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REHABILITATION MEDICINE / CENTER FOR REHABILITATION Use of Functional Capacity Evaluation for the assessment of Residual Work Capacity Michiel Reneman Liverpool 2008 2 1 2 Disclosure: no COI Michiel Reneman UMCG Rehabilitation FCE-research

  1. REHABILITATION MEDICINE / CENTER FOR REHABILITATION Use of Functional Capacity Evaluation for the assessment of Residual Work Capacity Michiel Reneman Liverpool 2008 2 1 2 Disclosure: no COI Michiel Reneman UMCG Rehabilitation FCE-research Groningen Professor – Pain and Work PT & Movement Scientist • 10 PhD theses Other activities • >50 international publications Pijn Alliance Netherlands (PA!N) Fit for Work platform • CLBP> healthy > OA hip, knee, hand > WAD & neck > Development center Pain Rehabilitation single arm Working group Pain Rehabilitation Netherlands Network ‘Early Intervention’ / Vroege Interventie • Topics FCE trainer and course – Safety, reliability, construct validity, usability, reference Editorial board Eur J Pain / J Occupational Rehbilitation EFIC – SIP societal Impact of Pain values, definitions 3 4 Use of Functional Capacity Evaluation for the assessment of An FCE is an evaluation of capacity of Residual Work Capacity activities that is used to make recommendations for participation in FCE definition and positioning work , while considering the person’s body functions and structures, environmental factors, personal factors and health status Capacity … The highest probable functioning of a person … at a given point in time, in a standardized environment Performance … what a person actually does in her or his current environment. It describes the person’s functioning as observed or reported in the person’s real-life environment with the existing facilitators and barriers 6 5 6 1

  2. An FCE is an evaluation of capacity of activities that is used to FCE is limited to Health / Functional Capacity foundation of make recommendations for participation in work , while Work Ability ‘House’ considering the person’s body functions and structures, environmental factors, personal factors and health status FCE ≠ ‘a buch of tests’ or ‘a machine’ FCE = clinical reasoning 1. Diagnosis 6. Tests 2. History – health 7. Observations 3. History - work 8. Analysis deficiencies 4. questionnaires 9. Analysis reasons 5. Physical examination 10. Recommendations 7 8 Functional Capacity Evaluation FCE tests • 12-50, depending on protocol • Lifting and carrying low Technology high • Posture tolerance: bending, overhead work low Marketing high • Repetitive work / reaching: sideways, low, overhead high Research low • Hand functions: grip strength, vinger strength, fine motor functions UE and hand • All tests > hours • 1 or few tests 10 9 10 Example low tech test materials FCE: different shapes and forms FCE en WCE • FCE = standardized • WCE = tailored to work Examples: police, firefigthers Protocols: generic and specific, short and long, 1 or 2 days, 1-4 hour Choice of tests: question, diagnosis, work Report: (ultra) short – very long 11 12 2

  3. Scientific developments FCE 20 years – 1 sheet summary 1. We can measure FC safe and reliable Work Capacity Evaluation – WCE 2. We are getting better grip on validity Firefighters 3. We can use FCE to predict work status And: 1. (ultra) short protocols (1-5 tests; lifting test) 2. Relevant references – criterion references (work load) But: • Grip on validity ≠ ‘it is valid’ • Individual variation in test results substantial and insufficiently explained – Individual interaction with B-P-S factors 13 13 14 Validity of FCE for RTW It may be questioned whether FCEs by themselves will ever be found valid for the prediction of a safe and lasting RTW… The construct of ‘workability’ is multidimensional. Whether a patient successfully returns to work or not, depends on more than functional capacity by itself. It is critical to understand that an instrument measuring a single dimension cannot be expected to assess a multidimensional construct. It is, therefore, by definition incorrect to suggest or to claim that the results of an FCE should be able to predict a person’s work ability, or even more complex, a successful return to work. At best, one may expect an FCE, … , to More studies should evaluate the predictive validity of measure an individual’s immediate functional ability to perform promising job-specific performance and complementary non- work-related activities. This should be seen as one of the performance based measures. prerequisites for a successful return to work. Reneman, Wi ttink, Goss, AMA, 2008 15 16 An FCE is an evaluation of capacity of activities that is used to Testresults or capacity? make recommendations for participation in work , while considering the person’s body functions and structures, environmental factors, personal factors and health status FCE: we measure test output - behavioural measure FCE ≠ tests Test behaviour: part of capacity that a person is willing and/or able FCE = clinical reasoning to munster, based on B-P-S factors 1. Diagnosis 6. Tests Question: 2. History – health 7. Observations • How to disentangle ‘physical’ from other factors during FCE? 3. History - work 8. Analysis deficiencies 4. questionnaires 9. Analysis reasons 5. Physical examination 10. Recommendations 17 18 3

