Practical Aspects of Functional Capacity Evaluations

Abstract

Physicians, employers, insurers, and benefits adjudicators often rely upon functional capacity evaluations (FCEs) to determine musculoskeletal capacity to perform physical work, often with legal or occupational consequences. Despite their widespread application for several decades, a number of scientific, legal, and practical concerns persist. FCEs are based upon a theoretical model of comparing job demands to worker capabilities. Validity of FCE results is optimal with accurate job simulation and detailed, intensive assessments of specific work activities. When test criteria are unrelated to job performance, or subjective evaluation criteria are employed, the validity of results is questionable. Reliability within a subject over time may be adequate to support the use of serial FCE data collection to measure progress in worker rehabilitation. Evaluation of sincerity of effort, ability to perform complex or variable jobs, and prediction of injury based upon FCE data is problematic. More research, especially studies linking FCE results to occupational outcomes, is needed to better define the appropriate role for these evaluations in clinical and administrative settings.

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Journal of Occupational Rehabilitation, Vol. 14, No. 3, September 2004 ( C°2004)
Practical Aspects of Functional Capacity Evaluations
Glenn S. Pransky1,3and Patrick G. Dempsey2
Physicians, employers, insurers, and benefits adjudicators often rely upon functional ca-
pacity evaluations (FCEs) to determine musculoskeletal capacity to perform physical work,
often with legal or occupational consequences. Despite their widespread application for
several decades, a number of scientific, legal, and practical concerns persist. FCEs are
based upon a theoretical model of comparing job demands to worker capabilities. Validity
of FCE results is optimal with accurate job simulation and detailed, intensive assessments
of specific work activities. When test criteria are unrelated to job performance, or subjective
evaluation criteria are employed, the validity of results is questionable. Reliability within a
subject over time may be adequate to support the use of serial FCE data collection to mea-
sure progress in worker rehabilitation. Evaluation of sincerity of effort, ability to perform
complex or variable jobs, and prediction of injury based upon FCE data is problematic.
More research, especially studies linking FCE results to occupational outcomes, is needed
to better define the appropriate role for these evaluations in clinical and administrative
settings.
KEY WORDS: disability evaluation; work capacity evaluation; physical fitness; work physiology.
INTRODUCTION
Physicians, employers, insurers, and benefits adjudicators often rely upon functional
capacity evaluations (FCEs) to provide definitive answers in a variety of situations involving
physical work. These evaluations are quite common—over half a million formal evaluations
of impairment and ability to work are conducted each year within the U.S. workers’ com-
pensation system, many including FCEs (1). Results of these evaluations have significant
implications for further rehabilitation efforts, employment, compensability determinations,
and cash benefits. Despite their widespread application for several decades, a number of
scientific, legal, and practical concerns persist. This paper will examine these issues, on
the basis of available scientific evidence and practical experience, focusing on those FCEs
designed to evaluate ability to perform physical work.
1Liberty Mutual Research Institute for Safety, Center for Disability Research, Hopkinton, Massachusetts.
2Liberty Mutual Research Institute for Safety, Center for Safety Research, Hopkinton, Massachusetts.
3Correspondence should be directed to Glenn S. Pransky, Center for Disability Research, 71 Frankland Road,
Hopkinton, Massachusetts 01748; e-mail: glenn.pransky@libertymutual.com.
217
1053-0487/04/0900-0217/0 C
°2004 Plenum Publishing Corporation

