Are performance-based functional assessments superior to semistructured interviews for enhancing return-to-work outcomes?

OBJECTIVE: To examine whether use of functional capacity evaluation (FCE) leads to better outcomes for injured workers. DESIGN: Cluster randomized controlled trial conducted with analysis at level of claimant. SETTING: Rehabilitation facility. PARTICIPANTS: Participants included claimants (N=203); of these, 103 were tested with FCE. Data were collected on all claimants undergoing RTW assessment at the facility for musculoskeletal conditions. Participants were predominantly employed (59%) men (73%) with chronic musculoskeletal conditions (median duration, 496d). INTERVENTIONS: FCEs are commonly used to identify work abilities and inform return-to-work (RTW) decisions. Therefore, FCE results have important consequences. Clinicians who were trained and experienced in performing FCEs were randomized into 2 groups. One group included 14 clinicians who were trained to conduct a semistructured functional interview; the other group (control group) continued to use standard FCE procedures. MAIN OUTCOME MEASURES: Outcomes included RTW recommendations after assessment, functional work level at time of assessment and 1, 3, and 6 months after assessment, and compensation outcomes. Analysis included Mann-Whitney U, chi-square, and t tests. RESULTS: All outcomes were similar between groups, and no statistically or clinically significant differences were observed. Mean differences between groups on functional work levels at assessment and follow-up ranged from 0.1 to 0.3 out of 4 (3%-8% difference, P>.05). CONCLUSIONS: Performance-based FCEs did not appear to enhance RTW outcomes beyond information gained from semistructured functional interviewing. Use of functional interviewing has the potential to improve efficiency of RTW assessment without compromising clinical, RTW, or compensation outcomes.

A cluster randomized clinical trial comparing functional capacity evaluation and functional interviewing as components of occupational rehabilitation programs.

PURPOSE: Functional capacity evaluations (FCE) are used to identify work abilities and are commonly integrated into rehabilitation programs. We studied whether integrating FCE into rehabilitation leads to better outcomes for injured workers. METHODS: A cluster randomised controlled trial was conducted at a workers' compensation rehabilitation facility (registration ISRCTN61284905). Clinicians were randomised into 2 groups: 1 group used FCE while another conducted semi-structured functional interviews. Outcomes included recommendations following assessment, rehabilitation program outcomes including functional work levels and pain intensity, as well as compensation outcomes at 1, 3, and 6 months after assessment. Analysis included Mann-Whitney U, Chi square and t tests. RESULTS: Subjects included 225 claimants of whom 105 were tested with FCE. Subjects were predominantly employed (84 %) males (63 %) with sub-acute musculoskeletal conditions (median duration 67 days). Claimants undergoing FCE had ~15 % higher average functional work levels recommended at time of assessment (Mann-Whitney U = 4,391.0, p < 0.001) but differences at other follow-up times were smaller (0-8 %), in favour of functional interviewing, and not statistically significant. Clinically important improvement during rehabilitation in functional work level (0.9/4, SRM = 0.94), pain intensity (2.0/10, SRM = 0.88) and self-reported disability (21.8/100, SRM = 1.45) were only observed in those undergoing the functional interview. CONCLUSIONS: Performance-based FCE integrated into occupational rehabilitation appears to lead to higher baseline functional work levels compared to a semi-structured functional interview, but not improved RTW rates or functional work levels at follow-up. Functional interviewing has potential for efficiency gains and higher likelihood of clinically important improvement following rehabilitation, however further research is needed.

The Patient-Specific Functional Scale: validity in workers' compensation claimants.

OBJECTIVE: To examine the construct and predictive validity of the Patient-Specific Functional Scale (PSFS) in workers' compensation claimants. DESIGN: Prospective cohort study with 1-year follow-up. SETTING: A workers' compensation rehabilitation facility. PARTICIPANTS: Subjects included 294 claimants with a variety of musculoskeletal disorders. The sample was predominantly male (70%), with a mean age of 44 years. Subjects completed a battery of measures at baseline including the PSFS, the Pain Disability Index (PDI), and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcomes for determining predictive validity included administrative indicators of timely return to work and recovery during the 1-year follow-up. Analysis included Pearson correlation and multivariable Cox and logistic regression. RESULTS: At baseline, the PSFS correlated moderately (r range, 0.3-0.5) with other indicators of functional limitation (PDI, SF-36 role-physical subscale) but negligibly with the SF-36 mental health and role-emotional subscales. The PSFS was associated with timely recovery (adjusted hazard ratio, 1.16; 95% confidence interval, 1.07-1.27) with increasing functional limitation related to delayed recovery. CONCLUSIONS: Results provide construct and predictive validity evidence for the PSFS as an indicator of functional limitation in workers' compensation claimants.

Evaluation of a short-form functional capacity evaluation: less may be best.

PURPOSE: Functional Capacity Evaluation (FCE) contributes to clinical decisions regarding fitness-for-work and may improve return-to-work outcomes. However, FCE is a burdensome clinical tool in terms of time and cost. We evaluated the effectiveness of a short-form FCE protocol. METHODS: A cluster randomized controlled trial was conducted. Data were collected on all claimants undergoing FCE at Alberta's workers' compensation rehabilitation facility. Twenty-three clinicians who were trained and experienced with FCE were randomized to either an intervention or control group. The intervention group was trained to conduct short-form FCE and used this protocol through the trial's duration, while the control group continued standard FCE procedures. Data on subject characteristics, administrative outcomes (days to suspension of time loss benefits, days to claim closure, and future recurrence) and claimant satisfaction were extracted from the WCB-Alberta computer databases. Clinicians logged time taken to complete assessments. Analysis included examining differences between groups using independent samples t tests, Cox and logistic regression. RESULTS: Subjects included 372 claimants of whom 173 were tested with short-form FCE. Subjects were predominantly employed (64%) males (69%) with chronic musculoskeletal conditions (median duration 252 days). Administrative recovery outcomes were similar between groups as were claimant satisfaction ratings. No statistically significant or clinically relevant differences were observed on these outcomes between groups. A 43% reduction in functional assessment time was seen. CONCLUSION: A short-form FCE appears to reduce time of assessment while not affecting recovery outcomes when compared to standard FCE administration. Such a protocol may be an efficient option for therapists performing fitness-for-work assessments.

Functional self-efficacy beliefs influence functional capacity evaluation.

OBJECTIVES: The relationship between functional self-efficacy and Functional Capacity Evaluation (FCE) lift performance was examined in workers' compensation claimants' with low back pain. METHODS: A cross-sectional design was used. Forty-two claimants with back pain and 38 subjects without back pain were enrolled. Subjects completed a measure of functional self-efficacy related specifically to lifting. Subjects also underwent FCE floor-to-waist, waist-to-overhead and horizontal lift testing. Potential confounders were also assessed including perceived disability, pain intensity, and self-rated health. Analysis included Pearson correlation and multivariable linear regression. RESULTS: Higher functional self-efficacy beliefs were highly associated with better FCE performance on each of the lift items tested (r = 0.50-0.73). In multivariable analysis, the measure of functional self-efficacy remained independently associated with lift performance after controlling for potential confounders. CONCLUSION: Functional self-efficacy beliefs appear to influence FCE lift performance. Strategies for altering functional self-efficacy beliefs and their resulting impact on patient functional performance and outcomes should be examined.