Returning to work after a Stroke: The role of the Functional Capacity Evaluation.
I wanted to share this article with you regarding returning to work after suffering a Stroke. A functional capacity evaluation may be able to help...
Facilitating return to work in the stroke patient utilizing the Functional Capacity Evaluation Tool
Stroke is a leading cause of death in the United States, killing nearly 130,000 Americans each year – 1 of every 19 deaths. Annually 795,000 people suffer a stroke. About 610, 000 of these are new strokes; 185,000 are recurrent strokes.(1)
Stroke risk increases with age but as of 2009, 34% of people hospitalized for stroke were younger than 65.(4) It is the leading cause of serious long term disability in the U.S.(2)? b The estimated accumulated annual cost (Direct and Indirect) of stroke in the US is an estimated $65.5 billion. Of this $21.8 billion is attributed to indirect cost associated with lost productivity and time away from work. It is estimated that nearly $13 billion or 20% of all stroke cost are related to expenses associated with the inability of stroke survivors to return to work (RTW). As well it’s been recognized the importance of returning to work for the individual’s well-being and life satisfaction, as well as the healthcare communities lack of knowledge in the area of work rehabilitation for stroke survivors. (2) This is such a concern for the U.S. that the Department of Education has selected the need to enhance the functional and employment outcomes of stroke survivors as their top research priority. (1)
Some noted factors for determining an individual stroke survivor’s ability to return to work are severity of hemiparesis, cognitive deficits, communication deficits, and ability to perform activities of daily living. While some factors are inconsistent predictors such as age, gender and race to the likelihood of returning to work, other factors such as job type (skill work), higher education, absence of comorbidities, and social environmental factors such as social support and job accommodations have received support in the literature as being strong predictive factors in return to work.(3) Hartke et al (2011) looked at factors related to return to work and found some barriers to a successful return to work included lack of communication, lack of skills assessment, lack of job readiness or vocational counseling resources in attempting a return to work.(3)
Culler et al, (2011) found that although stroke survivors expressed concerns for being unable to perform their prior job duties, due to the potential need for accommodations, both employers and vocational rehabilitation counselors related a desire to reasonably accommodate workers within the ADA guidelines to allow successful transition back to work.(2) Knowing the workers actual abilities and limitations far enough in advance of attempting return to work, would seem to be one method for promoting success in the process.
Since better management of community/work reintegration of the stroke patient is the goal, the functional capacity evaluation, with the job function match (if a job description is available) may be just the tool to assist a clinician, seeking objective findings in determining readiness to return to work. As I was not able to find any studies that examined the value or use of the functional capacity evaluation tool in assessing the readiness of a stroke survivor to return to work. This case study is performed to examine the effectiveness of the Functional Capacity Evaluation in determining RTW readiness..
Functional Capacity Evaluation defined:
A Functional Capacity Evaluation (FCE) is an objective set of tests, practices and observations that are combined to determine the ability of the evaluated subject to function in a variety of areas most often related to employment. The test can be used to help determine readiness to work and identify needed work accommodations or changes to the workload. Insurance companies utilize FCE’s to determine the level of functional loss and assist in determining disability payments and disability permanency. (See Appendix for DSI FCE forms).
The HOAC II method was utilized in developing this patient case study approach.
The patient is a 51 y/o African American female with history of uncontrolled Hypertension who suffered Acute Cerebrovascular accident (3 x 2 mm left basal ganglia hematoma) on 9/23/14. Presented initially with slurred speech, and right arm and leg weakness. Speech improved now without slur and only slight residual right hand grip strength and coordination weakness as well and minimal strength variance of the right lower extremity compared to the left (See FCE physical exam).
Prior to her stroke, the patient was separated from her husband living with her two children (22 and 15 y/o). She acknowledges that she is the primary provider for herself and her children at present and has some financial challenges. She works as a teacher part time and a coordinator for a middle school parent support center. In her spare time, she enjoys running marathons and conducting training clinics for youth marathon runners. She often ran 20-36 miles per week. She fully desires to return to her previous work and activity and especially would like to eventually return to running again.
The Functional Capacity Evaluation and or Job Function match would benefit the patient in determining her readiness to return to work as the primary provider for her children and herself at this time. Studies show that returning to work has important psychological effects in boosting confidence and self-esteem as well as reducing the risk of depression. (4),(7)
The DSI FCE was conducted on the patient without the benefit of having a Job description to perform a functional job match for her position at this time.(8) The patient has not yet been cleared to return to work and remains under close management by her physician. She has return home and continues therapy as an outpatient awaiting release to return to work. In the mean time she has taken the advice of her care coordinator and the hospital rehab unit and begun the process of applying for state disability in the event she is unable to return to work.
The FCE results identified that the patient has abilities in the following functional areas; Standing, sitting, walking, bend-reach, low level activity, climbing stairs, and shows limitations in right hand coordination, grip and elevated work above 60 “ on the right side.
The functional capacity evaluation tool did show to be an affective tool for measuring the patient’s physical and functional capacity to perform work. The results achieved do identify the physical demand level of work that she can safely work within (light). It is a tool that can be utilized to provide valuable information to the rehab team. What it is not able to assess is her readiness cognitively to perform the more complex mental aspects of her job. Determining this, within some fields of work could be vital to determining some stroke survivor’s readiness to return to work. This is important from the mental competence, and safety awareness. As the functional capacity evaluation does not specifically designed to address high level cognitive abilities, additional testing would be warranted in the case of certain stroke survivors before clearing them to return to work. What the test is able to provide to the patient, MD, rehab therapist, and vocational rehab specialist is quantifiable measures to allow functional job task matching to be accomplish in a timely and coordinated manner. Also further analysis of the FCE tool design to better meet the needs of the stroke patient wanting to assess their mental readiness to return to work is needed and should be then piloted and the results measured for benefits to the cause of timely return to work.
1. CDC Stroke Fact Sheet August 2014.
2. Culler, KH, Wang, Y, Byers, K, and Trierweiler, R. (2011) Barriers and facilitators
of return to work for individuals with strokes; Perspectives of the stroke survivor, vocational specialist, and employer. Top Stroke Rehabil. 18(4): 325-340.
3. Hartke, RJ, Trierweler, and R, Bode, R (2011) Critical factors related to return to
work after stroke: A qualitative study. Top Stroke Rehabil. 18(4): 341-351.
4. Vestling, M, Tufvesson, B, and Iwarsson, S. (2003) Indicators for return to work
after stroke and the importance of work for subjective well-being and life satisfaction.
5. Wolf, TJ, Baum, C, and Connor, LT. (2009) Changing face of stroke: Implications
for occupational therapy practice. Am J Occup Ther. 63(5): 621-625.
6. Stroke Impact Scale Version-3.
7.http://www.swostroke.ca/components/site_news/files/RTW Literature Review.pdf
8. DSI FCE tool product comparison: