Functional Continuum Questionnaire
Thirty years ago, the Functional Continuum Questionnaire (FCQ) was developed to measure functional outcomes using biofeedback in an occupational therapy context. Initially, the assessment was designed to identify dysfunction in various areas that influence occupational behavior (daily tasks) and performance, to identify goals for therapy. Over time, the FCQ was reformatted to produce a score that correlates as a discreet point on a continuum of function/dysfunction (functional continuum). This score may be used as a pre- and post-assessment to evaluate patients' perception of change in function as an outcome of biofeedback and occupational therapy. The FCQ is presented in this article along with the functional continuum. A brief discussion about the theoretical framework—the model of human occupation—is provided. The statements used in the FCQ describe components of occupational behavior from the model, providing a comprehensive set of factors influencing occupational performance. The FCQ was also designed to provide a perspective regarding the unique focus of occupational therapy interventions, which can be communicated through the use of this tool. The FCQ has been used in my private practice over the past 30 years. It is an easy-to-use self-assessment tool that provides measurable data to identify patients' specific challenges in occupational performance as well as their overall perception of their function.
It was love at first sight. My kinesiology professor in graduate school presented a basic biofeedback device to our class. It resembled a Geiger counter. It was just a box that had a scale with a little movable needle that shifted to the right as a fellow student flexed a muscle connected to a sensor. I felt as if a whole new world of possibility had just revealed itself.
In an incredible stroke of luck, the hospital where I first worked had a computer-based biofeedback system—a two-channel surface electromyography unit—that was not being used. It was stuck in the back of a storage closet. To my surprise, no one seemed interested in using it. Thrilled with this discovery, I laid claim to the equipment, toting it around on a small cart, ready to use it on any willing victim/patient. It quickly became an integral part in my treatment for patients who required neuromuscular reeducation.
Initially, I used biofeedback to address modulating muscle tone and spasticity with stroke patients. Then I started retraining agonist and antagonist muscles to help restore use of an affected extremity. I continued expanding my use of biofeedback to help decrease muscle bracing observed in chronic pain patients. Many patients who were hypersensitive or exhibited symptoms of overarousal were successfully trained in relaxation coupled with surface electromyography and thermal biofeedback to increase their tolerance for participating in daily activities.
I started getting referrals from doctors who had “difficult patients”—patients with fibromyalgia, reflex sympathetic dystrophy, nonspecific back pain, irritable bowel syndrome, rumination syndrome, dystonias, as well as patients who simply did not improve from other therapies. The common denominator for these patients appeared to be untreated anxiety, stress, or autonomic imbalance due to a preexisting condition or as a response to illness or injury. These issues were not typically addressed by physical medicine at the time. (This was the early 1990s, when medicine was more reductionist, before the days of integrative medicine.)
When I spoke with the patients' doctors about using biofeedback as part of my treatment plan, it was met with amusement. The head of the cardiology department would refer patients to me with his tag line written on the bottom of his prescription for occupational therapy: “Do whatever that magic thing is . . . .”
I can levitate birds. No one cares.
—Woody Allen
It was clear that I needed to develop a tool to capture how biofeedback was beneficial to patients by reducing symptoms and improving functional outcomes from an occupational therapy standpoint. What kind of measure could capture the level of a patient's ability to function in daily activities? How could I quantify the patient's experience using biofeedback and the resulting changes in function? I needed a tool with valid content that could provide evidence of change. This was the impetus for creating the Functional Continuum Questionnaire (FCQ).
Development of the FCQ
I chose to use the model of human occupation (MOHO), developed by Gary Kielhofner (1985), as a frame of reference for integrating biofeedback into my practice in occupational therapy. MOHO views human behavior as a dynamic open system. It is composed of three hierarchically arranged subsystems that motivate, organize, and produce occupational behaviors. According to this model, human beings grow, develop, and change through interaction within the context of their environment (physical, social, cultural) and internal feedback to modify behavior. Health is defined as being able to demonstrate adaptive behavior:
The concept of adaptation acknowledges that human life involves the person's struggle to adapt to, and to control, environmental conditions. A person is considered adaptive who is able to meet the challenges, expectations and opportunities of the environment and who behaves so as to maintain and enhance personal integrity and potentials. (Keilhofner, 1985, p. 63)
Facilitating adaptation is a prime therapeutic focus in occupational therapy. How could using biofeedback help patients change behavior as it relates to daily performance and function? Could the use of biofeedback and self-regulation training help patients learn to become more adaptable in response to life stressors? What could be identified as a measure to reflect the patients' experience before and after treatment with biofeedback in occupational therapy? Three key components of MOHO provided guiding concepts that helped answer these questions and formed the basis of the FCQ. These are as follows.
