Quantification of functional abilities in Rett syndrome: a comparison between stages III and IV

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

The relationship between social support and functional capacity in elderly persons with cognitive alterations

The objective of this study was to identify the relationship between social support and the functional capacity of elderly persons with cognitive alterations. It is a descriptive, cross-sectional and quantitative study. The subjects were 101 elderly persons registered in Family Health Centers whose performance in the Mini-Exam for Mental Status was below a certain specified level in a previous study. The Medical Outcomes Study questionnaire, Katz Index and Pfeffer Questionnaire were applied. The dimensions of material, affective, emotional, informational and positive social interaction support resulted in an average final score of 74.32 points, indicating a better level of material and affective support in relation to the other dimensions of support. There was a statistically significant correlation between emotional support and the Katz Index. Knowledge about this relationship favors the development of a nursing care pathway for the elderly which is capable of maintaining their functional capacity and ensuring satisfactory social relations.

Functional capacity and assistance from the caregiver during daily activities in Brazilian children with cerebral palsy

Abstract Background Cerebral Palsy (CP) presents changes in posture and movement as a core characteristic, which requires multiprofessional clinical treatments during children’s habilitation or rehabilitation. Besides clinical treatment, it is fundamental that professionals use evaluation systems to quantify the difficulties presented to the individual and their families in their daily lives. We aimed to investigate the functional capacity of individuals with CP and the amount of assistance required by the caregiver in day-to-day activities. Methods Twenty patients with CP, six-year-old on average, were evaluated. The Pediatric Evaluation Inventory of Incapacities was used (PEDI - Pediatric Evaluation Disability Inventory), a system adapted for Brazil that evaluates child's dysfunction in three 3 dimensions: self-care, mobility and social function. To compare the three areas, repeated measures analysis of variance (ANOVA) were used. Results We found the following results regarding the functional capacity of children: self-care, 27.4%, ±17.5; mobility, 25.8%, ±33.3 and social function, 36.3%, ±27.7. The results of the demand of aid from the caregiver according to each dimension were: self-care, 9.7%, ±19.9; mobility, 14.1%, ± 20.9 and social function, 19.8%, ±26.1. Conclusion We indicated that there was no difference between the performance of the subjects in areas of self-care, mobility and social function considering the functional skills and assistance required by the caregiver.

PReS-FINAL-2170: Work disability in adult patients with juvenile idiopathic arthritis (JIA)

Introduction Approximately 20% JIA patients enters adulthood with clinically active disease and disabled, therefore work condition may be affected. Objectives To assess the prevalence of work disability among adult patients with JIA regularly attending a tertiary heumatology center and to determine possible associated risk factors. Methods This was a cross-sectional study that enrolled 43 JIA patients according to 2004 revised ILAR criteria. A questionnaire was developed in order to evaluate working status and labor activity: occupation, current/previous work, employment status and withdrawal rate were actively searched. Demographic data, JIA characteristics, clinical activity (DAS28>2.6), therapeutic intervention, comorbidities, physical activity, sedentarism (WHO definitions), functional class (1991 ACR criteria), HAQ and SF-36 were recorded. The prevalence of work disability was calculated using 95% confidence interval, and compared to all parameters; qualitative variables were analyzed using tests of association (chi-square test) and quantitative variables by Mann-Whitney or student test. Results Patients' mean age was 29+7.4 yrs (range 19-41) with mean JIA duration = 17.2+12.3 yrs (range 3-33); 63% were males and 37% females. JIA subtypes were 64% polyarticular, 11% oligoarticular, 9% systemic, 9% ERA, 2% extended oligoarticular, 2% psoriatic arthritis; 7% had uveitis. Serum RF was positive in 21% and ANA in 21%. The majority (72%, n = 31) of JIA patients were employed, whereas 28% (n = 12) were currently not working. In the latter group, 83% (10/12) were retired due to JIA related disability. Further analysis comparing those currently working vs. Those not working revealed similar age (25,3 yrs vs.29,5 yrs, p = 0,09). Although not significantly, most patients currently working had Poly onset JIA (22 vs. 6 p = 0,37), higher frequencies of good education level >12 yrs of school (31 vs.9, p = 0,38), functional class I (p = 0,96), practiced regular physical activity (9 vs. 0, p = 0,89), were singles (26 vs. 8, p = 0,15). Both groups had comparable HAQ and DAS 28 scores (0,62 vs. 0.59, p = 0,47 and 2,51 vs.2,07, p = 0,64) and similar arthroplasty rate (8 vs. 4, p = 0,427). Frequencies of hypertension (3 vs.1, p = 0,999), dyslipidemia (1 vs. 1, p = 0,125), diabetes (1 vs. 0 p = 0,999), depression (1 vs. 0, p = 0,999) and smokers (3 vs. 1, p = 0,99) were alike in both groups. Remarkably, employed patients had higher SF 36 mental health component (84.0 vs. 70.42, P = 0.01). Conclusion High prevalence of almost 1/3 work disability and of retirement due to disease related incapacity remain major problems for adult JIA individuals. We also identified worse mental health in employed patients indicating that further research is needed, in addition to intense affirmative disability actions in order to remove possible disabling barriers and to adapt restrictive environments for these patients. Moreover, enhanced strategies and policy for inclusion of JIA patients in the job market is urged.

