Survey of kinesiologists’ functional capacity evaluation practice in Canada

Abstract

BACKGROUND: In Canada, functional capacity evaluations (FCEs) are commonly administered by several health care professions including kinesiologists. Kinesiologists have been recently regulated as health care professionals in Ontario and we know little about their demographics, the frequency of FCE administration, or the types of FCEs used by this group.

OBJECTIVE: The purposes of this study were to identify: 1) the demographic characteristics and FCE education of kinesiology FCE practitioners; 2) the FCE systems most used by these practitioners and 3) the constructs from assessments used to determine functional capacity.

METHODS: A survey was distributed to members of the Canadian Kinesiology Alliance. Descriptive statistics and frequency distributions were calculated from the survey responses (n = 77).

RESULTS: FCE practitioners were represented by kinesiologists (79%) practicing more than 15 years and 1–5 years, who received FCE training from a certification course. ARCON (23%) was the most common FCE system used. Low-level lifting (43%), mid-lift (38%), pulling (38%) and walking (38%) are the most common FCE task components used to assess functional capacity. Although kinesiologists consider multiple factors when making decisions about task component endpoints, biomechanical observations/body mechanics are the primary methods used.

CONCLUSIONS: Kinesiologists are conducting FCEs for the primary purpose of preparing return-to-work or workplace accommodation recommendations. Although functional capacity is determined using multiple factors, there is an emphasis on biomechanics and body mechanics. Focusing FCE training and research on these constructs may provide opportunities to further strengthen the reliability and validity of FCE outcomes.

Keywords

Return-to-work functional capacity assessments kinesiology allied health professionals occupationalrehabilitation

1 Introduction

Functional capacity evaluations (FCEs) are clinical assessments of individual ability to perform whole body functional tasks such as lifting, carrying, walking, and squatting. Insurers, employers, physicians, and allied health care professionals use FCE results to identify fitness to return-to-work, general functional capacity and ability to perform physical components of a job (i.e., pre-employment screen) [1 –5]. FCEs are conducted based on the underlying principal that if an individual’s capacity is insufficient to meet job demands, they are at greater risk for developing acute or chronic injuries [6, 7]. However, FCE’s used in these applications have been criticised due to lacking validity, reliability and questionable outcomes that do not correlate with sustained return-to-work [1 , 8–10]. In recent years, there has been an increased emphasis on the development of the scientific basis of FCEs [3 , 11–13], driven by both market demand and the needs of insurance providers and governmental agencies, who often make critical decisions on indemnity benefits based on FCE results [1 , 15]. Results of a recent meeting from the 2nd International Functional Capacity Research Meeting identified several research priorities including a general evaluation of FCE procedures and the validation of FCE procedures [13]. Regardless of the ongoing discussion surrounding the scientific value of FCEs and application in predicting RTW and work injury, FCEs continue to be implemented through-out Canada and other countries, as part of the rehabilitation process. Contributing to the complexity of FCEs, multiple factors influence FCE administration including the skills and attributes of the individual performing the assessment [16, 17] and the approach utilized to conduct the assessment [1 , 18].

FCEs have become critical in litigation cases for determining the presence or extent of a disability and the subsequent allocation of financial and medical disability benefits [1 , 19]. Within this legal arena, the process of administrating FCEs and preparing recommendations has also become increasingly relevant. Although rarely discussed in the FCE literature, the FCE administrator plays an important role in both conducting the FCE and interpreting the FCE results. While conducting an FCE, the FCE administrator provides instructions to the participant, operates equipment, and interprets FCE results to provide recommendations regarding individual functional limitations and fitness for work [1 , 20].It is reasonable to expect that practitioners of FCEs participate in training of FCE protocols and have some level of training in movement science, however the qualifications of people administrating FCEs are not always clear. In Ontario Canada, kinesiologists, individuals trained in movement science, have recently been designated as regulated health care professionals with a tightly defined scope of practice. This scope includes clinical assessment in the form of an FCE. With the advancement of the profession’s status, and increasing questions about FCE administration, it is timely to investigate how FCEs practitioners administer FCEs with a particular focus on kinesiologists.

