Fitness for work: a guide to functional capacity evaluation

New guidance on functional capacity evaluation from the professional body for physiotherapists in occupational health has been released to help OH specialists give better advice on employees’ physical fitness for work. Glyn Smith, author of the guidance, provides more details.

An important aspect of the role of many OH professionals is to provide advice to an employer on an employee’s physical fitness for work, using a range of tools, tests and observations, which can often include a functional capacity evaluation (FCE). An FCE may be used to help develop an occupational rehabilitation programme, particularly if the employee concerned has lost confidence in their work ability or has become de-conditioned (ie is experiencing a decline in physical capacity).

A capacity evaluation is also helpful in cases where there is a discrepancy between an employee’s perception of their work ability and the opinions set out in a clinician’s report. However, it is also important for OH practitioners to understand the limitations of an FCE in assessing an individual’s functional performance, particularly in the context of musculoskeletal disorders (MSDs).

How an FCE works

An FCE can be defined as an evaluation of capacity to undertake activities that is used to make recommendations for participation in work, while also considering an employee’s body functions and structures, environmental and personal factors and health status.

The main focus of a typical FCE is to measure an employee’s physical condition in relation to their job demands, often using a standard system of classifications to report back to an employer or other stakeholders (for example, using terms such as “sedentary”, “light”, or “heavy” to describe the role).

Postural tolerance and mobility are also assessed in many FCE tools, often using descriptors such as “standing”, “kneeling” and “stooping”. Common task categories used in FCE systems are: dynamic strength (for example, floor-to-waist lifting or unilateral carrying); postural tolerance (for example, standing tolerance or reclining reach); mobility (for example, steps or ladder climbing; and an “other” category (for example, hand dexterity or pinch grip).

When providing an FCE service, physiotherapists and other OH professionals should:

• ensure that the referral they receive is appropriate and, in particular, confirm what questions the FCE purchaser needs to have answered, and what workplace adjustments or rehabilitation opportunities are potentially available;
• try to access and review relevant medical information before the FCE is carried out, and obtain contact details for the client’s GP in advance;
• check that the FCE tests proposed do not present any contraindications;
• look at the client’s job description in advance, if the purpose of the FCE is to advise on fitness for a specific job; and
• ensure that the client receives information in writing on what to expect during the FCE process, including what to bring or wear (eg reading glasses or hearing aids).

The OH professional must ensure that the client is clear about who will receive a copy of the FCE report and how they can access their own copy. Clients should also be made aware that they can request to see and comment on an FCE report before it is sent to an employer/referrer or other stakeholder.

Clients should also be informed about the limits to the confidentiality of the FCE process and about what information is to be shared and with whom. They should be informed about the potential consequences of withdrawing consent for the FCE, namely, that the employer will be told and may, as a consequence, still make fitness-for-work decisions without the results of the evaluation.

FCE methods

The range of FCE tools on the market is huge, but there is increasing evidence that relatively short evaluations (for example, those lasting one to two hours) are probably as reliable as two-day processes. I tend to use commercial, standardised assessments in my clinic and less standardised ones in workplaces. Whichever tools I use, I am always aware of the need to relate functional capacity to job demands and roles.

There are several key requirements for any FCE method:

• Safety: clients must believe that the levels of functional capacity testing they are exposing themselves to are safe, especially given the psychosocial factors around fitness for work. I do not want clients to feel that they might be putting themselves at risk of injury and we must not cause stress or high blood pressure. Evidence suggests that FCE is generally a safe process, however.
• Reliability: the overall reliability of individual tests, and some systems, is good, although there is some debate around reliability given that there is little normative data for a UK population against which to benchmark individuals.
• Validity: the base validity of FCE as a generic tool is good as it measures what a person does. However, FCE alone is unlikely to measure all the factors influencing a return-to-work process, so it must be used in conjunction with other tools. There is no robust evidence that FCE can predict whether or not it is safe for an employee to return to work, but it is a valid method of measuring pain and functional limitation.