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218 Pransky and Dempsey
Current Scope and Use of FCEs
FCEs include a wide range of activities (2). The simplest evaluations involve a se-
ries of standardized tasks with measured weights and distances, and a trained observer;
these are available for upper extremity as well as back/lower extremity activities. Other
approaches use machines to measure peak force, velocity, and range of motion in several
planes, with isometric and isokinetic techniques, for arm/hand, back and lower extrem-
ity function. In these situations, workers are generally asked to exert a maximal effort.
Job simulation, using tasks and equipment specific to a particular job, has recently be-
come more popular, in part due to the Americans with Disabilities Act requirement that
valid testing should be job-specific and focus on a comparison of capacity to actual job
demands (3).
One of the earliest applications of FCEs was in the preplacement setting, to identify in-
dividualsatincreased risk of injuryinphysicallydemanding jobs. Prior medicalapproaches,
such as X-rays or lumbar range of motion, had failed to provide useful information about
risk for future work injury (4). Using an isometric FCE testing protocol based on biome-
chanical similarity to strenuous job tasks, Chaffin et al. demonstrated that those hired who
had marginal strength in comparison to job demands were three times more likely to have a
back injury at work, compared with those who had the highest relative strength compared
to job demands (5). Subsequently, there was a proliferation of isometric testing devices,
followed by development of machines to evaluate dynamic strength during movement, for
use in preplacement screening evaluations. One variation that developed was the use of
FCEs on a periodic basis to certify continued ability to perform infrequent but physically
demanding tasks, such as firefighting.
The principles of measuring ability to perform a job were extended to postinjury
populations. These evaluations were designed to determine work capacity in relation to a
specific job or class of jobs, as well as level of consistent effort and cooperation. The results
of these evaluations are frequently used to direct treatment and rehabilitation efforts, and
in legal proceedings, to determine work capacity and eligibility for indemnity benefits.
THEORETICAL BASIS OF FCEs
AbriefreviewofthetheoreticalbasisofFCEsisimportanttounderstandhowthedesign
of FCEs relates to their intended purposes, and the scientific evaluations of these tests. The
concept of matching job/workplace demands to the capabilities and limitations of a worker
is a fundamental assumption underlying FCE application. Figure 1 illustrates one model
that describes the relationship between job demands and worker capabilities, including
the components of each construct (6). Job demands include the workers’ physical and
organizational surroundings. The capabilities and limitations of the worker are expressed in
terms of what have been called the “limiting subsystem”—the human aspect corresponding
tothepredominantmismatchbetweenjobrequirementsandworkerperformance(7).Ideally,
adjustments (at a worker or job level) can lead to a favorable ratio of worker capacity to job
demands, and subsequently to safe and productive work that is sustained for long periods
(health), as illustrated in Fig. 2 (8).
One of the most important aspects of an FCE is that the measurement of capacity is
specific to the demands posed by the job. Given that most capacity measures, whether they

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Practical Aspects of Functional Capacity Evaluations 219
Fig. 1. Conceptual model of ergonomics practice (adapted from Dempsey et al. (6)).
be measures of aerobic capacity or muscle strength, are highly task-specific, this implies
that the test may need to consider multiple tasks within a job. Thus, before any FCE is
administered, a job analysis is required. This is critical from the standpoint of both scientific
and legal perspectives. The task-specific nature of human capacity is further complicated
by the fact that capacity can change because of injuries, aging, and other influences.
Although the concept of functional capacity relative to specific job demands is fairly
straightforward, actual evaluation of functional capacity is a technically challenging process
that often occurs within a complex legal and medical context. Because of the dynamic and
complex nature of most job demands, as well as the dynamic nature of capacity due to
morbidity, functional capacity is necessarily dynamic. This potential for variation presents
a challenge to another conceptual basis for the use and interpretation of FCE results, that of
scientific certainty. FCEs are often regarded as capable of providing data that is definitive
in both measurements of capability as well as sincerity of effort, with accurate projections
Fig. 2. A model of ergonomic evaluation rehabilitation,
and person–job matching (from Armstrong et al. (8)).