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Occupational behavior:
Occupational behavior is an activity in which persons engage during most of their waking time; it includes activities that are playful, restful, serious and productive. These work, play and daily living activities are carried out by individuals in their own unique ways based on their beliefs and preferences, because of experiences they have had, environments and the specific patterns of behavior they acquire over time. (Kielhofner, 1985, p. 12)
Individual statements on the FCQ define various components of occupational behavior based on key concepts from MOHO. Statements included factors such as motivation, choice, values, habits, roles, routines, and performance. A self-assessment questionnaire format was chosen to allow patients to consider and rate multiple factors affecting various aspects of their occupational behavior. This information could help to identify potential problem areas that might be contributing to current challenges as well as to explore the relationship between psychophysiological status and occupational behavior.
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Occupational performance:
Occupational performance is the ability to perceive, desire, recall, plan and carry out roles, routines, tasks and sub-tasks for the purpose of self-maintenance, productivity, leisure and rest in response to demands of the internal and/or external environment. (Chapparo & Ranka, 1997, p. 58)
Assessment of occupational performance in the FCQ was used to obtain a more global sense of how patients perceive their ability to function within the context of their environment. Although occupational behavior provides a description of the components of behavior, occupational performance is a form of self-perception, which drives how we see and organize behavior. Occupational performance could offer a window into a patient's general view of how they see their ability to carry out more complex patterns of behavior. This concept is embedded in some of the statements in the FCQ.
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View of function/dysfunction continuum:
Kielhofner (1985) defines six levels of function and dysfunction along a continuum from helplessness to achievement. I incorporated this continuum as the functional continuum in my practice, looking at function without overtly designating dysfunction within the continuum.
The functional continuum is used along with the FCQ. This allows patients to reference their score from the FCQ to a defined continuum of function. The six levels of function described by Kielhofner were the impetus behind choosing an ordinal 1 to 6 scale for rating statements. I was curious to see how patients' individual rating on statements and overall score would fall along the six definitions of function on the functional continuum. Would patients agree with where their ratings placed them on the continuum? Would there be a noticeable change in the patient's perceived function when contrasting an initial assessment versus a reassessment at the end of therapy?
FCQ Format
The FCQ is a 36-item self-score inventory developed by operationalizing key components of the MOHO. An ordinal scale of 1 to 6 is placed next to statements describing occupational behaviors. Patients are asked to rate the statement using 1 as the most negative response to the statement and 6 as the most positive response.
The FCQ is designed in four sections corresponding to different components in MOHO. The four areas reflect further details in the MOHO, referred to as volition, habituation, performance, and environment.
Numerical values (ranging from 1–6) are added for each of the four sections. The grand total (all four sections tallied) is used to identify a place on the functional continuum. See Figure 1 for the FCQ, and see Figure 2 for the functional continuum descriptions.
Citation: Biofeedback 48, 3; 10.5298/1081-5937-48.03.01
Citation: Biofeedback 48, 3; 10.5298/1081-5937-48.03.01
Citation: Biofeedback 48, 3; 10.5298/1081-5937-48.03.01
Citation: Biofeedback 48, 3; 10.5298/1081-5937-48.03.01
Qualitative Use of the FCQ: Witnessing the Patient's Story
I review the individual FCQ statements with the patient before discussing the functional continuum. Statements are intentionally general to leave room for patients to interpret them as it relates to them personally. Items rated lower (ratings of 1, 2, or 3) catch my attention, and I ask patients to describe what the statement means to them and to share why they provided that rating. This yields a great deal of information, providing clues to issues that are creating stress. Over the years, various statements from the FCQ have led to opportunities for patients to discuss areas that they had been unable to face or acknowledge. For example, when a patient rates statement 34 (“I am happy living in my current home”) as a 1, 2, or 3, and I ask the patient to clarify what it means for them, some patients demonstrate muscle bracing and appear agitated. I try to provide a safe environment for patients to disclose whatever is challenging at home if and when they would like to do so. Sadly, domestic violence is a frequently revealed reason for this behavior. Some people report that they have not disclosed this information “because they didn't know where to bring it up and no one ever asked.”
If patients have not rated any statements as a 3 or less, I ask them to further explore the statements they rated lowest. I frame my questions as general inquiries, using information from the FCQ to get to understand them and to facilitate setting additional meaningful goals for their therapy.
