What do you do when a client has a goal 'to establish functional abilities for work', spends a lot of time looking at setting baselines at home, develops a good knowledge of how to maintain consistency, starts to work and sustains abilities in a specific workplace, then completes a functional capacity evaluation that says he can do more than what he's personally identified he can?

Andrew is a man who’s been off work with nonspecific low back pain for about 2 years. When he first came to see us he was very fearful of moving, he thought there was ’something wrong’ with his back that meant he shouldn’t bend, and he was very deactivated. He used a stick, and walked unsteadily and very, very slowly. As a previously very fit man with a history of competitive team sports and having been in the military, this was an incredibly frustrating experience for him.

He’d moved from being an earner to being quite settled in the care-giving role for his young child. His wife worked full time, but also carried out most of the household activities – including mowing the lawns, cleaning the car, doing the laundry.

This man had no confidence at all in his ability to return to work – he thought his medication would interfere with functioning (and it probably did – he was very drowsy after using meds ‘as needed’), he was fearful of telling anyone about his back pain, and he thought he had no skills for work given that he wasn’t even able to carry out a full day’s household activity. His past employment was physically demanding and he thought he wouldn’t be able to study because of his medication.

His main pain management challenge was to learn how to reduce his over-activity, while at the same time learning how to do things that he thought might increase his pain. In other words, he struggled with being reliable and consistent with his activity level.  He didn’t manage flare-ups very well, and usually reached straight for his medication, with the inevitable result of drowsiness and nausea.

The part I’ve played (along with others in the team – physiotherapy and psychology) has been to review his coping strategies, and identify the ‘obstacles’ to using these at work. As a team we’ve tweaked his pain management plan so that he has lots of options for ‘what to do’ in the event of pain fluctuations. He’s minimised his use of ‘as needed’ medication which has reduced the side effects that do interfere with his functioning. He’s learned how to set realistic activity goals while also persisting when his pain levels increase.

Yesterday he turned up in suit, shirt and tie, looking absolutely spiffy. He’s got brochures introducing himself to potential clients. He’s reorganised his life so he and his wife share child-care. He’s fit and working towards a specific fitness goal (to play in the Masters tournament). He’s coped with several setbacks – successfully!

BUT – and you knew there would be one! – he’s completed a functional capacity evaluation (FCE).  He’s a worried man. The FCE findings suggested that he can do far more than he knew he could actually sustain every day of a working week.  The worst thing is that in New Zealand, people like Andrew who are nearing the completion of their vocational rehabilitation with ACC are required to participate in an FCE.  The findings from these assessments are included in reports sent to the medical assessors determining whether a person has ‘capacity for work’ as defined in ACC’s legislation. 

I've had a long interest in whether functional assessments carried out in a clinic or work setting over a single session (or even two-day period) can predict sustainable function in a 'real world' setting such as work. Most FCE’s have some degree of reliability - that is, they can be carried out by two different people or over two different times and the result will be the same. What they do seem to lack is validity - specifically, predictive validity. What this means is that they don't have a good track record of being able to predict from the results of the testing whether someone can actually return to work, or even a specific job.

There are quite a few reasons for this - most FCE's sample what a person WILL do within a clinic setting over a relatively short period of time. Issues of tolerance or performance consistency over an eight hour day or 40 hour week are not sampled, neither are the tasks carried out in the same way or under the same conditions as in a real work setting (like having a deadline, need to make a profit, boredom, having an argument with a coworker - or even the same sort of container, starting position or lighting).

FCE's can't establish what a person CAN do (I don't know of any way to establish this!), simply what the person will do on that day. So if the person is fearful of increasing pain (or worse - harming him/herself), or hasn't carried out that specific activity for a long time, or even if the person is worried about what the assessment findings will mean in terms of the future - well, their performance may be a lot lower than what they would do in a completely different setting.

More than these factors, though, is that FCE’s don’t measure some of the most important factors that predict whether a person will manage at work – I know of only one FCE that integrates psychosocial factors relevant to return to work within the testing format. Some testing batteries include questionnaires but don’t integrate the findings from these with the results of the assessment. Most place the majority of emphasis on biomechanical factors – can the person walk, bend, twist, reach, carry and lift?

In Andrew’s case, as a result of his FCE, he experienced an increase of his pain. This is quite normal - even people without chronic pain experience an increase in their pain the day after they've completed a standard FCE (Soer, R; Groothoff, J; Geertzen, JHB; et al. 2008). He coped quite well with the increase, but for some people this is a real problem - especially those who haven't developed effective flare-up management plans, or who catastrophise. On the other hand, Andrew also recognised that he wouldn't be able to sustain the level of performance he'd achieved during the test. This meant that, to him, the results were inaccurate, and he felt quite afraid that they would be misinterpreted by people who were unaware of the limitations of an FCE.

As a health professional, one job I take quite seriously is to help people recognise the limitations of various investigations and assessments. This is an ethical responsibility in terms of the assessments I conduct and on which I report. For example, if I was doing cognitive testing I’m ethically bound to advise the client that the results obtained on such a test would not be the same as what they would achieve in the ‘real world’.

I often discuss the limitations of MRI, CT and x-ray with people who have pain. Most of them have a strong belief in the value of these tests to ‘detect pain’ – it’s mistaken. There are many people with quite marked changes on radiological investigations who have no pain, while I can’t think of one instance where these investigations show pain. Similarly, I think it’s important to discuss the limitations of other testing procedures – one of them being functional capacity evaluations.  I duly reported Andrew’s concerns about the FCE findings, and the limitations of conclusions drawn from FCE’s in the report to the case manager.  I’ve now been advised that doing this is ‘inappropriate’.

The results from FCE’s do have limitations, and for clients who are anxious about their ability, perhaps have spent much of their rehabilitation time learning how to reduce their level of activity so they can achieve consistent and reliable performance, it’s important to help them understand these limitations and trust what they have learned for themselves.

What can a functional capacity evaluation measure? It measures what a person will do in a clinical testing situation on a given day or days over a specific set of activities. It does not measure ‘can do’, it measures ‘will do’, and it doesn’t measure ‘can do at work’, it measures ‘will do here and now’.  It’s up to health providers to help people understand what an FCE can and cannot do – and that’s part of my role.

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