Referral questions

The range of circumstances in which an FCE may be requested is wide. This makes it vitally important that those involved in the process accept a referral only if they believe they are able to answer the questions posed by the person or organisation requesting it (usually an employer).

For example, said employer may expect the OH professional to use an FCE to identify whether or not an employee is malingering or less disabled than they are claiming. New guidance from the Association of Chartered Physiotherapists in Occupational Health and Ergonomics (ACPOHE) warns against accepting such a remit, stating that there is no evidence that FCEs can be used effectively for this, and advising that “assessments should not be offered or accepted for this purpose”.

Similarly, an FCE should not be used to identify so-called symptom magnification (a tendency on the part of the client to underestimate capacity and overstate limitations), although I am aware that evaluations are sometimes used for this purpose in the US. However, an FCE may justifiably be used to identify the need for more detailed psychological assessment of a client..

Assessment options

Methods to assess fitness for work, including subjective medical history, investigations and measures of work functioning using specific tools and questionnaires collected under the umbrella of FCEs. As a physiotherapist, I like to have a client’s medical history alongside the data from an FCE. I find that this helps clients to understand their disability and assists me in screening for orange, yellow and blue flags [the flag system is used by physiotherapists as indicators of the seriousness of conditions].

I also undertake an analysis of work demands, carry out cardio fitness tests and consider any clinical factors that might help predict a return to work. For example, we know that those with depression and some other common mental health problems in addition to MSDs are among the least able to return to work.

To gain an idea of the overall fitness for work, a physiotherapist needs to evaluate the employee’s job, understand the biopsychosocial issues, and undertake a clinical assessment or FCE. Only then are they in a position to address the employer’s original referral questions, such as: Is the employee fit for work? What are the barriers to them returning? Or, what adjustments should we make?

The first thing a physiotherapist should get to grips with in assessing fitness for work is the nature of the client or employee’s work: look at overall job demands; undertake task analyses; and ask for job descriptions. Unless the expectations are understood, it is impossible to assess fitness relative to these demands. Explore the different factors associated with work, including tolerance and strength, but also more specific tasks performed.

Biopsychosocial model

Physiotherapists and other OH professionals carrying out fitness-for-work assessments will also need to explore the risk factors associated with the development and reporting of MSDs in order to understand how these particular conditions might make sickness absence more likely.

A biopsychosocial model is increasingly used by many specialists to explore factors likely to impact a return to work. In a similar vein, the barriers to work associated with work organisation can have a significant impact on an employee’s ability to return, and need investigating. The new ACPOHE guidance sets out the importance of incorporating these factors in assessing fitness for work.

Addressing and managing these organisational and biopsychosocial factors increases the accuracy of the fitness-for-work assessment; these types of tools can
include an Orebo musculoskeletal pain screening tool or similar questionnaire. Professionals need to ask the client how they cope with pain and how they envisage responding to a return-to-work plan. This is important to gain an idea of the client’s beliefs and anxieties around any barriers to rehabilitation.

Professionals need to use an FCE to understand a client’s perceptions about work. For example, if they see work as harmful it will be difficult to get them to accept the need to return, irrespective of any physical issues. The organisational barriers to rehabilitation also need exploring but are incredibly diverse and include factors connected to management style and organisational culture. Unless we understand and address concerns, we will not understand how a return-to-work process is best managed.

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There are many risk factors associated with the development and reporting of MSDs, in particular, by employees, and we need to come up with return-to-work strategies that address all of the potential barriers. As professionals involved in assessing fitness for work, we need to understand the jobs that the clients perform, the psychosocial perspective, clinical factors and physical capabilities. FCEs can help us piece together a comprehensive picture, and therefore produce more relevant reports for employers, and deal head-on with referral questions from managers.

FCEs are a really useful element of assessing fitness for work, but there is plenty more research to do into how we might use them effectively. I believe that the next step is for the ACPOHE to explore the establishment of normative values for the UK and the efficacy of using short-form FCEs in pre-employment screening.