FOI 24.25 0380 12.Research Request self reported functional capacity.pdf

DOCUMENT 12
FOI 24/25-0380
Research Request – Impact of funding on self-reported
functional capacity and perceived difficulty Vs actual
functional performance
1. Search for evidence that self-reporting of functional capacity is
influenced when funding for supports is involved i.e. that self-reporting
of capacity may be an unreliable way to assess function when money
for supports is dependent on the person’s responses.
Brief
2. Search for evidence that perceived difficulty does not equate to actual
functional performance. We need some evidence that supports that a
person could have severe difficulty doing something but still be able to
do it independently – this is about the legal test for Access to the NDIS
under s24.1(c)
Date
27/08/2020
Requester
S47F -
(TAB Director)
Personal
Researcher
S47F -
(Research Team Leader)
Personal
Contents
Question 1 ............................................................................................................................................... 2
Question 2 ............................................................................................................................................... 6
Reference List ........................................................................................................................................ 11
Please note:
The research and literature reviews col ated by our TAB Research Team are not to be shared
external to the Branch. These are for internal TAB use only and are intended to assist our advisors
with their reasonable and necessary decision making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates require
further information on access or planning matters they are to call the TAPS line for advice.
The Research Team are unable to ensure that the information listed below provides an accurate &
up-to-date snapshot of these matters
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Question 1
Search for evidence that self-reporting of functional capacity is influenced when funding for
supports is involved i.e. that self-reporting of capacity may be an unreliable way to assess function
when money for supports is dependent on the person’s responses.

Literature investigating whether self-reported functional capacity is impacted by the possibility for
compensation/financial gain has primarily focused on claimants of injury compensation. Controversy
has often surrounded injury compensation in relation to the motivations and personal
characteristics of claimants [1]. These criticisms include suggestions that claimants were “sick” prior
to the event, that claimants are malingering or exaggerating symptoms for financial or other
secondary gain and that the system encourages people to “stay sick”[1]. Various meta-analyses and
prospective observational studies have identified that participants who are receiving compensation
routinely self-report greater pain and disability [2-5]. A meta-analysis of the association between
compensation status and the experience and treatment of chronic pain found that patients who
received compensation self-reported a greater experience of pain (Effect size = 0.60, p <.0002) and
reduced treatment efficacy [2]. Similarly, Binder et al [4] performed a meta-analysis to evaluate the
impact of financial incentives on disability, symptoms and objective findings after closed head injury.
The authors found greater abnormality and disability in patients with financial incentives despite less
severe injuries (ES = 0.47, p <0.001). Both studies concluded that financial incentives have a
powerful effect on perceived level of disability, however, they note that other factors need to be
taken into consideration such as psychiatric history, evidence of malingering or health status.
Similar to Binder et al [4], a prospective observational study comparing long-term disability and
health related quality of life outcomes of patients with lumbar disc herniation found that moderate
or severe physical examination findings were less common in patients receiving workers’
compensation (62% vs. 82%, P 0.003) [3]. Interestingly, those on workers compensation (less severe
injury) were less likely to report improvements in either back or leg pain compared to those not
receiving workers’ compensation (53.7% vs. 72.2%, respectively, P 0.001) and that workers’
compensation is associated with an increased likelihood of long-term disability (adjusted OR of 2.55,
95% CI 1.01_7.11). The authors conclude that because diagnosis critically depends on the symptoms
reported by patients, the disability compensation process can skew pain perceptions and their
functional impact.
An investigation into whether symptom exaggeration is a factor in complaints of cognitive
dysfunction in patients with fibromyalgia (FM) who are claiming disability payments compared to
those who aren’t was performed by Gervais et al [5]. Results showed that a significant proportion of
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the patients in the FM Disability group (at least 35%) demonstrated incomplete effort, a behaviour
associated with over reporting and exaggeration of cognitive difficulties, at the time of assessment
and would probably produce invalid results on ability tests. It should be noted no differences
between demographic characteristics of both groups were reported. A pattern of higher symptom
reporting consistently observed in the FM Disability group, which obtained significantly higher scores
than the FM No Disability group on all SCL-90-R (self-report symptom checklist) scales. These results
clearly indicate that tests of effort designed to detect incomplete effort and potential exaggeration
of cognitive deficits have a role to play in the assessment of patients with FM, particularly where
eligibility for medical disability benefits owing to claimed cognitive impairment is an issue.
This is a very complicated area in which it is hard to find definitive answers. The compensation
process takes place in complex contexts that are different for each claimant, a variety of motivations
and influences impact in different ways on each person. However, various studies have identified
that the possibility for financial compensation can impact symptoms, subjective level of disability
and possibly end up rewarding disability.
Table 1 below provides an overview of included studies.
Table 1
Title
Study
Results
Conclusion
design/question
Rohling et al.  Meta-analysis of the  32 included studies, 3,802 pain
Clear that receiving financial
(1995)
association between  patients and 3,849 controls
compensation is associated
compensation status  (non-compensated)
with a greater experience of
and the experience
- Patients who received
pain and reduced treatment
and treatment of
compensation self-reported a
efficacy.
chronic pain
greater experience of pain (ES =  The authors suggest that it is
Focus on workers
0.60, p <.0002)
possible that patients that seek
compensation,
compensation have a more
Veterans Affairs,
difficult time managing pain,
civil suit settlements
however, included studies
and social security
lacked characteristics on
disability insurance
psychiatric history, evidence of
malingering or health status.
Atlas et al.
Prospective,
172 receiving and 222 not
Measured differences in
(2006)
observational study.  receiving workers compensation  clinical characteristics, baseline

