Functional Capacity Evaluation (FCE)
The functional capacity evaluation (FCE) has evolved in many ways since its inception in the 1980s when the work capacity test was becoming the normative test to evaluate disability and return to work status.1 In our quest to be able to identify applicants who might be at higher risk for lower spine injuries once employed, we began utilizing various forms of pre-employment testing including radiographic screening.2 As we all know, this specific practice was short-lived and pre-employment screening as an evaluation tool has subsequently been abolished with the advent of research showing a poor correlation between radiographic findings and risk of future injury.3 Radiologic abnormalities in the musculoskeletal system have not been demonstrated to have any significant predictive capabilities for future risk of injury and, along with legislative changes—most notably the American with Disabilities Act (ADA) and it’s antecedents—have led to the demise of pre-employment screening efforts.4
The most politically correct post-ADA terminology for workplace testing is pre-placement screening. Today, the applicant is hired and then tested (in that order) and a decision made as to whether they can safely and effectively perform the job. The “fit for duty” assessment is performed after the hiring, and not before, as was the case in the past. For the remaining sections of this report, the terms FCE, physical capacity evaluation (PCE), and work capacity evaluation (WCE) will be used to denote separate but distinct (although interrelated) testing formats. The PCE is a physical capacity evaluation that identifies basic human motion parameters, both quantitatively and qualitatively—such as muscle strength, endurance, flexibility, stamina, power, balance, coordination and proprioception. It is important to distinguish these most basic parameters since they are the foundation of the next level test—the FCE, or functional capacity evaluation. This test examines functional limitations that are defined by more complex multi-joint movements that require neuromuscular synergy to form integrated and purposeful patterns aimed at task completions and could be anything from climbing stairs to lifting a box or sweeping the floor. Within the context of an occupational setting, the term WCE or work capacity evaluation implies a work related FCE since the test evaluates the person’s ability to perform work-related functional tasks, as opposed to home or recreation/social activities of daily living.
Selecting The Appropriate Test
In our practice, we find that different groups request different tests depending on their needs. For example, attorneys want both impairment data (PCE) and functional data (FCE) in no fault cases, but FCE and WCE data in workman’s compensation litigation. In social security determinations, the data requested is primarily FCE-oriented. Our case managers who deal with occupational injury/disease need specific WCE data that is an occupationally-oriented FCE. I have made the distinction between a generic versus specific FCE because one of the real problem areas with FCEs has been poor test selection—i.e., using a generic FCE when the situation warrants a specific FCE based on essential job demands—gathered using a valid job description and/or a job site analysis.
When a general (generic) versus a specific FCE is used to make a return to work determination, the end result can be suboptimal. Some recent litigation, James versus Goodyear Tire and Rubber Co., has shed some light on how FCEs are viewed in a medico-legal milieu.5 In this case, the company recommended an FCE to determine where to safely put a certain employee who was suffering from a progressive disease. Although the worker retired—never having been FCE-tested—he still sued claiming that the FCE would have been a discriminatory action. The court ruled against him stating that the evaluation was motivated by reasonable safety concerns and therefore not an adverse action. If the FCE were to have been carried out, the court stated it would have assessed the relevance or correlation between the test and actual job. It becomes clear that the more specific the test, the greater the relevance for the worker and employer. In another case, Indergard versus Georgia Pacific, the worker was not allowed to return to work based on results gathered from PCE-FCE test(s) and went on to file a discrimination suit.6 There are a number of issues that arise from this case including sharing information with the employer, who performs the actual test and, not least important, did the test criteria or test items on the PCE-FCE match the actual job requirements—i.e., specificity.
FCEs Current Scope
The conundrum of identifying persons most at risk for injury while working, or whether a person is ready and/or capable of returning to work at all, persists even today. The FCE has become, arguably, more functional and less reliant on expensive technology—e.g., utilizing boxes for lifting/carrying tasks and sleds for push/pull tasks. Only relatively few facilities are able to offer the more sophisticated dynamometric testing for PCE data, such as might have been the norm in the past. The lingering questions remain, however, as to whether the FCE is an accurate representation of a person’s ability to perform physical work. Are the results of the FCE reproducible (consistent)? Does it measure what it purports to measure (validity)? Is the FCE sensitive enough to measuring functionally-important changes that might translate into a higher probability of a patient returning to work? And finally, are the results of the FCE-WCE predictive of the primary outcome of interest, namely, the return to work? The results of these assessments have implications for employment, compensability determinations, further medical/rehabilitative efforts, disability evaluations, and indemnity/cash benefits.7
The number of FCE vendors has risen noticeably over the last 15 years, and this form of testing is often used in combination with work conditioning and work hardening (job simulation) programs aimed at returning injured workers back to their respective workplaces. The various vendors have their own proprietary systems that they sell to providers—mostly physical and occupational therapists who are those ultimately performing the testing. We have no idea how the various FCE tests sold relate to each other. In other words, are the test results from one system transferrable to another? Is there a gold standard FCE out there? If there was, we could begin to compare FCE systems with the gold standard and derive an estimate of concurrent validity but, as it stands, we do not. Important to note, however, is that the major FCE vendors do use a standardized set of tasks, with each device having their own internal validity. Variability in test administration (test format, instructions provided, timing, etc.) is minimized with training and experience. As well, when evaluating an FCE, it might be impractical to expect tight test-retest reliability measures such as one would expect to see when performing repeated measures on a machine or instrument. The FCE is made up of a series of tests that contribute to the total disability rating, with each test measuring a potentially different dimension of human movement and capability.