Section 1 in the FCQ reflects components of the volitional subsystem from MOHO, which is defined as “a collection of beliefs and expectations which a person holds about his or her effectiveness in the environment.” (Keilhofner, 1985, p. 15). This includes belief in oneself such as having a range of skills to use, expectancy of success or failure, values, and interests. This subsystem describes factors that motivate occupational behavior. Lower ratings on these statements can reveal a great deal about why patients are having trouble initiating changes in their lives.
The second section of the FCQ addresses a subsystem referred to as habituation. “The habituation subsystem is a collection of images which trigger and guide performance of routine patterns of behavior” (Kielhofner, 1985, p. 24). Statements listed in this section address routines, habits, and roles, including socially appropriate behaviors and internal and external expectations of performance. Habits, routines, and roles help us organize our behavior. Lower ratings in this section often indicate poor performance in these areas that can be a source of stress. For example, the coronavirus pandemic has dramatically changed the work role. Social distancing, temporary layoffs, and job modification have disrupted patients' daily routines. Many have reported feeling disorganized, unproductive, and unfocused, adding to the stress they might have already been experiencing (prepandemic issues, uncertainty about health risks, etc.). Potential sustained loss of the work role can create a great deal of stress both financially and emotionally, because the role contributes to shaping the individual's identity.
The third section of the FCQ addresses various aspects of performance that represent a collection of our skills. Communication, process, and perceptual motor skills are all part of this area. For example, a patient might rate statement 19 (“I am able to verbally communicate my needs assertively and clearly”) as a 2. Further discussion about this item may reveal problems in a relationship with a domineering boss who is causing the work environment to be stressful. Clarifying the problem and identifying possible solutions could help mitigate one source of stress, along with using biofeedback and self-regulation.
The fourth section in the FCQ provides statements about interactions in one's environment including socialization, relationships, living environment, and external feedback. How does the physical environment support optimal living for the patient? Are there any cultural factors affecting the patient? Low ratings on statements from this section can help to identify sources of stress that can be modified. All of the statements in the FCQ are general enough to allow personal interpretation. The statements allow the patient to share salient information. Using the FCQ as a pre- and postmeasure is useful even as interpreted uniquely by the patient, because the relevance of the statement remains the same for the individual and can be reviewed later on with the same lens to assess change regarding the issue presented.
Subjectivity is objective.
—Woody Allen
Education about the functional continuum is provided to the patients along with their total score on the continuum. Numbers are provided as reference points underneath descriptions of the functional continuum so patients can see what level of perceived function their score indicates. The score reflects how the patient sees himself or herself along the continuum at this moment in time. Patients are encouraged to discuss the findings and are welcome to disagree or clarify the measure. Our perception of occupational performance (which is what we are really measuring) is dynamic and may change over the course of a lifetime. Being able to find a reference point to measure patients' perceptions of how they are functioning before and after therapy was the impetus for developing the FCQ.
The FCQ Retrospective
The FCQ was designed as a pre- and postmeasurement tool to allow the patient and therapist to observe changes in occupational behavior and overall performance. We all change from moment to moment, integrating new information and evolving into another version of ourselves.
I have found the FCQ to be an extremely useful tool in my practice. The process of reading and rating the statements appears to enhance patient awareness of their motivations, choices, values, ways of organizing their behavior, skills, and the effects their environment has on their actions. The concepts and statements from the MOHO bring to light the multiple factors that contribute to our occupational behavior and sense of self in an organized, comprehensive, and holistic presentation. The FCQ was developed by referencing these concepts in a format that patients could use for self-assessment. Pairing the FCQ with the functional continuum provides additional information for the patient, offering an overview of how the components of occupational behavior, occupational performance, and overall perception of function come together.
Most of us do not stop to assess how we are functioning at any moment unless we are going through some type of transition, illness, injury, or major life event. The FCQ seems to be sensitive to the patient's current situation. It is not uncommon for people to become emotional while they are completing it. By stepping back and considering perceptions about their function, patients have reported that their score on the functional continuum allows them to identify a “you are here” moment. I encourage patients not to judge the experience but to simply observe it. Awareness offers a vantage point for consideration—it offers an opportunity to change, adapt, and plan for the future. This has been an exciting part of my experience using the FCQ with my patients.
Conclusion
The FCQ is in its initial 30-year testing phase. It is still a work in progress. I hope this presentation will encourage clinicians to try the FCQ, personally and with their patients. I encourage any interest and research using the FCQ as an evidence-based measurement tool.
Functional Continuum Questionnaire.
Continued.
Continued.
Functional continuum.
Contributor Notes