Eurosoft FCE of Employee

Joyce Bernal

Texas Mutual Insurance Company

221 West Sixth Street,

Suite 300

Austin, Texas 78701-3403

Patient Name: Michael D Smith SSN: 555-55-5555

This report is a FCE performed on an employee of Eurosoft, Dallas TX. This report was responsible for finding fraud and led to the conviction of the doctor for fraud.

FUNCTIONAL CAPACITY EVALUATION

Dear Ms. Bernal:

The above named evaluee was recently referred to this facility for a functional capacity evaluation. This testing consisted of a routine physical exam, as well as computerized range of motion, isometric lift strength, dynamic lift tasks, work activities and postures, and computerized hand strength testing. The evaluee was instructed to lift normally and any way most comfortable and to stop the test if their comfort level changed. The physical examination included appropriate protocols of orthopedic and neurologic tests. The evaluee was required to sign a consent form prior to testing.

The results of this evaluation are discussed below.

PAST MEDICAL HISTORY

Onset Date: 9/15/2003

Mr. Michael D. Smith states that on the above date he was carrying an entertainment cabinet out of an aircraft.  He stepped on grease on the floor and fell while holding onto the cabinet.  He states that this caused pain to his neck, shoulder, and lower back.  He stated that he did not hit his head; the cabinet went straight to the floor and brought him with it.

Mr. Smith states that the neck pain does not bother him now and that his main complaint is low back pain.  Antonio Fred Guerra M.D. in San Antonio, TX is currently treating Mr. Smith.

Dr. Guerra has prescribed and Mr. Smith states that he is currently taking Methadone (10mg 3 times per day) and Ibuprofen (800mg as needed for pain – usually 2 – 3 times per day).

Mr. Smith states that he is able to exercise regularly with medication.  His regular exercise consists of walking approximately 1 mile per day 5 days a week.  Mr. Smith also states that he can perform his typical yard work if he paces himself and takes his medication.  Mr. Smith indicated that he could drive or ride in a vehicle for 1 – 2 hours before he needs to stop and get out of the car; however he states that he cannot sit through a typical movie, play, concert or performance.  Mr. Smith states that he is able to take care of basic personal needs – bathe, feed, dress, care for himself – without assistance.  During a typical day, Mr. Smith states that he sits for 12 hours, stands for 2 hours and reclines or lies down for 10 hours.

Mr. Smith states that in the past he has experienced arthritis (diagnosed during draft process in 1966), concussion (football injury approximately 1963), indigestion (recent), German measles, headaches, neck pain (due to a work related injury in the 1990’s), rheumatic fever (as a child approximately 10 years of age), and sinus trouble (over the last 15 to 20 years).  Current symptoms he is experiencing are depression (for the last 1 ½ months – Dr Guerra prescribed medication), pain in the low back, tingling numbness in the left upper leg, pins and needles in left shoulder blade area.

Mr. Smith states the tingling numbness in his left upper leg occurs when standing for long periods of time (approximately 30 minutes or longer).  He states that he notices the numbness when he is standing at the kitchen sink doing dishes or while in the backyard grilling.  He stated that Dr Guerra suggested that when he is at the sink doing dishes he should open the cabinet door and rest his left foot inside the cabinet.  Mr. Smith states that this seems to help.

Mr. Smith states that the pins and needles in the left shoulder blade area occur while taking a shower or when sitting for a prolonged period of time.

Mr. Smith states that currently he is working six hour shifts, he had tried eight hour shifts but felt that was too much for him.

PREVIOUS INJURIES

Mr. Smith indicates he has had surgery on his right elbow for a work related injury in the 1980’s, surgery on right index finger for a work related injury in 1986 or 1987, and a head and neck work related injury in 1993 or 1994.  He also stated that in 1978 he had colon surgery for an abscess.

Review of medical records from Business Health Partners LLC, an injury/illness history dated 9/18/2003 reveals evidence of a previous injury.  The previous related injuries/problems section states “30 yrs ago pt fell off a loading dock.” No further mention as to extent of injury was noted.

 

 

 

 

SURVEILLANCE TAPE REVIEW

Dr. Barras and Dr. Kramer reviewed videotape of Mr. Smith in various activities that include repeated bending, standing, twisting for approximately for 5 minutes and 53 seconds. It appears on the videotape to be servicing his vehicle with water. In the tape, Mr. Smith is handed a green pitcher of water by an unidentified female. Mr. Smith is able to bend and rise multiple times unencumbered, move, bend twist and turn without hindrance, guarding, antalgic posture or minor’s sign as well as any noticeable wincing.  One would expect an individual in any stage of injury repair to exhibit guarding or even the hint of restriction and pain. Analysis of the video tape utilizing NIOSH standards will be reviewed in the discussion section of this report.

