More discussion on Functional Capacity Evaluations


Some years ago I wrote about Functional Capacity Evaluations and the lack of evidence supporting their use, particularly their use as predictive tools for establishing work “fitness”. 

I’ve received some sharp criticism in the past for my stance on FCE, and I continue to look for evidence that FCE are valid and reliable.  I haven’t found anything recently, and I’m still concerned that FCE are used inappropriately for people with chronic pain.  There is nothing like the demand characteristics of a testing situation for a person with chronic pain to either push themselves – and have a flare-up for some days afterwards but get a “good” report suggesting they have put in “full effort” and that they can manage a full time job of a certain MET demand; or to pace themselves, using pain management strategies – and avoid a flare-up but receive a “bad” report, suggesting they haven’t put in “full effort” and despite this, they can manage a full time job of a certain MET demand.

I can’t understand why FCE providers don’t work alongside people with chronic pain and their vocational counsellors, to help them define their sustainable level of physical demand, and systematically help them to gain confidence that they can find suitable work without exacerbating their pain. 

For the record, I’m not against establishing functional abilities.  And I think having a systematic approach to doing this.  I am against FCE’s being touted as a way to reliably determine work capacity, or to being able to determine “effort” through “consistency”. There simply isn’t published evidence to support these claims.  If someone can provide me with evidence, I’ll gladly change my mind because if there is one thing scientific training teaches, it’s that it’s OK to change your mind – if there’s evidence to do so.

This doesn’t mean that FCE’s would then be fine and dandy – because, as I’ve seen far too many times – HOW they’re used goes often well beyond what any FCE can possibly do, and very often is used as a blunt instrument when some good motivational interviewing and careful vocational counselling would achieve the same.

Here’s my original post, and some very good references are at the end of it.

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9 comments

  1. One of the little recognized and even less understood problems with functional capacity evaluations arises in what they do not do. Most people with chronic pain have what I call a “delayed crescendo” of pain and stiffness triggered by exertion, The flare reaches its peak in hours to days and can last a day or two or a week or two. During the flare up or delayed crescendo physical capacity is markedly decreased.

    For chronic pain sufferers true functional capacity over time can only be estimated by repeat testing over time. Insurance companies hate to do more than one. In the rare instances where I have been able to get FCEs done three days apart, they have in fact shown a significant decline in pysical functional capacity.

    They should also be designed to duplicate the task that is in question, but too often the are misused to implicate that “passing” a functional capacity tests means the person is able to do a job with no limitations.

    So the bottom line is that I agree with your points. Well said!

    1. Thanks for your kind words – you are absolutely correct, flare-ups are very common, but it’s interesting to note that one researcher has found that people without pain problems also experience muscle soreness the day after completing FCE. The difference for people with chronic pain is that the exacerbation lasts longer, and the pain intensity can be greater. And yes, I agree, it’s the misinterpretation of FCE that causes heartache for people who find themselves unable to work despite having “passed” their FCE.

  2. Agree! Focus of FCEs also ignore cruicial role of psychosocial variables. Also need to take account of strongest evidence in vocational rehab is for supported employment (or Individual Support Model) rather than ‘readiness’ model.

  3. I have found that people who do not succeed at FCE are often labelled as malingerers. i too have looked for research to support this type of treatment and I have not found anything either

  4. I agree so much I have seen so many patients go through that and are told they can go back to work when they do a certain level and when they go back and are injured or just can’t perform on the job they say What can I do the work insurance says i should be able to go back and now they are implying I am faking and they are sincere in that they don’t understand what happened

  5. So great to see the excellent contributions to this topic, as I have had many similar thoughts over the years. As a clinician in a pain management unit I not infrequently spend some of my first consultation helping peope to address their anger regarding OT’s as a profession as a result of having undergone a FCE which not only aggravated their symptoms and lead to an unrealistic report which over inflated their functional capacity, or made unhelpful assumptions regarding not giving maximum effort in an attempt to avoid aggravation of symptoms, but also sometimes lead to loss of income from their erroneous reproted capacity.

    I wil sometimes do a “functional estimation” with my clients after providing input on pacing and doing a graded activity program, in whch we share infomadtion to guide a a brief review of their fuctional capacity. I think the going gazetted fee for this service is $15 on top of a standard consultation, much cheaper and proabably much more effective in regards to giving a true picture of the client’s capacity than a FCE. Better therapeutically as well, as acknowledges the client’s experience.

    1. There is much appeal to both client/patient and clinician in an assessment that provides both with quality information about how a person manages functional activities. It’s only when the reports are used inappropriately, or the provider suggests that the assessment can show more than it actually can (or the process is conducted inappropriately eg clients encouraged to “use full effort” when they have chronic pain) that we have a problem. In NZ FCE’s are carried out by both occupational therapists and physiotherapists – and appeared to be supported by ACC as a method for ensuring a “medical-only” estimation of a person’s ability to work has more information available to it. Sadly, I don’t think it’s fit for purpose in its current guise.

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