features, or initial treatment
To compare long-
-Groups had similar physical
received could not explain
term disability and
examination findings, but
differences found.
health related
among patients with advanced
For patients with back pain,
quality of life
imaging studies available for
those who enter the workers’
outcomes of
review, moderate or severe
compensation system face an
individuals receiving  findings were less common in
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or not receiving
patients receiving workers’
adversarial process that can
workers’
compensation (62% vs. 82%, P
end up rewarding disability.
compensation at
0.003).

baseline evaluation

Because the diagnosis critically

-Patients initially receiving
depends on the symptoms
Lumbar Disc
workers’ compensation were
reported by patients, the
Herniation
less likely to report that
disability compensation
their predominant pain
process can skew pain
symptom, either back or leg
perceptions and their
pain, was improved compared
functional impact.
to those not receiving workers’
compensation at baseline
(53.7% vs. 72.2%, respectively, P
0.001)

-Workers’ compensation claim
is associated with an increased
likelihood of long-term disability
(adjusted OR of 2.55, 95% CI
1.01_7.11).
Binder at al.  Meta-analysis
18 included studies, 2,353
The effect of monetary
(1996)
To evaluate the
participants
incentives is more powerful for
impact of financial
The data showed more
patients with mild head injury
incentives on
abnormality and disability in
than those with moderate to
disability, symptoms  patients with financial
severe injury.
and objective
incentives despite less severe
Authors suggest that the effect
findings after closed  injuries (ES = 0.47, p <0.001).
of financial incentives on
head injury
symptoms and objective
cognitive abnormalities be
considered. A formal measure
of motivation and effort should
be conducted because the
absence of these measures
means clinicians are oblivious
to malingering.
Gervais et al.  To examine whether  A significant proportion of the
Our results clearly indicate that
(2001).
symptom
patients in the FM Disability
tests of effort designed to
exaggeration is a
group (at least 35%)
detect incomplete effort and
factor in complaints
of cognitive
demonstrated incomplete
potential exaggeration of
effort, a behaviour associated
cognitive deficits have a role to
dysfunction using 2
with over reporting and
play in the assessment of
new validated
exaggeration of cognitive
patients with FM, particularly
instruments in
difficulties, at the time of
where eligibility for medical
patients with
assessment and would probably  disability benefits owing to
fibromyalgia (FM).
produce invalid results on
claimed cognitive impairment
ability tests.
is an issue
No difference in demographic

characteristics between groups
(age, education, pain duration,
Any disability related
assessment or other
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memory problem, how much
investigation of the
pain, verbal scores)
neuropsychological status of
Only 2 patients with FM who
patients with FM that does not
were working and/or not
employ formal effort testing
claiming disability benefits
procedures to screen for
scored below the cut-offs for
exaggeration of memory or
exaggeration of memory
other cognitive problems runs
difficulties
the risk of drawing conclusions
based on invalid test data or
Pattern of higher symptom
questionable self-reported
reporting consistently observed symptoms and limitations.
in the FM Disability group,
which obtained significantly
higher scores than the FM No
Disability and RA groups on all
SCL-90-R (self-report symptom
checklist) scales

