J Occup Rehabil

DOI 10.1007/s10926-017-9734-x

REVIEW

Updating the Evidence on Functional Capacity Evaluation

Methods: A Systematic Review
Stijn De Baets1   · Patrick Calders2 · Noortje Schalley1 · Katrien Vermeulen3 ·
Sofie Vertriest3 · Lien Van Peteghem3 · Marieke Coussens1 · Fransiska Malfait4 ·
Guy Vanderstraeten2,3 · Geert Van Hove5 · Dominique Van de Velde1   

© Springer Science+Business Media, LLC 2017

Abstract  Objectives To synthesize the evidence on
the psychometrics functional capacity evaluation (FCE)
methods. Methods A systematic literature search in nine
databases. The resulting articles were screened based on
predefined in- and exclusion criteria. Two reviewers inde-
pendently performed this screening. Included studies were
appraised based on their methodological quality. Results
The search resulted in 20 eligible studies about nine differ-
ent FCE methods. The Baltimore Therapeutic Equipment
work simulator showed a moderate predictive validity. The
Ergo-Kit (EK) showed moderate variability and high inter-
and intra-rater reliability. Low discriminative abilities and
high convergent validity were found for the EK. Concurrent
validity of the EK and the ERGOS Work Simulator was low
to moderate. Moderate to high test–retest, inter- and intra-
reliability was found in the Isernhagen Work-Systems (IWS)
FCE. The predictive validity of the IWS was low. The physi-
cal work performance evaluation (PWPE) showed moderate
test–retest reliability and moderate to high inter-rater reli-
ability. Low internal and external responsiveness were found
for the PWPE, predictive validity was high. The predictive
validity of the short-form FCE was also high but need to be
further examined on several psychometric properties. Low
discriminative and convergent validity were found for the
work disability functional assessment battery. The WorkHab
showed moderate to high test–retest, inter- and intra-rater
reliability. Conclusion Well-known FCE methods have been
rigorously studied, but some of the research indicates weak-
nesses in their reliability and validity. Future research should
address how these weaknesses can be overcome.
Keywords  FCE · Functional capacity evaluation · Return
to work · Assessment instruments · Psychometric
Introduction

A synthesis of research conducted by the Organization for

* Stijn De Baets
Economic Co-operation and Development (OECD) showed
Stijn.debaets@ugent.be
that almost all countries in the OECD experienced a sig-
1
Occupational Therapy Program, Department nificant social and economic impacts from the high num-
of Rehabilitation Sciences and Physiotherapy, Faculty ber of workers permanently leaving the labor market due to
of Medicine and Health Sciences, Ghent University, De
health problems or disability. Additionally, research shows
Pintelaan 185, 9000 Ghent, Belgium
2
that people with reduced work capacity or with more work
Department of Rehabilitation Sciences and Physiotherapy,
absence, are less likely to remain employed [1, 2]. The
Faculty of Medicine and Health Sciences, Ghent University,
Ghent, Belgium budget for disability benefits makes up a significant propor-
3 tion of public expenditure across OECD countries, with an
Department of Physical and Rehabilitation Medicine, Ghent
University Hospital, Ghent, Belgium average of 1.2% of the gross domestic product (GDP) [1]. In
4 the Netherlands, Norway and Sweden the proportion of GDP
Centre for Medical Genetics, Ghent University Hospital,
Ghent, Belgium is even higher at 3.5% [1]. Furthermore, the employment
5 rates of people with a disability are on average 40% lower
Department of Special Needs Education, Faculty
of Psychology and Educational Sciences, Ghent University, than the overall level of employment [1]. These low employ-
Ghent, Belgium ment rates are accompanied by high social costs [1, 3, 4] due