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220 Pransky and Dempsey
to actual ability to return to specific jobs. However, as discussed below, the validity of
FCE results and associated conclusions about sincerity of effort and work capacity are
questionable in most situations, and thus present important limitations to application of
FCE results (9).
VALIDITY
Validity primarily relates to the relationship between the FCE result and return to work
or safe continuation of work as the primary outcome of concern; this is usually referred to
as criterion or predictive validity. One of the most comprehensive investigations of RTW
criterion validity was conducted by Dusik et al. (10). They compared FCE results using
a standardized testing protocol for job simulation, and then followed RTW outcomes of
a functional rehabilitation program postdischarge. The FCE appeared to be less accurate
than the job simulation, and consistently underestimated actual ability to do the job, unless
the job required only simple, repetitive motions that were similar to those encountered
in the FCE protocol. Christian et al. reached a somewhat different conclusion, in a study
of persons judged to be employable after a formal work capacity assessment related to
indemnity compensation benefits in New Zealand (11). Of those judged employable but not
workingat follow-up(57% of the 141participantsinthestudy),some had repeat orreopened
claims, possibly indicating a return to work at jobs that placed them at risk for further injury.
Others have also observed similar findings, where limitations documented in the evaluation
setting do not correlate with ability to return to work; these discrepancies appear to be
most problematic with static tasks, less so with dynamic tasks or job simulation (12,13).
Of all commercially available FCE protocols reviewed recently by Innes and Straker, only
the Physical Work Performance Evaluation had adequate documentation of validity, for a
narrow range of jobs (14).
Validity problems are due in part to both poor characterization of job demands, and
inaccurate measurement of a worker’s actual performance capability in relation to these
demands. FCEs are generally based on an engineering—stress/strain model, where the
physicaljob demands are compared withthemeasuredworkcapacityofthe individualtested
to determine whether the “actual capacity” meets the “requirements” of the job. Barring
a thorough job analysis, the job requirements are often extrapolated from the job title,
and broad classifications of work requirements typically associated with the job, derived
from the U.S. Department of Labor’s O*NET database, or its predecessor, the Dictionary
of Occupational Titles. Both systems provide rankings for each job group of the typical
relative levels of demands along several dimensions (15).
For example, the DOT classifies “frequency of activity” into three categories: occa-
sional (1–33% of the time), frequent (34–66% of the time), and constant (67–100% of the
time). Job categories by lifting requirements are classified as shown in Table I.
O∗NET provides rankings for relative level of job demands across hundreds of di-
mensions, for several thousand occupational titles. Dimensions in O∗NET that are relevant
to FCEs and physical job demands include trunk strength, stamina, handling objects, and
dynamic flexibility (16). Both systems were developed primarily as vocational counseling
aids. The intent of the DOT was to categorize the physical requirements for each generic
occupational title and provide a standard method to analyze and classify jobs. These systems

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Practical Aspects of Functional Capacity Evaluations 221
Table I. Dictionary of Occupational Titles Definition of Job
Categories by Lifting Requirement (in Pounds)
Frequency of Maximum
lifting (% occasional
DOR job category of time) lifting (pounds)
Sedentary <10
Light 10 20
Medium 20 50
Heavy 50 100
Very heavy 100 >100
were not designed to analyze people and their performance. The estimates of job demands
are inexact generalizations that have not been validated through empiric testing. For exam-
ple, information on the method, mechanism, or quantity or variation in required lifting is
absent in DOT. Thus, the likelihood is high that results based upon generalizations from
DOTorO
∗
NET will be inaccurate, unless very large discrepancies between performance
and job requirements are noted. Innes and Straker (17) concluded that the absence of a for-
mal job evaluation in over 60% of the FCEs they reviewed constituted an important threat
to validity.
Thus, a formal job assessment is desirable for those FCEs intended to measure ability
to work at a specific job. Several assessment systems are available, designed to interface
with FCE protocols. However, accurate assessment of job demands can be challenging.
Job modifications (both formal and informal), and complex tasks that can be performed
in a variety of ways are important threats to validity (3,18). Workers frequently alter how
a job is performed or implement informal accommodations in order to perform a job de-
spite physical limitations. Discussion with the examinee regarding job requirements may
be helpful, but workers may not always be able to provide reliable data about physical
job demands (19). Standard job descriptions from employers can be equally inaccurate.
When an FCE is being performed to assess ability to perform a broad class of jobs, a
high degree of job-specific validity may not be required; however, evaluators should note
that results could easily be misleading. For example, the authors have observed multiple
employees within a facility that have a job title such as “material handler” or similarly
vague title, but that have very different job demands in terms of the loads handled and the
frequency of lifting. Thus, the validity of an FCE across workers in the same job title could
vary.Implementation and execution of an FCE protocol that accurately simulates job tasks
and adequately tests limiting subsystems is difficult. The standardized tasks offered in
most FCEs do not correspond to actual work demands, except for those jobs where tasks
are few, simple, and regularly repeated. FCE protocols often extrapolate from tasks that are
stereotypical,orperformedatnear-maximallevelsforashortperiodoftime,topredictability
to sustain job activities for a full workday and workweek. Extrapolation from maximal
ability to perform occasional lifting to expected ability to perform frequent lifting on the
job is a frequent practice that lacks a firm scientific basis (20). This is where the limiting
subsystem becomes important, as the capacity to perform low-frequency, high load lifts
taxesthemusculoskeletalsystem, whereas highly repetitive tasks bring the cardiopulmonary
system into consideration.

