The role of functional capacity evaluation in management of foot and ankle dysfunction
Section snippets
What is the distinction between impairment, disability and function?
The World Health Organization defines impairment as a loss of physiologic function or anatomic structure. Disability is defined as an alteration of an individual's capacity to meet personal, social, or occupational demands due to impairment [2]. Function refers to the individual's ability to perform specific tasks. The three concepts are often linked. A person with ankle impairment (limited range of motion) may have a functional limitation (limited ability to walk) that may result in disability
What is functional capacity evaluation?
An FCE is a test of physical, work-related function. FCEs are typically comprised of a battery of tasks that involve the testing of manual materials handling abilities (lifting, carrying, pushing, and pulling) and nonmaterials handling (activities or positions required for work that do not involve handling significant weights). Box 1, Box 2 present a list of the physical demands and classification of work defined by the US Department of Labor in the Dictionary of Occupational Titles (DOT) [3]
Are there different types of FCEs?
FCEs can be classified into two broad categories: comprehensive and job-specific. When administering the comprehensive FCE, most evaluators use a complete battery of tasks that cover all physical demands listed in the DOT. In job-specific testing, the evaluator tests only those tasks that are related to the person's job. The disability insurance industry typically differentiates between three different types of FCEs: (1) “own job”, (2) “own occupation”, and (3) “any occupation”. For an “own
When and how often should an FCE be performed?
Functional capacity evaluations are grossly underutilized. They are typically reserved for cases where treatment has failed, poor motivation is suspected, return to work attempts have not been successful, or the patient is in the chronic phases of impairment. These are all appropriate times to perform a comprehensive FCE. If FCE components were used at the conclusion of acute care when the initial return to work decision is being made, fewer cases would become chronic; efficient and effective
Can FCEs help direct treatment?
If patients are to begin a program of work simulation and conditioning after acute-care treatment, FCEs (combined with job demands information) can be used to help establish the focus and goals of the program. There are many work-related functions that the patient could perform as part of an industrial rehabilitation program. Why should a patient work on ladder-climbing if this task is not a requirement of his job or if his performance on that task already meets his job demand? Using FCEs can
How can an FCE be applied to the foot and ankle?
Some referral sources will request an FCE on the foot and ankle only. Such requests may be impossible to fulfill, primarily because of the biomechanical function of the lower extremity. Most lower extremity function occurs with the foot planted on an immovable surface while bearing a portion of the body's weight. This type of function is referred to as “closed kinetic chain function” [19].
In a closed kinetic chain, movement in one of the lower extremity joints creates movement in all other
Reliability
Reliability refers to the consistency of a measure. Two types of reliability are important in an FCE, intrarater or “test-retest” reliability and interrater reliability. Because individual tasks of the FCE are often selected for job specific testing, reliability must be established for each individual task as well as for the test as a whole.
Interrater reliability refers to the ability to achieve similar scores on the evaluation when administered by different evaluators [20]. Given the staffing
What are the legal ramifications of FCEs?
The legal ramifications of FCE are enormous. FCEs are used to make decisions regarding employment, disability, case settlement, further treatment, and continuation of workers compensation and disability benefits. As such, these tests should be performed with serious consideration regarding objectivity, reliability, validity, and patient safety. Most FCEs end up in the hands of attorneys and are used to resolve legal cases. FCEs must comply with the legal standards for expert testimony
Summary
Both job-specific and comprehensive FCEs can be valuable tools in clinical decision-making for the injured worker with foot and ankle dysfunction; however, FCE is an extremely complex and multifaceted process. There are many considerations when selecting or developing a testing protocol or selecting an FCE provider. A myriad of approaches are commercially available and an even greater variety of homegrown tests exists. Little is known about the reliability and validity of these tests and more
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