Analysis of Copy Number Variants identifies new candidate genes for Autism Spectrum Disorder and Intellectual Disability

Autism spectrum disorder (ASD) and Intellectual Disability (ID) are complex neuropsychiatric disorders characterized by extensive clinical and genetic heterogeneity and with overlapping risk factors. The aim of my project was to further investigate the role of Copy Numbers Variants (CNVs), identified through genome-wide studies performed by the Autism Geome Project (AGP) and the CHERISH consortium in large cohorts of ASD and ID cases, respectively. Specifically, I focused on four rare genic CNVs, selected on the basis of their impact on interesting ASD/ID candidate genes: a) a compound heterozygous deletion involving CTNNA3, predicted to cause the lack of functional protein; b) a 15q13.3 duplication containing CHRNA7; c) a 2q31.1 microdeletion encompassing KLHL23, SSB and METTL5; d) Lastly, I investigated the putative imprinting regulation of the CADPS2 gene, disrupted by a maternal deletion in two siblings with ASD and ID. This study provides further evidence for the role of CTNNA3, CHRNA7, KLHL23 and CADPS2 as ASD and/or ID susceptibility genes, and highlights that rare genetic variation contributes to disease risk in different ways: some rare mutations, such as those impacting CTNNA3, act in a recessive mode of inheritance, while other CNVs, such as those occurring in the 15q13.3 region, are implicated in multiple developmental and/or neurological disorders possibly interacting with other susceptibility variants elsewhere in the genome. On the other hand, the discovery of a tissue-specific monoallelic expression for the CADPS2 gene, implicates the involvement of epigenetic regulatory mechanisms as risk factors conferring susceptibility to ASD/ID.

Identification of problems in functioning of people with sleep disorders in a clinical setting using the International Classification of Functioning Disability and Health (ICF) Checklist

We conducted an explorative, cross-sectional, multi-centre study in order to identify the most common problems of people with any kind of (primary) sleep disorder in a clinical setting using the International Classification of Functioning, Disability and Health (ICF) as a frame of reference. Data were collected from patients using a structured face-to-face interview of 45-60 min duration. A case record form for health professionals containing the extended ICF Checklist, sociodemographic variables and disease-specific variables was used. The study centres collected data of 99 individuals with sleep disorders. The identified categories include 48 (32%) for body functions, 13 (9%) body structures, 55 (37%) activities and participation and 32 (22%) for environmental factors. 'Sleep functions' (100%) and 'energy and drive functions', respectively, (85%) were the most severely impaired second-level categories of body functions followed by 'attention functions' (78%) and 'temperament and personality functions' (77%). With regard to the component activities and participation, patients felt most restricted in the categories of 'watching' (e.g. TV) (82%), 'recreation and leisure' (75%) and 'carrying out daily routine' (74%). Within the component environmental factors the categories 'support of immediate family', 'health services, systems and policies' and 'products or substances for personal consumption [medication]' were the most important facilitators; 'time-related changes', 'light' and 'climate' were the most important barriers. The study identified a large variety of functional problems reflecting the complexity of sleep disorders. The ICF has the potential to provide a comprehensive framework for the description of functional health in individuals with sleep disorders in a clinical setting.