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Performance on FCE tasks are often compared with population or coworker norms, as
actual job force requirements (such as the amount of torque generation at the joints required
for lifting a given load) are not often estimated during this process. One study noted that
preplacement judgments based on very general, non-work-related tests that often measure
aerobic capacity, with comparison against normative data, leads to discrimination against
those who have higher body mass indices, even though they are capable of performing the
requirements of the job (21). Isotonic or isokinetic tasks do not represent agility, coordi-
nation, or constrained postures required at work (20). Evaluator judgment can also be a
source of low validity, especially when the test criteria have little relationship to job per-
formance. Several studies have demonstrated that attitudes and prejudices of the examiner
can also affect interpretation of results and outcomes (22,23). Observations of changes in
body mechanics when lifting loads of increasing weight has been proposed as a criterion for
maximal acceptable load. This kinesiophysical approach mandates that lifting methods be
judged within safe guidelines, and evaluators extrapolate from safe body mechanics in test
situations (24), despite absence of scientific support for its validity (25). Both overestima-
tion as well as underestimation of actual ability can occur as a result (26). Abdel-Moty et al.
concluded, and we concur, that general testing is of little value to measure actual capacity
to perform a particular job, and that job-specific testing with direct linkage to job tasks is
needed for valid results (15).
FCEs based on job simulation test only the physical components of the job, and fail
to simulate the environmental (hot, cold, vibration) or psychological components (time
pressure, working in isolation) (27). Thus, validation is difficult in some situations without
strong evidence for job performance linkage around physical tasks (28). Even if physical job
demands are accurately measured and appropriately simulated in the FCE setting, actual
return to work is a function of not only physical demands and capacity, but also skill,
motivation, workplace, and psychosocial factors. Using this standard, the validation of a
particular FCE method is impossible without taking into account all the other factors that
may affect a successful return to work (29).
There is better evidence that changes in FCE performance over time can represent
actual, meaningful improvement in function (30–32). Whether small changes over time
are important, and how much change is sufficient for RTW, is hard to determine (33). Im-
proved isokinetic measures did not predict RTW in one longitudinal study (31). Poor or
absent documentation of inter- and intrarater reliability for most FCE approaches leaves
clinicians without a scientific basis for evaluating whether changes over time represent
actual improvement or measurement error (34,35). Most studies of reliability have failed
to carefully link results to actual ability to sustain work, instead focusing on body me-
chanics or other intermediate measures (36). Innes and Straker concluded that reliability
was sufficient for medicolegal purposes in only a few tests. Furthermore, the practice of
obtaining repeated functional measurements during the course of physical rehabilitation
may represent an unnecessary expense that is not required to achieve optimal outcomes
(37).The FCE represents findings from a single point in time, and it is not practical to
perform a reevaluation every time a change in function or work demands occurs (Fig. 2)
(8). Thus, there is little justification to conduct formal FCEs with patients who are early
in their recovery, when physical capacity and pain tolerance is changing, or when the full
range of available job accommodations has not been explored. Some type of preliminary