In addition to considering skills and attributes of FCE practitioners, multiple approaches to administering FCEs are available. FCEs can be conducted using standardized system approaches (i.e., Isernhagen/WorkWell) and/or component based-systems (i.e., Arcon, Metriks and BTE/Hanoun), each with corresponding scientific evidence regarding their measurement properties [9 , 21–25]. Yet, we know little about which are most commonly used by kinesiology FCE practitioners in Canada or why. For example, there is no clear consensus on which factors should be measured, or how they should be measured in order to evaluate individual capacity [13]. Based on previous research identifying which biomechanical factors do indeed limit occupational performance, it is clear that at least four factors (range-of-motion, joint strength, balance, friction) define ones biomechanical capacity to exert force when performing functional tasks such as pushing, pulling and lifting [20 , 27]. It remains unclear, however, if and how these factors are being evaluated in practice as part of an FCE to determine individual capacity.

Consequently, the primary objectives of this study were to describe: 1) the demographic characteristics and training received by kinesiology FCE practitioners in Canada; 2) the protocols and FCE systems primarily in use by kinesiology FCE practitioners and 3) the constructs used to determine functional capacity. This research has important translational implications for individuals conducting FCEs and ultimately, the stakeholders in occupational rehabilitation who prepare decisions regarding fitness for work based on FCE outcomes.

2 Methods

2.1 Participants and recruitment

Participants were contacted electronically through the Canadian Kinesiology Alliance (CKA) mailing list (approximately 4000 members). The CKA is the national organization supporting the practice of kinesiology in Canada. A letter of invitation to participate in the study was forwarded directly to individuals on the CKA mailing list in the form of an e-blast via the CKA administration. There were no exclusion criteria other than being a member of the CKA. In addition to the letter of invitation to participate in the study, a link to the online survey was included. Participants clicked on the survey link to consent and participate in the study. The study protocol was approved by the Queen’s University general research ethics board.

2.2 Data collection

An investigator-developed questionnaire was administered using Survey-Monkey (https://www-surveymonkey-com-s.web.bisu.edu.cn/[surveymonkey.com/]). Questions and categorical responses were based on terminology typically used in FCE practice. The questionnaire was divided into three sections: 1) general information, 2) general functional testing usage and 3) usage and applications of functional testing components. Questions were posed using a closed-ended method, with scaled and ranked options. Open-ended questions were used to allow participants to elaborate on which FCEs were being administered, how they were being administered and for what purposes. The questionnaire was administered between July and August 2012.

The general information category inquired about the participants’ year of birth, practice specialization and length of time in practice. Participants were asked to choose from one of four allied health care professional categories to determine professional specialization: kinesiology, occupational therapy, physiotherapy and other. Length of time in practice was determined from participants’ selection of one of five categories: <1 year, 1–5 years, 6–10 years, 11–15 years and >15 years.

The general functional testing usage category identified how participants acquired skills to perform FCEs, years of experience completing FCEs, why participants administer FCEs and the type of FCE protocol typically administered. To determine how participants acquired skills to perform FCEs, participants were asked to select one of 7 categories (certification course, university undergraduate course, manufacturer-provided course, formal in-house training through employer, informal in-house training through employer, university graduate program, college program or other). The number of years of experience completing FCEs was determined through participants’ selection of one of five categories: <1 year, 1–5 years, 6–10 years, 11–15 years and >15 years in response to the question “For how many years have you been conducting functional testing?” To determine the most common reason for completing FCEs in their clinic, participants were asked to choose one of the following: as a pre-hire screen, to establish a baseline capacity, as a proactive screen relative to a baseline, to guide return to work/workplace modifications or other. To determine the most commonly administered FCE system, participants were asked to select the most frequently used from the following list: WorkWell (formerly Isernhagen), WorkHab, Blankenship, Ergo Science, Arcon, Ergos, EPIC Lift Capacity, BTE/Hanoun, Joule/Valpar System, In-house employer developed system, Non-standardized system or Other.