EXAMINATION FINDINGS

Michael D Smith is a 55-year old obese male, 5′ 10″ tall, 204 pounds. He appears his stated age and is in good physical condition. Muscle testing revealed +5 muscle strength in the upper and lower extremities.

ORTHOPEDIC SIGNS AND TESTS

Provocative Test	Result	Comment
Patellar Reflex	Positive RT	1+
Achilles Reflex	Positive RT	1+
C5 Dermatome Sensation	Normal
C6 Dermatome Sensation	Normal
C7 Dermatome Sensation	Normal
C8 Dermatome Sensation	Normal
L4 Dermatome Sensation	Positive RT	Hyperaesthetic
L5 Dermatome Sensation	Positive RT	Hyperaesthetic
S1 Dermatome Sensation	Normal
Double Leg Raise	Negative
Ely	Positive LT	Positive for tightness in the SI joint. Not a true positive test.
Nachlas	Positive LT	Positive for tightness in the SI joint. Not a true positive test.
Patrick Fabre	Positive Bilaterally	Positive for tightness in the hip joints. Not a true positive test.
Heel to Heel	Negative
Toe Walk	Negative
Finger to Nose	Negative

The following tests were performed to determine the evaluee’s ability to perform the specific job functions safely without causing themselves harm or harm to others.

 

 

CARDIOVASCULAR FITNESS TESTING

Depending upon the identified goals for the evaluation, cardiac testing is necessary for specific concerns regarding individuals with specific cardiac disease, job positions that require significant walking, stepping, or constant upper extremity demands. The evaluee’s pre-test heart rate was 85 BPM and blood pressure 135/90. Post-test heart rate was 100 BPM and blood pressure 150/90.

Test	MET Level	Ability
Step Test	2.7	Light

Mr. Smith had a 2-minute warm-up on the recumbent bike and then the step test began.  Mr. Smith had no complaints during this portion of the exam.

 

COMPUTERIZED RANGE OF MOTION

The patient was tested today using the JTECH Tracker ROM – a computerized range of motion measurement system utilizing dual inclinometers. ROM tests were performed in accordance with the protocols published by the American Medical Association.

Cervical	Norm	Max	% of Norm
Flexion	50 °	52 °	104
Extension	60 °	48 °	80
Left Lateral	45 °	38 °	84
Right Lateral	45 °	36 °	80
Left Rotation	80 °	85 °	106
Right Rotation	80 °	68 °	85

Thoracic	Norm	Max	% of Norm
Minimum Kyphosis	20 °	46 °	230
Flexion	60 °	20 °	33
Left Lateral	10 °	24 °	240
Right Lateral	10 °	18 °	180
Left Rotation	30 °	20 °	67
Right Rotation	30 °	26 °	87

Lumbar	Norm	Max	% of Norm
Left Lateral	25 °	15 °	60
Right Lateral	25 °	27 °	108
Left Rotation	0 °	13 °
Right Rotation	0 °	6 °
Minimum Lordosis	15 °	22 °	147
Flexion	60 °	57 °	95
Extension	25 °	5 °	20
Sacral Hip Flexion	45 °	38 °	84
Sacral Hip Extension	5 °	9 °	180

Validity	Norm	Max	% of Norm
Left Straight Leg Raise	65 °	19 °	29
Right Straight Leg Raise	65 °	23 °	35

Upper Extremity	Norm	Left Active	Left % of Norm	Right Active	Right % of Norm
Shoulder Internal Rot.	75 °	90 °	120	59 °	79
Shoulder External Rot.	55 °	73 °	133	73 °	133
Shoulder Flexion	175 °	154 °	88	147 °	84
Shoulder Extension	45 °	20 °	44	49 °	109
Humerus/Scapula Flex.	140 °	133 °	95	148 °	106
Humerus/Scapula Ext.	20 °	24 °	120	36 °	180
Shoulder Adduction	35 °	19 °	54	3 °	9
Shoulder Abduction	165 °	53 °	32	39 °	24

During this portion of the examination process the patient indicated changes in his comfort level and complained of various symptoms.

After performing cervical lateral flexion Mr. Smith stated he had pain.  His heart rate had not increased from his resting heart rate of 85.