13
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to unemployment benefits, lower incomes and much higher
poverty risk [1].
Changes in the labor market due to the global financial
crisis, such as increased unemployment rates, might lead to a
higher number of people dependent on sickness and disabil-
ity benefits [1]. Meanwhile, the incidence of occupational
injuries leading to long-term absenteeism and potentially
leading to job loss is still on the rise in high income coun-
tries [5, 6]. There is a growing awareness under healthcare
professionals and policymakers about the return to work
theme. Even though, the number of people depending on
sickness and disability benefits is still increasing. Next to
that, also the prevalence of occupational disabilities and
related costs continue to increase. So, one can conclude
that current return to work approaches are not always that
adequate [5].
Furthermore, “except for a few countries, the share of
spending on vocational rehabilitation and employment
programs is less than 8%, and in most cases less than 4%,
of total disability-related spending” [1]. The discrepancy
between the costs associated with unemployment and those
related to incapacity and disability are of concern. There is
a need for increased investment in vocational rehabilitation
in an effort to increase employment rates, including employ-
ment of people with disabilities. In order to determine work
capacity, it is necessary to have appropriate measurement
tools. Functional capacity evaluation instruments (FCE)
could play a key role in decreasing incapacity-related spend-
ing by determining work capacity and matching this with
appropriate employment; either by matching the abilities to
job requirements or by identifying necessary modifications
to the work environment or workload [7]. “An FCE is an
evaluation of capacity of activities that is used to make rec-
ommendations for participation in work while considering
the person’s body functions and structures, environmental
factors, personal factors and health status” [8]. The purpose
of FCE is considered to be the evaluation of a person’s abil-
ity to participate in work [8] by matching the capacities with
functional job requirements [9]. The underlying assumption
here, is that a better performance in the FCE is associated
with faster return-to work and lower risk of re-injury or
pain exacerbation [9]; however, it is important to note that
many other factors which are not measured by FCE, such as
personal causation, also influence return-to-work outcomes
[10].
FCE’s are used most commonly with individuals who
have work disabilities [6] in a clinical setting to develop a
customized rehabilitation program; to adjust the rehabilita-
tion program; to measure changes in physical abilities and
to determine functional work abilities and match these with
employment prior to return to work [6, 7, 11]. When the
FCE shows that the functional abilities of the patient are
insufficient to meet the physical job demands, a vocational
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J Occup Rehabil
rehabilitation program to improve the ability to return to
work can be developed. FCE’s have also become part of
medico-legal assessments to determine whether claimants
should receive disability benefits, based on their assessed
functional abilities [7]. In conclusion, many disciplines from
various organizations use FCE’s as part of their clinical prac-
tice, including making recommendations that have implica-
tions for people with work-related disabilities, employers,
insurers, other health professionals and stakeholders. There-
fore, it is important that FCE users know whether FCE meth-
ods provide reliable and valid information and subsequently
which method is preferable.
There is a growing interest in the psychometric proper-
ties because “a FCE should give reliable and valid meas-
urements” [12]. Numerous studies have been conducted to
validate FCE methods and to demonstrate their reliability in
varying client groups. These studies have also been reviewed
over the years. The most recent comprehensive review on
FCE dating from 2006 [7] states that there is a clear need for
an updated global review of the existing evidence. Especially
since the past years, new, promising FCE methods have been
developed and known methods have been refined and more
thoroughly researched [7]. Another important reason for
updating current comprehensive evidence on FCE validity
and reliability, is the continuing use of FCE’s in important
decision-making processes regarding occupational rehabili-
tation, insurances and disability benefits. Although, the main
scope of this review is to give an overview of current FCE
methods and their psychometric qualities; nevertheless, we
should also highlight the importance of bio-psycho social
reasoning regarding the subject of returning to work with
a disability. In practice, all components of evidence based
practice should be used. In this case, scientific evidence must
be used in therapy, but we may nog forget that client centere-
dness will always be the central concept in rehabilitation, so
is the return to work approach. Next to that, we also need to
take into account the psychological and social factors con-
cerning labor. Only when all these abovementioned factors
are included in the decision-making, one can make a well-
informed and deliberate decision and an accurate advice
towards clients, employers and society.
Materials and Methods
For this systematic review, a literature search was conducted
to identify relevant studies from the following electronic
databases; Web of science, Trip Database, Journal Stor-
age, Pubmed, Embase, PEDro and OTSeeker. Before the
actual literature search, scoping searches were performed
to determine which of these search terms would provide the
highest number of relevant results. These were used as key
terms (Table 1) and were combined into search phrases using
J Occup Rehabil

