birmingham, Kramer, Speechley, Chesworths, & MacDermid, 1998). Simonsen (1995) concluded that the Coefficient of Variation could not be used independently to determine an evaluee’s sincerity of effort while Schetman (2000) concluded that the Coefficient of Variation is not an appropriate method for determining sincerity of effort. The bell shaped curve is based on the principle that grip strength in five positions will be stronger in the central position and weaker at the narrower or wider grip (Lechner et al., 1998). When these grip values are plotted on a graph, the results produce Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 47 a bell curve (Lechner et al., 1998). The results of an evaluee with insincere effort would be a flattened curve. However, evaluees with hand weakness would also produce a flatter curve (Baker, 1998; Joughin et al., 1993). There have been research limitations identified in studies that have concluded that this is an accurate method of determining sincerity o f effort (Lechner et al., 1998). Additionally, in the clinical setting, clinicians are visually examining the curves to determine sincerity of effort which results in the process being reflective of clinical opinion (Lechner et al., 1998). Rapid exchange grip assumes that an evaluee will have greater difficulty sustaining submaximal effort when the speed of the grip force is increased from one sustained grip to 80-90 squeezes per minute (Lechner et al., 1998). As with the Coefficient o f Variation, there are no established norms to determine sincerity of effort based on rapid exchange grip (Lechner et al., 1998). Joughin et al. (1993) concluded that the rapid exchange grip could not be expected to distinguish between sincerity of effort and discomfort or mechanical weakness. The correlation between musculoskeletal evaluation and the Functional Capacity Evaluation is another method used to determine sincerity of effort (Lechner et al., 1998). This method examines results of range of motion and muscular strength testing with the results of the Functional Capacity Evaluation (Lechner et al., 1998). The limitation of this approach is that there is not a linear relationship between muscle testing results and functional abilities (Lechner et al., 1998). An examination of pain behaviour is also used to determine sincerity of effort. Pain behaviour can be assessed through a variety of methods (Lechner et al., 1998). However, the relationship between the results of pain behaviour measurements and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 48 sincerity o f effort remains unknown and should not be interpreted for such purposes (Lechner et al., 1998). Finally, the relationship of heart rate to pain intensity has been used to determine sincerity o f effort (Lechner et al., 1998). The underlying principle is that as pain increases so does an evaluee’s heart rate and therefore, those who cite pain as a limitation for maximum effort should exhibit an increased heart rate (Lechner et al., 1998). However, research has indicated that there is a complex relationship between pain intensity, physiologic responses, and pain perception; and therefore, heart rate should not be the basis for determining sincerity of effort (Lechner et al., 1998). A validity profile is sometimes used to assess an evaluee’s consistency in regards to physical effort (Kyi, 2000). Some of the tests included in a validity profile may be the Jamar Coefficient of Variation Testing, Jamar Rapid Exchange Grip Testing, Jamar Bell Curve Analysis, Non-Organic Sign Testing, Placebo Testing, and Consistency of Pain Reports (Kyi, 2000). Validity profiles have limitations. They tend to give equal weighting to each test item within the profile, thus giving each result equal rating without consideration to each individual test’s reliability and validity (Kyi, 2000). The profile is also based on methods that have been assessed to be not appropriate for the determination o f sincerity o f effort. Matheson (2003) suggested two additional methods of detecting sincerity of effort internal to the testing protocol. One method is to review the results for intra-test inconsistency specifically examining for results that exceed the normal error values (Matheson, 2003). The other method suggested is to examine the results concentrating Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 49 on detecting the “absence of expected relationships among related measures” (Matheson, 2003 p. 8). Another limitation of all the methods described previously for detecting sincerity of effort is that none o f the methods can suggest to the clinician the reason why the evaluee is providing submaximal effort (Cooke, Dusik, Menard, Fairbum, & Beach, 1994; Gibson & Strong, 2002; Gross, 2004). As a result, clinicians cannot conclude that a lack of effort does not have a biological explanation (Cooke et al., 1994). Lechner (2002) suggested that a lack of effort may be reflective of pain, fear of injury, anxiety, depression, or a conscious or unconscious attempt to change the test results. The literature supports the notion that sincerity of effort is a reflection of a clinical opinion. It is suggested that methods for determining sincerity of effort have limited scientific support and should not be included in Functional Capacity Evaluations (Fishbain, Abdel-Moty, Cutler, Rosomoff, & Steele-Rosomoff, 1999a; Gibson & Strong, 2003; Kennedy, 2003; Lechner et al., 1998; Lemstra et al., 2004; Strong & Westmorland, 1996). Furthermore, there is no evidence about the reliability or validity of the application of the tests to determine sincerity of effort specific to Functional Capacity Evaluations (Reneman, Fokkens, Dijkstra, Geertzen & Groothoff, 2005). The implications o f identifying an evaluee as providing submaximal effort are significant and could include the termination of benefits, loss of employment, loss of retraining opportunities, loss o f accommodation, reduced medical legal settlements, or loss of access to medical services (Lemstra et al., 2004; Matheson, 2003; Roy, 2003). Matheson (2003) acknowledged that there is considerable pressure on the clinician from funders to determine sincerity o f effort and this is reflected in clinical practice through the usage of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 50 unproven assessment methods to determine sincerity of effort. Roy (2003) recommended that the clinician discuss inconsistent results with the evaluee thus providing the evaluee with an opportunity to correct the behaviour. In this case study, the Sample Functional Capacity Evaluation Report presented physical effort findings (also referred to in the report as Maximum Voluntary Effort Testing). These findings were based on the Jamar Five-Position Grip, Grip Curve Analysis, and Jamar Rapid Exchange Grip Test. Data was presented for each task as well as a summary statement of findings. For the Jamar Five-Position Grip, the conclusion was “...this is suggestive of maximum voluntary effort during testing.” The conclusion for the Grip Curve Analysis was two fold. Analyzing the data based on a bell curve pattern concluded that: .. .a bell curve pattern was not observed in [the evaluee’s] case for [the evaluee’s] right hand and was not present for [the evaluee’s] left hand, suggestive o f a lack o f full effort on the right and of a lack o f full effort on the left. The clinician then engaged a second method of analyzing the data using standard deviation. Using this method of analysis, the conclusion regarding the data for the right and left hand was “.. .this standard deviation [is] indicative of good effort.” The conclusion for the Jamar Rapid Exchange Grip Test was the “finding is suggestive of low effort on the [evaluee’s] behalf.” There was no further discussion in the report regarding these test results nor was there the provision of an overall summary statement regarding effort. No rationale was provided regarding the variation in test results or a plausible cause for the determination of less than maximal effort. Although, the report Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 51 did note in reference to the Jamar Rapid Exhange Grip Test that “the [evaluee] was noted to demonstrate no signs of physical discomfort.” The Clinician identified that within the protocol of the Functional Capacity Evaluation that the clinician is looking for consistency of effort rather than sincerity of effort. The Clinician identified the use of the Waddell Non-Organic testing, Placebo testing, Consistency o f Movements, and distracting testing. The Clinician identified that the clinician also observes for indicators of competitive behaviours or discomfort. The Clinician explained distraction testing as: You [clinician] know they [evaluee] have some difficulties standing or sitting. You would have them fill out their paperwork in that form and you’d start timing them right away and they don’t really realize that’s what you’re doing because the testing hasn’t started yet.. .you’re distracting them with other tests while they’re in a sitting position or a standing position. You drop their coat on the floor and you get them to pick it up and see their movement.. .You can get them to do a repetitive squat where you.. .put their hands on a shelf and get them do a repetitive squat. Have them go down and their arms are up here. So you can look at that and if they really do have a range of motion limitation, you’ll notice it in some o f the different distractions. The Clinician explained placebo testing as: .. .testing things where it’s not even remotely close or would even affect the joint that’s even been injured. One of them is the Finger Distraction. If they’ve [evaluee] got a shoulder injury, you [clinician] can just pull on their finger gently and if they say it hurts then you know that’s a little bit off. The Clinician identified the following potential observations that are consistent with competitive behaviours: (a) “they’re [evaluee] going hard; hard as they can”; (b) “they’re sweating”; (c) “they’re wiping their hands”; (d) “they’re wanting to do more even after they shouldn’t”; and (e) “they’re consistently checking their progress [asking] how am I doing [or] how much weight was that.” Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 52 The Clinician explained that signs of discomfort can include: (a) leaning on knees; (b) shifting their weight; (c) hiking their shoulders; (d) counter balancing; and (e) limping. The Clinician discussed concerns about commenting on someone’s consistency of effort: ...personally, I don’t like the consistency of effort. I don’t know the person from Adam so I don’t like judging them and that’s basically what you’re being asked to do is judge their effort. There [are] tests you can do and you watch for consistency in terms of range of motion when they’re distracted or when they’re not. But there’s also a point where there’s some judgment involved and that becomes subjective. The Clinician emphasized the importance of ensuring that the reporting regarding consistency of effort was as objective as possible, however, noted that the challenge was that “you can’t measure pain.” The Clinician also noted that the procedures for evaluating consistency o f effort were based on research by the designers of the Functional Capacity Evaluation protocol. The Clinician explained that: We try to use the forms as much as possible. The research that was done to validate those questionnaires and can back up that they’re valid and reliable. If the person says they can’t do this and then they demonstrate it, you know that the questionnaire is a valid questionnaire. The Clinician reflected that providing consistent effort ultimately benefited the evaluee “in terms of the best treatment plan for them whether it’s going back to their previous job or some kind o f new job. If you put in full effort, you’ll get a truer Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 53 description o f what you’re able to do.” The clinician also noted that employers and insurance companies “when they ask for consistency of effort, they’re already thinking this person isn’t true to their word .. .they’re trying to find ways to get rid of them [evaluee] rather than keep them around.” With regards to reporting consistency of effort, the Clinician noted that “if it’s blatantly obvious then I’ll comment on it but if it’s in the middle, then it’s not as important.” The Clinician explained that when there is a discrepancy with the evaluee’s self-report and actual functional abilities that the Clinician will inquire with the evaluee regarding the discrepancy and will include the explanation in the report. Specific to inconsistent effort within the testing protocol, the Clinician indicated that “you [clinician] can’t really mention anything as to why you think they’re [evaluee] doing that [providing inconsistent effort] because that’s just an opinion .. .1 have really no idea why they’re doing it.” The Clinician speculated that “a lot of times, people who are really inconsistent are trying to prove to you that there is something wrong and they’re hurt. I don’t think they’re doing it consciously, it’s just something that happens.” The Employer commented on the importance of sincerity of effort and implications o f providing less than maximal effort. “That’s an indication of their [evaluee] motivation and that definitely would raise some questions. If I’m going to work with somebody and give it my all to get them back to work, the expectation is I’m going to get the same.” The Employer did