Mr. Smith also stated he felt a pulling sensation across his lower back during the thoracic lateral flexion and that his comfort level was now close to a 6 (his beginning comfort level was 5).  His heart rate was 92. Their was not palpable muscle spasm or guarding consistent with his complaints.

During thoracic rotation his comfort level was still close to a 6 and his heart was 91.

During lumbar rotation he stated he felt pulling in his left lower back and his comfort level was at 6.  His heart rate was 90.

After completing lumbar flexion/extension, Mr. Smith stated his comfort level was at a 6.  His heart rate was 98.

No complaints were noted during shoulder range of motion.  His heart rate during this testing began at 85 and ended at 90.

COMPUTERIZED HAND STRENGTH TESTING

The patient was tested using the JTECH GripTrack, a computerized grip strength evaluation system. Grip strength can be used to determine the nature of the injury (organic vs. psychological) or the evaluee’s sincerity of effort.

5 Position Grip Strength Test

Grip tests indicate a 14% Left side deficit at position 2 when compared with the opposite hand, with less than 15% considered within normal limits.

Grip Position	Left Avg.	Right Avg.	Deficit
II	49 lb	57 lb	14% Left

A Coefficient of Variation (CV) of 14% or less indicates validity, reproducibility, and consistency of effort (Chaffin, 1976). 2 of 2 tests performed met the validity criterion.

Mr. Smith had no complaints during this portion of the exam.

Rapid Exchange Grip Test

The Rapid Exchange Grip (REG) Test was used to help determine the patient’s level of effort. Because of the minimized time of muscle recruitment, forces generated during the REG at a specific dynamometer setting, should not exceed those values seen during the 5-position test performed at the same setting (Hildreth, 1989). The results of this test indicate the patient has given valid efforts.

Mr. Smith had no complaints during this portion of the exam.

Sustained Grip Test

A sustained grip test was performed to establish patient’s ability to maintain contraction. Results indicate a 30% Left side deficit when compared with the opposite hand.

No complaints were noted during this portion of the exam.

Pinch

The patient was tested using the JTECH PinchTrack, a computerized pinch strength evaluation.

The results of the tip pinch test indicate a 23% Left side deficit, with less than 15% considered normal.

The results of the key pinch test indicate an 8% Left side deficit, with less than 15% considered normal.

A Coefficient of Variation (CV) of 14% or less indicates validity, reproducibility, and consistency of effort (Chaffin, 1976). 6 of 6 pinch tests performed met the validity criterion.

This data is used to compare a patient’s pinch strength to published norms. The 50th percentile indicates the average for the patient’s gender and age group. More than two standard deviations below the average indicates that a deficit exists.  Right side Tip results fall in the 82 percentile with a SD of 0.9.  Left side Tip results fall in the 50 percentile with a SD of 0.0.  Right side Key results fall in the 46 percentile with a SD of -0.1.  Left side Key results fall in the 38 percentile with a SD of -0.3.  Right side Palmar results fall in the 31 percentile with a SD of -0.5.  Left side Palmar results fall in the 31 percentile with a SD of -0.5.

No complaints were noted during this portion of the exam.

 

COMPUTERIZED ISOMETRIC LIFT STRENGTH

The patient was tested using the JTECH computerized static lift strength evaluation system.

A Coefficient of Variation (CV) and/or difference between successive reps of 14% or less indicates validity, reproducibility, and consistency of effort (Chaffin, 1976). 5 of 5 tests performed met the validity criteria.

The data is used to compare a patient’s lift strength to published norms. The 50th percentile indicates the average for the patient’s gender. NIOSH has determined a minimum of the 25th percentile should be demonstrated for the worker to safely perform the lift on the job (Work Practices Guide for Manual Lifting, 1981).

NIOSH Lift Test	Ability	PDL
Arm	38 lb	Light Medium
Torso	29 lb	Light
Leg	49 lb	Light Medium
High far	12 lb	Sedentary
High near	31 lb	Light
Floor – Patient stated he could not pull anymore.

The NIOSH lift testing began with Mr. Smith’s heart rate at 85 and a comfort level of 6. Five of the six tests were completed.  After the fifth test, Mr. Smith stated he could not pull anymore and the NIOSH portion of the tested was terminated.