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Question 2
Search for evidence that perceived difficulty does not equate to actual functional performance.
We need some evidence that supports that a person could have severe difficulty doing something
but stil be able to do it independently – this is about the legal test for Access to the NDIS under
s24.1(c)

Literature in this area is scant, with most studies investigating the correlation between subjective
questionnaires compared to objective measures of functional capacity rather than an individual’s
level of capacity to perform a task independently. A prospective cohort study [6] of participants with
non-specific low back pain compared self-report measures (Roland Disability Questionnaire,
Oswestry Disability Questionnaire, Quebec Back Pain Disability Questionnaire) to the Isernhagen
Work Systems Functional Capacity Evaluation (FCE). The self-reported measures were consistent
with moderate to severe disability. In contrast the results from the performance-based measures
suggested that the participants should be able to work at a physical intensity level of moderate to
heavy. This led to little to moderate observed correlation between the self-report and performance-
based measures (Spearman rank correlations: Roland-FCE (-0.20), p > 0:05; Oswestry-FCE (-0.52), p <
0:01; Quebec-FCE (-0.50), p < 0:01). The authors concluded that self-report of ability to perform
certain activities cannot be interchanged with the actual ability to perform that same activity, and
that both performance-based and self-report measures of disability should be used in order to
obtain a comprehensive picture of the disability. Similarly, Gross et al [7] and Goverover [8] found a
moderate and non-significant correlation between subjective and objective functional measures
respectively. Both studies investigated different populations (multiple sclerosis and low back
injuries) and used different performance measures. However, both concluded that performance can
be impacted by many factors and that reliance solely on self-report assessments of everyday
activities may provide information that may not reflect actual performance in everyday life.

In the realm of mental health, Bowie et al [11] examined the convergence of schizophrenia patients’
reports of their everyday functional status (using a self-report of real-world functional outcomes)
and found that 24 (36%) of the patients were accurate estimators, 27 (40%) were over-estimators,
and 16 (24%) were under-estimators. Patients who underestimated their functional skil s had the
highest level of cognitive ability, but also the highest level of self-rated depression. This study
provided evidence that patients with Schizophrenia give internally consistent self-reports across
different domains, but that self-reports were not associated with objective indices of functioning.

Self-efficacy has been investigated as a potential factor which influences the relationship between
self-reported functional capacity and disability [9]. The Prosthesis Evaluation Questionnaire –
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Mobility Scale (PEQ-MS), World Health Organization Disability Assessment Schedule 2.0 (WHODAS
2.0) and Self-Efficacy of Managing Chronic Disease (SEMCD) scale were delivered to patients with
dysvascular transtibial amputation and found that the relationship between perceived functional
capacity and self-reported disability is partially mediated by self-efficacy. This means that lower self-
efficacy can impact on a person’s perceived functional capacity.

The relationship between perceived and objective cognitive functioning in a large sample of MS
patients has been investigated by Middleton et al [10]. Results showed that perceptions of global
cognitive functioning during the course of their daily lives were unrelated (r =−.11) to objective
performance, indicating that MS patients’ metacognitive skil s are well preserved. These results have
important implications for clinical practice. A patient’s complaints of cognitive difficulty are often the
primary criterion upon which referral for neuropsychological assessment is based. Therefore, basing
cognitive impact solely on subjective symptoms is not advisable and complaints of cognitive difficulty
should be corroborated by reports of caregivers and by brief screening measures.
Self-report instruments may provide useful information about the client’s view and perspective,
such as issues related to cultural background, motivation, perceptions, and life choices. However,
subjective measures do not always correlate with a patient’s actual real-world functional capacity.
Table 2 below provides an overview of included studies.

Table 2
Title
Study design/question  Results
Conclusion
Reneman et  Prospective cohort
Study compared the results of self- Self-report of ability to
al. (2002)
study
reported and performance-based
perform certain activities

measures of disability in 64
cannot be interchanged
To investigate the
consecutive patients with CLBP.
with the actual ability to
concurrent validity of

perform that same
two approaches to
The mean scores from the self-
activity.
disability measurement  report measure are as follows:

in patients with chronic  Roland 13.5 (scale 0–24), Oswestry  A performance measure
nonspecific low back
28.2 (scale 0–100), and Quebec
should be used to
pain (CLBP).
37.8 (scale 0–100) consistent with
measure “a person’s

moderate to severe disability. In
ability to perform an
self-report measures
contrast the results from the
activity,” whereas a
used were: the Roland
performance-based measures
questionnaire should be
Disability Questionnaire  suggested that the subjects should  used to measure “a
(Roland); the Oswestry
be able to work at a physical
person’s self-reported
Disability Questionnaire
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(Oswestry); and the
intensity level of moderate to
ability to perform an
Quebec Back Pain
heavy.
activity.”
Disability Questionnaire