Table 1  Used keywords and Assessment Study objective Study topic

their synonyms
Functional capacity evaluation(s) Psychometric properties Vocational rehabilitation
FCE Psychometrics Return to work
Functional assessment Vocational participation
Reliability Work
Reliable Job
Repeatable
Validity
Valid

Boolean operators. The following search string was used
(Functional Capacity Evaluation OR FCE) AND (Psycho-
metrics OR Psychometric properties OR Validity OR Reli-
ability) AND (Return to Work OR Vocational rehabilitation
OR Work OR Job OR Participation in work). In Fig. 1, an
overview can be found of the whole search process. Fil-
ters for publication date and type of study were used when
available.
These hits were screened by applying the inclusion and
exclusion criteria. Articles were included when the type
of study was an RCT, CCT, meta-analysis or systematic
review. A second criterion was the inclusion of participants
in selected studies. Articles were selected when healthy sub-
jects or subjects with an occupational disability resulting
from a disease or disability, were included. Next to that,
psychometric properties (validity and reliability), FCE meth-
ods that assess the global physical/functional capacity of
the subject, publication date after May 2004 and written in
English, French or Dutch were important criteria. Articles
were excluded when studies only measured certain specific
functional/physical capacities, studies of FCE methods with
a specific target population or studies that are not relevant
to the research question. In the first phase of the screen-
ing process, the inclusion criteria were applied to the title
and abstract. When studies showed questionable relevance
in the first phase, they were included and more thoroughly
screened in the following phase. In the second phase, the
selected studies were screened based on their full texts. In