Spinal Cord Diffusion-Tensor Imaging and Motor-evoked Potentials in Multiple Sclerosis Patients: Microstructural and Functional Asymmetry

Purpose: To assess possible association between intrinsic structural damage and clinical disability by correlating spinal cord diffusion-tensor (DT) imaging data with electrophysiological parameters in patients with a diagnosis of multiple sclerosis (MS). Materials and Methods: This study was approved by the local ethical committee according to the declaration of Helsinki and written informed consent was obtained. DT images and T1- and T2-weighted images of the spinal cord were acquired in 28 healthy volunteers and 41 MS patients. Fractional anisotropy (FA) and apparent diffusion coefficients were evaluated in normal-appearing white matter (NAWM) at the cervical level and were correlated with motor-evoked potentials (n = 34). Asymmetry index was calculated for FA values with corresponding left and right regions of interest as percentage of the absolute difference between these values relative to the sum of the respective FA values. Statistical analysis included Spearman rank correlations, Mann-Whitney test, and reliability analysis. Results: Healthy volunteers had low asymmetry index (1.5%-2.2%). In MS patients, structural abnormalities were reflected by asymmetric decrease of FA (asymmetry index: 3.6%; P = .15). Frequently asymmetrically affected among MS patients was left and right central motor conduction time (CMCT) to abductor digiti minimi muscle (ADMM) (asymmetry index, 15%-16%) and tibialis anterior muscle (TAM) (asymmetry index, 9.5%-14.1%). Statistically significant correlations of functional (ie, electrophysiological) and structural (ie, DT imaging) asymmetries were found (P = .005 for CMCT to ADMM; P = .007 for CMCT to TAM) for the cervical lateral funiculi, which comprise the crossed pyramidal tract. Interobserver reliability for DT imaging measurements was excellent (78%-87%). Conclusion: DT imaging revealed asymmetric anatomic changes in spinal cord NAWM, which corresponded to asymmetric electrophysiological deficits for both arms and legs, and reflected a specific structure-function relationship in the human spinal cord. © RSNA, 2013.

Are there accurate predictors of long-term vital and functional outcomes in cardiac surgical patients requiring prolonged intensive care?

BACKGROUND AND OBJECTIVE: The decision to maintain intensive treatment in cardiac surgical patients with poor initial outcome is mostly based on individual experience. The risk scoring systems used in cardiac surgery have no prognostic value for individuals. This study aims to assess (a) factors possibly related to poor survival and functional outcomes in cardiac surgery patients requiring prolonged (> or = 5 days) intensive care unit (ICU) treatment, (b) conditions in which treatment withdrawal might be justified, and (c) the patient's perception of the benefits and drawbacks of long intensive treatments. METHODS: The computerized data prospectively recorded for every patient in the intensive care unit over a 3-year period were reviewed and analyzed (n=1859). Survival and quality of life (QOL) outcomes were determined in all patients having required > or =5 consecutive days of intensive treatment (n=194/10.4%). Long-term survivors were interviewed at yearly intervals in a standardized manner and quality of life was assessed using the dependency score of Karnofsky. No interventions or treatments were given, withhold, or withdrawn as part of this study. RESULTS: In-hospital, 1-, and 3-year cumulative survival rates reached 91.3%, 85.6%, and 75.1%, respectively. Quality of life assessed 1 year postoperatively by the score of Karnofsky was good in 119/165 patients, fair in 32 and poor in 14. Multivariate logistic regression analysis of 19 potential predictors of poor outcome identified dialysis as the sole factor significantly (p=0.027) - albeit moderately - reducing long-term survival, and sustained neurological deficit as an inconstant predictor of poor functional outcome (p=0.028). One year postoperatively 0.63% of patients still reminded of severe suffering in the intensive station and 20% of discomfort. Only 7.7% of patients would definitely refuse redo surgery. CONCLUSIONS: This study of cardiac surgical patients requiring > or =5 days of intensive treatment did not identify factors unequivocally justifying early treatment limitation in individuals. It found that 1-year mortality and disability rates can be maintained at a low level in this subset of patients, and that severe suffering in the ICU is infrequent.

