CNA FCE – Lumbar Injury

CNA Insurance Services

LMMS, LLC
Kinematic Specialists

Dr. Allen S. Miller

411 E. Huntington Dr. 107-285 Arcadia CA 91006

(626) 399-6834

E-Mail Drasmiller@Earthlink.net ·

August 8, 2008

Bill Larkin
Claims Manager
P.O. Box 6500
Brea, CA 92822

RE:
Patient Name: Michelle Gomez
CNA Claim#:
Employer: Polo Shop
Job Description: Lead Cashier
Date of Birth: 11/
SS #
Claim #
DOI: 11/07/2007
DOE: 12/01/2008

PHYSICAL EVALUATION

• 411 E. Huntington Dr. 107-285 Arcadia CA 91006 (626) 399-6834
• · E-Mail Drasmiller@Earthlink.net ·

HISTORY OF INJURY:
Ms. Gomez is a well developed 17 year old Hispanic female. She states that she was the lead cashier at Ralph Lauren Polo Shop during a busy time of year. She states that she was helping her counterpart with customers, packing clothes, emptying the trash and both carrying and emptying clothing sensors. Ms. Gomez further states that because of the busy nature of sales, the sensors, placed on clothing for anti-theft precautions were placed in a box after they were removed. It was her duty to lift the box of sensors weighting between 25 lbs (weight not verified) and carry it to the back of the store. She then placed the box down pulled out a large trash-can-like container containing the other previously dumped sensors and lifted the box to empty the sensors into the container. Ms. Gomez states that on the 6th and final time she had to empty the box, while lifting the box she felt her back “go out”. She states that the pain was sharp and intense and she was unable to move.
She further states that she was going to cry but didn’t as she was at work. Ms. Gomez states that she finished her shift although she was walking like an “old lady”. She states she was assisted by two coworkers because she was in so much pain. Ms. Gomez states that she went home, took some Ibuprophen, went to bed, and upon waking was unable to move. She states that she called her mother, who advised her to call her supervisor and her family physician immediately for an evaluation. Ms. Gomez presented to Dr. Cruz of St. Bernadine’s two days later and was subsequently examined and referred for an MRI of the lumbar spine. Ms. Gomez was provided pain medication and muscle relaxants. Following the MRI, Mrs. Gomez was referred to physical therapy for muscle stimulation and acupuncture, which helped reduce her pain for a short amount of time. She was saw Dr. Raffat Mattar, MD for an orthopedic consult. Dr. Mattar had recommended lumbar epidural injections however, Ms. Gomez states that she “hates needles”. Additionally, the claimants’ mother states that her husband, Ms. Gomez’s father got no relief of his back pain with injections’.

Ms. Gomez was a very polite and cooperative subject. She was driven to the office by her mother. She was able to walk, sit and stand for a total of 2 + hours without visible signs of discomfort. Mrs. Gomez states that she did not take any pain medication the day of the examination.

When asked what activities Ms. Gomez participates in all day, she replied she does “teenager stuff” walks around the mall and watches television and movies. Ms. Gomez says that she can sit, walk and stand for about 30-45 minutes before the pain starts to become so bad she must move around or sit down.

The results of this evaluation are discussed below.

REVIEW OF RECORDS:

1. 6/23/2008 Raffat Mattar, MD, US Healthworks Medical Group
a. Findings: Recommended epidural injections to the lumbar spine. Dr. Mattar, will ad another anti-inflamatory to help relieve the symptomology.
2. 7/08/2008 Raffat Mattar, MD, US Healthworks Medical Group
a. Findings: Recommended epidural injections to the lumbar spine. The patient’s pain medications were renewed and the patient was advised of the contraindications.

DIAGNOSTIC TESTING:

1. There is an MRI of the Lumbar Spine, per Dr. Rosegon. Findings are as follows:
a. L4-L5 disc desiccation and mild loss of disc height and a 6mm central disc herniation.
b. L5-S1 disc desiccation and mild loss of disc height with a 3mm central disc protrusion. Mild facet hypertrophy is identified. There is no spinal stenosis at either level.

EXAMINATION FINDINGS:
This is a well developed 17 year-old Hispanic female complaining of diffuse pain at the low back, left lumbar para-spinal musculature, point tenderness and sharp pain at L4-L5 and L5-S1. The patient also complains of point tenderness at the left SI joint, with a “pulling and tearing” sensation down into the left buttock. Ms. Gomez also states that she has intermittent sharp pain radiating from her low back through the center of the leg to the knee. Ms. Gomez was asked to describe and number her overall pain on a scale of 1-5, 5 being described to her as the worst pain ever and I would need to take her to the hospital. She stated her pain was a 2 1/2.

She appears her stated age and is in good physical condition. Muscle testing revealed +5 muscle strength in the upper and lower extremities bilaterally.

ORTHOPEDIC SIGNS AND TESTS

Provocative Test Result Comment
Patellar Reflex Positive RT 1+
Achilles Reflex Positive RT 1+
L4 Dermatome Sensation Normal
L5 Dermatome Sensation Normal
S1 Dermatome Sensation Normal
Straight Leg Raise (Right) 75 degrees Negative
Straight Leg Raise (Left) 75 degrees Pain Left SI Joint
Sitting Straight Leg Raise (Right) 90 degrees Negative
Sitting Straight Leg Raise (Right) 90 degrees Pain Left SI Joint
Double Leg Raise Positive With Pain in the left tenderness at the SI Joint.
Kemps Positive LT Positive for sharp pain in the left L4-L5 joints.
Nachlas Positive LT Positive for tightness in the left L4-L5 joint.
Patrick Fabre Positive Bilaterally Positive for tightness in the low back.
Heel to Heel Negative
Toe Walk Negative

The following tests were performed to determine the subject’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, and job positions that require significant walking, stepping, or constant upper extremity demands. The subject’s pre-test heart rate was 66 BPM. Post-test heart rate was 106 BPM.

Test MET Level Ability
Step Test 3.5 Medium

Ms. Gomez had a 45-minute warm-up performing the hand strength testing, range of motion testing, and isometric left testing. Before the step test began, Ms. Gomez was visibly out of breath and complained of low back pain along with throbbing and the tenderness which was beginning to get worse at the left SI Joint.

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.

Lumbar ROM Exam

Test Name Norm Max % Norm Deviation
Left Lateral 25° 27° 108 2°
Right Lateral 25° 27° 108 2°
Left Rotation 0° 20° 20°
Right Rotation 0° 12° 12°
Minimum Lordosis 15° 7° 47 -8°
Flexion 60° 37° 62 -23°
Extension 25° 24° 96 -1°
Sacral Hip Flexion 45° 45° 100 0°
Sacral Hip Extension 5° -14° -280 -19°

Validity ROM Exam

Test Name Norm Max % Norm Deviation
Left Straight Leg Raise 65° 65° 100 0°
Right Straight Leg Raise 65° 75° 115 10°

The patient was tested today using the JTECH RangeTrack – a computerized goniometer for measuring joint range of motion. ROM tests were performed in accordance with the protocols published by the American Medical Association.

