Defining functional testing … now that is interesting!!
Depending on the individual evaluator, the professional level, and the region of the country, one finds many different versions of functional testing. Practically and legally, there are three primary applications of functional testing.
- Functional Capacity Evaluations (FCE) may also be known as Functional Capacity Assessments (FCA) or Physical Capacity Evaluations (PCE) (referrers include physicians, workers’ compensation case managers, disability insurers, employers, and attorneys).
- Early return to work evaluations (referrers include employers, workers’ compensation case managers, or physicians).
- Postoffer functional tests for the purpose of injury prevention (referrers are primarily employers).
How function is evaluated depends on the definition of function. In traditional therapy, it can be joint ROM or muscle strength. In functional testing, however, it is “whole person” testing. The purpose of functional capacity testing is to define work abilities (eg, can the person do xx job or xx level of work). Professionals must answer the work question. Muscle strength testing or joint motion testing may find impairments, but they do not directly translate to the ability to work. One only has to go into industry to see that successful workers come in all sizes and shapes, all ages, both genders, have different gait patterns and different ways to get the job done. Anything less than respect for allowing an evaluee to demonstrate function within safe parameters is to undermine the ability to be accurate in work-related conclusions.
The three types of functional testing are described below:
FUNCTIONAL CAPACITY EVALUATIONS: GUIDELINES PROVIDE PROFESSIONAL DIRECTION
Historically, FCEs have been used in disability management. The referrer wants to know the physical work ability of a person for placement at work, in a vocational process, or to settle a claim. Significant variation in types and lengths of tests has created market confusion. To assist in standardization, new FCE guidelines recently have been created and published by the American Physical Therapy Association.1 Occupational therapists also are progressing in creating such guidelines. An international forum has added to functional testing definitions in order to become more aligned with the World Health Organization definitions.2
ASPECTS OF FCE ARE:
- Evidence-based testing. FCE evaluators should ensure the methods have been researched with positive results. FCEs should be able to stand up in court as scientifically reliable and must have accuracy for physicians, employers, case managers, and insurers.
- Professionals are the evaluators. As an example, APTA guidelines state that the FCE evaluator is a physical therapist.
- The test is comprehensive and thorough. Short noncomprehensive FCEs are not supported by guidelines. For example, the APTA definition is 3 to 5 hours for a 1-day test and 5 to 8 hours for a 2-day test. Job-specific tests can be added to those basic timelines when necessary.
- The history and physical examination are an integral part of the FCE process. This preliminary information should assure safety and also assist in defining physical factors behind limitations and recommendations
- Expertise requirements indicate that any FCE therapist must demonstrate evidence of education, training, and competencies specific to the delivery of FCEs.
- Work-related items include lifting, carrying, pushing, pulling, grip, pinch, standing, sitting, reaching, bending, hand coordination, standing, walking, climbing, elevated, and low level activities.
An international study by Soer et al2 utilized a Delphi Survey technique involving 22 FCE experts from six countries. The experts defined many aspects of FCE. There was agreement on most definitions, and this can be utilized in creating international formats for FCE and to promote research. The definition of FCE with 63% agreement was “An FCE is an evaluation of capacity of activities that is used to make recommendations for participation in work while considering the person’s body functions and structures, environmental factors, personal factors and health status.” Refer to the article for more details and definitions.
A new text, Guide to the Evaluation of Functional Ability, edited by Elizabeth Genovese, MD, and Jill Galper, PT, presents a comprehensive overview of the state of the functional evaluation process. It focuses on the disability FCE, but also discusses other forms of testing.3
Credibility of both the FCE and FCE evaluator is critical. For referrers, credibility is a driving force. But the ultimate user of the FCE is the person being evaluated. As adversarial relationships may be present in chronic cases, the professional evaluator must rise above this and work with the evaluee in an objective and interactive method. If the evaluee complains of evaluator bias, lack of expertise, or poor professional conduct, the FCE can be considered useless to case management. Obtaining cooperation and understanding from the person being tested is important for the results to be trusted and relevant.
What is “new” is only what is expected of professionals: expertise, objectivity, scientific basis, interaction, safety, and clear results with professional interpretation.
EARLY RETURN TO WORK FUNCTIONAL TESTING: WHY ISN’T IT DONE OFTEN?
Professionals who have performed FCEs realize that if they could have intervened sooner, the case of the injured/ill worker most likely would have been more quickly resolved. Even with that logical conclusion, early work-related functional evaluations have been slow to evolve.