Fig. 1  PRISMA flow diagram

13

this phase of the screening process, references of included
systematic reviews were also screened for relevant stud-
ies through citation searching. To ensure objectivity in
the screening process, 2 independent reviewers (2 junior
researchers under supervision of the research group) were
asked to independently complete the same process of screen-
ing. The percentage of agreement by Cohen’s kappa was
calculated.
The methodological quality of the included studies was
assessed using the three-level quality appraisal scale, devel-
oped by Gouttebarge et al. [6]. The items “internal consist-
ency‟ and “responsiveness‟ were added, based on the cri-
teria proposed by Terwee et al. [32]. Relevant data were
extracted and gathered into a standardized data-extraction
form. The core findings in each study were expressed by
measures of validity and/or reliability. All the above men-
tioned aspects were independently assessed by the two first
authors under supervision of the research team.
Results
A total of 1381 hits were retrieved from the nine databases.
Of these, 200 were duplicates. After screening the remain-
ing 1181 references by applying the inclusion and exclu-
sion criteria to their titles and abstracts, 1142 were excluded
in phase 1. Citation searches were performed by using the
reference lists included in these reviews and applying the
inclusion and exclusion criteria, resulting in 1 additional
eligible original paper. Other citations were excluded based
on title or abstract. In phase 2, inclusion and exclusion cri-
teria were applied to the 40 eligible full-texts, resulting in
the exclusion of 20 full-texts. This left 20 original studies
to be included in this review. Agreement between the two
reviewers on the inclusion of studies based on abstract and
title, was high. 98.17% agreement and κ = 0.96 (SE = 0.03;
95% CI 0.910–1.00), and excellent after deliberation/dis-
cussion, with 100% agreement and κ = 1.00. Disagreements
on the inclusion or exclusion of studies were resolved by a
discussion between the two reviewers and the research team.
Studies on 9 FCE methods were reviewed (Tables 2 and
3). The literature on the Baltimore Therapeutic Equipment
work simulator (BTE) resulted in no studies on the reliabil-
ity. Two studies were found on the predictive validity of the
BTE [13, 14]. There is 1 article that gave an overview of the
intra- and inter-rater reliability of the Ergo-Kit functional
capacity evaluation (EK) [15] and 1 on the inter-rater reli-
ability and agreement [16]. One study described the dis-
criminant, divergent and convergent validity [17] another
study researched the concurrent validity of the EK and the
ERGOS Work Simulator [18]. No studies were found on
the reliability of the ERGOS work simulator (EWS). One
study was found on the concurrent validity of the EWS in
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J Occup Rehabil
comparison with the Ergo-Kit FCE [18]. No studies were
found on the reliability or validity of the Blankenship FCE,
1 was found on the sensitivity and specificity [19]. Three
studies were found on the reliability of the Isernhagen work
systems (IWS), One on the test–retest reliability and repro-
ducibility [20], one on the inter-rater reliability [21] and 1
on both inter-rater as intra-rater reliability [22]. Two stud-
ies on the predictive validity [8, 23]. Two studies on the
reliability of the ErgoScience physical work performance
evaluation (PWPE) were found, 1 on the test–retest reli-
ability/reproducibility [24] and 1 on the inter-rater reliability
[25]. One study on the predictive validity of the PWPE was
found [26] and 1 on the internal and external responsiveness
of the assessment [27]. There were no studies on the reli-
ability of the Short-Form Functional Capacity Evaluation,
and only 1 article on its predictive validity [28]. No studies
were retrieved on the reliability of the Work Disability Func-
tional Assessment Battery (WD-FAB), 1 study was retrieved
on the discriminant/divergent and convergent validity of the
assessment [29]. Two studies were found on the reliability of
the WorkHab, 1 researching test–retest reliability [30] and
one on intra- and inter-rater reliability [31]. Another paper
researched the WorkHab’s internal consistency [30].
The overall methodological quality of the reviewed stud-
ies (Table 2) was moderate to high. Sixteen studies showed
high methodological quality [11, 29–34, 37, 39, 42–45],
3 studies showed moderate quality [19, 20, 24], only 1
study was rated with low quality [22]. Nearly all studies
reported whether a full FCE method or subtests was stud-
ied and clearly mentioned the study objective. Four studies
did not report data on the health or work status, while the
number of subjects, their gender-distribution and mean age
were always mentioned. Overall, the methodological qual-
ity scores decreased because of a questionable study design
or the use of inadequate statistics [32]. Notwithstanding
the fact that the overall quality of the reviewed studies was
considered moderate to high based on the three-level qual-
ity appraisal scale from Gouttebarge [6], some important
aspects remained unclear because this system does not con-
sider all important factors to determine the methodological
quality of reviewed studies. For instance: none of the stud-
ies reported that study objects were randomized. Also, with
regard to the psychometrics that were investigated: some
studies investigated only a limited number of psychometric
properties (see Table 4) and that limits the ability to compare
the quality of the included studies.
Most studies did not report the subject selection method,
or used convenience sampling. Almost all studies reported
the used inclusion and exclusion criteria. Of the studies in
which allocation was relevant, only three performed ran-
dom allocation. The subjects were never reported to be
blinded. In most cases, rater blinding was not performed or
not mentioned. Many studies were faced with missing data.
 J Occup Rehabil

Table 2  Studies sorted by FCE method

Baltimore Thera- Blankenship Ergo-Kit (EK) ERGOS work Isernhagen work systems FCE Physical work Short-form func- Work disabil- WorkHab func-
peutic Equip- WorkEval func- functional capac- simulator performance tional capacity ity functional tional capacity
ment (BTE) tional capacity ity evaluation evaluation evaluation assessment bat- evaluation
work simulator evaluation (PWPE) tery (WD-FAB)
Full FCE studied Full FCE studied Full FCE studied Full FCE studied Full FCE studied Full FCE studied Full FCE studied Full FCE studied Full FCE studied

Cheng and Brubaker et al. Reneman et al. [20] Brassard et al. Branton et al.
Cheng [13] [19] [24] [28]
Cheng and Gross and Battié [9] Durand et al.
Cheng [14] [25]
Durand et al.
[27]
Lechner et al.
[26]
Subtest(s) Subtest(s) Subtest(s) Subtest(s) studied Subtest(s) Subtest(s) Subtest(s) Subtest(s) Subtest(s) studied
studied studied studied studied studied studied studied

Gouttebarge et al. [15] Rustenburg et al. [18] Reneman et al. Meterko et al. James et al. [30]
[21] [29]
Gouttebarge et al. [16] Trippolini et al. James et al. [31]
[22]
Gouttebarge et al. [17] Gross and Battié
[33]
Rustenburg et al. [18]

Some studies are mentioned more than once, because they study multiple FCE methods