COMPUTERIZED HAND STRENGTH TESTING
The patient was tested using the JTECH GripTrack, a computerized grip strength evaluation system.

5 Position Grip Strength Test
Grip tests indicate 4% right 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 48 lb 46 lb 4% Right

Grip strength was tested in all five rung positions of the dynamometer. A bell-shaped curve is typically indicative of maximum effort for both injured and uninjured people alike (Stokes, 1983). The results of this test as denoted by the examiner show undetermined effort.

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.

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 invalid efforts.

Sustained Grip Test
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). 6 of 6 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 Max of Avg. Pop. %Tile
Arm 14 lb < 10%
Torso 15 lb < 10%
Leg 13 lb < 10%
High far 10 lb < 10%
Floor 16 lb < 10%
High near 15 lb < 10%

WORK ACTIVITIES
Work activity testing is used to evaluate and determine a worker’s ability to perform dynamic non-material handling activities. Activities are assessed either to the DOT standard activities 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.

WORK POSTURES
Work posture testing is used to determine a worker’s tolerance for maintaining specific postures and is evaluated to determine their ability to perform the given posture to either the DOT standards (Occasional, Frequent or Constant) or to a specified standard or time requirement. Testing is performed either formally or informally depending on the significance of the posture relative to the overall required work demands. Ms. Gomez exhibited pain on bending, twisting, squatting and stooping. Ms. Gomez did not exhibit pain while sitting, standing, or standing from a sitting position, and did not walk with an antalgic posture. Her abilities are listed below:

Standing Frequent
Sitting Frequent
Walking Frequent
Climb Not Tested
Squat Occasional
Reach-up Frequent
Reach-out Frequent
Bend Occasional

DIAGNOSIS

1. 724.8 Lumbar Facet Syndrome

CONCLUSIONS
Reliability of Effort
Subjective determination of effort is based on 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.

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.

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. Ms. Gomez was very cooperative and exhibited reliability of effort on every test.

Causation:
I am in agreement with Dr. Mattar and in reviewing the history, medical records, the forensic biomechanics of the injury, examination, it appears that the patient did sustain an injury arising of or caused by the industrial exposure of December 1, 2007

Current Job Description and Dot Explanation:
Upon review of the patients duties associated with her employment. It is determined through review of the Dictionary of Tiles that the patient is comparable to CODE: 299.677-010
TITLE(s): SALES ATTENDANT (retail trade) alternate titles: attendant, self-service store: (http://www.occupationalinfo.org/92/920687030.html). This job Task as outlined and defined as DOT level of Light work consisting of lifting 20lbs occasionally, 10lbs frequently and Negligible weight constantly in all positions1.

Discussion:
Ms Gomez portrays classic lumbar facet syndrome. This syndrome is a jamming of the lumbar facets by lifting and twisting while holding a weight of some kind. It was not the size of the load Ms. Gomez lifted, but that the movement was awkward and involved twisting. This twisting resulted in excessive shear factor at the lumbar joints causing pain and inflammation. Records indicate that Ms. Gomez has a 6 mm herniation at L4-L5 and 3 mm disc herniation at L5-S1. Even though, there is a two-disc-level herniation; the radiating pain in the leg is not classic of Lumbar Disc Syndrome or a Disc Herniation2,3 but due to the swelling at the L4-L5 and L5-S1 joint structures. As the available literature dictates, 76% of human beings have non symptomatic lumbar disc herniation up to 6mm2. The force of this related to lifting this box, did not produce enough force to injure the disc in a healthy 17-year-old female. These disc herniations are most likely related to genetics, a prior non-stated accident, or the mere fact that human beings walk upright against gravity. The diagnosis of Disc Syndrome was indicated in Raffat Mattar, MD, examination reports, Dr. Mattar is an excellent physcian and I have no doubt that Ms. Gomez stated that she had pain radiating from her low back down her leg. However, following extensive evaluation and interview time, Ms. Gomez, defined her pain as “located within the leg”, intermittent in nature and not down the back of the leg. Ms. Gomez, without the assistance of others, portrays the classic symptomology and accepted medical findings related to Lumbar Facet Syndrome.

The literature indicates that “The lumbar facet joints are biomechanically important. They absorb significant loads in extension and are a significant part of the three joint complex. Their role is to limit excessive mobility of the spinal segment and distribute load over a broad area”3. In this case, Ms. Gomez aggravated the joint structure when she bent, lifted and twisted holding the box with the sensors causing, simply put “jamming” of the facet joints.
Additionally, the patient was in a “rush” due to the nature of Christmas gift buying season, not taking proper lifting precautions. When these set of circumstances occur, and when confronted with this type of injury the body’s natural course is to inflame the area and tighten the muscles surrounding the area, protecting it from further injury, which most likely happened in this case. Lumbar Facet Syndrome is a painful injury, however, not serious, not usually requiring surgery, and responds well to conservative treatment modalities. Additionally, Ms. Gomez has been for the most part sedentary in her activities since the 12/01/2007 injury. The lifting examination as well as the cardiac MET level indicates that Ms. Gomez is able to perform sedentary work consistent with DOT Guidelines, limiting lifting to 5lbs from floor to waist1.

RECOMMENDATIONS:
With the information derived from the FCE, related documentation, we can make the following conclusions:

It should be evident from the records and this evaluation that Ms. Argeuello did suffer an injury arising out of employment for Ralph Lauren, and it would not seem reasonable at this juncture to formally recommend temporary limitations or preclusions from work. Furthermore, she has reasonably demonstrated her ability to engage in her routine activities of daily living. Ms. Gomez may return to modified duty to Sedentary Work restricting lifting to waist of 5lbs.

Ms. Gomez should be treated conservatively with Chiropractic Manipulative Therapy augmented by physiotherapy not to exceed eight (8) treatments. As Ms. Gomez has deconditioned during the time she was injured to present, Ms. Aguello should participate in work conditioning for eight visits to run concurrently with the Chiropractic treatments. I anticipate that the patient with the above described treatment process would be returned to pre-injury status without restriction or impairment. At the end of the treatment program, Ms. Gomez, should be referred back to Dr. Mattar and myself so we can evaluate this patient and address Permanent and Stationary status as well as impairment.

Ms. Gomez exhibits strength consistent with Sedentary Work Consistent with Dictionary of Occupational Guidelines1. The physical examination, MRI, as well as x-rays indicate that Ms. Gomez does have Lumbar Facet Syndrome. Ms. Gomez was found to be able to perform sedentary work (10 lbs. on an occasional basis) 3, from the waist to an overhead level. It is recommended that Ms. Gomez perform sedentary work from floor to waist limiting lifting to 5lbs. Ms. Gomez, works on a part time basis usually 5 days a week approximately 4 hours per day. Ms. Gomez may return to her previous level of work consistent with the above guidelines.