Perhaps “treating” therapists do not see themselves as involved in return to work. Perhaps just treating the “part” is what therapists do. A therapist may treat a “back” or “shoulder” rather than a housekeeper or a machine operator. On the other hand, in sports medicine therapists know the sport and what their patient has to do in that sport. In neuro rehab, therapists understand what the home conditions will be and work functionally toward them. But in work-related cases, there is a disconnect between the traditional therapist and the required functional daily activity of a worker. The therapist may not be successful in producing work “outcomes” or be seen as a work function expert.
Work-related testing, starting very early in the treatment regime, can be an extension of “functional” and “objective” goals. By obtaining a list of work activities and determining objectively what work activities are safe to be done by the patient, the therapist would become far more valuable to the patient, the employer, and the case manager.
Modified early return to work benefits the worker, the employer, and society. Unneeded work disability is avoided. Yet, without information on safe work abilities, measured through objective functional testing, the physician fills out “restriction” forms by guessing or asking the patient.4
The most important two recipients in early return to work functional testing are the worker and the supervisor. The focus is on function rather than pain. Progress can be seen incrementally as reevaluation shows progress. The physician can release the person to work at appropriate levels. Progress does not stop.
Early return to work testing is used in such a minority of cases that most employers do not recognize therapists as more than “treatment givers.” Workers/patients are kept in the medical world instead of the work world. There is much opportunity for expansion in this area. Early work-related functional testing can play a strong role.
POSTOFFER (PREWORK) TESTING IN THE HIRING PROCESS
Many workers become injured during the first year of employment related to poor matching between the physical work demands and workers’ functional abilities. Powerful financial forces for employers create the need for more effective hiring practices.
- US employers annually spend more than $131,000,000,000 on direct cost of workers’ compensation (wages, medical, and benefits).
- They spend three to five times that much on indirect cost (administration, production loss, recruiting, disability).
- 60% of injuries are musculoskeletal, but they account for more than 70% of the direct and indirect costs.
Employers look to the medical professions to identify when an applicant cannot safely do the job. An old model is the physician exam. The newer models include job-related functional testing. Employers’ acceptance of therapists in the role of postoffer test provider depends on the ability to reduce new hire injuries, reduce turnover, and be cost-effective.
The Equal Employment Opportunity Act and the Americans with Disabilities Act with its 2008 amendments delineate legal, job-related, and accurate functional testing. Since medical testing can be done only after the offer of hire, therapists do primarily “postoffer” testing.
The issues for both employers and legal compliance are:
- The functional test be job-related;
- The test must meet one of several definitions of validity;
- The test should measure the person against the essential functions of the job;
- The tests should not screen out capable people who can do the job with or without reasonable accommodation—this creates the need for work function testing rather than mere strength testing; and
- To lower the risk of a person perceiving discrimination, the applicant should understand how the test directly relates to the job.
If a person demonstrates an inability to do an essential function of the job and they fall under the broad definition of disability, the employer must enter into an “interactive process” to determine if reasonable accommodations can be made. With appropriate testing and job modification information, the therapist can be of assistance to the employer for objective information.
Done well, according to guidelines, laws, evidence, and usefulness, accurate work-related functional evaluation will continue to grow in importance. At DSI, we work with therapists and employers who are utilizing all forms of work-related functional testing for injury prevention and earlier return to work. We see the benefit to all parties.
In these times of reimbursement turmoil, the referral bases for rehabilitation professionals can be expanded significantly. The therapist can be a far more effective link between the medical and the work world in assisting workers to return to work and in primary injury prevention.
Susan J. Isernhagen, PT, is COO of DSI Work Solutions and can be reached at or (218) 625-1051. Free articles and newsletters of occupational health interest can be found at www.dsiworksolutions.com.
- APTA Occupational Health Physical Therapy Guidelines: Evaluating Functional Capacity. Updated August 15, 2008. www.apta.org.
- Soer R, van der Schans CP, Groothoff JW, Geertzen JH, Reneman MF. Towards consensus in operational definitions in functional capacity evaluation: a Delphi Survey. J Occup Rehabil. 2008;18(4):389-400. Open access at Springerlink.com.
- Genovese E, Galper J. Guide to the Evaluation of Functional Ability. American Medical Association, 2009. www.ama.bookstore.com.
- Isernhagen SJ. Back to the original job with less light duty days through job specific testing. Journal of Workers Compensation. 2006;15(4).