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Practical Aspects of Functional Capacity Evaluations 223
assessment of functional capacity might be useful, however, at this stage, to set goals and
establish a baseline from which further progress can be measured.
Using the results of the FCE to establish an arbitrary weight-lifting limit does not
make sense from a biomechanical standpoint, as the maximum safe load is a function of
several factors besides the weight of the object. Ideally, the FCE might provide information
about the postures and situations that are most problematic for an individual recovering
from an episode of low back disability, and thus provide suggestions for effective work
modifications.
Although FCEs are often promoted as a method of “objectively” identifying conscious
attempts to reduce effort, no conclusive scientific proof of discrimination ability across a
rangeof injured subjectsis available (38). One study reported high sensitivityand specificity
of tests used to determine sincerity of effort, but only in subjects who were instructed to
provide a very significant (50%) reduction of maximal force, without specific information as
to what was being measured to determine sincerity (39). Other studies have demonstrated
that subjects can reproducibly perform at voluntarily reduced strength levels (40). Little
evidence exists for a threshold of coefficient of variation that is unacceptable; suggested
levels range from 5 to 29% (41).
The typical variations in pain and function that accompany chronic low back pain may
well account for observed variability in performance even in persons who are consistently
providing a maximal tolerated effort. Reliability can be poor because of variations in pain,
position, self-limitation to avoid injury, equipment function, testing protocols, subject com-
prehension, or ability to follow specific directions (42). Poor performance can be due to
failure to understand the degree of effort required, anxiety related to the test situation, de-
pression, pain, fear-avoidance, unconscious or conscious illness behavior or exaggeration,
or malingering (43). Training and acclimation can also affect reliability over time. Signif-
icant reactivity (learning effect) has been demonstrated in LBP patients with an isokinetic
protocol, resulting in variations of 17–28% (44). Patients may have reasonable fears about
overexertion leading to subsequent reinjury. Thus significant variability may occur for many
reasons besides insincere effort (45,46).
Waddell’s signs are often used to detect signs of exaggeration or voluntarily reduced
effort,eventhoughthey were nevertestedinthiscapacity.These signs aremoreappropriately
used to detect symptoms that occur without a specific organic basis, and thus positive
results may be most indicative of those who will benefit from psychological intervention.
Whether or not the presence of these signs is directly related to proven insincerity of effort
in subsequent FCE testing is unknown (47). However, kinesiophobia was not linked to
decreased FCE performance in one study, suggesting that certain FCE results may not be
overly influenced by fear of pain (48).
Conversely, consistent self-limitation can be interpreted as a “valid” result, and overex-
ertion (effort in a range that is unsafe for the individual) is also a possibility. Pain can greatly
hinder FCE performance, so testing may actually provide a measure of pain tolerance,
not peak functional capacity (49). Thus changes over time may reflect changed psycho-
logical or behavioral factors affecting pain tolerance, not muscle strength (50). Hazard
compared several indices of subject effort, including isokinetic force/distance curve pat-
terns, peak force variations, blood pressure, and heart rates. He concluded that even the
best physiologic measures and force curve analysis are not as reliable as an expert ob-
server in detecting voluntary self-limitation. Although most FCE reports are restricted to