The final section of the questionnaire, usage and application of functional testing components, inquired about specific functional testing components (i.e., lifting, pushing, pulling, carrying), how the components were administered and how component endpoints were determined. To determine which FCE components were administered, participants were asked to identify how frequently (Never-0%; Rarely-25%; Sometimes-50%; Often-75%; Always-100% or Only if a job requirement) each of the following 21 FCE components were included in their FCE protocol: low lift, mid lift, high lift, full lift, push, pull, long carry, short carry, walk, stair climb, kneel, crouch/squat, bend, cardiovascular fitness, front reaching, side reaching, finger dexterity, finger strength, grip strength, manual coordination, overhead work.

FCEs practitioners are often required to determine an appropriate FCE task component endpoint while administering an FCE protocol. To identify how FCE practitioners determine FCE component endpoints, participants were asked to indicate whether they used ‘biomechanical observation/body mechanics’, ‘achievement of a pre-set criteria’ (weight, force, time, range-of-motion), ‘physiological signs’, ‘test participant terminates test’, ‘psychophysical scale’ or ‘other’ when administrating each of the previously reviewed 21 FCE task components. Participants were able to select as many of these constructs that applied for each of the FCE task components. For example, if participants identified using a low level lift during FCE administration, they were asked how they determined endpoint of low level lifting by selecting as many of the above constructs (biomechanical observation/body mechanics, achieve a pre-set criteria, physiological signs, test participant terminates test, psychophysical scale or other) that applied.

2.3 Analysis

Data was extracted from the Survey-Monkey database and imported into Microsoft Excel (v.14.4.6) where descriptive statistics were calculated for participants’ demographic information; frequency distributions were calculated for responses to questions relating to general functional testing usage and usage and application of functional testing components. Responses to questions regarding general functional testing usage were calculated as a percentage of the total sample (n = 77) to identify the percentage of participants who use task components at various frequencies; for example, the percentage of participants who include a high-lift “always –100% of the time” and/or “sometimes – 50% of the time” in their FCE protocol. Responses to questions regarding usage and application of functional testing components were calculated as a percentage of the total number of responses per task component as participants were permitted to select more than one endpoint criteria per task component. For example, during a low-lift, participants may have selected three of the possible 6 endpoint criteria to capture a multi-level approach when determining an individual’s endpoint during a low-lift. The average number of endpoint criteria per task component was determined by dividing the total number of endpoint criteria responses per task component by the total sample size; this outcome (average number of criteria/task component) was used to identify the number of multiple constructs used by participants when determining task endpoint.

3 Results

3.1 Practitioner demographics, experience and training

Kinesiology (79.2%) and chiropractic (7.8%) were the most frequently reported health care professionals. The majority of participants reported practicing for more than 15 years (37.7%) or 1–5 years (31.2%) (Table 1). When asked the length of their experience conducting FCEs, the greatest percentage of responses was 1–5 years (37.1%) followed by over 15 years of experience (20.0%); 17.1% of respondents indicated they had been performing FCEs for less than 1 year. Most participants (50%) reported receiving training through a certification course; 12.5% reported receiving training through a university undergraduate course or formal in-house training by the employer.

Table 1
Participant demographic information and application of functional capacity evaluations

Variable Mean n (%)

Age (years) 39.6 +/–9.3 76 (99)

Professional Category (n = 77)

Kinesiology 61 (79.2)

Chiropractor 6 (7.8)

Occupational Therapy 2 (2.6)

Physiotherapy 2 (2.6)

Other 6 (7.8)

Years of Practice Experience (n = 77)

1–5 24 (31.2)

6–10 15 (19.5)

11–15 8 (10.4)

>15 29 (37.7)

<1 1 (1.3)

Number of years participant has performed FCEs (n = 70)

<1 12 (17.1)