Multiple retinal detachment surgery: A functional outcome study. The Houston Vision Assessment Test-Retina (HVAT-Retina)

Retinal detachment is a common ophthalmologic procedure, and outcome is typically measured by a single factor-improvement in visual acuity. Health related functional outcome testing, which quantifies patient's self-reported perception of impairment, can be integrated with objective clinical findings. Based on the patient's self-assessed lifestyle impairment, the physician and patient together can make an informed decision on the treatment that is most likely to benefit the patient. ^ A functional outcome test (the Houston Vision Assessment Test-Retina; HVAT-Retina) was developed and validated in patients with multiple retinal detachments in the same eye. The HVAT-Retina divides an estimated total impairment into subcomponents: contribution of visual disability (potentially correctable by retinal detachment surgery) and nonvisual physical disabilities (co-morbidities not affected by retinal detachment surgery. ^ Seventy-six patients participated in this prospective multicenter study. Seven patients were excluded from the analysis because they were not certain of their answers. Cronbach's alpha coefficient was 0.91 for presurgery HVAT-Retina and 0.94 post-surgery. The item-to-total correlation ranged from 0.50 to 0.88. Visual impairment score improved by 9 points from pre-surgery (p = 0.0003). Physical impairment score also improved from pre-surgery (p = 0.0002). ^ In conclusion, the results of this study demonstrate that the instrument is reliable and valid in patients presenting with recurrent retinal detachments. The HVAT-Retina is a simple instrument and does not burden the patient or the health professional in terms of time or cost. It may be self-administrated, not requiring an interviewer. Because the HVAT-Retina was designed to demonstrate outcomes perceivable by the patient, it has the potential to guide the decision making process between patient and physician. ^

El fitness como factor determinante en el riesgo de discapacidad, su relación con la composición corporal y el estado cognitivo en población mayor institucionalizada y de vida independiente = Fitness as a determinant factor in the risk of disability, and its relationship to body composition and cognitive status in institutionalized elderly population and independent living

La condición física, o como mejor se la conoce hoy en día el “fitness”, es una variable que está cobrando gran protagonismo, especialmente desde la perspectiva de la salud. La mejora de la calidad de vida que se ha experimentado en los últimos años en las sociedades desarrolladas, conlleva un aumento de la esperanza de vida, lo que hace que cada vez más personas vivan más años. Este rápido crecimiento de la población mayor de 60 años hace que, un grupo poblacional prácticamente olvidado desde el punto de vista de la investigación científica en el campo de la actividad física y del deporte, cobre gran relevancia, con el fin de poder ayudar a alcanzar el dicho “no se trata de aportar años a la vida sino vida a lo años”. La presente memoria de Tesis Doctoral tiene como principal objetivo valorar los niveles de fitness en población mayor española, además de analizar la relación existente entre el fitness, sus condicionantes y otros aspectos de la salud, tales como la composición corporal y el estado cognitivo. Entendemos que para poder establecer futuras políticas de salud pública en relación a la actividad física y el envejecimiento activo es necesario conocer cuáles son los niveles de partida de la población mayor en España y sus condicionantes. El trabajo está basado en los datos del estudio multicéntrico EXERNET (Estudio Multi-céntrico para la Evaluación de los Niveles de Condición Física y su relación con Estilos de Vida Saludables en población mayor española no institucionalizada), así como en los datos de dos estudios, llevados a cabo en población mayor institucionalizada. Se han analizado un total de 3136 mayores de vida independiente, procedentes de 6 comunidades autónomas, y 153 mayores institucionalizados en residencias de la Comunidad de Madrid. Los principales resultados de esta tesis son los siguientes: a) Fueron establecidos los valores de referencia, así como las curvas de percentiles, para cada uno de los test de fitness, de acuerdo a la edad y al sexo, en población mayor española de vida independiente y no institucionalizada. b) Los varones obtuvieron mejores niveles de fitness que las mujeres, excepto en los test de flexibilidad; existe una tendencia a disminuir la condición física en ambos sexos a medida que la edad aumenta. c) Niveles bajos de fitness funcional fueron asociados con un aumento en la percepción de problemas. d) El nivel mínimo de fitness funcional a partir del cual los mayores perciben problemas en sus actividades de la vida diaria (AVD) es similar en ambos sexos. e) Niveles elevados de fitness fueron asociados con un menor riesgo de sufrir obesidad sarcopénica y con una mejor salud percibida en los mayores. f) Las personas mayores con obesidad sarcopénica tienen menor capacidad funcional que las personas mayores sanas. g) Niveles elevados de fuerza fueron asociados con un mejor estado cognitivo siendo el estado cognitivo la variable que más influye en el deterioro de la fuerza, incluso más que el sexo y la edad. ABSTRACT Fitness is a variable that is gaining in prominence, especially from the health perspective. Improvement of life quality that has been experienced in the last few years in developed countries, leads to an expanded life expectancy, increasing the numbers of people living longer. This population consisting of people of over 60 years, an almost forgotten population group from the point of view of scientific research in the field of physical activity and sport, is becoming increasingly important, with the main aim of helping to achieve the saying “do not only add years to life, but also add life to years”. The principal aim of the current thesis was to assess physical fitness levels in Spanish elderly people, of over 65 years, analyzing relationship between physical fitness, its determinants, and other aspects of health such as body composition and cognitive status. In order to establish further public health policies in relation to physical activity and active ageing it is necessary to identify the starting physical fitness levels of the Spanish population and their determinants. The work is based on data from the EXERNET multi-center study ("Multi-center Study for the Evaluation of Fitness levels and their relationship to Healthy Lifestyles in noninstitutionalized Spanish elderly"), and on data from two studies conducted in institutionalized elderly people: a total of 3136 non-institutionalized elderly, from 6 Regions of Spain, and 153 institutionalized elderly in nursing homes of Madrid. The main outcomes of this thesis are: a) sex- and age-specific physical fitness normative values and percentile curves for independent and non-institutionalized Spanish elderly were established. b) Greater physical fitness was present in the elderly men than in women, except for the flexibility test, and a trend toward decreased physical fitness in both sexes as their age increased. c) Lower levels of functional fitness were associated with increased perceived problems. d) The minimum functional fitness level at which older adults perceive problems in their ADLs, is similar for both sexes e) Higher levels of physical fitness were associated with a reduced risk of suffering sarcopenic obesity and better perceived health among the elderly. f) The elderly with sarcopenic obesity have lower physical functioning than healthy counterparts. g) Higher strength values were associated with better cognitive status with cognitive status being the most influencing variable in strength deterioration even more than sex and age.

Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task

Study Design. Cross-sectional study. Objective. This study compared neck muscle activation patterns during and after a repetitive upper limb task between patients with idiopathic neck pain, whiplash-associated disorders, and controls. Summary of Background Data. Previous studies have identified altered motor control of the upper trapezius during functional tasks in patients with neck pain. Whether the cervical flexor muscles demonstrate altered motor control during functional activities is unknown. Methods. Electromyographic activity was recorded from the sternocleidomastoid, anterior scalenes, and upper trapezius muscles. Root mean square electromyographic amplitude was calculated during and on completion of a functional task. Results. A general trend was evident to suggest greatest electromyograph amplitude in the sternocleidomastoid, anterior scalenes, and left upper trapezius muscles for the whiplash-associated disorders group, followed by the idiopathic group, with lowest electromyographic amplitude recorded for the control group. A reverse effect was apparent for the right upper trapezius muscle. The level of perceived disability ( Neck Disability Index score) had a significant effect on the electromyographic amplitude recorded between neck pain patients. Conclusions. Patients with neck pain demonstrated greater activation of accessory neck muscles during a repetitive upper limb task compared to asymptomatic controls. Greater activation of the cervical muscles in patients with neck pain may represent an altered pattern of motor control to compensate for reduced activation of painful muscles. Greater perceived disability among patients with neck pain accounted for the greater electromyographic amplitude of the superficial cervical muscles during performance of the functional task.

Measuring functional outcome in paediatric patients with burns: methodological considerations

Methodological criticisms of research undertaken in the area of paediatric burns are widespread. To date, quasi-experimental research designs have most frequently been used to examine the impact of impairments such as scarring and reduced ran e of motion on functional outcomes. Predominantly, these studies have utilised a narrow definition of functioning (e.g. school attendance) to determine a child's level of participation in activities post-burn injury. Until recently, there had been little attempt to develop and/or test a theoretical model of functional outcome with these children. Using a conceptual model of functional outcome based oil the International Classification of Functioning, Disability and Health, this review paper outlines the current state of the research literature and presents explanatory case study methodology as an alternative research design to further advance the Study of functional outcome post-burn injury. (C) 2004 Elsevier Ltd and ISBI. All rights reserved.