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224 Pransky and Dempsey
“objective” findings, inclusion of self-reported data from subjects could help to explain
apparent inconsistencies.
In essence, it is difficult to determine whether limitations are based on what the appli-
cant cannot do versus what they will not do. It is important to distinguish between validity as
a scientific concept (primarily external validity) and attempts to measure sincerity of effort
(the latter term is preferred) often evaluated through measures of reliability. Mislabeling as
insincere leads to misdiagnosis, improper treatment, increased litigation, and increased cost
of care (41). For practical purposes, FCEs appear to be effective in detecting submaximal
efforts only when variation is high and the lack of full effort is obvious.
Thus, it is not surprising that in an analysis of demographic and FCE data in 539
subjects, only a small amount of variance in relation to RTW outcome was explained by
FCE results. There was considerable overlap in performance between those who did and
who did not RTW, and only one FCE test (floor to waist lift) was necessary to achieve
this level of discrimination. Demographic and injury-related factors (gender and length of
disability) were more predictive of RTW (51). Ruan et al. compared FCEs that consisted of
a simple submaximal series of functional tests (static and dynamic lifting tests) with a more
extensive evaluation, along with psychological testing, for chronic back pain patients and
healthycontrols (52). The main predictors of functional status werepsychological measures,
and the added information from the physical testing was minimal. They concluded that
more extensive testing was unnecessary and likely not valid. Although accuracy of RTW
prediction may be acceptable for a group of persons, the level of accuracy for an individual
may be low and unacceptable. Passive tests of impairment are available (such as evaluations
according to the AMA Guides to Evaluation of Permanent Impairment), but these results
do not correlate with return to work, except in cases of severe impairment (53).
Clinical examination and mechanical methods of strength testing may often be compa-
rable in terms of the accuracy of information they yield about a subject’s work performance
in relation to their capacity (54,55). In many instances, a thorough clinical evaluation that
includes a review of functional activities of daily living may be sufficient to determine
readiness to return to work. Some investigators have argued that, absent an accurate work
simulation, questionnaires have greater validity and sensitivity to important change in work
capacity than “objective” evaluations of functional capacity (56).
PREPLACEMENT TESTING AND LEGAL CONSIDERATIONS
In the preplacement setting, FCEs may have a role in injury prevention, but this has
been demonstrated only in jobs involving a high level of physical demands, where FCE
tasks were similar to actual job demands (5). Preplacement screening using FCEs raises
concerns about practicality and cost, unless the risk of injury is very high. Since the majority
of disability in industry due to low back pain is associated with the few cases that become
chronically disabled, an ideal test must predict not only those who will be more likely to
develop an injury, but also develop chronic disability. Currently, none of the FCE tests in
commonuse havebeen shownto predict both the occurrenceof LBP and discern betweenthe
majority that will have a quick recovery versus those who will go on to prolonged disability
(57). Thus, inappropriate selection and discrimination can easily occur, as well as incurring
significant expense for FCEs on all prospective employees without equivalent benefits in
termsof avoidanceof injury-related expenses. Furthermore, if prospectiveworkersare given

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Practical Aspects of Functional Capacity Evaluations 225
a heavy lifting load, described as a job requirement, most will try to lift it regardless of
capability, with potential risk of resulting injury (58).
Laws to prevent discrimination against a class of job applicants require that such tests
represent a valid simulation of the job. The Uniform Guidelines on Employee Selection
Procedures (1978) (29 Code of Federal Regulations, Chapter XIV, Part 1607) were designed
toprovidea “frameworkfor assessing the properuse of tests and other selection procedures.”
These guidelines apply to all employee-selection procedures. More recent legislation, the
Americans with Disabilities Act (ADA), applies specifically to individuals with disabilities.
In the case of preplacement testing, both regulations must be considered when selecting a
particular FCE and applying the results.
The Uniform Guidelines on Employee Selection Procedures specify requirements for
the validity of selection test(s), including criterion-related, content, and construct validity.
Any test must have documented evidence for at least one of these types of validity. Such ev-
idence can come from experimental data showing that a test is predictive of or significantly
correlated with elements of job performance (criterion-related validity), that the content of
the test is representative of important aspects of performance on the job (content validity), or
that the protocol measures the degree to which candidates have identifiable characteristics
which have been determined important for successful job performance (construct validity)
(14). The regulations state that when such a test cannot be conducted, that, selection pro-
cedures should be “as job related as possible.” Thus, aside from the scientific importance
of properly assessing the job demands to worker capacity ratio discussed earlier, the same
concept is critical for establishing a legal test.
The Uniform Guidelines on Employee Selection contain technical standards for valid-
ity studies. The validity study should include a review of the job, which may seem obvious
when the goal is to assess the degree of match between job demands and worker capacity;
however, not all FCE providers perform a job analysis. The job analysis is required to insure
that measures of work behavior or performance have at least some relevance to the job. The
first step should always be an accurate job description, from the perspective of both legal
requirements and technical appropriateness. In fact, the job description is required when
considering the ADA.
Title 1 of the ADA specifically addresses the timing, nature, scope, and use of results
of FCEs, and significantly limits the ability of employers to require evaluations of those
who are already employed. The Act protects those who have a significant disability, as well
as those who are not actually disabled, but where an employer wrongly regards them as
disabled (59). Agility tests, including measures of physical and functional capacity that
might be part of an FCE, are allowed if they are consistently applied and job-related—in
other words, have a valid relationship to ability to perform essential job functions. This is
why the concept of a “generic FCE” should always raise concerns.
Thus employers who use FCEs of questionable validity to select workers or limit those
who RTW after an injury may be subject to litigation based upon these antidiscrimination
laws. Other legal considerations may include liability for injury occurring to patients as a
result of FCE testing, and liability to employers for inaccurate results.
Practicality implies that the ease of FCE administration, acceptability, interpretation,
and reporting are all reasonable, and that the benefits outweigh all associated costs. Ex-
tensive job simulation may be ideal from a legal and validity perspective, but prohibitively
expensive in most cases. Safety is also a concern; for example, exacerbation of LBP is
often noted with isometric tests (60). There is no infallible method to determine when FCE