1–5 26 (37.1)

6–10 8 (11.4)

11–15 10 (14.3)

>15 14 (20.0)

Training participant received for completing FCEs (n = 72)

Certification course 36 (50.0)

University undergraduate course 9 (12.5)

Manufacturer provided course 6 (8.3)

Formal in-house training through employer 9 (12.5)

Informal in-house training through employer 6 (8.3)

University graduate program 1 (1.4)

College program 1 (1.4)

Other 4 (5.6)

Frequency participant performs FCEs (n = 73)

Daily 9 (12.3)

2-3/week 18 (24.7)

1/week 10 (13.7)

2-3/month 13 (17.8)

1/month 5 (6.8)

<12/year 12 (17.8)

Not currently performing FCEs 6 (8.2)

Most common reason for performing FCEs (n = 69)

Guide return-to-work/workplace modification recommendations 32 (46.3)

Establish baseline capacity 20 (29.0)

As a pre-hire/post-offer employment screen 8 (11.6)

Vocational Rehabilitation 2 (2.9)

Other 7 (10.1)

Type of FCE System/Protocol Used (n = 74)

Arcon 17 (23.0)

WorkWell/Isernhagen 9 (12.2)

Epic Lift Capacity 5 (6.8)

BTE /Hanoun 3 (4.0)

Ergos 2 (2.7)

ErgoScience 2 (2.7)

In-House System 11 (14.9)

Non-standardized system 11 (14.9)

Workhab/Blankenship/Joule/Valpar 0 (0)

Other 18 (24.3)

Metriks 10 (13.5)

Matheson 4 (5.4)

Functional Movement Screen (FMS) 3 (4.0)

VMax 1 (1.4)

Variable	Mean	n (%)
Age (years)	39.6 +/–9.3	76 (99)
Professional Category (n = 77)
Kinesiology		61 (79.2)
Chiropractor		6 (7.8)
Occupational Therapy		2 (2.6)
Physiotherapy		2 (2.6)
Other		6 (7.8)
Years of Practice Experience (n = 77)
1–5		24 (31.2)
6–10		15 (19.5)
11–15		8 (10.4)
>15		29 (37.7)
<1		1 (1.3)
Number of years participant has performed FCEs (n = 70)
<1		12 (17.1)
1–5		26 (37.1)
6–10		8 (11.4)
11–15		10 (14.3)
>15		14 (20.0)
Training participant received for completing FCEs (n = 72)
Certification course		36 (50.0)
University undergraduate course		9 (12.5)
Manufacturer provided course		6 (8.3)
Formal in-house training through employer		9 (12.5)
Informal in-house training through employer		6 (8.3)
University graduate program		1 (1.4)
College program		1 (1.4)
Other		4 (5.6)
Frequency participant performs FCEs (n = 73)
Daily		9 (12.3)
2-3/week		18 (24.7)
1/week		10 (13.7)
2-3/month		13 (17.8)
1/month		5 (6.8)
<12/year		12 (17.8)
Not currently performing FCEs		6 (8.2)
Most common reason for performing FCEs (n = 69)
Guide return-to-work/workplace modification recommendations		32 (46.3)
Establish baseline capacity		20 (29.0)
As a pre-hire/post-offer employment screen		8 (11.6)
Vocational Rehabilitation		2 (2.9)
Other		7 (10.1)
Type of FCE System/Protocol Used (n = 74)
Arcon		17 (23.0)
WorkWell/Isernhagen		9 (12.2)
Epic Lift Capacity		5 (6.8)
BTE /Hanoun		3 (4.0)
Ergos		2 (2.7)
ErgoScience		2 (2.7)
In-House System		11 (14.9)
Non-standardized system		11 (14.9)
Workhab/Blankenship/Joule/Valpar		0 (0)
Other		18 (24.3)
Metriks		10 (13.5)
Matheson		4 (5.4)
Functional Movement Screen (FMS)		3 (4.0)
VMax		1 (1.4)

Some participants declined to respond to all questions therefore n < 77 for some variables. For “Type of FCE System/Protocol Used”, participants were allowed to choose multiple protocols corresponding to the methods used, therefore n > 77.