identify fear and motivation as the two primary reasons for providing less than maximal effort. The Employer indicated that “your assessor [clinician] is hopefully getting a sense of that and we’re [clinician and employer] talking that through.” The Employer also indicated that “sometimes there’s Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 54 outside influences for them [evaluee] and it’s maybe not their own personal motivation but it might be something in their family that influences them as well.” The Employer could not recall a Functional Capacity Evaluation report that identified submaximal effort and provided a potential rationale for this finding noting that usually the report includes just a blanket statement in regards to sincerity o f effort. The Funder identified that a Functional Capacity Evaluation should include “whether or not the [evaluee] was making a good effort during the Functional Capacity Evaluation and a lot o f them [reports] don’t say whether or not the [evaluee] was doing the best that they could do.” The Funder continued “Functional Capacity Evaluations should identify discrepancies between what the [evaluee] reports they can or cannot do and what they observe [including] when they’re not actually involved in the Functional Capacity Evaluation activities within the clinic.” In regards to the implication of providing submaximal effort during the Functional Capacity Evaluation, the Funder provided this commentary: Their [evaluee] credibility becomes questionable and that leads to us, in a lot of cases, not even looking at the Functional Capacity Evaluations for measurables because it discredits all the information that the Functional Capacity Evaluation provides us. That’s a huge implication because then we’re left with an [evaluee] who we could interpret as not participating in the process. When you don’t participate in the process (i.e. make full efforts) then you are at risk [of benefits] being suspended. The Funder identified that the evaluee could be providing submaximal effort because of deconditioning, self efficacy regarding disability, fear of re-injury, family Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 55 influences, benefit status, workplace issues, and poor communication related to the Functional Capacity Evaluation process. The Funder noted that they do not consider the reasons for submaximal effort but suggested that perhaps they should. Despite the concerns identified in the literature regarding the assessment of sincerity o f effort, it appears that this continues to be a valued measure in this case study. Both the Funder and Employer identified the expectation that the Functional Capacity Evaluation report provide information regarding the sincerity of effort. The Clinician preferred the term consistency of effort. The Clinician did identify personal discomfort assessing this dimension, however, justified the inclusion o f this in the Functional Capacity Evaluation Report based on the funder’s request, as well as, objective reporting relying on what is perceived as scientifically researched methods (inclusive o f reliability and validity) for the determination of consistency of effort. The literature review did not identify a reliable method of determining sincerity of effort. As identified in the literature, sincerity of effort is widely assessed despite limited scientific support (Reneman et al., 2005). The Clinician identified that despite support from the testing protocol with the determination of submaximal performance, ultimately, it was a judgment and a subjective measure. This is consistent with the literature review which identified this measure as a clinical opinion. From the perspective of both the Clinician and the Sample Report, multiple measures were used to determine sincerity of effort. However specific to the Sample Report, the results from each test were included in the report and despite inconsistent conclusions ranging o f good effort to low effort, no explanation was provided nor was a final conclusion regarding effort provided. It could be interpreted that the measurement Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 56 o f sincerity o f effort was entirely an administrative process either due to a standardized protocol or in response to the funder’s request. The result is that the information regarding sincerity o f effort has little value as the interpretation of results is left to the reader rather than the clinician. The literature identified validity profiles (using more than one test to determine sincerity o f effort) as a method of determining sincerity of effort, however, this method also presents scientific limitations. The significant implications regarding submaximal performance were supported in both the literature and the case study. The Employer identified submaximal performance as a lack of motivation to return to work and indicated that this would in turn influence the employer’s motivation in assisting an evaluee with return to work planning. The Funder identified that submaximal performance could be viewed as not participating in the process which could result in the termination of benefits. Despite the identification o f a number of factors that could affect an evaluee’s sincerity of effort; the Clinician, Funder, and Employer identified that the significance of the assessment findings specific to sincerity of effort was the prime consideration and that the potential cause o f submaximal effort was insignificant in comparison. Component 11: Psychometrics The value of a measure to the user is referred to as utility (Matheson, 2003). Specific to Functional Capacity Evaluation, utility of a measure is impacted by safety, reliability, validity, and practicality (Matheson, 2003). Functional Capacity Evaluations need to be able to demonstrate acceptable levels of reliability and validity in order for the tools to be useful to the clinician (King et al., 1998; Schonstein & Kenny, 2001). Of particular concern is the tool’s predictive validity for predicting return to work outcomes Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 57 (Gross, 2004; Gross et al., 2004; Isemhagen, 1992; Schonstein & Kenny, 2001). Unfortunately, there is limited peer reviewed research regarding the reliability or validity o f Functional Capacity Evaluations (Gibson & Strong, 2002; Gross & Battie, 2003). Strong (2002) noted that the research available is limited due to the reliability of the research and limitations o f research design. Some of the research only appears in the manuals o f specific Functional Capacity Evaluation protocols (Strong, 2002). Even with the research that has been completed, there are not high levels of established reliability or validity (Allen et al., 2004). Lechner et al. (1991) suggested that an implication of the lack o f reliability and validity information of formal Functional Capacity Evaluation protocols is that they are not much of an improvement on the previous informal testing. Lechner (2002) also noted the unavailability o f randomized control studies that compare the different approaches to Functional Capacity Evaluation. There is a dichotomy between reliability and validity. Clinicians tend to want flexible Functional Capacity Evaluation protocols that meet the needs of the evaluee and thus make the testing protocol more valid, however, this flexibility negatively affects the evaluation’s reliability (Gibson & Strong, 2002; Innes & Straker, 2003). The following will provide an overview of key psychometric measures for Functional Capacity Evaluations. Reliability considers the consistency of a test’s measurement (Lechner, 2002). This measurement is important as it affects the interpretation of change. For Functional Capacity Evaluations, the most important measures of reliability are inter-rater and intra-rater (test-retest) (Gross, 2004; Innes & Straker, 1998c; King et al., 1998; Lechner et al., 1991; Velozo, 1993). Innes and Straker (1999a) completed a detailed review of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 58 Functional Capacity Evaluation research that examined reliability. The conclusion of their review was that there was a limited number of assessments that had evidence of sufficient reliability for clinical or legal purposes (Innes & Straker, 1999a). Reliability must be established for an assessment in order for validity to be established (Gouttebarge, Wind, Kuijer, & Frings-Dresen, 2004). Innes and Straker (1999a) cautioned that research that examines a specific type of reliability for a portion of a testing protocol cannot be generalized to the reliability of the entire assessment. In addition, this concept can be broadened to include specific Functional Capacity Evaluation research results cannot be applied to other Functional Capacity Evaluations (Reneman & Dijkstra, 2003). Also, King et al.(l 998) cautioned that the results from reliability studies that are based on individuals that do not have disability could be misleading when applied to a clinical setting. Inter-rater reliability refers to the test’s ability to achieve similar results when administered by different clinicians (King et al., 1998; Lechner et al., 1991). In the absence o f inter-rater reliability, the evaluee can go to another clinician for an assessment and get different results (Lechner, 2002). Lechner (2002) also noted the significance of this measurement when considering large clinics where different clinicians may administer the Functional Capacity Evaluation test at the beginning and end o f the rehabilitation process. Inter-rater reliability is important so that documented changes in the evaluee’s function are accurately determined. The consequence is that perhaps the changes in an evaluee’s performance may reflect limitations inherent to testretest scenario rather than performance changes. Inter-rater reliability is dependent on Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 59 clinician training and operative definitions (Gardener & McKenna, 1999). Inter-rater reliability is more difficult for complex movements (Durand et al., 2004). Intra-rater or test-retest reliability explores the consistency of a measurement made by the same evaluator over time (Gross, 2004; Lechner, 2002). Intra-rater reliability is impacted by the stability of the evaluee’s condition, the time between evaluations, and the memory o f the clinician and the evaluee regarding previous evaluations (Lechner, 2002). Validity refers to the accuracy of the evaluation (Lechner, 2002). Without validity, there is no way of determining if the evaluation results are accurate (King et al., 1998). There are a number of challenges when considering the measurement o f validity. There is no gold standard in which to compare the outcome of the evaluation (Schonstein & Kenny, 2001). Another challenge is in respect to considering the outcome measure as return to work (Schonstein & Kenny, 2001). Functional capacity is only one factor that influences return to work outcomes (Schonstein & Kenny, 2001). Other factors that are influential include willingness to return to work, workplace negotiations and flexibility, pain tolerance, and an individual’s beliefs regarding return to work (Schonstein & Kenny, 2001). As a result of these challenges, establishing validity for an evaluation is more difficult than establishing reliability (King et al., 1998; Lechner, Jackson, Roth, & Straaton, 1994) and resultantly fewer studies examining validity issues have been published in the literature (Gross, 2004). Innes and Straker (1999b) completed an extensive review of the validity of work related assessments. They concluded that most of the assessments have limited evidence o f validity (Innes & Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 60 Straker, 1999b). Innes and Straker (1999b) also noted that there was not a single instrument that demonstrated moderate to good validity in all areas. Content, construct, and criterion related (both predictive and concurrent) are considered important validity measures specific to Functional Capacity Evaluations (Gross, 2004; Innes & Straker, 1999b; Velozo, 1993). Lechner (2002) noted that there appears to be confusion between validity and sincerity o f effort, however, Lechner (2002) continued by noting that test validity is determined through research and that test validity does not change reflective of an individual’s cooperation. Content validity explores whether the Functional Capacity Evaluation comprehensively examines the attribute that it is claiming to measure (Baker, 1998; Gibson & Strong, 2002; King et al., 1998; Lechner et al., 1991). One of the challenges relates to the difficulties defining function and then capturing all the factors that affect function (Schonstein & Kenny, 2001). One way to establish content validity is to compare the Functional Capacity Evaluation measures to the physical demands in the Dictionary of Occupational Titles, however, Gibson and Strong (2002) noted that this is not an adequate method to assess content validity. Content validity can be determined by a panel o f experts and must be evaluated in terms of a particular purpose (Gross, 2004; Innes & Straker, 1999b). Lechner (2002) suggested that content validity is not empirically based and as a result, it represents the weakest form of validity. Construct validity examines whether “a test can be shown to measure a hypothetical construct” (Innes & Straker, 1999b, p. 128). Construct validity can be established by comparing group results involving individuals with particular characteristics such as the ability to discriminate between those that are working and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 61 those that are not, or by comparing the Functional Capacity Evaluation to other tests that measure the same or different values (Lechner, 2002). When comparing the Functional Capacity Evaluation and valid self-report disability questionnaires, Hart (1999) and Reneman, Jorritsma, Schellekens, and Goeken (2002) concluded that unique information is obtained through each evaluation process and suggested that both methods should be employed. Specifically, Reneman et al. (2002) suggested that the Functional Capacity Evaluation considers an evaluee’s ability to perform a task while the disability questionnaire measures an evaluee’s self-report regarding their ability to complete a task. Concurrent validity considers the “correlation between two or more measures given to the same subjects at approximately the same time so that both reflect the same incident of behaviour” (Innes & Straker, 1999b, p. 127). The challenge is that there is no gold standard which a Functional Capacity Evaluation can be compared (Gouttebarge et al., 2005; Gross, 2004; Innes & Straker, 1999b). Gouttebarge et al. (2005) suggested that because of the lack of a gold standard that concurrent validity is an inappropriate measure and that research should focus on comparison or co-relations studies. IJmker, Gerrits and Reneman (2003) examined whether Functional Capacity Evaluations could be used interchangeably and it was concluded that the upper lifting strength of the Ergokit Functional Capacity Evaluation and the waist to overhead lift of the Isemhagen work systems were not interchangeable. In addition, Rustenburg et al. (2004) compared the maximum lifting capacity based on the ERGOS Work Simulator and Ergo-kit Functional Capacity Evaluation and concluded that the concurrent validity between the two evaluations were poor. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 62 Functional Capacity Evaluations are used as prognostic tools with expectation that the evaluation will be able to predict return to work (functional tolerance) or the likelihood of re-injury (Gross, 2004). Gross and Battie (2005) concluded that Functional Capacity Evaluations could not predict the ability of the evaluee with back pain to return to work safely without re-injury. The challenge is that there does not exist an objective method for predicting return to work (Lechner et al., 1991). As a result, predicting based on the Functional Capacity Evaluation is dependent on the clinician’s intuition (Lechner et al., 1991). As stated earlier, predicting return to work is impacted by a number of variables including psychological and socioeconomic factors (Gross et al., 2004). This means that the predictive validity of the Functional Capacity Evaluation must consider more than just an evaluee’s performance on the physical demands component (Gibson & Strong, 2002; Gibson et al., 2005; King et al., 1998). Gibson and Strong (2002) noted that there have been very few follow-up studies that examine the relationship between the Functional Capacity Evaluation results and the actual return to work. Gross et al. (2004) suggested that predicting return to work should not be exclusive to Functional Capacity Evaluation results but rather Functional Capacity Evaluation results should be considered in conjunction with other available information. Jones and Kumar (2003) noted that components o f the Functional Capacity Evaluation, specifically strength and range of motion testing, are not predictive of return to work. Matheson, Rogers, Kaskutas, and Dakos (2002) concluded that time off work and gender were the strongest predictors of return to work. In contrast, Fishbain et al. (1999b) concluded that the strongest predictor o f return to work was pain levels at discharge. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 63 Another potential limitation of assessment tools is data interpretation. Many of the assessment tools used in gathering data during the Functional Capacity Evaluation rely on normative tables for interpretation (Strong, 2002). However, the normative tables are frequently developed using well populations and therefore the validity of the data interpretation for injured individuals is questionable (Strong, 2002). Innes and Straker (1999b) identified the need for further research regarding the reliability of assessment tools and cited the need for the research to include a diverse range of injured individuals. In regards to the utility of Functional Capacity Evaluations in this case study, the Clinician identified that the test results were most useful for those evaluees who were trying to find a job versus the evaluees who were trying to return to a specific job. The Clinician felt that this was due to the “lack of specificity” and the lack of ability to test under work conditions with work equipment. The Funder discussed the value or utility in terms of the evaluee’s attachment to the employer: If the attachment to the employer is still there then there’s less of a value for the Functional Capacity Evaluation. If the attachment with the employer is broken and we’re [funder] looking at what else can the [evaluee] do, assuming they’re [evaluee] making full effort..., then there’s more value. So it all depends on whether they’re [evaluee] attached or disenfranchised from their workplace and then there’s different values attached to the Functional Capacity Evaluation. In regards to reliability and validity, the Clinician had the following comments: The test and the questionnaires have been researched and have been found to be valid and reliable. That’s what we base everything on. I am not sure about the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 64 reliability and validity of the actual whole Functional Capacity Evaluation and being comprised o f all those different tests. But a lot o f people do them and a lot o f people use them so there’s gotta be something there. I feel confident if I got called into court, I could go in and say the research backs me up. This person [evaluee] did this. I know that this is their safe level because of this and that’s been backed up by years of research by [the Functional Capacity Evaluation protocol designers]. In regards to the utility of the assessment, the Funder identified that the Functional Capacity Evaluation “is developed in such a way that they do provide measurements but what do they mean.” The Funder identified that the Functional Capacity Evaluation does have some predictive value: They [Functional Capacity Evaluations] either predict that the [evaluee] is not making an effort and in that case they have some value to them; or the [evaluee] is making an effort and we have some findings. So either way, there is some value to it. The Employer identified that: We’ve had situations where someone’s gone through this with flying colours and they [clinician] say it’s a match [regarding job demands and physical abilities] and we’ve had an issue [with] physical problems...within a very short time frame. So then you [employer] question, did this [Functional Capacity Evaluation] get at what we were looking for because how did they [evaluee] get through this process and only work here for a couple of months and have problems. The Employer indicated that Functional Capacity Evaluations were predictive in the circumstance that Functional Capacity Evaluations were completed on individuals as part o f the pre-hiring process. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 65 Based on the literature review and the case study information, it appears that there is an underlying assumption that Functional Capacity Evaluations are both reliable and valid. The Clinician did question the reliability and validity of the entire protocol but noted that each specific test was reliable and valid. This demonstrates the concern identified by Innes and Staker (1999a) that reliability established for a specific portion of a test does not infer reliability for the entire testing protocol. The Clinician also relied on the prevalence o f the use of the Functional Capacity Evaluation as evidence of established reliability and validity. The Funder noted that Functional Capacity Evaluations did provide measurements but questioned what the measurements actually meant which is an issue of validity. Validity examines the accuracy of the evaluation. The Employer also questioned the validity of testing results based on the reoccurrence of injury upon return to work. This is consistent with Gross and Battie’s (2005, 2006) conclusions that Functional Capacity Evaluations are not predictive of re-injury for those individuals with low back pain or upper extremity injuries. In regards to the utility or usefulness of the test results, the Clinician felt the results were most useful for evaluees that were not returning to a specific job. The Clinician identified decontextualization of work as a primary barrier for usefulness of test results for evaluee’s that are returning to work in a specific job. The Employer felt the results were most useful for evaluees that completed the evaluation as part of a pre­ hiring process. The Funder identified that the usefulness of the test results rested primarily on the sincerity of effort measurement. If an evaluee provided maxmimal effort then the test results would be useful and if the evaluee provided submaximal effort Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 66 that this in itself was useful information. This is concerning, as the previous discussion identified a number o f significant limitations in the literature regarding the reliability and validity o f the measurements used to determine sincerity of effort. In addition to sincerity of effort, the Funder also suggested that there was a relationship between the evaluee’s attachment to the workplace and the value of the Functional Capacity Evaluation. The Funder explained that the greater the evaluee’s attachment to the workplace; the less useful the Functional Capacity Evaluation. Conversely, the less attachment the evaluee has to the work place, the greater utility of the Functional Capacity Evaluation. There was no mention of this finding in the literature. Component 12: Qualitative and Quantitative Information in Functional Capacity Evaluation reports Clinicians incorporate both subjective and objective data in Functional Capacity Evaluations (Allen et al., 2004; Strong & Westmorland, 1996). Innes and Straker (2003) reviewed the attributes of excellence for different types of Functional Capacity Evaluations. Innes and Straker (2003) noted that evaluations related to a specific work environment tended to be more qualitative while the evaluations that were not linked to a specific work environment tended to be more quantitative. Innes and Straker (2003) proposed that there are two characteristics that can be considered specific to each type of evaluation. Utility or qualitative characteristics include accurate, comprehensive, credible, flexible, practical, relevant, and useful (Innes & Straker, 2003). Dependability or quantitative characteristics include consistent, measurable, objective, reliable, reproducible, standardized, structured, and valid (Innes & Straker, 2003). As Innes and Straker (2003) explained, there is a direct relationship between increased focus on Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 67 qualitative attributes and increased specificity o f the results; while increased focus on quantitative attributes results in increased generalizability of the results. Innes and Straker (2003) suggested that the characteristics of excellence vary depending on the type of evaluation being completed and that further investigation exploring the relationship between evaluation type and attributes of excellence should be considered. Strong (2002) suggested that there are two opposing thoughts regarding what is a scientifically based Functional Capacity Evaluation. There are those that consider that clinicians must follow precisely the evaluation’s protocol versus those that incorporate clinical reasoning in achieving a balance between individualized and standardized data collection (Strong, 2002). It has been suggested that the focused testing approach requires a more experienced clinician compared to administering a standardized test battery (Matheson, 2003). The Sample Report in this case study included both subjective and objective data. The subjective data includes references to client self-report as well as the clinician’s impressions regarding the evaluee’s physical abilities. The Clinician acknowledged that Functional Capacity Evaluation reports are inclusive of both objective and subjective data. The Clinician qualified the subjective components: We [clinician] try to keep it [report] as objective as possible; we obviously put in some subjective stuff but it’s the most objective subjective stuff you can think of like [specific pain rating scales] for every test. Consistent with the literature, there was evidence in the case study regarding the inclusion of both subjective and objective data. The Clinician clarified that even the subjective data was objective. This certainly does support the notion that the Functional Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 68 Capacity Evaluations are considered objective measures of an evaluee’s functional abilities despite the inclusion of subjective information. As discussed earlier, the inclusion of subjective and objective data directly affects the