Effects of Helicobacter pylori eradication among adults with intellectual disability

Background Compared to the general population, Helicobacter pylori infection is more common among adults with intellectual disability (ID) and is associated with greater levels of disability, maladaptive behaviour, and institutionalization. Little information exists about the effects of eradication therapy in this group, so we aimed to evaluate: (1) success of a standard H. pylori eradication protocol; (2) frequency of side-effects; and (3) impact of eradication on level of functional ability and maladaptive behaviour. Method A cohort of adults with ID underwent assessment of their levels of function and maladaptive behaviour, medical history, physical examination, and H. pylori testing using serology and faecal antigen tests. Some received standard H. pylori eradication therapy. Twelve months later, participants underwent repeat assessment, were grouped by change in H. pylori status and compared. Results Of 168 participants, 117 (70%) were currently infected with H. pylori at baseline, and 96 (82%) of the 117 were given standard H. pylori eradication therapy. The overall eradication rate was 61% but 31% reported side-effects. Institutional status of the participants, their level of behaviour or function, and number of comorbid medical conditions were not associated with failure of eradication. There were no statistically significant differences in level of behaviour or function, ferritin, or weight between the groups in whom H. pylori was eradicated or stayed positive. Conclusion Adults with ID have lower H. pylori eradication and higher side-effect rates than the general population. Levels of maladaptive behaviour and disability did not improve with eradication and thus greater levels of maladaptive behaviour or disability appear to be risk factors for, rather than consequences of, H. pylori infection.

Personality disorders in the community: Results from the Australian National Survey of Mental Health and Well-Being Part III - Relationships between specific type of personality disorder, Axis 1 mental disorders and physical conditions with disability and health consultations

Background The aims of this study were threefold. First, to ascertain whether personality disorder (PD) was a significant predictor of disability (as measured in a variety of ways) over and above that contributed by Axis I mental disorders and physical conditions. Second, whether the number of PD diagnoses given to an individual resulted in increasing severity of disability, and third, whether PD was a significant predictor of health and mental health consultations with GPs, psychiatrists, and psychologists, respectively, over the last 12 months. Method Data were obtained from the National Survey of Mental Health and Wellbeing, conducted between May and August 1997. A stratified random sample of households was generated, from which all those aged 18 and over were considered potential interviewees. There were 10 641 respondents to the survey, and this represented a response rate of 78%. Each interviewee was asked questions indexing specific ICD-10 PD criteria. Results Five measures of disability were examined. It was found that PD was a significant predictor of disability once Axis I and physical conditions were taken into account for four of the five disability measures. For three of the dichotomously-scored disability measures, odds ratios ranged from 1.88 to 6.32 for PD, whilst for the dimensionally-scored Mental Summary Subscale of the SF-12, a beta weight of -0.17 was recorded for PD. As regards number of PDs having a quasi-linear relationship to disability, there was some indication of this on the SF-12 Mental Summary Subscale and the two role functioning measures, and less so on the other two measures. As regards mental consultations, PD was a predictor of visits to GPs, psychiatrists and psychologists, over and above Axis I disorders and physical conditions. Conclusion The study reports findings from a nationwide survey conducted within Australia and as such the data are less influenced by the selection and setting bias inherent in other germane studies. However, it does support previous findings that PD is a significant predictor of disability and mental health consultations independent of Axis I disorders and physical conditions.

Functional capacity evaluation as a performance measure - Evidence for a new approach for clients with chronic back pain

Objectives: To report the research and development of a new approach to Functional Capacity Evaluation, the Gibson Approach to Functional Capacity Evaluation (GAPP FCE) for chronic back pain clients. Methods: Four Studies, including pilot and feasibility testing, expert review, and preliminary interrater reliability examination, are described here. Participants included 7 healthy young adults and 19 rehabilitation clients with back pain who underwent assessment using the GAPP FCE. Thirteen therapists were trained in the approach and were silently observed administering the Functional Capacity Evalutions by at least 1 other trained therapists or the first investigator Or both. An expert review using 5 expert occupational therapists was also conducted. Results: Study 1, the pilot with healthy individuals, indicated that the GAPP FCE was a feasible approach with good utility. Study 2, a pilot using 2 trained therapists assessing 5 back pain clients, supported the clinical feasibility of the approach. The expert review in Study 3 found support for GAPP FCE. Study 4, a trial of the approach with 14 rehabilitation clients, found support for the interrater reliability of recommendations for return to work based on performance in the GAPP FCE. Discussion: The evidence thus far available supports the GAPP FCE as ail approach that provides a Sound method for evaluating the performance of the physical demands of work with clients with chronic back pain. The tool has been shown to have good face and content validity, to meet acceptable test standards, and to have reasonable interrater reliability. Further research is occurring to look at a larger interrater reliability study, to further examine content validity, and to examine predictive validity.