(Quebec). Performance  Little to moderate correlation was  Results are interpreted
was measured using the  observed between the self-report
to suggest that both
Isernhagen Work
and performance-based measures  performance-based and
Systems Functional
(Spearman rank correlations:
self-report measures of
Capacity Evaluation
Roland-FCE (-0.20), p > 0:05;
disability should be used
(FCE).
Oswestry-FCE (-0.52), p < 0:01;
in order to obtain a
Quebec-FCE (-0.50), p < 0:01).
comprehensive picture
of the disability in
patients with CLBP.

Gross et al.
To evaluate the
170 workers compensation
Performance on the FCE
(2005)
association between
claimants undergoing functional
appears to be influenced
performance on the
capacity evaluations for low back
by both physical factors
Isernhagen Work
injuries.
and self-perceptions of
System Functional

disability and pain.
Capacity Evaluation
Self-reported ratings of perceived

(IWS-FCE) and various
disability on the PDI and pain
Functional capacity
clinical and psychosocial  intensity using a VAS were
evaluations should be
factors
moderately associated with both
considered behavioural

performance-based functional
tests influenced by
Cross-sectional study
indicators, weight lifted on the
multiple factors,

floor-to-waist lift tasks and the
including physical ability,
Pain Disability Index
number of failed FCE tasks.
beliefs, and perceptions.
Pain Visual Analog Scale
Isernhagen
Work System Functional
Capacity Evaluation
Floor to Waist Lift
Goverover et  To investigate the
Al  correlations between subjective  Reliance solely on self-
al. (2005)
relation between
and objective functional measures  report assessments of
subjective and objective  were non-significant
everyday activities may
performance-based
provide information that
measures of functional
Scores on the FBP (but not the
FAMS) were significantly
may not reflect actual
status in persons with
associated with EFPT performance.  performance in everyday
multiple sclerosis (MS),  Thus, the current results support
life
and to compare their
and extend previous findings that
performance with
depressive symptomatology may
healthy controls
distort patients’ perception of their

instrumental ADLs and Quality of
-The Executive Function  Life
Performance Test
(EFPT)
-Functional Assessment
of Multiple Sclerosis
(FAMS)
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-Functional Behaviour
Profile (FBP).
Miller et al.
Describe the
38 men with dysvascular transtibial  Evidence that the
(2018)
relationships between
amputation.
relationship between
perceived functional
perceived functional
capacity, self-efficacy,
The relationship between self-
capacity and self-
and disability and 2)
reported functional capacity and
reported disability is
identify if self-efficacy
disability is partially mediated by
partially mediated by
mediates the
self-efficacy. Relationships
self-efficacy
relationship between
between WHODAS 2.0 and PEQ-MS
self-reported functional  (r = −0.61), WHODAS 2.0 and
capacity and disability
SEMCD (r = −0.51), and PEQ-MS
after dysvascular
and SEMCD (r = 0.44) were
transtibial amputation.
significant (P < .01). Controlling for

SEMCD (P = .04), the relationship
Data taken from a
between PEQ-MS and WHODAS 2.0
baseline RCT
remained significant (P < .01).

-Prosthesis Evaluation
Questionnaire –
Mobility Scale (PEQ-
MS).
-World Health
Organization Disability
Assessment Schedule
2.0 (WHODAS 2.0)
-Self-Efficacy of
Managing Chronic
Disease (SEMCD) scale
Middleton et  (a) examining the
221 patients with MS and 31
These results add to the
al. (2006)
relationship between
controls
understanding of
perceived and objective
patients’ expressed
cognitive functioning in  perceptions of global cognitive
concerns regarding their
a large sample of MS
functioning during the course of
cognitive functioning in
patients; (b) expand the  their daily lives were unrelated (r
the wake of multiple
construct of perceived
=−.11) to objective performance on  sclerosis, suggesting that
cognitive functioning to  the array of tasks composing the
such concerns should be
include both
cognitive battery results of the
interpreted with caution
perceptions of global
present study indicate that MS
by clinicians.
cognitive functioning
patients’ metacognitive skills are

and perceptions of
well preserved
performance on specific
cognitive tasks; (c)
identifying variables
that contribute to the
discrepancy between
perceived and objective
cognitive functioning in
MS patients.