FUTURE TREATMENT RECOMMENDATIONS
The recommended treatment includes Chiropractic Manipulative Therapy augmented by physiotherapy not to exceed eight (8) treatments. As Ms. Gomez has deconditioned during the time she was injured to present, Ms. Aguello should participate in work conditioning for eight visits to run concurrently with the Chiropractic treatments. Additionally, the patient will require follow-up examination following the conclusion of treatment to determine permanent and stationary status.

COMPLIANCE STATEMENT:
“I personally evaluated this patient and prepared this report. If others have performed any services in connection to this report, outside of clerical preparation, their name and qualifications are noted herein. The time spent was in accordance with Industrial Medical Council (IMC) guidelines. I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true. I have not violated Labor Code Section 139.3 and the contents of the report and bill are true and correct to the best of my knowledge. This statement is made under penalty of perjury.”

All available data supports the conclusions reached in this report. Thank you and Dr. Mattar, very much for considering this office for your referral. If there are any questions concerning this matter, please feel free to contact me.

Sincerely,

_________________________________08/10/2008
Allen S. Miller, DC, DACBSP Date:
(This signature will act as an original for the purposes of this document).
cc: Dr. Raafat Mattar
US Healthworks
850 Washington St., #100
Colton, CA 92324

REFERENCES:

1. Dictionary of Occupational Titles, U.S. Department of Labor Employment and Training Administration 1991. Volume II Fourth Edition, Revised 1991.
2. Low Back Pain: Mechanism, Diagnosis and Treatment by Jim Cox
3. Current Diagnosis & Treatment in Orthopedics by Harry B. Skinner – 2003
4. Foreman & Croft 1997. Radoff et all 1993.
5. The Forensic Documentation Sourcebook: The Complete Paperwork Resource for …
by Theodore H. Blau, Fred L. Alberts, Jr., Fred L. Alberts.

//

//

Great Western Administrators Iron Worker FCE

LMMS, LLC

Kinematic Specialists

Dr. Allen S. Miller

411 E. Huntington Dr. 107-285

Arcadia CA 91006

(626) 399-6834

E-Mail Drasmiller@Earthlink.net ·

August 15, 2008

Jennifer Stafella

Claims Manager,

S & C Claims

3380 West Sahara Ave. #100

Las Vegas, NV 89102

RE:

Patient Name:    Daniel Smith

DOB                  03/22/1981

Claim#:

Employer:           Bob’s Construction

Job Description: Steel Worker

DOI:                   05/23/2007

DOE:                  08/14/2008

PHYSICAL EVALUATION

 

• 
  

Daniel Smith presents today upon referral by his Claim Examiner for an examination to reassess further treatment and/or diagnostic testing. He is a 27-year-old, well developed 6’, 224 pound male previously employed in construction. He presents with a history of an occupational injury occurring on May 23, 2007, while working in Las Vegas. At that time, while standing on a ladder perched on a scaffold, platform, he states the scaffolds collapsed causing him to fall approximately 20 feet, landing onto a hard surface. He has no recollection of the events and is not certain how he landed or whether he had  loss of consciousness; however, it was a closed injury. Mr. Smith states that he originally refused to be transported to the hospital by ambulance, but later agreed to have his supervisor transport him to the emergency room at St. Vincent’s Hospital in Henderson, Nevada. Radiographs were obtained at that time and he was admitted to the hospital. He was diagnosed as having thoracic and lumbar compression fractures.HISTORY OF INJURY:

He was neurologically intact at that time, and was braced/casted for four to five months by Dr. Siegler. Mr. Smith states that he relocated to San Diego California and began physical therapy there with Dan Gross, PT.

The patient complains of intermittent dull pain throughout his mid to low back region, which is occasionally sharp and severe. The quality of pain is aching. Mr. Smith states that he has pain most of the time. The pain is not radiating. His symptoms are worse with prolonged bending or stooping and standing, however, sitting does not bother him. He has not worked since his date of injury. He regularly uses Lidoderm patches and takes Percocet and Ibuprophen for pain.

Mr. Smith was a very polite and cooperative subject; he states that he had his girlfriend drive him which consisted of 90+ minutes of sitting. He was able to walk to the office from the car unattended and without antalgia. He was able to negotiate the office, speak clearly and concisely with the office staff and sit in the waiting room without hindrance.

When asked what activities Mr. Smith participates in all day, he replied he takes “walks up and down the block a couple of times a day”.  He states that he “washes the dishes, which is time consuming and intense” and plays the guitar until his girlfriend comes home. He then helps prepare dinner and watches TV.  He states that his girlfriend is a massage therapist, however, does not give him any massages.

The results of this evaluation are discussed below.

PAST MEDICAL AND FAMILY HISTORY:

Mr. Smith states he fell and fractured his right patella. He states he has no prior industrial, family, or other injuries that are contributory to this case.

EXAMINATION FINDINGS:

This is a well developed 27 year-old Caucasian male complaining of focused pain at the lower thoracic and upper lumbar region. There are +2 muscle spasms of the thoracic and lumbar para-spinal musculature and point tenderness at T8 & L1. The patient states that he has no other symptoms, Radicular pain, numbness and tingling in any of the extremities.

Mr. Smith was asked to describe and number his overall pain on a scale of 1-5, 5 being described to him as the worst pain ever and I would need to take him to the hospital. He stated his pain was a 2 ½ and stated it “is that way all the time”.

He appears his stated age and is in good physical condition. Muscle testing revealed +5 muscle strength in the upper and lower extremities bilaterally.

ORTHOPEDIC SIGNS AND TESTS

Provocative Test	Result	Comment
Patellar Reflex	Positive Bilaterally	1+
Achilles Reflex	Positive Bilaterally	1+
L4 Dermatome Sensation	Normal
L5 Dermatome Sensation	Normal
S1 Dermatome Sensation	Normal
Straight Leg Raise (Right)	60 degrees	Negative-Pulling pain in the low back
Straight Leg Raise (Left)	75 degrees	Negative-Pulling pain in the low back
Sitting Straight Leg Raise (Right)	90 degrees	Negative-Pulling pain in the low back
Sitting Straight Leg Raise (Right)	90 degrees	Negative-Pulling pain in the low back
Double Leg Raise	Negative	Negative
Kemps	Positive Bilaterally	Sharp pain in the low back
Patrick Fabre	Negative Bilaterally
Heel to Heel	Negative
Toe Walk	Negative
Finger to Nose	Negative

The following tests were performed to determine the subject’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, and job positions that require significant walking, stepping, or constant upper extremity demands. The subject’s pre-test heart rate was 79 BPM and blood pressure 132/74. The heart rate during testing elevated to 170/99 with a heart rate of Post-test heart rate was 99 BPM. Mr. Smith’s blood pressure and heart rate returned to normal within approximate 2 minutes.

Test	MET Level	Ability
Step Test	3.5	Medium

Mr. Smith had a 45-minute warm-up performing range of motion testing, and isometric testing, before the step test began.  Mr. Smith states that he was out of breath, but had no increase in pain or discomfort.

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.