psychometric properties of the Functional Capacity Evaluation and creates a challenge for researchers. Component 13: Decontexualization o f work Strong (2002) identified the decontextualization of function as a potential limitation of the Functional Capacity Evaluation. This phenomenon occurs when occupational performance related to the work environment is reduced to smaller parts for the purposes o f assessment (Strong, 2002). The result is a lack of consideration for the evaluee’s work environment and the evaluee’s interaction within that environment (Strong, 2002; Strong et al., 2004; Velozo, 1993). Strong (2002) suggested that Functional Capacity Evaluations should consider context elements including work (every day workplace reality), clinical (the evaluee’s medical condition, contraindications, and disability), and whole person (the evaluee’s other life roles and psychosocial function). The more closely the Functional Capacity Evaluation simulates the actual work place tasks, the more valid the results (Strong, 2002). Strong (2002) suggested that assessors should incorporate work simulation, work trials, and work site assessment in the Functional Capacity Evaluation. The Clinician in this study reported that she/he does not routinely attend the work site as part of the process of completing a Functional Capacity Evaluation: I don’t generally go to the work place. If there is a request for us to do a Functional Capacity Evaluation and the employer cannot provide a physical demands [analysis] and they want a job specific [assessment], then we’ll offer to Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 69 do a physical demands analysis; go out to the work place and do it. We don’t generally have the client come to that because you just want the physical demands. You don’t want to muddy the waters if there [are workplace issues]. The Clinician commented on the difficulties regarding the simulation of the work experience within the clinical setting: It’s very difficult to mimic work; although we do work simulation tasks and circuits where they’re [evaluee] going for 20-30 minutes and doing the different types o f tasks that they have to do at work. It’s very difficult to mimic the conditions that somebody might have to work in, the exact equipment somebody might have to work with, [and] the exact speed that somebody might have to work in terms o f conveyors. The Clinician also noted that completing the assessment at the work site presents with some inherent challenges: If you go out into a work site and get them to do it in the work site, you start to lose the validity behind the tests in that everything is not protocol based. You’re using untested pieces of machinery and you don’t know their exact weight. If they’re asking for specific job recommendations, you can run into some difficulties. The Clinician did offer suggestions on how to avoid the decontexualization of work while maintaining the Functional Capacity Evaluation protocol: If somebody works a regular week, do some testing over the course of three or four days rather than just one or two days. Also make it as work specific as possible. If that means the employer providing some kind of equipment.. .where Reproduced with permission of the copyright owner. Further reproduction prohibited w ithout permission. Functional Capacity Evaluation 70 they’re working with the type of tools they would normally work with [or] the types o f stuff they would normally carry. The Clinician clarified that the evaluee’s physical functioning would be assessed prior to commencing the work simulation portion of the assessment. The Sample Functional Capacity Report did reference job demands throughout the document so the clinician did have access to this information. The source of the job demands data is not clear from the report: The job requirements used for comparison purposes in the report reflect the maximum physical requirements the worker would encounter working at [specific work site]. These physical requirements represent a composite of the commonly performed tasks within the [specific job]. The Employer expressed the importance of the clinician having an understanding o f the workplace: I think it’s really important that whoever is doing them [Functional Capacity Evaluations] actually understands the work site and what the job requirements are, versus just getting a job description from us [employer] and making some assumptions.. .1 think making them a little more realistic at times in comparison to what the job is. The Employer did recall a Functional Capacity Evaluation that was inclusive of the clinical assessment as well as the clinician attended the worksite with the evaluee to review specific jobs and discussed the situation with the employer. The Employer described this assessment as “it was a much more thorough, specific, assessment.” Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 71 The Evaluee expressed concern that the Functional Capacity Evaluation was not reflected of the actual daily job demands: The person [clinician] came and evaluated our jobs. But they evaluated our jobs when we were doing tum-overs, not on a day to day basis. So the [evaluation] was more of a lifting type trial where we don’t do that much lifting other than turnovers. The Evaluee noted the Functional Capacity Evaluations are “so general, they don’t take in the full perspective o f what the job is.” The Evaluee suggested a work site assessment component to the Functional Capacity Evaluation by having a “person come in for four hour shifts [and] get them to do all the things that we do including lifting.” The Evaluee also identified the concern that because the job demands analysis does not reflect the actual job demands, potential employees may not be given the opportunity to work that specific job because they could not successfully meet the erroneous job demands. The Funder viewed the work site assessment and the Functional Capacity Evaluation as two separate options: We need to figure out whether or not [the evaluee] could actually perform the duties o f an [alternate job]. So we are faced with the questions on a day to day basis, do we measure that by bringing an OT out to the employer’s site and actually watching him on the piece of equipment or do we bring the [evaluee] into Prince George and get him into a Functional Capacity Evaluation within the clinic to determine whether or not it’s safe return to work. In answering this question, the Funder reported that evaluees “will tell you in most cases that they would prefer to come to Prince George within a clinical environment.” The Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 72 Funder identified potential reasons for this preference as: (a) “they [evaluee] do not want to cause grief for the employer”; (b) “pride and work identity with their colleagues around”; (c) “stigma for the employer and funder”; and (d) “the [evaluee] feels responsible for their [situation].” The Funder did identify a preference for the work site evaluation versus the clinical assessment citing the difficulties with relying on National Occupational Classification for job demands. The Funder explained that specific job demands are not provided to clinicians completing Functional Capacity Evaluations citing that determining whether an evaluee can meet specific job demands is the determination of the funder and not the clinician. The Funder explained that this was a systems issue and did acknowledge that there may be some benefit to providing job demands to the clinician. The literature review supported the inclusion of work simulations, work trials and work site assessment in the Functional Capacity Evaluation. The importance of work site knowledge to the Functional Capacity Evaluation was acknowledged by the Clinician, Employer, and Evaluee although there was some discrepancy as to the best method of obtaining that information. The Employer and Evaluee identified the importance o f at least a component of the Functional Capacity Evaluation to be inclusive o f a work site evaluation including both the clinician and the evaluee. The Clinician also identified the importance of work site information but indicated that this information could be provided by the employer in terms of the job demands analysis or through the clinician completing a job demands analysis. The Clinician also suggested that the employer could provide work related tools and equipment to assist with the job Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 73 simulation in the clinic environment. The Clinician identified that the duration of the Functional Capacity Evaluation should increase to three or four days to better simulate an entire work week. The Clinician was not supportive of a work site assessment inclusive of the evaluee’s participation. The Clinician cited concerns for the validity of the assessment results as the assessment would not be following a standardized protocol and also noted concern that the identification of work site issues such as poor relationships would make the Functional Capacity Evaluation more difficult to complete. The Clinician identified concerns regarding the difficulties of mimicking work tasks within the context of the clinical environment. The Evaluee and the Employer both cited concerns that job demands analysis are not reflective o f the entire job demands. Both felt that it was necessary to have a better understanding o f the work site beyond the information provided in the job demands analysis. In contrast, the Clinician felt that the job demands analysis provided sufficient information to understand the specific job for the purposes of the Functional Capacity Evaluation. Surprising to this researcher was the Funder’s revelation that job demands analysis regarding a specific job would never be forwarded to the clinician completing the Functional Capacity Evaluations. In the event that there was a specific job the evaluee could return to, then a work site assessment would be completed to determine if the evaluee could meet the job demands. Functional Capacity Evaluations are completed based on the National Occupational Classification codes. The Funder acknowledged that specific job demands may be useful for the purposes of the Functional Capacity Evaluation, however, that is not possible at this time due to systems limitations. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 74 The Funder viewed the Functional Capacity Evaluation and the work site assessment as two distinct assessments noting that the work site assessment would not be a component of the Functional Capacity Evaluation but rather the work site assessment is a preferable option instead of the Functional Capacity Evaluation. This is counter to the findings in the literature that actually recommends that work site assessments and work trials be a component of the Functional Capacity Evaluation. The Funder did provide some reasons as to why the evaluee may actually prefer the Functional Capacity Evaluation in the clinical setting to the work site assessment. These potential concerns revolved around the evaluee’s perceptions regarding the employer, colleagues and themselves. Component 14: Administration It has been suggested that Functional Capacity Evaluations present as a significant administrative burden in respect to time, documentation, and equipment (Gross, 2004). Gross (2004) noted that the Functional Capacity Evaluation protocol is often lengthy and can be repetitive and provide information that potentially is not useful. The accepted practice o f evaluating an individual’s performance over multiple days contributes to the administrative burden (Dusik et al., 1993). Another potential limitation regarding data collection involves applying the results of a static test to a dynamic work situation (Strong, 2002). Abdel-Moty et al. (1993) suggested that this practice is not valid. Additionally it remains unknown as to whether the results are transferable to an eight hour a day - forty hour a week work situation (Isemhagen, 1992; King et al., 1998; Lechner, 2002; Pransky & Dempsey, 2004; Strong, 2002). There is Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 75 also uncertainty regarding the transferability of the evaluation results obtained in a clinical setting to the work setting (Gross, 2004; Pransky & Dempsey, 2004). There is pressure to reduce the length of the Functional Capacity Evaluation (King et al., 1998) and thus reduce the inherent costs. As a result, there is research examining whether specific tasks within a Functional Capacity Evaluation are as predictive o f return to work as the entire protocol (Gross, 2004). Matheson (n.d.) noted that Functional Capacity Evaluation fees are higher than treatment fees because of the higher level o f skill required in addition to the increased amount of equipment and space required. There are also concerns regarding a lack of regulations regarding clinician qualifications, how the evaluations are conducted, how the results are used, accountability and quality of service (Strong, 2002). One of the challenges is that different professions have developed functional assessments measures that are reflective of their own areas of interest (Matheson et al., 2001). In addition, there has been no organization that has examined an interdisciplinary approach in functional assessment and professional organizations have developed independent guidelines for functional assessments (Matheson et al., 2001). The Employer in this case study identified concerns that there was a limited availability o f