Other observations noted during the NIOSH portion of the exam were as follows:

Arm Lift –       Beginning Heart Rate 85 Beginning Comfort Level 6

Ending Heart Rate 95 Ending Comfort Level 6

High Near –    Beginning Heart Rate 85 Beginning Comfort Level 6

Ending Heart Rate 97 Ending Comfort Level 6+

Patient stated he “felt tingling in back”

High Far –        Beginning Heart Rate 90 Beginning Comfort Level 6+

Ending Heart Rate 95 Ending Comfort Level 6+

Patient stated he felt “numbness going across midback”

Torso –             Beginning Heart Rate 84 Beginning Comfort Level 6+

Ending Heart Rate 88 Ending Comfort Level 6 ½ +

Leg Lift –        Beginning Heart Rate 77 Beginning Comfort Level 6 ½ +

Ending Heart Rate 88 Ending Comfort Level 7

Patient stated he couldn’t pull anymore.

DYNAMIC LIFT TESTING

Once the evaluee’s safe lift capacity was determined to be sufficient for the defined job tasks via static lifting, the evaluee was referred for dynamic lift testing. The evaluee was required to lift weighted box starting at 16 pounds, proceeding to a maximum of 80% of the evaluee’s body weight or his safe comfort level. Lifting is performed to either a specific standard detailed by a job description or to the traditional work heights associated with the Dictionary of Occupational Titles (DOT).

Occasional Lift	Ability	PDL
Floor	38 lb	Light Medium
Knee	43 lb	Light Medium
Waist	31 lb	Light
Shoulder	23 lb	Light
Overhead	16 lb	Sedentary Light
Carry	26 lb	Light

WORK ACTIVITIES

Work Activity Testing is used to determine an evaluee’s ability to perform dynamic non-material handling activities. Activities are assessed either to the DOT standards or to work task specific movement patterns. Tool use or the ability to involve or negotiate the environment is also typically evaluated when specific activities are assessed.

Activity	Ability
Squat	Occasional
Reach-up	Frequent
Reach-out	Frequent
Bend	Frequent

DISCUSSION

Mr. Smith was transported both to and from his appointment by the same driver from the San Antonio office of EuroSoft to Natures Health Care in Austin.  The driver reported Mr. Smith to be relaxed and able to sit comfortably throughout the ride to and from the appointment.  Mr. Smith asked to stop on the way to the appointment to get something to eat.  Mr. Smith was able to exit and enter the car without difficulty or assistance.  The ride was 2 hours in each direction and Mr. Smith dozed on the ride home.  He did ask to stop and get a drink on the ride home.  The driver did not see Mr. Smith take any medication during the ride there or home.

Mr. Smith was observed by a staff member of Nature’s Healthcare to exit the vehicle and enter the building without assistance.  The staff member also noted that Mr. Smith had normal gait and did not appear to be in discomfort.

During the examination process, Mr. Smith was able to sit, walk, and stand without complaint.  He was also able to be seated and lie down on the examination table (height 29 inches) without discomfort or assistance.  While in the office, Mr. Smith was seated for approximately 30 minutes while completing the initial paperwork in at addition to the 2+ hours of drive time; he then walked with normal gait to the restroom.  Once he was finished in the restroom he was taken back to the examination room, normal gait still noted.  He then sat down on the examination table and was advised that the examination would be video taped.  He stated he had no objection as long as he received a copy of the video.

Dr. Kramer and Dr. Barras were both in the room and both examined Mr. Smith.  Mr. Smith was then escorted back to the restroom where he was instructed to put on the heart rate monitor.  He was then escorted back to the examination room and his blood pressure was taken.  He was seated for approximately 2 minutes and his resting heart rate was noted.  During the warm-up and step test, Mr. Smith made no mention of discomfort.  The step test was completed without incident. Mr. Smith was cooperative during all portions of the examination.

During the rest of the testing Mr. Smith was asked to sit, stand, walk, lift, and carry all in various positions.  Mr. Smith had no obvious physiological reactions even when he stated that his comfort level had changed.  His gait did not change, his biomechanics changed only slightly during the dynamic lift testing.  He did not perspire or get flush in the face during any portion of the testing.

During the ride back from Austin to San Antonio Mr. Smith was observed by the driver to snooze.  This clearly demonstrates that Mr. Smith did not have an increase pain response following the examination process.  This observation along with no pain response observed in both his blood pressure and heart rate during the examination indicates that Mr. Smith did not experience and increase in pain from this vigorous testing.