Thoracic ROM Exam
Test Name
Norm	Max	Deviation
Minimum Kyphosis	20°	60°	40°
Flexion	60°	15°	-45°
Left Lateral	10°	23°	13°
Right Lateral	10°	35°	25°
Left Rotation	30°	13°	-17°
Right Rotation	30°	24°	-6°

Lumbar ROM Exam
Test Name
Norm	Max	Deviation
Left Lateral	25°	29°	4°
Right Lateral	25°	29°	4°
Left Rotation	0°	8°	8°
Right Rotation	0°	5°	5°
Minimum Lordosis	15°	40°	25°
Flexion	60°	51°	-9°
Extension	25°	19°	-6°
Sacral Hip Flexion	45°	94°	49°
Sacral Hip Extension	5°	23°	18°

Validity ROM Exam
Test Name
Norm	Max	Deviation
Left Straight Leg Raise	65°	71°	6°
Right Straight Leg Raise	65°	72°	7°

The patient was tested today using the JTECH RangeTrack – a computerized goniometer for measuring joint range of motion. ROM tests were performed in accordance with the protocols published by the American Medical Association.

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). 6 of 6 tests performed met the validity criteria.

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 6 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	Max of Avg.	Pop. %Tile
Arm	14 lb	< 10%
Torso	34 lb	< 10%
Leg	35 lb	< 10%
High far	8 lb	< 10%
Floor	45 lb	< 10%
High near	27 lb	< 10%

DYNAMIC LIFT TESTING

Dynamic task lifting is used to determine a worker’s ability to negotiate weighted objects.  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).

WORK ACTIVITIES

Work Activity Testing is used to determine a subject’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	Frequent
Reach-up	Frequent
Reach-out	Frequent
Bend	Frequent

WORK POSTURES

Work posture testing is used to determine a worker’s tolerance for maintaining specific postures and is evaluated to determine their ability to perform the given posture to either the DOT standards (Occasional, Frequent or Constant) or to a specified standard or time requirement. Testing is performed either formally or informally depending on the significance of the posture relative to the overall required work demands.

Activity	Ability
Standing	Frequent
Sitting	Constant
Walking	Frequent
Climb	Frequent

REVIEW OF RECORDS:

1. Exam Date: 5/2312007 Physician: Lasry, Jason

Procedure: XR Thoracic Spine + Swim View Accession Number:

FINDINGS: There appears to be an acute compression deformity at the TB level. The Paraspinous soft tissues appear displaced. This is compressed approximately 30%. TB level appears slightly compressed as well but this may be an old finding. The lower thoracic spine fractures are again noted at approximately the T11, T12 and L1 levels.

IMPRESSION: 1. There appear to be acute compression fractures of the thoracolumbar spine. A T6 compression fracture of approximately 30%. The T11, T12, and L1 levels appear compressed as well and are dictated on previous lumbar spine examination.

1. Exam Date:5/23/2007 Physician: Lasry, Jason

Procedure: CT T-Spine wo Contrast

IMPRESSION:     1. Findings consistent with an acute compression fracture at the T8 vertebral body of 40% Pedicles appear intact, but there is a bilateral laminar fracture.

2. There may be a tiny epidural hematoma at the T5 level, but is not causing any central canal narrowing.

3. Compression deformities at the TI I and 112 levels, as described. See lumbar spine CT scan.

1. Exam Date: 5/23/2007 Lasry, Jason

Procedure: XR Lumbar Spine Series, Five Views 5/23/07

FINDINGS: There are several compression deformities of the lumbar spine. The T11 vertebral body compresses approximately 20%. The T12 vertebral body compresses approximately 30%. L1 vertebral body compresses approximately 25%. This is probably acute as the bones appear somewhat irregular. Bony alignment is still within normal limits, it

may be further evaluated with MRI scan. SI joints appear within normal limits. Paraspinous soft tissues appear within normal limits.

IMPRESSION: 1. There appear to be several compression deformities of the thoracolumbar spine with compression deformities at the T11 level of approximately 20%, T12 level approximately 30% and L1 level approximately 25%.

1. Exam Dale:5/29/200 Ordering Physician Martinez, Roger

Procedure: MRI of the Thoracic Spine 05/29/07

FINDINGS: A 40% anterior wedge compression fracture of the T8 vertebral body is noted that appears relatively recent with edema and some slight enhancement due to trauma. Some minimal anterior wedging of the TI1, T12, and LI vertebral bodies are also seen that appear relatively recent. A minimal anterior wedging of the T6 vertebral body is also seen that appears old.

At all levels of the spinal canal, however, the spinal canal is generous in size, as are the neural foramen bilaterally. No definite epidural or other abnormalities is seen in the spinal canal in the thoracic spine is seen.

IMPRESSION I – Multiple anterior wedge compression fractures, most new but some old, as described above. No epidural hematoma seen. Spinal canal generous in size at all levels of the thoracic spine, as well as the neural foramen bilaterally.

1. Exam Date: 5/29/2007 Physician: Martinez, Roger

Procedure: MR T~Spine wo Contrast

FINDINGS: A 40% anterior wedge compression fracture of the T8 vertebral body is noted that appears relatively recent with edema and some slight enhancement due to trauma. Some minimal anterior wedging of the T11, T12, and LI vertebral bodies are also seen that appear relatively recent. A minimal anterior wedging of the TB vertebral body is also seen that appears old.

At all levels of the spinal canal, however, the spinal canal is generous in size, as are the neural foramen bilaterally. No definite epidural or a process is seen in the spinal canal in the thoracic spine is seen.

IMPRESSION: 1. Multiple anterior wedge compression fractures, most new but some old, as described above. No epidural hematoma seen. Spinal canal generous in size at all levels of the thoracic spine, as well as the neural foramen bilaterally.

1. Exam Date: 7/5/2007 Physician: Peoples, Randal R

Procedure: Four Views Lumbosacral Spine 07/05/07 1217 Hours

FINDINGS: AP, lateral, flexion, and extension views of the lumbosacral spine were submitted for review. The lumbosacral spine is well aligned without evidence of subluxation despite the flexion and extension maneuvers. However, there is a mild wedge deformity noted of the T11, T12, and L1 vertebral bodies. These compression fractures were noted on a previous examination dated 05/23/07.

IMPRESSION: 1. With flexion and extension maneuvers, there was no subluxation noted of the lumbar spine.

2. Old mild anterior compression fractures noted of the T1l, T12 and LI vertebral bodies.

1. 12/28/07 Orthopedic Consultation Kevin M. Deitel, MD.
   1. Findings: Thoracic and Lumbar Compression fractures AOE 05/23/07. The patient is to be returned to work, light duty, restricted to no prolonged standing, walking, bending, stooping, climbing, lifting or carrying over 10 lbs.

DIAGNOSIS:

1. 1. Thoracic and Lumbar Compression Fractures

RELIABILITY OF EFFORT:

Subjective determination of effort is based on 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 workers performance was consistent clinically.

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.