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226 Pransky and Dempsey
maneuvers are unsafe, despite suggestions that body mechanics during lifting should be
used (61).
It is not uncommon for organizations that have not previously used FCEs to be overly
optimistic about the value of these tests, particularly when vendors provide a strong sales
pitch. However, FCEs should only be considered as one component of a broader program
that comprehensively addresses injury prevention and RTW. First and foremost, workplaces
need to be designed to minimize mechanical stress on to workers, as well as to minimize
pain and discomfort while performing their jobs after an injury occurs. Ergonomics efforts
should be undertaken first to determine if the problematic job demands can be minimized
or eliminated, as engineering control of risk is the ideal solution.
Criteria for acceptability of FCE use varies greatly by application. Accurate prediction
of safe RTW outcomes, including reinjury, may be most important when RTW is the goal of
an FCE. When the primary purpose is adjudication, the primary criterion for acceptability
of an FCE approach may be quite different—in this instance, the function is administrative
rather than rehabilitative, and thus consistency may be most important. In the third major
instance of FCE use, the well-person preplacement evaluation, a different set of criteria
might be most important—such as avoidance of discrimination, excessive cost relative to
benefit, and predictive ability for future serious injury.
CONCLUSION
Several scientific and practical limitations are associated with FCEs. In a few instances,
these have been overcome through thorough job analysis and careful work simulation, with
protocolsthat closely parallel work activities, directed byexpertevaluators,resultinginfind-
ings of reasonable certainty (62). Most FCEs do not achieve these standards of performance.
Generally acceptable, accurate measures of voluntary self-limitation are not available. Until
further research develops valid, reliable, and efficient measures that correlate well with safe
and sustained return to work, FCEs will not be very helpful for practicing clinicians involved
in return to work decisions. Perhaps it is appropriate to regard the majority of FCEs that are
not conducted in relation to a specific job as primarily administrative exercises, allowing
for a demonstration of a range of performance that is acceptable to the worker. In this con-
text, the FCE may be of significant therapeutic value. Although the validity of FCE scores
alone to accurately predict job performance is questionable, this form of observer-based
functional evaluation may be helpful to chart improvements, specify functional disparities
with respect to job demands, and identify nonmedical factors influencing the ability to
work. Thus, when combined with other sources of information, FCE results may ultimately
contribute to resolving issues of compensability, disability, and employability. Some re-
cently published research is beginning to address these concerns, and much more research
is needed to broaden the scope of applicability of these tests (63).
ACKNOWLEDGMENTS
Special thanks to Lyn Dempsey for editorial support, and to Bill Shaw and Ray
McGorry for scientific review.

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