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-Cognitive Battery of
tests
-Perceived Cognitive
Functioning
-Depression, Anxiety,
Fatigue

Bowie et al.
To examine the
24 (36%) of the patients were
Schizophrenia patients
(2007)
convergence of
accurate estimators, 27 (40%) were  give internally consistent
schizophrenia patients’  over-estimators, and 16 (24%)
self-reports across
reports of their
were under-estimators.
different domains, but
everyday functional

that these self-reports
status (using a self-
The correlations of patients’ self-
were not associated with
report of real-world
reported Work skills with
objective indices of
functional outcomes)
depression were greater in
functioning
with the reports of their  magnitude than case manager
case managers and to
ratings.
identify the correlates

of the level of accuracy  Patients who underestimated their
of these reports.
functional skil s had the highest

level of cognitive ability, but also
Specific Levels of
the highest level of self-rated
Functioning (SLOF)
depression.
Functional capacity

assessments
Across the functional skill domains,
Performance-based
case manager ratings were more
skills assessment
highly correlated with objective
Social Skills
measures such as cognitive
Performance
performance, UPSA performance,
Assessment (SSPA)
and SSPA performance than were
Beck depression
self-appraisals. Patients’ self-
inventory Self-rated
ratings tended to be correlated
Quality of Life Scale
with measures of subjective
outcomes, such as depression and
quality of life, but less so with the
objective measures of functional
skills and cognition.

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Reference List
1.  Varker, T., Creamer, M., Khatri, J., Fredrickson, J., & O’Donnell, M.L. (2018). Mental health
impacts of compensation claims assessment processes on claimants and their families: Final
report. Phoenix Australia – Centre for Posttraumatic Mental Health.
2.  Rohling ML, Binder LM, Langhinrichsen-Rohling J. Money matters: A meta-analytic review of
the association between financial compensation and the experience and treatment of
chronic pain. Health Psychology. 1995 Nov;14(6):537.
3.  Atlas SJ, Chang Y, Keller RB, Singer DE, Wu YA, Deyo RA. The impact of disability
compensation on long-term treatment outcomes of patients with sciatica due to a lumbar
disc herniation. Spine. 2006 Dec 15;31(26):3061-9.
4.  Binder LM, Rohling ML. Money matters: a meta-analytic review of the effects of financial
incentives on recovery after closed-head injury. American Journal of Psychiatry. 1996 Jan
1;153(1):7-10.
5.  Gervais RO, Russell AS, Green PA, Allen LM, Ferrari RO, Pieschl SD. Effort testing in patients
with fibromyalgia and disability incentives. The Journal of Rheumatology. 2001 Aug
1;28(8):1892-9.
6.  Reneman MF, Jorritsma W, Schellekens JM, Göeken LN. Concurrent validity of questionnaire
and performance-based disability measurements in patients with chronic nonspecific low
back pain. Journal of Occupational Rehabilitation. 2002 Sep 1;12(3):119-29.
7.  Gross DP, Battié MC. Factors influencing results of functional capacity evaluations in
workers' compensation claimants with low back pain. Physical therapy. 2005 Apr
1;85(4):315-22.
8.  Goverover Y, Kalmar J, Gaudino-Goering E, Shawaryn M, Moore NB, Halper J, DeLuca J. The
relation between subjective and objective measures of everyday life activities in persons
with multiple sclerosis. Archives of Physical Medicine and Rehabilitation. 2005 Dec
1;86(12):2303-8.
9.  Miller MJ, Magnusson DM, Lev G, Fields TT, Cook PF, Stevens-Lapsley JE, Christiansen CL.
Relationships Among Perceived Functional Capacity, Self-Efficacy, and Disability After
Dysvascular Amputation. PM&R. 2018 Oct;10(10):1056-61.
10. Middleton LS, Denney DR, Lynch SG, Parmenter B. The relationship between perceived and
objective cognitive functioning in multiple sclerosis. Archives of clinical neuropsychology.
2006 Aug 1;21(5):487-94.
11. Bowie CR, Twamley EW, Anderson H, Halpern B, Patterson TL, Harvey PD. Self-assessment of
functional status in schizophrenia. Journal of psychiatric research. 2007 Dec 1;41(12):1012-8.

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