DISCUSSION:

Mr. Smith presents today for an examination to reassess his current treatment, need for further treatment, and for diagnostic testing to assist him in returning to gainful employment. Mr. Smith states that he takes four Percocet pills and 1 Lidoderm patch a day. 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 36 inches) without discomfort or assistance to stand from a prone position.  While in the office, Mr. Smith was seated for approximately 30 minutes while completing the initial paperwork in addition to the 1 1/2+ hours of travel time; he then walked with normal gait to the examination room.  He had forgotten some paperwork and walked back out to his vehicle and back to the examination room, which involved opening the front glass door that takes considerable effort to open. Once he was finished with the examination, he walked out to the vehicle, opened the door, climbed in and sat in the vehicle without effort or discomfort.

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 noted³.  During the warm-up and step test, Mr. Smith stated, with movement his complaints subsided.  The step test was completed without incident. Mr. Smith’s blood pressure rose and fell consistent with the work load, what you would expect of a 27 year-old male. Mr. Smith was cooperative during all portions of the examination. Mr. Smith did state that his pain level slightly increased during the isometric testing to a 3 out of 1-5 scale.

During the rest of the testing Mr. Smith was asked to sit, stand, walk, lift, and carry in all NIOSH lifting positions. He was tested with blood pressure and heart rate monitor at every step of the examination.  Mr. Smith had no obvious physiological reactions i.e. severely elevated Heart Rate, myospasm or failure to complete the exam. We had to repeat many portions of the examination, as Mr. Smith would not provide full effort on a continuous basis.  His gait did not change, his biomechanics changed only slightly during the isometric testing and it is noted that his palpable muscle spasms increased from +2 to +3 which would be expected considering the amount of force that the patient exhibited.

As discussed, we were able to evaluate Mr. Smith over a significant amount of time. This testing is quite strenuous, and designed to reveal the true condition of the subject’s injuries. In Mr. Smith’s case, there was slight palpable muscle spasms in the Thoracic-Lumbar junction area of the spine, and restriction of lumbar extension.

There was no significant guarding, antalgia or abnormal posture associated with his movements over the extensive period of time he was evaluated. This lack of significant muscle spasm or guarding indicates that there is no biomechanical instability and thus no active injury as substantiated by the 7/5/2007 flexion/extension studies. It was noted that Mr. Smith has been, in his words, sedentary since the time of the accident only walking up and down the block and vacuuming as well as other household activities during the day. We would expect significant de-conditioning associated with the lack of activities that he is participates in all day as they are extremely sedentary. Mr. Smith to the contrary, is well fit, his blood pressure and heart rate lowered following exertion consistent with a subject of physical capacity and not one of a de-conditioned man that has not worked since the time of the accident².  Additionally, his heart rate did not stay elevated as one would expect of a man in extreme pain as he describes².

As referenced in the literature, a person that has essentially been inactive for over a year, one of which that wore a body brace for 5 months, would have degraded in his physical ability to perform work. Mr. Smith was injured on 05/23/2007, his only stated activities are walking up and down the block a couple of times a day, vacuuming, washing dishes and playing guitar calculating to the DOT Guidelines as sedentary work¹ . Also, an individual in extreme pain, as described by Mr. Smith would have had, decreased muscle tone, decreased cardiac MET Level, an elevated heart rate and blood pressure that does not reduce over time and would increase substantially with “work”³.

Objective computer testing, cardiac step testing, as well as the extensive physical examination reveled Mr. Smith, was able to  lift, twist, turn stoop and perform activities consistent light-medium work in all positions ¹ full time, indicating activities well above a sedentary lifestyle as described by the patient. These factors indicate that Mr. Smith was performing physically more strenuous activities than he states he was performing while TTD. Human beings accommodate physically to the work they perform⁴. Additionally, Mr. Smith denied any previous injuries except a “fall” that resulted in a patellar fracture. It was noted by 5/29/2007MRI by Roger Martinez, MD, noted that “there was a minimal anterior wedging of the T6 vertebral body seen that appears old”, indicating an old thoracic compression fracture. This information calls into question the severity of the fall or prior injuries Mr. Smith has experienced that were not expressed during the interview. Mr. Smith was disingenuous in his statements concerning his previous injures, which of course calls into question his credibility in regards to this examination. Statements made by Mr. Smith indicate that he has had numerous jobs and this job was obtained by “meeting a guy in a bar”. He moved to Las Vegas to “get a job” as he was out of work in his home town in Massachusetts. Mr. Smith worked in the steel industry while in California, and due to some conflict issues with his supervisor left that place of employment.

Mr. Smith is very apprehensive about moving, twisting, turning or lifting due to his injury, however was able to these activities well without repercussions.  He indicated that his life is one of moving from place to place and job to job as he desired. He stated he is quite happy in his current relationship and his duties as a home maker and that he is apprehensive about returning to the job market. Mr. Smith states that his current physician stated that he would never return to construction. I respectfully disagree with this idea, as these fractures are well healed, the subject has minimal movement restrictions consistent with this injury and his strength level will increase once he becomes more active.

With these corollaries in mind I can state with medical probability the following conclusions and recommendations.

CONCLUSION

With the information derived from the physical examination, cardiac step test, computerized range of motion, isometric strength testing, related documentation, I can make the following conclusions:

Mr. Smith’s complaints of pain have been unchanged since his 12/28/07 examination with Kevin Deitel, MD.  Mr. Smith has reached a Permanent Stationary Status, Maximum Medical Improvement, and can return to work full time, with the current permanent restrictions of  Light-Medium work (35lbs Occasionally, 18 lbs Frequently, 7 lbs Constantly)¹ in all positions is consistentwith NIOSH Guidelines².

The physical examination, MRI, CAT scan as well as x-rays indicate that Mr. Smith does have moderate thoracic and lumbar compression fractures. Mr. Smith will continue to have some dull pain and slight restriction consistent with these healed fractures; additionally I can state with some medical probability that his current pain, is significantly less than the patient articulates and does not require the amount and type of medications he is receiving at this time.

Mr. Smith has reached a permanent and stationary status as well as maximum medical improvement and is in not in need of further treatment. According to the Dictionary of Occupational Titles¹, Mr. Smith can return to work full time, and can perform job tasks consistent with light-medium duty work¹.

FUTURE TREATMENT RECOMMENDATIONS

The patient has reached maximum medical improvement and is not in need of future treatment in regards to the 05/23/2007 work related accident. Physical Rehabilitation would be a valid treatment method to bring this patient back to his pre-injury strength. This type of treatment is quite valid and successful when a patient is motivated. However, I can state with some medical probability that Mr. Smith has very little desire to exert the energy required to participate in a physical rehabilitation program.

PHYSICAL DEMAND LEVEL

Mr. Smith is capable of performing permanent restricted full time duty of light-medium work in all positions (35lbs Occasionally, 18 lbs Frequently, 7 lbs Constantly) ¹.