  4. Indiators described in FCE literature • Consistcy – clinical reasoning • Waddell Non-Organic Signs • Correlation pain intensity / performances / heartrate CV – coefficient of variation • REG - Rapid Exchange Grip • Grip strength curve • Heartrate / performances 19 20 Observing effort Observations of pain behavior Strong evidence : therapists can identify ‘physical’ sub-max Pain behavior: acts we understand to communicate pain • performance (LBP, lifting) FCE: differentiate pain behavior from ‘physical activity’ behavior • • biomechanics, physiology (biomechanics physiology) Standardized – modified PBS scale (not validated for FCE) • No evidence FCE can detect ‘malingering’ or judge (in)sincerity Interpretation: influence of PB on test results • Biopsychosocial framework • Reason submax: Central Sensitization? • • depression, FCE done in non-native language, etc • Biopsychosocial framework 21 22 An FCE is an evaluation of capacity of activities that is used to Analyses deficiencies make recommendations for participation in work , while considering the person’s body functions and structures, Workload = reference environmental factors, personal factors and health status FCE ≠ tests Comparison capacity to workload FCE = clinical reasoning 1. Diagnosis 6. Tests 2. History – health 7. Observations 3. History - work 8. Analysis deficiencies 4. questionnaires 9. Analysis reasons 5. Physical examination 10. Recommendations 23 24 4

  5. Reference values Reference values Netherlands • Workload = reference / criterion • Assessment workload time consuming and scientifically challenging 702 workers • Reference for FCE: FC of good functioning healthy workers 184 professions • Compare FC patient to FC of good functioning workers with similar 12 tests workload – Patient FC = worker FC: OK – Patient FC < worker FC: ? 25 26 Manager - DOT 1 Brick layer - DOT 4 40 kg: decile 6 40 kg: decile 1-2 8 kg: decile 1 20 kg: decile 1 5 kg: decile 0 5 kg: decile 0 NL 27 28 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 Validity reference values FCE ≠ tests FCE = clinical reasoning Hypothesis: FCE>WL Methods: Standardized WL assessment at workplace 1. Diagnosis 6. Tests 2. History – health 7. Observations Results 3. History - work 8. Analysis deficiencies S/L work: 10 e percentile correct 98% • M/H work: 30 e percentile correct in 88% 4. questionnaires 9. Analysis reasons • 5. Physical examination 10. Recommendations 29 30 5

  6. Deficiencies - Reasons: biopsychosocial framework Sample • 372 patients • 54 clinicians 2 examples: • 18 facilities • 8 countries • Patient related • Clinician related 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 31 32 FCE Test results Netherlands Canada Switzerland Floor-to-waist lift (kg) 6 minute walk (m) 25 600 20 400 15 10 200 5 0 0 NL CA CH DE AT ZA NZ CN NL CA CH DE AT ZA NZ CN Right handgrip strength Left handgrip strength (kgF) 60 (kgF) 60 40 40 20 20 0 0 NL CA CH DE AT ZA NZ CN NL CA CH DE AT ZA NZ CN 33 34 Multiple Regression (R 2 ) Floor-to-Waist Lift Patient’s Sex (male/female) Height (cm) Six-Minute Walk Test Floor-to-Waist Lift Right Handgrip Strength Patient-Reported Disability (PDI) Pain Intensity (NRS) 16% 25% 38% Social Isolation 43% 46% 44% 15% 16% Clinician’s Observed Physical Effort during Lift Test 31% 43% 16% 26% 15% FCE Measurement Country Test Ended Prematurely (yes/no) Reason for Ending the Test 26% Bio Psycho Social Unknown 35 36 6

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