3.2 Functional system and usage

Participants most frequently (24.7%) reported administrating FCEs 2-3 times per week; 17.8% of participants reported performing FCEs 1 time per week or less than 12 per year. The most common reasons for performing FCEs were return-to-work planning or workplace modifications (46.3%)followed by establishing baseline capacity (29.0%). The most commonly used assessment protocol was the Arcon system (23%) followed by In-House protocols (14.9%) and Non-Standardized Systems (14.9%). 24.3% of respondents reported performing assessment protocols not included in the survey categories; within this “Other” category, 13.5% of all respondents reported using the Metriks system followed by 5.4% using the Matheson system (see Table 1).

3.3 Determining functional capacity

The FCE protocol components included ‘always’ or ‘100% of the time’ in FCE protocols, were low-lifts (43%); walking (38%) and mid-lift, push and pull testing (38%). The protocol components commonly not included in FCE protocols were an upper extremity task component (23%) and a short carry task (22%). Overhead work (23%) and side reaching (18%) were most commonly identified as being performed “only if a job requirement” (Table 2).

Table 2
Summary of task components selected by FCE Practitioners during completion of a Functional Capacity Evaluation

Frequency STRENGTH BODY POSITION CV UPPER EXTREMITY

Low Mid High Full Push Pull Long Short Walk Stair Kneel Crouch/ Bend Cardio. Front Side Finger Finger Grip Co-ord. OH

Lift Lift Lift Lift Carry Carry Climb Squat Reach Reach Dexterity Strength Work

Never (0%) 8 10 14 16 3 3 10 22 6 8 9 3 12 6 6 14 9 18 3 23 10

Rarely (25%) 1 3 6 14 6 5 3 14 5 12 4 4 1 14 16 8 1 4 3 6 4

Sometimes (50%) 4 4 9 10 4 8 6 8 12 8 9 13 9 18 3 8 4 5 6 6 5

Often (75%) 17 18 12 13 21 16 16 6 6 12 17 13 12 8 12 4 9 5 6 1 6

Always (100%) 43 36 18 8 36 36 27 6 38 19 15 27 20 10 27 9 22 16 34 12 10

Only if Job Requirement 4 4 16 13 4 5 8 12 3 10 13 9 14 12 13 18 16 13 6 10 23

Frequency	STRENGTH	BODY POSITION	CV	UPPER EXTREMITY
Never (0%)	8	10	14	16	3	3	10	22	6	8	9	3	12	6	6	14	9	18	3	23	10
Rarely (25%)	1	3	6	14	6	5	3	14	5	12	4	4	1	14	16	8	1	4	3	6	4
Sometimes (50%)	4	4	9	10	4	8	6	8	12	8	9	13	9	18	3	8	4	5	6	6	5
Often (75%)	17	18	12	13	21	16	16	6	6	12	17	13	12	8	12	4	9	5	6	1	6
Always (100%)	43	36	18	8	36	36	27	6	38	19	15	27	20	10	27	9	22	16	34	12	10
Only if Job Requirement	4	4	16	13	4	5	8	12	3	10	13	9	14	12	13	18	16	13	6	10	23

^*Values reported are percentage of total sample (n = 77). Note that not all participants responded to each question therefore n < 77 for some variables and consequently total percentage for the corresponding variable will be less than 100%. The highlighted category represents the highest percentage response.

Participants reported using on average 3 different constructs when determining strength-based task endpoints and 2 when determining body position, cardiovascular fitness and upper extremity task endpoints. Across all task components, biomechanical observation/body mechanics was the most frequent response category for determining FCE task component endpoints. Participants reported using psychophysical endpoints the least frequently across all FCE task components (Table 3).