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 J Occup Rehabil

Table 3  Results of the methodological quality appraisal

Author(s) and year of publication FCE method Objective Population Procedure Statistics Methodological quality

Studies on the Baltimore Therapeutic Equipment (BTE) work simulator

 Cheng and Cheng [13] + + + + + 5 = High
 Cheng and Cheng [14] + + + + + 5 = High
Studies on the Blankenship WorkEval functional capacity evaluation
 Brubaker et al. [19] + - + + + 3 = Moderate
Studies on the Ergo-Kit (EK) functional capacity evaluation
 Gouttebarge et al. [15] + + + + and ± + 4–5 = High
 Gouttebarge et al. [16] + + + ± + 4 = High
 Gouttebarge et al. [17] + + + + and + + 5 = High
Studies on the ERGOS work simulator (EWS)
 Rustenburg et al. [18] + + + + + 5 = High
Studies on the Isernhagen work systems (IWS) functional capacity evaluation
 Gross and Battié [9] + + + + + 5 = High
 Gross and Battié [33] + + + + + 5 = High
 Reneman et al. [20] + + ± ± + 3 = Moderate
 Reneman et al. [21] + + ± + + 4 = High
 Trippolini et al. [22] - + ± −* and + + 1–2* = Low
Studies on the physical work performance evaluation (PWPE)
 Brassard et al. [24] + + + − + 3 = Moderate
 Durand et al. [25] + + + + + 5 = High
 Durand et al. [27] + + + + ± 4 = High
 Lechner et al. [26] + + + + + 5 = High
Studies on the short-form functional capacity evaluation
 Branton et al. [28] + + + + + 5 = High
Studies on the work disability functional assessment battery (WD-FAB)
 Meterko et al. [29] + + ± + + 4 = High
Studies on the WorkHab functional capacity evaluation
 James et al. [30] + + + + and + + 5 = High
 James et al. [31] + + − + and + + 4 = High

*The test–retest time interval was 10 months long. However, video recordings of subjects were used to assess intra- and inter-rater reliability,
preventing learning effects and carry-over effects in the subjects

All studies did report the necessary outcomes, but in some
studies it was unclear whether extra results were reported.
In studies which needed to use two equivalent groups of
subjects, it was mostly not mentioned whether these groups
were really comparable at baseline. In most of the studies
that did report this aspect, groups were equivalent for impor-
tant characteristics. Lastly, it was sometimes unclear whether
studies received funding from involved parties. Four studies
clearly reported that there was no financial influence, while
most others did not mention financial support.
The job-specific BTE has a moderate predictive valid-
ity for return-to-work and employment status [13, 14]. The
Blankenship FCE has a sensitivity of 80.0% and specificity
of 84.2% [19]. This indicates good diagnostic abilities. The
EK shows an overall agreement for outcomes on the lift-
ing tests ranged from 8.6 to 3.4, which might be interpreted
as moderate and indicates moderate variability between
outcomes on the lifting tests [16]. Agreement between raters
strongly varied for the lifting tests of the EK from low to
high, but was mostly high [15, 16]. The same applies to
agreement within raters [15]. Low discriminative abilities
were found for the EK lifting tests (discriminant/divergent
validity). Little or no association was found between the
EK lifting tests and the Von Korff Questionnaire, indicat-
ing good convergent validity [17]. The EWS shows a low
to moderate concurrent validity in comparison with the EK
[18]. Within the IWS a varying test–retest reliability and
reproducibility was found in the material-handling compo-
nent with moderate to high agreement between outcomes.
Overall, this IWS component provided relatively stable out-
comes with limited variation [20]. Agreement between raters
was moderate for the lifting tests of the IWS [21] and moder-
ate to high agreement between raters was found for the phys-
ical and behavioral scales used in the IWS [22]. Agreement

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 J Occup Rehabil

Table 4  Studies sorted by topic (type of studied psychometric property)

Reliability Validity Other
Reproducibility/test–retest reliability Criterion-related validity Construct validity Diagnostic properties Responsiveness Internal con-
sistency
Agreement Reliability Concurrent Predictive Discriminant/ Convergent Sensitivity Specificity Internal External
validity validity divergent Validity responsive- responsive-
validity ness ness