COMPLIANCE STATEMENT:

“I personally evaluated this patient and prepared this report.  If others have performed any services in connection to this report, outside of clerical preparation, their name and qualifications are noted herein.  The time spent was in accordance with Industrial Medical Council (IMC) guidelines.  I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others.   As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true.  I have not violated Labor Code Section 139.3 and the contents of the report and bill are true and correct to the best of my knowledge.  This statement is made under penalty of perjury.”

All available data supports the conclusions reached in this report.  Thank you very much for considering this organization for your referral.  If there are any questions concerning this matter, please feel free to contact me.

Sincerely,

________________________________08/15/2008

Allen S. Miller, DC, DACBSP                       Date:

(This signature will act as an original for the purposes of this document).

cc:        Lisa Anderson Esq., 601 South Ninth Street, Las Vegas, NV

REFERENCES:

1. Dictionary of Occupational Titles, U.S. Department of Labor Employment and Training Administration 1991. Volume II Fourth Edition, Revised 1991.
2. Nursing Diagnosis: Application to Clinical Practice by Lynda Juall Carpenito-Mojet
3. Foreman & Croft 1997. Radoff et all 1993.

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

3.       Health Psychology, By Michael Feuerstein, Elise E. Labbé, Andrzej R. Kuczmierczyk

4.       Cardiovascular/Pulmonary Essentials, By Marilyn Moffat, Donna Frownfelter

7.       The Forensic Documentation Sourcebook: The Complete Paperwork Resource for …

by Theodore H. Blau, Fred L. Alberts, Jr., Fred L. Alberts.

Police FCE Report

Mr. John Doe

Risk/Safety Manager

City of Bradenton

5555 Street Blvd.

Bradenton, Fl. 34444

Re:                                          Joan Smith

SS#:                                       000-00-0000

Claim #:                                 11111111

Employer:                              City of Bradenton

Job Description:                   Police Officer

Date of Injury:                       05/29/1998

Date of Examination:          09/03/1998

FUNCTIONAL CAPACITY EXAMINATION

Dear Mr. Doe;

The above named individual was recently referred to this facility for a Functional Capacity examination.  This testing consisted of computerized range of motion, computerized isometric lift tasks, dynamic lift tasks, computerized hand strength analysis, along with a routine physical exam.  The protocol consisted of lifting isometrically and dynamically within the NIOSH 5-position protocol. The patient was instructed to lift normally and anyway she felt best, and to stop if her comfort level changed. The routine physical examination as stated was within Dr. Gordon Waddell’s protocols and included range of motion, orthopedic and neurologic tests.  The patient was required to read and sign a consent form enabling this facility to examine, test, analyze and report findings to you, the employer. The objective of this testing was to determine the participants Physical Demand Level (PDL) for return into a suitable job task .

The results of this exam are discussed below.

Re:      Joan Smith

SS#:   000-00-0000

HISTORY:

On 5/29/98, Officer Smith was the operator of a Crown Victoria Police vehicle. Officer Smith states that another vehicle collided with the passenger side of the Police vehicle while she was driving through an intersection in the course of her duties as a Police Patrol Officer. She states that the collision was of enough force as to roll the vehicle rolled over one and one quarter times, coming to rest on the passenger side. Officer Smith denies any loss of consciousness, and states that somehow her seat belt came unfastened as her vehicle rolled over. She further states that she struck her head, left arm and right leg on the vehicle interior.

Immediately following the accident, Officer Smith stated that she was “stunned”. Within a few hours following the accident, she began to experience left sided forehead pain, neck pain, mid back pain, left arm pain, low back pain and bilateral leg pain.

She was transported from the accident scene by ambulance, to Bradenton Memorial Hospital in Bradenton, Florida. She was examined by the physician on duty. She received x-rays of her neck and was prescribed “Tylenol # 3” and released. The same day she presented herself to Dr. Head at Oaks Medical Center for examination and was subsequently prescribed “Tylenol # 3”. Officer Smith was then examined by Dr. M. Jones and received x-rays of her neck and back. Dr. Jones prescribed physical therapy for Officer Jones at Mediplex. The physical Therapy treatments were described as consisting of thirty minute treatment sessions consisting of TENS therapy, Heat, and Rehabilitative Spinal Exercises. MRI’s of the Cervical and Lumbar spine were prescribed and performed. Officer Smith states that she continues to see Dr. Jones on an as needed (prn) basis.

Officer Smith states that she saw Dr. Bob Mets, a Bradenton Chiropractor once a week for treatment. She states that she saw Dr. Mets for a prior work related automobile accident. Treatment consisted of Cervical Spine Manipulation and massage therapy.

Officer Smith is currently working in the capacity of Desk Officer. This task requires her to answer a phone and interact with the public. She does not wear a Sam brown belt only a gun and holster. She states that she has recently requested a head set as answering the phone aggravates her neck symptoms.

Re:      Joan Smith

SS#:   000-00-0000

PAST HISTORY:

On January 29, 1993, Officer Smith states that she was driving her patrol vehicle in the course of her duties as a Bradenton Police Officer. She states that she was performing a U-turn, and was struck in the driver’s door by another vehicle. She states that she struck her head on the door frame with her head turned to the left. She was seen by multiple physicians. She was then seen by Dr. Bob Mets.

Her initial visit and treatment frequency with Dr.Mets was 3 times per week. Officer Smith states that she is currently on a “on call basis” for treatment.

MEDICAL/SURGICAL:

Contributing Medical History:        Denied.

Contributing Surgical History:       Denied.

PRESENT COMPLAINTS:

1. Low back pain, bilateral, ache in nature, worse with sitting, graded 1 to 4/10 on the Borge pain Scale.
2. Right arm pain, ache in nature, extending from shoulder to forearm, graded 0 to 3/10 on the Borge pain scale, worse with repeated arm use.
3. Neck pain, posterior, bilateral, dull to sharp in nature, graded 1 to 4/10 on the Borge pain scale, worsens with repeated head movement.
4. Right leg ache, intermittent, graded 0 to 3/10 on the Borge pain scale, worsens with prolonged sitting.
5. Head pain, occiput to frontal, intermittent, graded 0 to 4/10 on the Borge pain scale.
6. Intermittent bilateral hand and foot paresthesias.

PERSONAL:

Police Officer, married, no children, non-smoker, and social alcohol user. Hobbies: Golf, Jet-ski and scuba diving.

EXAMINATION FINDINGS:

Joan Smith is a 32-year old female, 5′ 8″ tall, 155 pounds.  She appears her stated age and is in excellent physical condition. Muscle testing revealed +5 muscle strength in the upper and lower extremities. Sensory testing was performed indicating no loss of pain or sensation along the dermatomes in the upper and lower extremities bilaterally.

Re:      Joan Smith

SS#:   000-00-0000

Officer Smith does not demonstrate any abnormal scars, or protrusions connected with the  injury.