Table 3

Criteria used by FCE practitioners to determine task component endpoint

Endpoint	STRENGTH								BODY POSITION					CV	UPPER EXTREMITY
	Low	Mid	High	Full	Push	Pull	Long	Short	Walk	Stair	Kneel	Crouch/	Bend	Cardio.	Front	Side	Finger	Finger	Grip	Co-ord.	OH
	Lift	Lift	Lift	Lift	Carry	Carry	Climb	Squat	Reach	Reach	Dexterity	Strength	Work
Biomechanical Observation/	43	41	42	40	43	44	40	41	43	43	41	42	42	31	45	45	45	38	40	49	41
Body Mechanics
Achieve a pre-set criteria	12	12	12	12	10	10	13	13	10	9	14	14	14	13	13	15	15	13	13	15	14
(weight/force/time/range of motion)
Physiological Signs (HR/RR)	18	18	18	18	20	19	18	17	20	21	19	17	18	24	15	13	12	16	16	12	16
Participant terminates test	16	16	17	17	16	17	17	19	17	17	16	16	18	19	17	19	18	22	21	17	18
Psychophysical scale	11	12	10	11	10	10	10	9	9	9	10	9	9	10	10	9	9	11	10	7	9
Other	0.4	1	1	1	2	1	1	2	0.5	0	0.5	1	0	3	0.6	0.7	1	0	0	1	1
Total # Observations	239	228	198	220	230	222	210	150	194	190	188	214	177	188	178	150	150	102	141	102	158
Average Number of Criteria/	3	3	3	3	3	3	3	2	2	2	2	3	2	2	2	2	2	1	2	1	2
Task Component

*Values reported are percentage of “Total # Observations” where n > 77 as participants were able to select more than one endpoint criteria for each task component. The highlighted category represents the highest percentage response per task component.

4 Discussion

Our survey results identified that FCE practitioners from this sample are represented by kinesiologists with either more than 15 years of clinical experience or less than 1 year of experience, administer FCEs on average 2-3 times per week, primarily for the purpose of guiding return-to-work and /or workplace modification recommendations. Given that our study sample was obtained through an association supporting kinesiology practice, it is not surprising that the majority of study participants identified as kinesiologists. Kinesiologists from both ends of the practice spectrum reported most frequently conducting FCEs, which has important implications for FCE training as well as opportunities for professional mentorship. For example, our study identified that 50% of individuals reported receiving FCE training through a formal certification course and only 20.8% of individuals reported receiving either formal or informal training through their employers. This finding suggests that kinesiologists need to be either employed and/or identify a FCE provider to obtain assessment skills, which is further supported by our findings that only 12.5% of respondents reported receiving their FCE training through formal academic training. Consequently, our survey results suggest that with respect to FCEs, there exists a representative sample of kinesiologists with little practice experience, conducting FCE’s with clinical populations, who received no FCE training during their academic coursework. This seems to be an important consideration for academic institutions when reviewing core curriculum components in their kinesiology programs and where the science of measurement and assessment are key concepts.

The science of measurement, particularly the importance of the reliability and validity of FCE measurements cannot be overstated. If an FCE measurement does not have established reliability, the data collected from subsequent tests could vary and without validity testing, there is no way of knowing whether the results are accurate. At face value, FCEs aim to be a systematic, comprehensive and multi-faceted, objective measurement tool designed to measure an individual’s physical ability to perform work-related tasks [1 , 3–5]. Because of the important medico-legal decisions made based on information gained from an FCE [15], the need to demonstrate the reliability and validity of functional capacity evaluations has prompted a dramatic increase in the research conducted in this area. However, for many of these FCE systems, there is limited evidence about the reliability and validity, which in turn could diminish confidence in the data obtained with FCEs.

