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Functional Capacity Evaluation

The functional capacity evaluation (FCE) has become an important part of what physical therapists and occupational therapists can add to the rehabilitation process of the injured worker with chronic pain.^1–3 Unfortunately, operationally, when these evaluations are performed, there is great confusion about the kind of information they give and how this information can be utilized.¹ The reasons for this statement and the status of this issue are presented below:

1. Currently, there is not a universally accepted operational definition for functional capacity.¹ Thus, there are numerous measurement approaches^1,3 for functional capacity, each claiming to measure patient fitness for return to work.³ This situation has created confusion in the field and has masked the central scientific issue of whether these FCEs actually measure the ability of a patient with chronic pain to do a specific job.
   
2. Although some researchers are using tests normalized for age, sex, and body weight, norms for most FCEs are not yet available.¹ Therefore, it is unclear what these results mean in relationship to "normal" populations.
   
3. Each job or job category has what has been termed the "demand minimum functional capacity" for that job.⁴ Although one may accurately delineate the functional capacity of a patient with chronic pain, that functional capacity may not readily translate into the "demand minimum functional capacity" of the patient's job.¹
   
4. Although functional capacity testing usually includes nonspecific tests that do not readily translate into job functions, these tests may not accurately reflect the actual demands of repetitive job activities.^1,5 Thus, job-specific functional capacity batteries need to be developed.
   
5. Even if one were able to accurately measure the ability of a patient with chronic pain to perform the "demand minimum functional capacity of some job or jobs,"⁴ these measurements would not necessarily translate into knowledge of the patient's ability to perform those job functions over an 8-hour period.^1,5
   
6. As pointed out by King et al,³ the validity for predicting actual return to work (predictive validity) for all functional capacity batteries is unknown. Lechner et al² have reported on the validity of the Physical Work Performance Evaluation battery, but the type of validity measured was not predictive validity for actual return to work.
   
7. In an attempt to address some of these problems with functional capacity testing, Fishbain et al⁶ developed a functional capacity battery based on the Dictionary of Occupational Titles (DOT). The advantage of this battery was that it partially circumvented the "demand minimum capacity functional capacity" problem. Although the DOT functional capacity battery was found to yield reliable measurements,⁶ predictive validity was not tested. In a recent study, the first of its kind, Fishbain et al⁷ tested this battery for predictive validity for actual return to work in patients with chronic pain. They found that the DOT functional capacity battery could not predict employment levels. However, if a patient with chronic pain could pass 8 DOT job factor measures (stooping, climbing, balancing, crouching, feeling shapes, handling left and right, lifting, carrying) and had a pain level of less than the 5.4 cutoff point, he or she would have a 75% chance of being employed at 30 months after treatment in a pain facility.
   

It is important to note that Fishbain et al⁷ could not predict actual return to work without taking pain into account. This finding points to the importance of measuring pain in patients with chronic pain and utilizing that measurement to make statements about possibilities for job function. Finally, although this study demonstrated that some DOT job factors have predictive validity in the "real world," it nevertheless again points to the limitations of functional capacity testing for predicting whether the patient with chronic pain will or will not be able to function at some job. Practitioners for functional capacity testing should be aware of these issues in interpreting functional capacity data for patients with chronic pain in the reference to return to work.

David A Fishbain, MD, FAPA

Professor, Psychiatry & Neurological Surgery & Anesthesiology
University of Miami School of Medicine
University of Miami Comprehensive Pain and Rehabilitation Center

References

1. Abdel-Moty E, Fishbain DA, Khalil TM, et al. Functional capacity and residual functional capacity and their utility in measuring work capacity. Clin J Pain.1993; 9:168–173.[ISI][Medline]
2. Lechner DE, Jackson JR, Roth DL, Straaton KV. Reliability and validity of a newly developed test of physical work performance. J Occup Med.1994; 36:997–1004.[ISI][Medline]
3. King PM, Tuckwell N, Barrett TE. A critical review of functional capacity evaluations. Phys Ther.1998; 78:852–866.[Abstract/Free Full Text]
4. Battista ME. Disability evaluations: expectations of insurers and payors. Journal of Disability.1990; 1:168–177.
5. Rodgers SH. Job evaluation in worker fitness determination. Occup Med.1988; 3:219–239.
6. Fishbain DA, Abdel-Moty E, Cutler R, et al. Measuring residual functional capacity in chronic low back pain patients based on the Dictionary of Occupational Titles. Spine.1994; 19:872–880.[ISI][Medline]
7. Fishbain DA, Cutler R, Rosomoff HL, et al. Validity of the Dictionary of Occupational Titles residual functional capacity battery. Clin J Pain.1999; 15:102–110.[ISI][Medline]

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