Gouttebarge Brassard et al. [24] Rustenburg Branton et al. Gouttebarge Gouttebarge Brubaker Brubaker Durand et al. Durand et al. James et al.
et al. [16] Reneman et al. [20] et al. [18] [28] et al. [17] et al. [17] et al. [19] et al. [19] [27] [27] [30]
Inter-rater Intra-rater
reliability reliability
James et al. Durand et al. Gouttebarg Cheng and Meterko et al. Meterko et al.
[30] [25] et al. [15] Cheng [13] [29] [29]
Gouttebarge James et al. Cheng and
et al. [15] [31] Cheng [14]
Gouttebarge Trippolini Gross and
et al. [16] et al. [22] Battié [9]
James et al. Gross and
[31] Battié [33]
Reneman Lechner et al.
et al. [21] [26]
Trippolini
et al. [22]

13

within raters was moderate to high for the physical and
behavioral scales [22]. Studies show that performance in
the IWS (number of failed tasks and weight lifted) has no or
low predictive value for recovery outcomes such as timely
or sustained return-to-work and future pain, based on days
to benefit suspension, days to claim closure and recurrence
[9, 33]. A varying test–retest reliability and reproducibility
was found for the sections of the PWPE with moderate to
high agreement between outcomes and moderate agreement
between outcomes of the overall PWPE [24]. In other words,
the PWPE provides relatively stable outcomes with limited
variation. Agreement between raters was moderate to high
for the PWPE sections and high for the overall PWPE score
[25]. Change within subjects was observed by two PWPE
sections (the dynamic strength section and the position tol-
erance section), but not by the mobility sections or by the
overall PWPE (internal responsiveness) [27]. The PWPE
was not able to distinguish change on the subjects’ outcomes
for reference measures (concurrent and empirical data) of
health status (external responsiveness) [27]. A study by
Lechner et al. [26] shows that performance in the PWPE has
a high predictive value in return to work. The performance
items in the short-form FCE has got predictive value for
recovery outcomes such as timely and sustained return-to-
work [28]. Good discriminative abilities were found for the
WD-FAB physical functioning and behavioral health scales
for differentiating between physical and mental disability
(discriminant and divergent validity) [29]. Low to moderate
association was found between the WD-FAB physical func-
tioning scale and the PROMIS (convergent validity) [29].
Low to high associations were found between the WD-FAB
behavioral health scale and the BASIS [29]. A moderate to
high agreement between outcomes in the three subtests of
the WorkHab manual handling component was found and
a high agreement between outcomes on the overall manual
handling score (test–retest reliability and reproducibility)
[30]. Overall, the WorkHab manual handling score provided
stable outcomes with little variation. Agreement between
raters was moderate to high for the outcomes of the subtests
of the WorkHab manual handling component and moderate
for the overall manual handling component outcome (inter-
rater reliability) [31]. Agreement within raters was moder-
ate to high for the subtests and high for the overall manual
handling component (intra-rater reliability) [31]. James et al.
found a high internal consistency for the manual handling
component and the individual tests of the manual handling
component [30].
Discussion
Overall, the psychometric properties of the studied FCE
methods somewhat vary between, but also within, methods.
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J Occup Rehabil
The predictive validity, for example, is low in some meth-
ods, but high in others. An important question, however,
remains whether FCE’s should be used to predict, establish
or diagnose work abilities. In case of the latter, sensitivity
and specificity become more important. Inter-rater reliability
seems to be good in most FCE methods, as well as intra-
rater reliability. Test–retest outcomes are also promising in
most cases. It can be suggested that the reliability of current
FCE methods is generally well researched, although validity
has been studied less frequently. Overall, the FCE methods
included in this review show variable results, however, most
outcomes show moderate to good validity.
An important side note to the study results is that,
“according to several authors, when a rater is involved in
scoring the evaluation, intra-rater reliability is equivalent
to test–retest reliability because the accuracy of the FCE is
influenced by the skill of the rater” [34]. In present study
however, the term test–retest reliability is used, seeing this is
the term that was chosen in the original papers. Furthermore,
concurrent validity should be determined by studying the
relation between the studied assessment and its gold stand-
ard [6]. In FCE however, there is no gold standard available
[6]. Therefore, the use of the term “concurrent validity” in
the study by Rustenburg et al. [18] seems to be inadequate.
It could be better to speak in terms of ‘comparison’ or ‘cor-
relation’ [6]. Another aspect that should be taken into con-
sideration is the study sample in which the psychometric
properties of the FCE methods are researched. The outcomes
of the reviewed studies should not be generalized to broader
populations, because they are specific to the study sample
at hand. Validity or reliability of FCE methods in certain
pathologies might not be the same for the general popula-
tion. Finally and most important, this review only included
evidence published since May 2004. The outcomes of the
present study should be integrated with the pre-existing evi-
dence found in systematic reviews by Innes and Straker [35,
36], Gouttebarge et al. [6], Wind et al. [37] and Innes [7],
for a comprehensive understanding.
Since one of the main aims of this review was to enable
comparison of FCE methods in order to make objectively
informed decisions, it is also important to look beyond their
psychometric properties (effectiveness). The efficiency of
FCE methods is another essential aspect to take into account.
According to Hart et al., safety should be achieved before
considering validity and reliability. When validity and reli-
ability are demonstrated, practicality and utility should sub-
sequently be taken into account, in that order [38]. Costs,
time spent on the assessment, user-friendliness and accept-
ability are some important factors, which might sometimes