Although the Isernhagen Work System (renamed to the WorkWell system) has been most extensively researched in the scientific literature demonstrating the most compelling evidence for validity and reliability [11 , 28–31], only 13.0% of respondents reported using this system. In contrast, the most frequently used FCE as identified in our study was the Arcon system (23%) despite the limited scientific evidence supporting its use [11, 31]. These results suggest that scientific evidence supporting the measurement properties of an FCE may not be the primary factor clinicians consider when selecting FCE tools, systems or protocols. Innes and Straker’s study of current FCE practices of clinicians inAustralia [32], identified that factors such as expectations of FCE referral sources such as workers’ compensation boards and/or private insurance as well as the purpose of the assessment (i.e., for vocational rehabilitation or to determine capacity to perform a job), influence the FCE system/protocol that assessors select, overriding the scientific evidence supporting the protocols. For example, the Isernhagen System requires implementation of the test components in a standardized sequence and the validity and reliability of the outcomes relies on this sequence. This is in contrast to the Arcon system which affords clinicians more flexibility in selecting and sequencing FCE task components and outcomes rely on the measurement properties of the individual test components (i.e., grip strength dynamometer [33], PILE lifting protocol [34, 35]). Our findings suggest that kinesiologists in Canada may optimize the inherent flexibility of the Arcon system and other non-standardized systems/protocols to developing FCE protocols that respond to referral needs addressing return-to-work and workplace accommodation. Survey results of managers and therapists from clinics conducting FCEs in New South Wales also identified that the level of evidence supporting use of FCE assessment brands does not influence use and that flexibility of the system was the most salient factor [36]. Further exploring how kinesiologists in Canada select their FCE equipment/protocol and whether their approach is similar to assessors in other countries, would provide useful information for researchers and FCE trainers, particularly if incorporating FCE training in academic training programs.

The study findings identified tasks generally administered by FCE practitioners in Canada. Strength-based tasks including lifting (particularly low- and mid-level lifts), push/pull and a long carry, assessment of body position including walking, stair-climbing, crouching/squatting and bending and upper extremity mobility including front reach, finger dexterity and grip strength are the primary methods used to assess functional ability. Respondents indicated that side reaching and overhead work are assessed only if identified as a specific job requirement. Overall, these results suggest that FCE assessors target the primary constructs associated with biomechanical capacity including range-of-motion, strength and balance during FCE administration [20 , 27]. However, an important consideration is whether FCE practitioners develop and implement job simulations during FCEs, which may limit the generalizability and comprehensive nature of the assessment. For example, an FCE approach may be used to assess general functional capacity or to conduct job specific simulations, or to achieve both purposes. Therefore, flexibility in the protocol while maintaining the validity and reliability of the system would be required.

Although FCE practitioners use a multi-level approach when determining FCE task component endpoints, biomechanical observation/body mechanics is the primary method used, even when determining endpoints of cardiovascular fitness. Our study was not designed to determine the mechanism(s) FCE practitioners implement to operationalize “biomechanical observation and assessment of body mechanics” nor was the survey designed to test whether those methods are administered consistently between assessments and between assessors. However a recent study [16] identified that inter- and intra-rater reliability varied considerably when making determination about physical effort and submaximal effort when viewing FCE performance on a video. Although important context is lacking when reviewing FCEs from a video, these findings suggest it is unlikely that FCE assessors establish a standardized method for example, preparing formal kinematic calculations during the FCE process, when using biomechanical observations to determine task component endpoints that applies between assessors (i.e., establishing inter-rater reliability). Although using a kinesiophysical basis for determining FCE task endpoints is common, it is likely that using subjective judgement to determine task component endpoint will influence inter-rater reliability and possibly the accuracy of the FCE findings. Regardless, the question of how biomechanical observations are utilized in FCE administration remains unclear [20]. Previous studies have identified that FCE assessors consolidate information from various sources during an FCE to develop their clinical impression and recommendations [32]. The process and theoretical framework that FCE assessors use to link biomechanical observations with recommendations for return-to-work and/or workplace modifications (i.e., linking observations with theoretical frameworks associated with musculoskeletal injury such as muscle fatigue, muscle force-length relationship) and whether they consider the impact of individual factors such as gender, height and weight remains unknown. Further research to understand how clinicians interpret and apply biomechanical analyses during FCEs has important implications for determining RTW status particularly with respect to determining the reliability and the accuracy of FCE results.