Spinous percussion was positive for sprain type injury at L5 spinous level. Digital palpation of the Cervical, Thoracic and Lumbosacral regions revealed mild + 1 parapsinal myospams with accompanying mild tenderness at C2 through T3 bilaterally. Mild tenderness at the left of T10 through T12 and L4 through the sacrum and the right sacroiliac articulation. Officer Smith stated her comfort level to be 1 ½ on a 1 to 5 scale.

Cervical Lateral Compression Test (for nerve root compression) was negative bilaterally however the patient reported right sided neck pain. Cervical Flexion and Extension Compression Tests ( for nerve root compression) were negative however the patient reported right sided neck pain. Maximum Foraminal Compression test (for nerve root compression) was negative bilaterally  however the patient reported right sided neck pain.

Cervical Distraction and Shoulder Depression Tests were negative.

Straight Leg Raise Test (for space occupying lesion) was positive bilaterally at 50 degrees of leg elevation for low back pain. Lindner’s test (for space occupying lesion) was positive bilaterally for low back pain complaint. Gaenslen’s and Nachlas Tests (for sacroiliac articulation lesion) were positive on the left for complaints of sacroiliac tenderness.

Deep Tendon Reflexes, motor strength levels and sensory pin prick were all within normal limits in the upper and lower extremities bilaterally.

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

RADIOLOGICAL FINDINGS:

1. 11/25/96 – Magnetic Imaging Center of Bradenton – Todd Osoow, M.D.

Impression: Moderate sized central and right paramedian, broad based disc herniation at C5-6 with flattening of the cord with minimal spinal stenosis.

Small central herniation at C4-5, best appreciated on axial images.

Neural Foraminal narrowing, predominantly on the left at C5-6.

Re:      Joan Smith

SS#:   000-00-0000

1. 08/28/98 – Magnetic Imaging Center of Bradenton – Todd Osoow, M.D.

Impression: Broad Based Central Herniation at C5-6 which has advanced when compared to the previous study. There is significant flattening of the spinal cord.

There is cord flattening also at C4-5 due to small Central disc herniation. There is also a small central protrusion at C6-7.

Neural Foraminal narrowing, predominantly on the left at C5-6.

1. 08/28/98 – Magnetic Imaging Center of Bradenton – Todd Osoow, M.D.

Impression: Minor degenerative changes no disc herniation, spinal Stenosis or Neural foraminal narrowing is present.

CARDIOVASCULAR TESTING:

Depending on the identified goals for the Functional Capacity Examination, cardiovascular 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 patients resting Heart Rate was 88 BPM and a Blood Pressure 100/70.  The patient was tested and a Step test was performed. The patient performed a maximum of 4.3 METS with a Heat Rate of 165 BPM. The patients MET level corresponded with a Physical Demand Level of Medium work which does equal the PDL of the job task.

COMPUTERIZED RANGE OF MOTION:

The patient was tested utilizing the computerized inclinometer to determine their Cervical, Thoracic, and Lumbar Spine range of motion. This ration of the patients ROM is analyzed for any impairment utilizing the AMA guidelines 4^th, Edition as a reference.

The patient exhibited the following findings.

Cervical Spine:

Officer Smith exhibited mild restriction in the Cervical flexion/extension, left lateral flexion and  right/left rotation with a cervical impairment 7%.

Thoracic Spine:

Officer Smith exhibited mild restriction in the thoracic flexion, and  right/left rotation with a thoracic impairment 3%.

Re:      Joan Smith

SS#:   000-00-0000

Lumbar Spine:

Officer Smith exhibited mild restriction in the lumbar flexion/extension lumbar spine impairment 7%.

¬  Whole Person Spine Impairment 16%.

These figures were calculated utilizing the AMA’s Guides to the Evaluation of Permanent Impairment. The patients test results are attached to this report.

COMPUTERIZED HAND STRENGTH TESTING:

There are many reasons to measure an patients grip strength. Grip strength can be used to determine the nature of injury (organic versus psychological) or the patient’s sincerity of effort as in a Functional Capacity Examination. As part of a Functional Capacity Examination, grip strength will be used to determine a sincerity of effort along with determining any residual muscle strength loss due to injury.

5 Position Grip Strength Test: This will be of use as a validity test check as part of a Functional Capacity Examination.

Left Hand Right Hand (Dominate):

Position 1 47 lb. Average. 28% CV. Test Valid.    48 lb. Average. 13% CV. Test Valid.

Position 2 84 lb. Average. 10% CV. Test Valid.    84 lb. Average.   4% CV. Test Valid.

Position 3 72 lb. Average. 18% CV. Test Valid.    91 lb. Average.   7% CV. Test Valid.

Position 4 59 lb. Average. 13% CV. Test Valid.    86 lb. Average.   6% CV. Test Valid.

Position 5 58 lb. Average.   9% CV. Test Valid.    59 lb. Average.   3% CV. Test Valid.

The patient failed to give consistent effort in repetitions 1 and 3 of the left hand.

Rapid Exchange Grip Test: The REG test will be used as a validity check and supplement the 5 position grip test. The will be the distinguishing test for the cooperative, uncooperative or malingering subject.  This test validated the subjects maximum strength curves.

Sustained Grip Test: The SGT test will be used as a validity check and supplement the 5 position grip test. This will be the distinguishing test for the cooperative, uncooperative or malingering subject.

Re:      Joan Smith

SS#:   000-00-0000

Position 2:

Left Hand Right Hand (Dominate):

Rep 1 53 lb. Average. Test .    59 lb. Average. Test .

Rep 2 50 lb. Average. Test .    54 lb. Average. Test .

Rep 3 47 lb. Average. Test .    48 lb. Average. Test .

Rep 4 42 lb. Average. Test .    67 lb. Average. Test .

The patient’s strength was within  limits and are detailed in the attached documents.  The testing revealed a 20% deficit on the left hand is consistent with Officer Smith’s use, training and proficiency with the right hand and weapons training.

Pinch Tests (Finger Strength):

Left Hand Right Hand (Dominate):

Tip                  14.5 lb. Average. Test .    16.1 lb. Average. Test .

Key                 20.9 lb. Average. Test .    22.6 lb. Average. Test .

Palmar           20.2 lb. Average. Test .    18.5 lb. Average. Test .

Opposition       5.2 lb. Average. Test .      5.4 lb. Average. Test .

COMPUTERIZED ISOMETRIC STRENGTH TESTING:

The Isometric strength testing is performed in accordance with the NIOSH Practices Guides for Manual Lifting and utilized the NIOSH 6 positions. The six lifting postures will be used to compile an isometric strength database.

NIOSH Arm Lift Statistics (Back, Shoulder, & Bilateral Arm Lift):

Max lift average 46 lb.

NIOSH 45 %tile.

The test CV was 9 % and .

The Patients Dynamic Rating was: Light-Medium

35 lbs. Occasionally (0-33%), 14 lbs. Frequently (34-66%) 7 lbs. constantly (67-100%).

NIOSH Torso Lift Statistics (Bilateral Arm, Back & Leg Lift):

Max lift average 33 lb.

NIOSH 6 %tile.

The test CV was 18 % and .