play a bigger role in the choice of FCE method than their
psychometric properties. Many FCE methods have promis-
ing psychometric properties, but are sometimes inefficient
in both time and cost [39]. Short-form FCEs or FCEs in the
J Occup Rehabil
form of a structured interview provide a potential answer
to many problems. Nonetheless, the psychometrics of these
FCE methods need more scientific substantiation. Accept-
ability of FCE was studied by questioning its usefulness in
an expert panel [40]. The results showed that two-thirds of
the experts found FCE useful because they confirm per-
sonal judgements and provide objective information. How-
ever, reasons for not finding FCE useful were that it did not
seem objective and did not provide any new information.
Job-specific FCE might provide a solution to the lack of
new or non-specific information. The client-centeredness of
this kind of FCE is an important asset, as it should reduce
redundant information and provide directly applicable input
for the vocational rehabilitation process. Furthermore, only
20% of the experts judged FCE to be a useful prognostic
instrument. Most of them argued that FCE is an evaluative
measure and is not to be used for predictive purposes. Stud-
ies on the predictive validity of several FCE methods should
replace these opinions with evidence.
RTW is often seen a binary event; either the person
returns to work (in the same job or an adapted job) or not.
Predicting whether the person will be able to return to work
involves assessing his skills versus the demands from the
job. Since RTW has become a central aspect on both politi-
cal and clinical level, improvement in the prediction of RTW
could have a huge potential. Not only to inform vocational
rehabilitation workers during the rehabilitation process but
also to inform policy makers in their RTW policy. Future
research should therefore not only focus on reviewing and
researching predictors for RTW but also examining the
incremental predictive validity beyond the described predic-
tors. In the Cochrane review of Mahmud et al. no evidence
was found for or against the effectiveness of performance-
based measures in preventing re-injury after return to work
[41]. Kuijer et al. performed a systematic review on the pre-
dictive validity of performance-based measures to predict
work participation in patients with MSD and concluded that
the predictive strength is in general modest [42]. They con-
cluded that this needs not be surprising as work participation
can be seen as a multidimensional construct according to
the ICF [43]. Personal and environmental factors influence
whether or not the patients returns to work; the results of an
FCE can be integrated in the ICF model (domain of activi-
ties). The definition of an FCE also implies that the capacity
to execute activities may be determined by a range of factors
or determinants [8, 44]. Using the ICF the complex nature
of work participation can be captured. A combination of
performance and non-performance based measures assessing
different constructs of work participation can also be used to
improve the ability to predict work participation. Pas et al.
found that both RTW experts as clients found FCE useful
for the advice on RTW and that clients felt they were taking
seriously by performing an FCE [45].
Some researchers state that the literature search in sys-
tematic reviews should be exhaustive, so that all possibly
relevant data are obtained [36]. However, given a limited
time frame and limited resources, an exhaustive approach
could not be guaranteed for this review. Therefore, it is a
possibility that potentially relevant studies were missed. For
example: studies that were not available in the researched
databases, studies that used different keywords or studies
published in languages other than English, Dutch or French.
An important limitation of this study is that names of known
FCE methods were not used as search terms. This may have
resulted in some relevant studies being missed and this
should be taken into consideration when interpreting the
results. Lastly, publication bias could have had a potential
confounding effect on the literature search, where studies
with negative outcomes were possibly not published. Nev-
ertheless, the literature search was performed as thoroughly
as possible, by researching all available databases, using
broad search terms and synonyms and applying the inclu-
sion and exclusion criteria. Another limitation of the study
is the fact that studies that focus on single tasks within a
full FCE evaluation such as for instance a ‘lifting assess-
ment’ were excluded. This choice could have diminished
the power of the study results. Further research is necessary
to evaluate also the psychometric properties of the separate
tasks of the FCE.
It is important to interpret the quality appraisal scores
in this review correctly. The scoring system used does not
consider all important factors that can determine the qual-
ity of reviewed studies. Although a checklist might provide
more useful information on these factors, a scoring system
was used to facilitate the interpretation of the study results.
Another reason for using the three-level quality appraisal
scale by Gouttebarge et  al. [6] was that most validated
checklists, such as the COSMIN checklist, did not seem to
be suitable for some of the reviewed studies. Other checklists
were mostly designed for appraising experimental studies,
but not for studies on psychometric properties.
This study has also some additional limitations. Firstly,
we decided to use only the search terms in English, Dutch
and French. Expanding this with other languages could have
given a broader view on the FCE methods. Secondly, we
only used Web of science, Trip Database, Journal Storage,
Pubmed, Embase, PEDro and OTSeeker as search engines
and did not include Scopus and Psychinfo. Our methodol-
ogy was primarily based on a previous systematic review by
Gouttebarge et al. [6]. They also did not include ‘Scopus’
and ‘Psychinfo’. In their study, no articles from Psychinfo
were included. Therefore, we decided not to include this
search engine. We are however not sure whether additional
information could have been added to this review. Thirdly,
many FCE methods have been used for a long time in
rehabilitation clinics and were evaluated internally. These
13