Mr. Smith spent a total of 7 hours, 4 hours riding of which in a vehicle and 3 hours of the examination process.  Mr. Smith did not appear to tire, request a rest break or have any difficulties. Additionally, as stated above both doctors and examiner viewed the 6/18/2004 surveillance tape. Mr. Smith is viewed bending twisting and holding a pitcher of water that weight approximately 8 lbs. Mr. Smith is able to hold this bottle and bend unsupported and pore the liquid precisely into the radiator. The calculated stress on the low back of a person Mr. Smith’s height and weight bending forward utilizing a NIOSH standard ¹ was calculated to be in excess of 430 lbs of compressive force along with 71 lbs of shear force. With this amount of force exerted on to his low back we would expect to see guarding and/or antalgic type of postures.

As discussed we were able to evaluate Mr. Smith over a significant amount of time as well as analyze the video tape. This testing is designed to reveal the true condition of the subjects’ injuries. In Mr. Smith’s, case there was no viewed or palpated muscle spasms, guarding or antalgia associated with his movements over the extensive period of time he was evaluated. This lack of muscle spasms or guarding indicates that there is no biomechanical instability and thus no active injury. Additionally, Mr. Smith exhibits strength consistent with his previous job description. Since there is no active injury, and Mr. Smith’s strength is consistent with his previous job description, then the injuries Mr. Smith allegedly received have healed and Mr. Smith has been returned to his pre-injury status.

Mr. Smith may certainly be experiencing a symptom magnification process, thus prolonging his disability and inhibiting his return to work full time.  Mr. Smith is capable of working full time, unrestricted and is capable of performing his previous assigned job task and needs no further treatment.

Reliability of Effort

Subjective determination of effort is based clinical opinion of how a worker participated in the FCE process. Eight questions are used to formalize the evaluator’s opinion as to whether the worker’s performance was consistent clinically.

Of 8 criteria observed by the evaluator during the FCE, 2 (25%) would be consistent with valid effort.

Objective tests that are not directly biased by direct interaction between the evaluator and the worker are tallied to assess the worker’s participation level and effort consistency. This is used as a checks and balance system to support and substantiate the evaluator’s clinical opinion. Objective tests are tallied by the software and are not directly biased by the evaluator. Additionally, objective tests can be imported from devices other than Tracker.

37 of 37 tests showed consistent effort.

Max Voluntary Effort offers additional insight into worker participation. Results from the worker’s standard grip test compared to their rapid exchange grip tests reveals information about the worker’s voluntary participation level.

5-position grip test showed valid effort.

REG test showed valid effort.

Overall Validity or Level of Effort is determined by looking at all of the end results of the subjective, objective and max voluntary effort. Consistency of effort or lack there of is identified as either Reliable or Unreliable relative to making accurate vocational placement plans. If the outcomes indicates that the results are Relatively Reliable, this reflects a situation where symptom magnification is not present but submaximal effort secondary to anxiety or fear is presenting as a limiting factor.

Based on the above results, the overall level of effort as deemed by the examiner is relatively reliable.  Mr. Smith is able to perform work levels consistent with and above his previous job description.  His heart rate did not increase enough during any part of the testing to indicate an increase in pain.  His increase in heart rate barely indicated that he gave maximum voluntary effort.  A normal heart rate increase with work load increase is 30 plus beats per minute.  Mr. Smith did not get anywhere near that increase in heart rate.  This shows that Mr. Smith is capable of performing a work load in excess of what he demonstrated during the testing process.

CONCLUSION

Mr. Smith has reached his pre-injury status and maximum medical improvement.  According to the Dictionary of Occupational Titles the Interior Installer 806.381-078 is a medium duty job task.  However, Mr. Smith’s employer and supervisor went over Mr. Smith’s actual job task and rated it as a light-medium job task.  This requires Mr. Smith to lift 35 lbs. on an occasional basis.

Mr. Smith was found to be able to perform Light-Medium work (35 lbs. on an occasional basis) from the floor, from the knee level and from the waist level.  This corresponds to the actual job task requirements.

Mr. Smith is able to return to work full time unrestricted.

 

Physical Demand Level

Mr. Smith is capable of performing light medium duty work from the waist, floor and from the knee (35 lbs. occasional).  Light duty work (20 lbs. occasionally) at the shoulder level, sedentary work from the overhead level full time.

If there are any questions concerning this matter, please feel free to contact me.

Sincerely,

Evaluator:  _Signatures on File_______________________Date:  __9/29/04_____________

Dr. Allen S. Miller

CC          Randy Miller

EuroSoft

1705 S. Capital of Texas

Suite 202

Austin, TX 78746

Footnote:

1. United States National Institute for Occupational Safety and Health (NIOSH)