The study results should be interpreted in context of the following limitations. The sample size as apercentage of the 4000 contacts on the CKA e-mail list is low and limits generalizability of results. It is important to note that not all kinesiologists would conduct FCEs as part of their normal practice so we anticipated a modest response rate at the outset. Although the study sample represents a small percentage of the total available population of Canadian FCE practitioners, the sample also includes individuals with a range of both professional experience (i.e., kinesiologists, occupational therapists, physical therapists, chiropractors, etc.) and years of experience. Increasing the sample size may provide improved insights into the way in which FCEs are administered and may access more of the sample with 6–15 years of experience to facilitate understanding of why they do not perform as many FCEs as their junior and more senior colleagues.

The study sample was also recruited from the Canadian Kinesiology Alliance, a professional association focussed on supporting kinesiology practitioners. This potential bias may impact the way that FCE practitioners determine component endpoints as professionals not trained in movement science may not link biomechanical observation as a dominant task endpoint determination with task performance strategies. Furthermore, distributors of FCEs (i.e., Isernhagen/WorkWell, BTE/Hanoun, ARCON, Metriks) as well as rehabilitation companies that have developed their own FCE protocols, have standardized training programs that assist FCE practitioners with determining FCE component endpoints. Consequently, although our sample is biased towards kinesiology professionals, it is likely that the process of administrating FCEs and determining FCE endpoints is representative of FCE practitioners as a whole.

Finally, the study did not elicit how respondents use FCE results to prepare conclusions or recommendations from the FCE assessment results. Although the study confirmed how task component endpoints are determined (using biomechanical and body mechanics information), it’s not clear whether the same processes are used to prepare recommendations from FCE results. Although previous research [32] has identified that assessors consolidate information from multiple sources and rely on clinical experience to facilitate recommendations, this implies that assessors have clinical experience. Our results suggest that a majority of assessors are junior kinesiologists with limited clinical experience. Future research to identify how FCE assessors of different clinical backgrounds and experience use assessment results to prepare recommendations, would provide important insights into the way FCEs are operationalized and may provide important insights into limitations associated with the predictive validity of current approaches.

5 Conclusions

Our study investigated which FCE systems are most commonly used by allied health professionals, how they implement components of the FCE system and how they determine component endpoints. The findings suggest that kinesiologists primarily conduct FCEs for the purpose of guiding RTW and workplace modification recommendations. An evidence-to-practice knowledge gap was identified where, although research exists supporting the Isernhagen /WorkWell system for conducting FCEs, kinesiology professionals utilize the Arcon system more often, a system which as a whole is supported by less scientific evidence but with inherentflexibility. Furthermore, when conducting FCEs, although multiple constructs are used to determine FCE task component endpoints, kinesiology FCE practitioners rely on biomechanical observations as a primary method to determine task component endpoints. The mechanism and process for determining how biomechanical observations are used to establish individual capacity is unclear. These results have important implications for future research positioned to develop FCEs and confirm measurement properties as well as for clinicians and stakeholders who use FCE results to make decisions regarding RTW, vocational rehabilitation and decisions regarding corresponding indemnity benefits. Although evidence exists about methods and approaches used to conduct FCEs, our results identify allied health care professionals and kinesiologists in particular, as important target audiences to consider when translating this evidence to practice.

Conflict of interest

Ms. Chapman is a Kinesiologist/Business Development Manager for BTE Technologies. BTE Technologies is a purveyor of FCE related equipment and services in Canada and the United States. Dr. Fischer is a member of the Ontario KinesiologyAssociation Academic Advisory Board, and both Drs. Fischer and Sinden have previously served as Directors for the Canadian Kinesiology Alliance.

Funding

This study was funded by a Queen’s University Senate Advisory Research Council internal grant awarded to Dr. Fischer.

Ethical standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from all participants included in the study.

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