evaluations are likely to exist only as white papers. Unfor-
tunately, we did not have access to these white papers. In
future research, additionally, a scoping review, including
also other literature of for instance qualitative research
on the use of FCE can also increase our knowledge or the
length, costs and procession time.
As an inclusion criterion, we focused solely on RCT’s and
CCT’s. This approach was specifically chosen because we
aimed to include only studies with a high level of evidence.
It has the advantage that the search strategy was clearly
delineated. However, a less strict method and including also
studies with less power could have broadened the scope of
this review.
This systematic review has provided a more extensive
and updated representation of the psychometric qualities of
several FCE methods. Some more ground has been covered
on the better known FCE methods, while new methods with
different approaches are on the rise and gaining scientific
support as well. We also highlight the fact that quality evalu-
ations of FCE methods were sometimes done by only one
research group. This can create a potential risk of bias. The
newer approaches, such as the short-form FCE need to be
further examined on several psychometric properties. Psy-
chometrics of most of the well-known methods are thor-
oughly researched but some of the research indicates weak-
nesses in their reliability and validity. Future research should
address how these weaknesses can be overcome, while also
taking into account practicality and utility-aspects of the
FCE.
Acknowledgements  The research team wants to thank Professor Ev
Innes, Professor Haije Wind, Professor Michiel Reneman, Mr Dirk
Vandamme and Ms Linda Gabriël for their feedback.
Compliance with ethical standards  18. Rustenburg G, Kuijer PP, Frings-Dresen MH. The concur-
Conflict of interest  Stijn De Baets, Patrick Calders, Noortje Schal-
ley, Katrien Vermeulen, Sofie Vertriest, Lien Van Peteghem, Marieke
Coussens, Fransiska Malfait, Guy Vanderstraeten, Geert Van Hove,
and Dominique Van de Velde declares that they have no conflict of
interest.
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