professionals in the community to complete Functional Capacity Evaluations. It was also noted that the quality of the Functional Capacity Evaluation was dependant on the clinician. “I know they [clinicians] have standards and everything but some people are better at it than other people.” The Funder identified that “until recently, we’ve had to fly people in to do the Functional Capacity Evaluation in Prince Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 76 George.” The Funder also noted that in other communities in the region, evaluees must travel to Prince George to participate in a Functional Capacity Evaluation. In regards to training, the Clinician explained that: I’m technically only allowed to do Functional Capacity Evaluations for [specific rehabilitation company] so if I went to work for another company, I wouldn’t be able to even though I could apply whatever I’d learned at [specific rehabilitation company] to the other company. I wouldn’t be able to because we did [company] specific training for it. It was a weekend course where we got certified [in one specific component of the Functional Capacity Evaluation].. .they just basically teach us how to do a Functional Capacity Evaluation - what test you do when and why you do them. The Clinician identified that as an internal quality control measure and training process that some of the Clinician’s initial Functional Capacity Evaluation reports were reviewed by someone else in the company. The clinician explained that “you’re insuring that your reports are up to a high level of standard so that if you did get called in [to court], there’s not a lot that they can really rake you over the coals for.” In regards to the duration of the Functional Capacity Evaluation, the Clinician and the Evaluee referred to two day Functional Capacity Evaluations. The Sample Functional Capacity Evaluation Report did not clearly delineate the duration of the Functional Capacity Evaluation but it can be inferred to be one day as the data presented did not include two sets of data representing day one and two. The Funder reported that the cost for the Functional Capacity Evaluation was $1500.00. The Funder did not think that Functional Capacity Evaluations were good Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 77 value. This was partially based on the timing of the Functional Capacity Evaluation in terms o f disability: I don’t think we’re getting good value because a lot of times we do it, as a result of the system, years after [disability] where psycho-social issues, unemployment, and deconditioning impact the Functional Capacity Evaluation...it’s not good cost benefit because we’re getting a picture of the [evaluee] many years later. The Funder noted that the Functional Capacity Evaluations presented as a positive cost benefit when: We’re absolutely at a huge impasse on what the [evaluee] says they can do and there’s a gap in their medical.. .and the [evaluee] made an effort. If the [evaluee is] going in there making an effort then the Functional Capacity Evaluation has some value because it gives us what we need. But if that [evaluee’s] role is not there then it doesn’t really provide us with anything. The case study identified concerns with both the availability of qualified clinicians as well as the quality of the Functional Capacity Evaluations. The literature also identified concerns regarding clinician qualifications and quality of service. The training the Clinician had was internal to the company and was not transferable to other settings. The formal training was specific to one particular test in the Functional Capacity Evaluation protocol. However, there was an in-house approach to training the entire Functional Capacity Evaluation protocol. In this scenario, the quality of the Functional Capacity Evaluation protocol is dependent on the company trainer. Based on the case study, it appears that Functional Capacity Evaluations range from hours to two days. The Clinician actually suggested that the evaluation time should Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 78 be extended so better simulate weekly job demands. This is counter to the literature review that identified the duration of the Functional Capacity Evaluation as a burden and researchers are trying to determine if there is a shorter protocol that could be predictive o f return to work. However, the Clinician was attempting to suggest an improvement to the Functional Capacity Evaluation protocol which would improve work simulation. The literature identified the concern regarding whether the Functional Capacity Evaluation results were transferable to the eight hours per day, five days a week work environment. The Funder did not think that Functional Capacity Evaluations were good value based on the timing of the evaluation in relationship to the individual’s onset of disability. The Funder indicated that the value of the Functional Capacity Evaluation was dependent on the evaluee’s motivation. Component 15: Utilization The results of the Functional Capacity Evaluations affect return to work and, therefore, impact the individual and society both directly and indirectly (Gardener & McKenna, 1999). The direct impacts include the number and length of insurance claims, medical and rehabilitation costs, employer costs for loss of production time, and medico-legal costs (Gardener & McKenna, 1999). The indirect impacts include an individual’s loss of function, family dysfunction, and employers’ loss of skilled labour (Gardener & McKenna, 1999). Despite the number of limitations identified, Functional Capacity Evaluations continue to be used in disability management and return to work planning. Functional Capacity Evaluations are complex evaluations. There is the notion that Functional Capacity Evaluations measure functional capacity objectively, however, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 79 it may be more accurate to reflect that Functional Capacity Evaluations objectively measure performance (Reneman & Dijkstra, 2003). Continuing with this reasoning, it is not feasible to expect Functional Capacity Evaluations to accurately predict the individual’s ability to return to work, rather it would be realistic that Functional Capacity Evaluations measures “an individual’s functional ability to perform work related activities” (Reneman & Dijkstra, 2003, p. 205). King et al. (1998) suggested that Functional Capacity Evaluations should not be used in isolation. Lechner (2002) suggested that in the absence of Functional Capacity Evaluations that return to work decisions would be based on the individual’s self-report, medical diagnosis, impairment measures, and physician intuition - all of which have inherent limitations. It is acknowledged that there has been an effort to overcome some of the limitations of Functional Capacity Evaluations by incorporating job analysis and work simulations (Pransky & Dempsey, 2004). Others suggest that until reliability and validity improve specific to safe and sustainable return to work, Functional Capacity Evaluations will not be of assistance to clinicians involved in return to work decisions resulting in the view that the evaluation is reflective o f an administrative effort (Pransky & Dempsey, 2004). Pransky and Dempsey (2004) suggested that Functional Capacity Evaluations may have therapeutic value in regards to the range of performance and has the potential to identify factors that may affect return to work. This may mean that when functional capacity results are used in conjunction with other information, the evaluation may assist with decisions regarding return to work (Pransky & Dempsey, 2004). Matheson (2003) speculates that as the current limitations of Functional Capacity Evaluations are addressed, Functional Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 80 Capacity Evaluations will become “indispensable to the process of disability determination” (p. 23). In terms of the overall impression regarding Functional Capacity Evaluations, the Clinician identified that Functional Capacity Evaluations: .. .definitely have their place in terms of treatment plans but I don’t think employers or insurance companies should take it as a be all end all for anything.. .Employers or whoever is asking for it, really need to realize that there’s more to a person and that before you just write them off if they do a bad Functional Capacity Evaluation, you should take that into account. I think a lot o f people use the Functional Capacity Evaluation as a tool to make final decisions in terms of people’s careers and I don’t necessary think that they should be used for that. The Employer summarized their overview of Functional Capacity Evaluations as: It doesn’t give you all the information. I think sometimes people tend to think that it’s going to be the answer. Whether that’s an employee or the employer, it’s not [the answer]. It’s just a piece of the puzzle or part of the tools. I think sometimes people put too much emphasis on it. The Funder was supportive of the Functional Capacity Evaluation and often referred to it as a last resort option. The Funder noted that in the absence of the Functional Capacity Evaluation, information could be obtained from the physician and through the evaluee’s self-report. The Funder explained that “We pose those questions to [the physicians] and we ask whether or not the [evaluee’s] reported limitations are Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 81 biologically plausible. If what the [evaluee] reports is in keeping with the diagnosis then we accept those.” The cautionary comments provided by the Clinician and the Employer regarding the use of the information provided in the Functional Capacity Evaluation are also supported in the literature. The Funder’s reference to the use of physician information as well as the evaluee’s self-report is also addressed in the literature. Brouwer et al. (2005) examined the information in self-report, physician clinical examination, and functional testing. This study suggests that an evaluee’s self-report may be most useful when the focus is the effectiveness of treatment and therefore the evaluee’s perceptions would be critical to the determination of treatment effectiveness (Brouwer et al., 2005). Furthermore, the study suggests that the medical examination is most useful when physician’s want to obtain an understanding of an evaluee’s “pain behaviour, distress, anxiety, emotions” (Brouwer et al., 2005, p. 1004) Finally, this study also identified that the Functional Capacity Evaluation may be most useful when assisting the evaluee to identify differences in their actual functioning level as compared to their perceptions (Brouwer et al., 2005). Therefore, the Funder’s point of view that Functional Capacity Evaluations can be replaced with physician consultation and evaluee self-report appears to be dependent on the purpose of the information being gathered. Brouwer et al. (2005) actually suggested that specific to disability benefits, that evaluee’s self-report should not be used in isolation but in conjunction with other information. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 82 Chapter 4 Conclusion Discussion There were two primary questions that this case study was designed to explore: (a) how are Functional Capacity Evaluations perceived by an evaluee, funder, employer and clinician in Prince George; and (b) how do these perceptions compare to the literature? As mentioned previously, a metaphor regarding the layers of an onion was applied to the Functional Capacity Evaluation by the Funder: When you look at the document superficially it becomes something of value because there are numbers. What happens though is that underlying, it’s like the peels on an onion and you peel it one step further and then you see how [Functional Capacity Evaluations] can be very much affected by all that stuff we talked about. The following will apply this metaphor to the discussion of the case study findings. Personal perceptions. The initial layer of the onion was my personal perception of the Functional Capacity Evaluation. I identified frustration with the utility of the Functional Capacity Evaluations and its ability to provide me, as the case manager, with the information necessary for the return to work planning process. General Responses. The next layer of the onion would be the responses received from the key stakeholders in reply to the general inquiry regarding the benefits and limitations o f the Functional Capacity Evaluations. This would equate to the macro perception o f the Functional Capacity Evaluation. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 83 The Clinician identified the benefits of the Functional Capacity Evaluation as the determination o f physical abilities and the opportunity to compare the evaluee’s selfreport to his/her demonstrated abilities. The Funder identified the benefit of Functional Capacity Evaluations as the ability to measure function. Developing an understanding of the evaluee’s restrictions specific to return to work was identified as a benefit by the Employer. The Evaluee noted that the benefit of Functional Capacity Evaluations was the determination as to whether or not the evaluee could do their job. Conversely, the Clinician, Funder and Evaluee identified the transferability of the Functional Capacity Evaluation results to the work setting as a limitation. The Clinician also noted that another limitation was that the consistency of effort determination was not an objective measure but rather based on the clinician’s opinion while the Funder noted the limitation that the Functional Capacity results are dependent on the evaluee providing maximal effort. The Funder further identified the limitation that the demonstrated level of functional ability is subjective; dependent on the evaluee’s perceived abilities and other factors beyond physical abilities. Both the Funder and Employer identified the concerns that there were limited clinicians available to complete the Functional Capacity Evaluation, and that the information obtained through the Functional Capacity Evaluation may conflict with other information obtained regarding the evaluee’s functional abilities. The Employer identified that expectations regarding the information that is provided through a Functional Capacity Evaluation and how that information can be applied is another limitation of Functional Capacity Evaluations. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 84 Components. Continuing with the metaphor of the onion, the next layer would be the detailed review of specific aspects of the Functional Capacity Evaluation based on the interviews with the key stakeholders as well as a thorough literature review. This would equate to the micro perception of the Functional Capacity Evaluation. The following identifies the key factors regarding Functional Capacity Evaluations based on the literature review and the case study. It is difficult to define Functional Capacity Evaluations and Functional Capacity Evaluations can be used for a variety of purposes. The nomenclature associated with Functional Capacity Evaluations is open to interpretation and may be unfamiliar to the audience reading the report. There is limited information regarding the theoretical framework applied to Functional Capacity Evaluations. There are three approaches to Functional Capacity Evaluations (metabolic, biomechanical, and psychosocial) which are incorporated into the assessment. There are a variety of Functional Capacity Evaluation protocols available including commercially based options. It is a challenge to determine the physical demands of a specific job. The literature supports the inclusion of cognitive functioning in the Functional Capacity Evaluation, however, there was no evidence o f the inclusion of cognitive functioning in this case study. Psychosocial considerations directly influence an individual’s functional abilities and are recommended as a component of the Functional Capacity Evaluation in the literature. However, in this case study, the inclusion of psychosocial considerations was limited. Safety is the primary attribute when reviewing Functional Capacity Evaluations according to the literature. Safe maximum level of performance can be determined through a psychosocial approach or a kinesiophysical approach and the case study Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 85 identified the use of both approaches concurrently. The case study revealed that education regarding proper lifting techniques is completed during the Functional Capacity Evaluation while according to the literature, there is controversy regarding the inclusion of education regarding safe lifting techniques during the Functional Capacity Evaluation. Sincerity of effort is a reflection of clinical opinion. The literature advised that this measurement should not be included in the Functional Capacity Evaluation while the case study revealed the importance of the sincerity of effort measurement for the Employer and the Funder. There is limited peer reviewed research regarding the reliability and validity of Functional Capacity Evaluations according to the literature. The inclusion of subjective and objective data in Functional Capacity Evaluations is dependent on the Functional Capacity Evaluation protocol, the clinician, and the purpose of the Functional Capacity Evaluation. The transferability of the Functional Capacity Evaluation results to the work setting is questionable. Functional Capacity Evaluations should incorporate aspects of work in the assessment. The case study identified opposing views about whether a work site assessment or work trial should be a component o f a Functional Capacity Evaluation. Functional Capacity Evaluation results can a significant impact on the individual and resultantly on society. Key findings Having peeled back the layers, the core or essence of the Functional Capacity Evaluation is revealed. The Functional Capacity Evaluation is a tool that can be used to assist with the process o f determining an individual’s functional abilities as well as assist return to work planning. The difficulty for Functional Capacity Evaluations is that they are saddled with unrealistic expectations. These unreasonable expectations include Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 86 being able to unequivocally answer the funder’s questions, determine sincerity of effort, directly transfer clinical findings to the work setting, assess all aspects of a particular job, predict or prevent the occurrence of re-injury, predict return to work outcomes, and being an objective measure of function. It is critical that there are reasonable expectations surrounding the Functional Capacity Evaluation specific to what the assessment can or cannot provide. Given that Functional Capacity Evaluations are well established as an assessment tool in vocational rehabilitation and that there is no gold standard available in regards to assessing function, it is likely that the Functional Capacity Evaluation will continue to evolve. Researchers continue to analyze the Functional Capacity Evaluation and recommend improvements based on the scientific research. However, in the mean time, Functional Capacity Evaluations will continue to be used despite the concerns already identified in the literature and case study. Given the information obtained through this case study and the literature review, there are some strategies that can be implemented into daily practice by the key stakeholders as to minimize some of the concerns that have been identified regarding Functional Capacity Evaluations. Communication between all the stakeholders involved in the Functional Capacity Evaluation is imperative. This communication is necessary to establish the purpose o f the Functional Capacity Evaluation; the parameters to be assessed; and the limitations inherent to the Functional Capacity Evaluation and the resulting recommendations. A team approach with the key stakeholders would contribute to improved communication regarding the Functional Capacity Evaluation. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 87 It is critical that all stakeholders are accountable for ensuring education around the reasonable expectations specific to the Functional Capacity Evaluation. Clinicians need to ensure that they are aware of the research regarding the reliability and validity of the assessment tools they use and communicate these limitations with the Functional Capacity Evaluation findings. If the expectations surrounding the Functional Capacity Evaluation remain reasonable based on the limitations identified in the literature, then the perceived utility of the Functional Capacity Evaluation may improve for the key stakeholders. The importance of the conceptualization of work within the parameters of the Functional Capacity Evaluation is paramount. Functional Capacity Evaluations should be viewed as a piece o f a puzzle and be used in conjunction with other information. The practice of determining sincerity of effort must stop because it has not been scientifically verified and the implications for the determination of submaximal performance are too significant to risk false identification of submaximal performance. Decisions regarding an individual’s vocational or financial future should not be determined based on the Functional Capacity Evaluation results in isolation. Information from other sources should be considered along with the Functional Capacity Evaluation results. The Functional Capacity Evaluation should not be viewed as providing more objective or significant findings than other available information rather the information from the Functional Capacity Evaluation information should be viewed as another piece in the puzzle when determining next step planning for an individual. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 88 Personal Reflections As I progressed through the journey of completing this case study about Functional Capacity Evaluations, my personal opinion regarding Functional Capacity Evaluations changed. As I have indicated previously, initially I was frustrated with the utility of the Functional Capacity Evaluation and questioned whether I had reasonable expectations surrounding the evaluation and its outcomes. While completing the literature review, I became concerned that perhaps Functional Capacity Evaluations were o f little value given the number of limitations that were identified. The review of the case study data placed the Functional Capacity Evaluation within a context. Upon analyzing the data from the case study and comparing it to the literature review, my views continued to grow and develop. I began to recognize that Functional Capacity Evaluations do have value but that this value is minimized when there are unrealistic expectations surrounding the evaluation. Additionally, I am hopeful that with continued research and development of Functional Capacity Evaluations that expectations can be further defined and the evaluations can evolve to better meet the identified needs in disability management. Concluding comments This case study examined the literature and explored the perceptions of Functional Capacity Evaluations in Prince George, British Columbia. In many areas, the Functional Capacity Evaluation limitations that were identified in the literature were also identified in the case study. The major differences identified between the literature and the case study were the inclusion of psychosocial and cognitive components in the evaluation; the use o f the sincerity o f effort determination; and the inclusion of a work Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 89 site assessment or work trial in the Functional Capacity Evaluation. Because the findings o f this case study are not generalizable to other settings, further research would be necessary to determine if these differences are unique to this case study or are more prevalent. Other opportunities for future research include focusing on one Functional Capacity Evaluation and analyzing the perceptions of the key stakeholders specific to the experience surrounding a specific Functional Capacity Evaluation to provide a more focused experience to understand. Another opportunity for further research may be to develop a ‘best practice’ model for Functional Capacity Evaluations based on an extensive review of the current practice and limitations within British Columbia. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 90 References Abdel-Moty, E., Fishbain, D., Khalil, T., Sadek, S., Cutler, R., Steele-Rosomoff, R., et al. (1993). Functional capacity and residual functional capacity and their utility in measuring work capacity. The Clinical Journal o f Pain, 9(3), 168 - 173. Allen, S., Rainwater, A., Newbold, A., Deacon, N., & Slatter, K. (2004). Functional capacity evaluation reports for clients with personal injury claims: A content analysis. Occupational Therapy International, 11(2), 8 2 -9 5 . Baker, J. (1998). Burden of proof in detection of submaximal effort. Work, 10,63 - 70. Baum, C. (2002). Creating partnerships: Constructing our future. Australian Occupational Therapy Journal, 49(2), 58 -62. Berg, B. (2004). Qualitative research methods for social sciences (5 ed.). Boston: Person. Birmingham, T., Kramer, J., Speechley, M., Chesworths, B., & MacDermid, J. (1998). Measurement variability and sincerity of effort: Clinical utility of isokinetic strength coefficient of variation scores. Ergonomics, 41(6), 853 - 863. Brouwer, S., Dijkstra, P., Stewart, R., Goeken, L., Groothoff, J., & Geertzen, J. (2005). Comparing self-report, clinical examination and functional testing in the assessment of work-related limitations in patients with chronic low back pain. Disability and Rehabilitation, 27(17), 999 - 1005. Casnig, J. (unknown). The seven veils of the onion. Retrieved June 13,2006, from http://knowgramming.com/Onion.htm Cooke, C., Dusik, L., Menard, M., Fairbum, S., & Beach, G. (1994). Relationship of performance on the ergos work simulator to illness behavior in a workers' compensation population with low back versus limb injuries. Journal o f occupational medicine, 36(1), 757 - 762. Creswell, J. (1998). Qualitative inquiry and research design choosing among five traditions. Thousand Oaks, California: SAGE Publications. Creswell, J. (2005). Educational research: planning, conducting, and evaluating quantitative and qualitative research (2nd ed.). Upper Saddle River, New Jersey: Pearson Prentice Hall, Inc. Dahl, T. (2002). International classification of functioning, disability, and health: An introduction and discussion of its potential impact on rehabilitation services and research. Journal o f Rehabilitation Medicine, 34, 201 - 204. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 91 Durand, M., Loisel, P., Poitras, S., Mercier, R., Stock, S., & Lemaire, J. (2004). The interrater reliability of a functional capacity evaluation: The physical work performance evaluation. Journal o f Occupational Rehabilitation, 14(2), 119129. Dusik, L., Menard, M., Cooke, C., Fairbum, S., & Beach, G. (1993). Concurrent validity o f the ergos work simulator versus conventional functional capacity evaluation techniques in a workers' compensation population. Journal o f occupational medicine, 35(8), 759 - 767. Feldman, J. (1998). The workers' compensation patient: A paradoxical cognitivebehavioural approach to rehabilitation. Current Review o f Pain, 2 , 11-18. Fishbain, D., Adbel-Moty, E., Cutler, B., Rosomoff, H., & Steele-Rosomoff, R. (1999a). Detection of a "faked" strength task effort in volunteers using a computerized exercise testing system. American Journal o f Physical Medicine & Rehabilitation, 78(3), 222-227. Fishbain, D., Cutler, R., Rosomoff, H., Khalil, T., Adbel-Moty, E., & Steele-Rosomoff, R. (1999b). Validity of the dictionary of occupational titles residual functional capacity evaluation. Clinical Journal o f Pain, 15 (2), 102-110. Frings-Dresen, M., & Sluiter, J. (2003). Development of a job-specific FCE protocol: The work demands of hospital nurses as an example. Journal o f Occupational Rehabilitation, 13(4), 233 - 248. Gardener, L., & McKenna, K. (1999). Reliability of occupational therapists in determining safe, maximal lifting capacity. Australian Occupational Therapy Journal, 46, 110-119. Gaudino, E., Matheson, L., & Mael, F. (2001). Development of the functional assessment taxonomy. Journal o f Occupational Rehabilitation, 11(3), 155 - 175. Geisser, M., Robinson, M., Miller, Q., & Bade, S. (2003). Psychosocial factors and functional capacity evaluation among persons with chronic pain. Journal o f Occupational Rehabilitation, 13(4), 259 - 276. Gibson, L., & Strong, J. (1997). A review of functional capacity evaluation practice. Work, 9, 3 -1 1 . Gibson, L., & Strong, J. (1998). Assessment of psychosocial factors in functional capacity evaluation of clients with chronic back pain. British Journal o f Occupational Therapy, 61(9), 399 - 404. Gibson, L., & Strong, J. (2002). Expert review of an approach to functional capacity evaluation. Work, 19, 231 - 242. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 92 Gibson, L., & Strong, J. (2003). A conceptual framework of functional capacity evaluation for occupational therapy in work rehabilitation. Australian Occupational Therapy Journal, 50(2), 6 4-71. Gibson, L., & Strong, J. (2005). Safety issues in functional capacity evaluation: Findings from a trial of a new approach for evaluating clients with chronic back pain. Journal o f occupational medicine, 15(2), 237 - 251. Gibson, L., Strong, J., & Wallace, A. (2005). Functional capacity evaluation as a performance measure evidence for a new approach for clients with chronic back pain. Clinical journal o f pain, 21(3), 207 - 215. Gouttebarge, V., Wind, H., Kuijer, P., & Frings-Dresen, M. (2004). Reliability and validity of functional capacity evaluation methods: A systematic review with reference to blankenship system, ergos work simulator, ergo-kit and isemhagen work system. International Archives in Occupational and Environmental Health, 77(8), 527 - 537. Gouttebarge, V., Wind, H., Kuijer, P., Sluiter, J., & Frings-Dresen, M. (2005). Intra- and interrater reliability o f the ergo-kit functional capacity evaluation method in adults without musculoskeletal complaints. Archives o f Physical Medicine and Rehabilitation, 86, 2354 - 2360. Gross, D. (2004). Measurement properties of performance-based assessment of functional capacity. Journal o f Occupational Rehabilitation, 14(3), 165 - 174. Gross, D., & Battie, M. (2003). Construct validity of a kinesiophysical functional capacity evaluation administered within a worker's compensation environment. Journal o f Occupational Rehabilitation, 13(4), 287 - 295. Gross, D., & Battie, M. (2005). Factors influencing results of functional capacity evaluations in workers' compensation claimants with low back pain. Physical Therapy, 55(4), 315 -322. Gross, D., & Battie, M. (2006). Does functional capacity evaluation predict recovery in workers' compensation claimants with upper extremity disorders? Occupational and Environmental Medicine, 6 3 ,404 - 410. Gross, D., Battie, M., & Cassidy, J. (2004). The prognostic value of functional capacity evaluation in patients with chronic low back pain: Part 1. Spine, 29(8), 914-919. Hart, D. (1999). Relation between three measures of function in patients with chronic work-related pain syndromes. Topics in Clinical Chiropractic, 6(2), 26 - 37. Harten, J. (1998). Functional capacity evaluation. Occupational Medicine, 75(1), 209 212 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 93 Hunt, D., Zuberbier, O., Kozlowski, A., Berkowitz, J., Schultz, I., Milner, R., et al. (2002). Are components of a comprehensive medical assessment predictive of work disability after an episode of occupational low back trouble? Spine, 27{23), 2715-2719. IJmker, S., Gerrits, E., & Reneman, M. (2003). Upper lifting performance of healthy young adults in functional capacity evaluations: A comparison of two protocols. Journal o f Occupational Medicine, 75(4), 297 - 305. Innes, E., & Straker, L. (1998a). A clinician's guide to work-related assessments: 1purposes and problems. Work, 1 1 ,183 - 189. Innes, E., & Straker, L. (1998b). A clinician's guide to work-related assessments: 2. Design problems. Work, 1 1 ,191 - 206. Innes, E., & Straker, L. (1998c). A clinician's guide to work-related assessments: 3 administration and interpretation problems. Work, 77,207-219. Innes, E., & Straker, L. (1999a). Reliability of work-related assessments. Work, 1 3 ,107 -124. Innes, E., & Straker, L. (1999b). Validity of work-related assessments. Work, 1 3 ,125 152. Innes, E., & Straker, L. (2003). Attributes of excellence in work-related assessments. Work, 20, 63 - 76. Isemhagen, S. (1992). Functional capacity evaluation: Rationale, procedure, utility of the kinesiophysical approach. Journal o f Occupational Rehabilitation, 2(3), 157 -168. Isemhagen, S., Hart, D., & Matheson, L. (1999). Reliability of independent observer judgments of level of lift in kinesiophysical functional capacity evaluation. Work, 12, 145 - 150. Johnson, L., & Miller, M. (2001). Functional testing: Approaches and injury management integration. Work, 16, 7 -11. Jones, T., & Kumar, S. (2003). Functional capacity evaluation o f manual materials handlers: A review. Disability and Rehabilitation, 25(4/5), 179- 191. Joughin, K., Gulati, P., Mackinnon, S., McCabe, S., Murray, J., Griffiths, S., et al. (1993). An evaluation of rapid exchange and simultaneous grip tests. The Journal o f Hand Surgery, 18A(2), 245 - 252. Kaplan, G., Wurtele, S., & Gillis, D. (1996). Maximal effort during functional capacity evaluations: An examination o f psychological factors. Archives o f Physical Medicine and Rehabilitation, 77(2), 161 - 164. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 94 Kennedy, L. (2003). How sincere are our efforts, Occupational Therapy Now 5(6). Retrieved January 12, 2004 from http://caot.ca/default.asp?ChangeID=96&pageID=715 King, P., Tuckwell, N., & Barrett, T. (1998). A critical review o f functional capacity evaluations. Physical Therapy, 78(8), 852 - 866. Kuijer, W., Gerrits, E., & Reneman, M. (2004). Measuring physical performance via self-report in healthy young adults. Journal o f Occupational Rehabilitation, 14(1), 77 - 87. Kyi, M. (2000). Physical effort and symptom magnification: Current issues in work capacity evaluation (WCE), Occupational Therapy Now 2(1). Retrieved January 12, 2004 from http://caot.ca/otnow.janOO-eng/jan-work.cfin Lechner, D. (2002). The role of functional capacity evaluation in management of foot and ankle dysfunction. Foot and Ankle Clinics, 7(2), 449 - 476. Lechner, D., Bradbury, S., & Bradley, L. (1998). Detecting sincerity of effort: A summary o f methods and approaches. Physical Therapy, 78(8), 867 - 888. Lechner, D., Jackson, J., Roth, D., & Straaton, K. (1994). Reliability and validity of a newly developed test of physical work performance. Journal o f Occupational Medicine, 36(9), 997 - 1004. Lechner, D., Roth, D., & Straaton, K. (1991). Functional capacity evaluation in work disability. Work, 1, 3 7-47. Lemstra, M., Olszynski, W., & Enright, W. (2004). The sensitivity and specificity of functional capacity evaluations in determining maximal effort. Spine, 29(9), 953 -959. Lyth, J. (2001). Disability management and functional capacity evaluations: A dynamic resource. Work, 1 6 ,13-22. Mathers, N., Howe, A., & Hunn, A. (2002). Trent focus for research and development in primary health care - ethical considerations in research. Retrieved Oct 10,2005, from http://www.trentfocus.org.uk/Resources/Ethics.pdf Matheson, L. (1996). Functional capacity evaluation. In G. Anderson, S. Demeter & G. Smith (Eds.), Disability Evaluation. Chicago, IL: Mosby Yearbook. Retrieved January 17, 2004 from http://ww.epicrehab.com/abstracts/abs-FCE.htm Matheson, L. (2003). The functional capacity evaluation. In G. Andersson, S. Demeter & G. Smith (Eds.), Disability Evaluation (2nd ed.). Chicago, IL: Mosby Yearbook. Retrieved May 13, 2005 from http://www.epicrehab.com/abstracts/ama-FCE.pdf Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 95 Matheson, L. (no date). Frequently asked questions: Clinical and technical. Retrieved May 14, 2005 from www.epicrehab.com/FAQs.htm Matheson, L., Kaskutas, V., McCowan, S., Shaw, H., & Webb, C. (2001). Development of a database of functional assessment measures related to work disability. Journal o f Occupational Rehabilitation, 11(3), 177 - 199. Matheson, L., Rogers, L., Kaskutas, V., & Dakos, M. (2002). Reliability and reactivity of three new functional assessment measures. Work, 1 8 ,41 - 50. May III, V. (1988). Work hardening and work capacity evaluation: Definition and process. Vocational Evaluation and Work Adjustment Bulletin, 21(2), 61 - 66. National Institute of Disability Management and Research, (n.d.). The impact of disability in Canada. Retrieved July 16, 2005 from http://nidmar.ca/career/career_context/context_impact.asp?printsafe=yes New illustrated Webster’s dictionary o f the English language. (1992). New York, NY: Pamco Publishing Company, Inc. Piela, C., Hallenberg, K., Geoghegan, A., Monsein, M., & Lindgren, B. (1996). Prediction of functional capacities. Work, 6, 107 -113. Pransky, G., & Dempsey, P. (2004). Practical aspects of functional capacity evaluations. Journal o f Occupational Rehabilitation, 14(3), 217-229. Reneman, M., & Dijkstra, P. (2003). Introduction to the special issue on functional capacity evaluations: From expert based to evidence based. Journal o f Occupational Rehabilitation, 13(4), 203 - 206. Reneman, M., Fokkens, A., Dijkstra, P., Geertzen, J., & Groothoff, J. (2005). Testing lifting capacity: Validity of determining effort level by means of observation. Spine, 30(2), E40 - E46. Reneman, M., Jorritsma, W., Schellekens, J., & Goeken, L. (2002). Concurrent validity of questionnaire and performance-based disability measurements in patients with chronic nonspecific low back pain. Journal o f Occupational Rehabilitation, 12(3), 119-129. Robinson, M., Geisser, M., Hanson, C., & O'Connor, P. (1993). Detecting submaximal efforts in grip strength testing with the coefficient of variation. Journal o f Occupational Rehabilitation, 5(1), 45 - 50. Robinson, M., Sadler, I., O'Connor, P., & Riley, J. (1997). Detection of submaximal effort and assessment of stability of the coefficient of variation. Journal o f Occupational Rehabilitation, 7(4), 207-215. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 96 Roy, E. (2003). Functional capacity evaluations and the use of validity testing. The Case Manager, 14(2), 64-69. Rudy, T., Lieber, S., & Boston, J. (1996). Functional capacity assessment: Influence of behavioural and environmental factors. Journal o f Back and Musculoskeletal Rehabilitation, 6, 277 - 288. Rustenburg, G., Kuijer, P., & Frings-Dresen, M. (2004). The concurrent validity of the ergos work stimulator and the ergo-kit with respect to maximum lifting capacity. Journal o f Occupational Rehabilitation, 14(2), 107 -118. Scalzitti, D. (1997). Screening for psychological factors in patients with low back problems: Waddell's nonorganic signs. Physical Therapy, 77(3), 306 - 312. Schetman, O. (2000). Using the coefficient of variation to detect sincerity o f effort of grip strength: A literature review. Journal o f Hand therapy, 75(1), 25 - 32. Schonstein, E., & Kenny, D. (2001). The value of functional and work place assessments in achieving a timely return to work for workers with back pain. Work, 16, 31 - 38. Simonsen, J. (1995). Coefficient of variation as a measure of subject effort. Archives o f Physical Medicine and Rehabilitation, 76, 516 - 520. Strong, S. (2002). Functional capacity evaluations - the good, the bad, and the ugly, Occupational Therapy Now, 14(1). Retrieved January 12, 2004 from http://www.caot.ca/default.asp?ChangeID=2346&pageID=2347 Strong, S., Bapiste, S., Cole, D., Clarke, J., Costa, M., Shannon, H., et al. (2004). Functional assessment of injured workers: A profile of assessor practices. Canadian Journal o f Occupational Therapy, 77(1), 13 - 23. Strong, S., & Westmorland, M. (1996). Determining claimant effort & maximum voluntary effort testing: Work Function unit. Tramposh, A. (1992). The functional capacity evaluation: Measuring maximal work abilities. Occupational Medicine, 7(1), 113 - 124. Vasudevan, S. V. (1996). Role of functional capacity assessment in disability evaluation. Journal o f Back and Musculoskeletal Rehabilitation, 6 ,237 - 248. Velozo, C. (1993). Work evaluations: Critique of the state o f the art of functional assessment o f work. The American Journal o f Occupational Therapy, 47(3), 203 -209. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation Wind, H., Gouttebarge, V., Kuijer, P., Sluiter, J., & Frings-Dresen, M. (2006). The utility of functional capacity evaluation: The opinion o f physicians and other experts in the field of return to work and disability claims. International Archives in Occupational and Environmental Health, 79, 528 - 534. Wittink, H. (2005). Functional capacity testing in patients with chronic pain. Clinical Journal o f Pain, 21(3), 197 - 199. Yin, R. (2003). Case study research design and methods (3 ed.). Thousand Oaks, California: SAGE Publications. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 98 Appendix A Interview protocols Interview Protocol - Evaluee 1. What are the benefits of a Functional Capacity Evaluation? Probing Questions: • How did the Functional Capacity Evaluation assist you? 2. What are the limitations of a Functional Capacity Evaluation? Probing Questions: • How would you improve Functional Capacity Evaluations? 3. What was the purpose of the Functional Capacity Evaluation? Probing Questions: • Why were you referred for a Functional Capacity Evaluation? 4. Describe what you had to do during the Functional Capacity Evaluation process? Probing Questions: • Describe the physical components of your evaluation? • Describe other areas that were assessed during the evaluation? • Describe how it was determined what the maximal level of performance possible for you was. 5. Describe how the clinician determined if you were providing maximal effort during the assessment? Probing Questions: • Describe the feedback you received during the assessment regarding how hard you were trying to do your best. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation • 99 If you did not provide your maximal effort during the assessment, what were your reasons? 6. How useful were the Functional Capacity Evaluation results? Probing Questions: • Describe how the evaluation results impacted your situation? • How did the Functional Capacity Evaluation results relate to your work situation? • How did the Functional Capacity Evaluation impact your return to work planning process? 7. Any additional comments regarding Functional Capacity Evaluations. Interview Protocol - Clinician 1. What are the benefits of a Functional Capacity Evaluation? Probing Questions: • Why would you recommend a Functional Capacity Evaluation? 2. What are the limitations of a Functional Capacity Evaluation? Probing Questions: • How would you improve Functional Capacity Evaluations? 3. What is the purpose of Functional Capacity Evaluations? 4. Describe the Functional Capacity Evaluation protocol that you use. Probing Questions: • What theoretical framework forms the basis of the functional assessment framework? • What is the specific protocol(s) that is (are) used? Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 100 • Describe the physical components of the evaluation. • Describe the cognitive components of the evaluation. • Describe other areas that are assessed during the evaluation? • Describe how safe level of performance is determined during the evaluation? • Discuss the inclusion of subjective and objective data in the Functional Capacity Evaluation report. 5. Discuss the role o f sincerity of effort determinations in Functional Capacity Evaluations? Probing Questions: • What is the importance of sincerity of effort determinations in Functional Capacity Evaluations? • Describe how sincerity of effort is determined. • Describe how sincerity of effort issues are documented in the assessment report. • Describe the implications of an individual not providing full effort. • Discuss why individuals may not provide maximum effort during the assessment process. 6. How useful are the Functional Capacity Evaluation results? Probing Questions: • Comment on the reliability and validity of the Functional Capacity Evaluation. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation • 101 Discuss the predictive ability of Functional Capacity Evaluations as related to return to work planning. • How do Functional Capacity Evaluations relate to the individual’s work situation? 7. Any additional comments regarding Functional Capacity Evaluations. Interview Protocol - Employer 1. What are the benefits of a Functional Capacity Evaluation? Probing Questions: • How do Functional Capacity Evaluations assist you? 2. What are the limitations of a Functional Capacity Evaluation? Probing Questions: • How would you improve Functional Capacity Evaluations? 3. What is the purpose of Functional Capacity Evaluations? Probing Questions: • Why would you have an employee complete a Functional Capacity Evaluation? • What information should the Functional Capacity Evaluation provide? 4. Describe what areas are assessed during the Functional Capacity Evaluation process? Probing Questions: • Describe the physical components of the evaluation? • Describe other areas that are assessed during the evaluation? Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 102 5. What is the importance of the worker providing maximal effort during the Functional Capacity Evaluation? Probing Questions: • What are the implications of a worker not providing maximal effort during the assessment process? • How are sincerity of effort determinations determined and documented? • Discuss why individuals may not provide maximum effort during the assessment process. 6. How useful are the Functional Capacity Evaluation results? Probing Questions: • How do Functional Capacity Evaluation results assist with return to work planning? • Discuss the predictive ability of Functional Capacity Evaluations as related to return to work planning. • How do Functional Capacity Evaluations relate to the individual’s work situation? 7. Any additional comments regarding Functional Capacity Evaluations. Interview Protocol - Funder 1. What are the benefits of a Functional Capacity Evaluation? Probing Questions: • How does the Functional Capacity Evaluation assist you? 2. What are the limitations of a Functional Capacity Evaluation? Probing Questions: • How would you improve Functional Capacity Evaluations? Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 103 3. What is the purpose of Functional Capacity Evaluations? Probing Questions: • Why would you refer an individual for a Functional Capacity Evaluation? • What information should the Functional Capacity Evaluation provide? 4. Describe what areas are assessed during the Functional Capacity Evaluation process? Probing Questions: • Describe the physical components of the evaluation? • Describe other areas that are assessed during the evaluation? 5. What is the importance of the worker providing maximal effort during the Functional Capacity Evaluation? Probing Questions: • What are the implications of a worker not providing maximal effort during the assessment process? • How is sincerity of effort determined and documented? • Discuss why individuals do not provide maximum effort during the assessment process. 6. How useful are the Functional Capacity Evaluation results? Probing Questions: • How do Functional Capacity Evaluation results assist with return to work planning? • Discuss the predictive ability of Functional Capacity Evaluations as related to return to work planning. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation • How do Functional Capacity Evaluations relate to the individual’s work situation? • 104 Discuss the value of the Functional Capacity Evaluation results as compared to the cost of the assessment. 7. Any additional comments regarding Functional Capacity Evaluations. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 105 Appendix B Informed consent form A preliminary case study regarding the perceptions of Functional Capacity Evaluations in Prince George. British Columbia INFORMATION SHEET Researcher’s name: Kimberley Thew Address: c/o Dr. Henry Harder 3333 University Wav Prince George. BC V2N 4Z9 Phone No: (2501 962 4606 (office') E-mail: thewk@,unbc.ca Supervisor’s name: Dr. Henry Harder Title of project: A preliminary case study regarding the perceptions of Functional Capacity Evaluations in Prince George. BC Type of project: Thesis Purpose of research: The purpose of this case study is to explore the perceptions regarding Functional Capacity Evaluation for the geographical area Prince George. British Columbia and relate the perceptions to the literature. Potential benefits and risks: There are no known risks or benefits to the respondent participating in this study. How was respondent chosen: The respondent was selected based on an expressed interest in participating in the study and based on their involvement with Functional Capacity Evaluations in the community of Prince George. What will the respondent be asked to do: The respondent will be asked to participate in a one to two hour audio-taped interview. In addition, the respondent will be asked if there are any documents that they would voluntarily release to the researcher that could supplement the discussion regarding Functional Capacity Evaluations. Who will have access to respondents’ responses: The researcher, the supervisory committee, and the transcriber will have access to the respondents’ responses. Voluntary nature of their participation (including participant’s right to withdraw at any time): The respondent’s participation in the study is entirely voluntary and they have the right to withdraw at anytime during the study. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 106 Renumeration: There is no renumeration for participating in the study. How anonymity is addressed: The researcher will modify the transcripts to remove all identifying information such as name, place of employment, and specific occunational title. How confidentiality is addressed: The transcriber of the taped interview will sign a confidentiality agreement. All identifiers will be removed from the transcripts therefore confidentiality will be maintained. How information is stored and for how long: The original transcripts with identifiers and the audiotape will be stored in a locked storage area at UNBC. The data will be destroyed one year after successful completion of the thesis defence. Paper will be shredded and disks will be physically destroyed. Name and phone number of person to contact in case questions arise: Please contact Kimberley Thew at 962 - 4606 (office! should any questions arise or if you require more information. How to get copy of research results: Please contact Kimberley Thew at 962 - 4606 ('office') if you would like copies of the research results. Name and phone number of person to call for more information: Please contact Kimberley Thew at 962 - 4606 ('office') for additional information. Please note that any complaints about the project should be directed to the office of the Vice-President Research, 960-5820. The participant must receive a copy of his or her signed consent form. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 107 A preliminary case study regarding the perceptions of Functional Capacity Evaluations in Prince George. British Columbia INFORMED CONSENT Do you understand that you have been asked to be in a research study? □ Yes □ No Have you read and received a copy of the attached information sheet? □ Yes □ No Do you understand that the research interviews will be recorded? □ Yes □ No Do you understand the benefits and risks involved in participating in this study? □ Yes □ No Have you had an opportunity to ask questions and discuss this study? □ Yes □ No Do you understand that you are free to refuse to participate or to withdraw from the study at any time? You do not have to give a reason. □ Yes □ No Has the issue of confidentiality been explained to you? □ Yes □ No Do you understand who will have access to the information you provide? □ Yes □ No This study was explained to me by: ______________________ Print Name I agree to take part in this study: ________________________________ Signature o f Research Participant Date: _________ Printed Name o f Research Participant ________________________________ Signature o f Witness Date: Printed Name o f Witness I believe that the person signing this form understands what is involved in the study and voluntarily agrees to participate. ____________________________________ Signature o f Investigator Date: ___________________ The Information Sheet must be attached to this Consent Form and a copy given to the Research Participant. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Functional Capacity Evaluation 108 Appendix C Transcriber’s Agreement A preliminary case study regarding the perceptions of functional capacity evaluations in Prince George. British Columbia Transcriber’s Agreement I have agreed to transcribe audio tapes for this case study. The researcher has explained to me the expectations regarding this process. Do you understand that you must maintain the confidentiality of all research materials that you have access to? □ Yes □ No Do you understand that audio-tapes and transcribed documentation must be stored in a locked cabinet while in your possession for transcription? □ Yes □ No Do you understand that the documents are only to be saved on the memory stick provided by the researcher? □ Yes □ No The remuneration for transcription will b e ___________________________ . I agree to the conditions as indicated on this form. Name o f Transcriber Name o f Investigator Signature Signature Date Date Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.