The Patients Dynamic Rating was: Light

17 lbs. Occasionally (0-33%), 7 lbs. Frequently (34-66%) 3 lbs. constantly (67-100%).

Re:      Joan Smith

SS#:   000-00-0000

NIOSH Leg Lift Statistics (Bilateral Leg, &  Back Lift):

Max lift average 124 lb.

NIOSH 79 %tile.

The test CV was 7 % and .

The Patients Dynamic Rating was: Medium

62 lbs. Occasionally (0-33%), 25 lbs. Frequently (34-66%) 12 lbs. constantly (67-100%).

NIOSH High Far Lift Statistics (Bilateral Arm, Shoulders & Back Lift):

Max lift average 29 lb.

NIOSH  50 %tile.

The test CV was 8 % and .

The Patients Dynamic Rating was: Light-Medium

42 lbs. Occasionally (0-33%), 17 lbs. Frequently (34-66%) 8 lbs. constantly (67-100%).

NIOSH Floor Lift Statistics (Bilateral Leg, Arm & Back Lift):

Max lift average 52 lb.

NIOSH 30 %tile.

The test CV was 8 % and non-Valid.

The Patients Dynamic Rating was: Light-Medium

31 lbs. Occasionally (0-33%), 12 lbs. Frequently (34-66%) 6 lbs. constantly (67-100%).

• Note: Officer Smith did not appear to offer a sincere effort at this point in testing.  This test had to repeatedly restarted due Officer Smith’s misunderstanding of the commands.

Push Statistics (Bilateral Arm, Legs & Back):

Max lift average 86 lb.

The test CV was 10 % and .

Note: The patient was able to exert significant force and was void of an increase in comfort level, myospasm or restriction.

Pull Statistics (Bilateral Arm, Legs & Back):

Max lift average 66 lb.

The test CV was 4 % and .

Note: The patient was able to exert significant force and was void of an increase in comfort level, myospasm or restriction.

Re:      Joan Smith

SS#:   000-00-0000

DYNAMIC LIFT TEST:

The patients safe lift capacity was determined by static lifting. Once it was determined that the patient could produce enough force and strength to lift the required weight for the job task the patient was referred to dynamic lifting to confirm the sincerity of effort.

The patient was required to lift a box of weights they felt comfortable lifting, proceeding to 80% of the patients body weight or a  safe comfort level which ever was less. This test was utilized to determine the patients sincerity of effort. The patient lifted the required weight in the 5 positions.

1. Floor Lift:               Max Weight Achieved – 35 Lbs. HR: 158 Comfort Level: From 2-2 ½.
2. Knee Lift:  Max Weight Achieved – 52 Lbs. HR: 171 Comfort Level: From 2 to 3.
3. Waist Lift:              Max Weight Achieved – 32 Lbs. HR: 160 Comfort Level: From 2 to 3.
4. Waist-Overhead:   Max Weight Achieved – 32 Lbs. HR: 160 Comfort Level: From 2 to 3.
5. Carry 20 Ft:           Max Weight Achieved – 32 Lbs. HR: 146 Comfort Level: From 3 to 2.

The patient was able to lift a weight box in anyway she felt comfortable and able in several positions. She complained of a slight increase in her comfort level, without an increase in myospasm, joint tenderness or restriction. Officer Smith was consistent and reliable in her effort and exceeded our expectations in this area.

POSTURES AND ACTIVITIES:

During testing, Officer Smith, was required to bend squat, reach, walk crawl, stand and sit. These are activities that coincide with her duties as a Police Officer. During this testing Officer Smith complained of pain, myospams and dizziness. Upon immediate physical examination her symptoms could not be validated by palpation or orthopedic tests.

Officer Smith was asked to run up 4 steps turn quickly and jump off of the 4 stairs to a concrete floor. Officer Smith’s only complaint was that of knee stiffness, with this type of physical stress dizziness should have been apparent. However, Officer Smith was able to perform this test without dizziness. Twenty two minutes later upon examination for arm numbness, Officer Smith experienced a “bout” of dizziness. However, this episode did not coincide with any positive Rombergs or other reliable neurologic testing methods.

Re:      Joan Smith

SS#:   000-00-0000

Conclusions:

Officer Smith was compliant and cooperative during the examination process. She was objectively examined with a multitude of tests and in several positions. She was given a full physical examination and tested utilizing computerized hand dynamometer, inclinometer, isometric and dynamic strength testing.

These tests were utilized to substantiate her complaints of pain, numbness, dizziness and disability and subsequently find Officer Smith a suitable job task for her to perform. The testing that Officer Smith participated in is quite rigorous and takes 3-4 hours to complete. Officer Smith exhibited the ability to sit still for 60-90 minutes without a change in her comfort level or heart rate. She did not need to rise or stretch, she sat while filling out  the forms and during the examination process unremarkably.  This contradicts her stated symptoms and limitations on the Functional Activities Questionnaire.  She exhibited fine motor skills and the ability to bend, squat, stand, reach, twist and turn without significant hindrance. Officer Smith stated that during these activities her comfort level changed from a 2 to a 2.5., at the same time she showed a lowering of her heart rate from 101 to 88 indicating a relaxed demeanor.

Following the initial interview and examination the participant underwent a cardiovascular step test. This test was utilized to determine the cardiovascular health of the participant and her Physical Demand Level (PDL) as it compares to her job description.

Officer Smith exhibited the ability to perform medium work, which correlates with the DOT description 375.367-010, that of police officer. The step test indicated that she is slightly de-conditioned in relation to her age, however this is consistent with her statements that she doesn’t “work out as much since the accident.”

The participant was also required to perform computerized hand and finger strength testing. This entails 7 isometric strength tests per hand where the participant is required to squeeze a non-moving isometric device as hard as possible. This registers the strength of the participant in 5 positions and compares it to the Mathowitz national database. Her complaints of bilateral hand numbness, specifically, could not be substantiated correlated to the test results.  When asked when her numbness occurs, she stated intermittently. When asked to further elaborate, she could not tell us when the numbness occurs, what causes it or how long it lasts.

Re:      Joan Smith

SS#:   000-00-0000

She also was inconsistent as  to the type of hand numbness she experiences. Officer Smith states that her numbness occurs in the 4^th and 5^th fingers bilaterally and simultaneously.

Then, she stated that her numbness also occurs in the 3^rd, 4^th, and 5^th fingers bilaterally and simultaneously. Yet during the computerized dynamometer testing she gave us maximum effort and produced significant valid strength curves.  This again is inconsistent with her reported symptoms.  She was tested multiple times bilaterally, with consistent and valid results. The strength, force and effort Officer Smith exhibited in conjunction with the other tests should have aggravated her hand complaints and numbness, however her comfort level never exceeded a level that of “2” and there was no loss of muscle strength, increased muscle spasm or resulting numbness.

Next, Officer Smith underwent computerized range of motion (ROM) testing. This test required the participant to move her cervical, thoracic and lumbar spine in all ranges of motion while it is measured and documented by the computer.  Officer Smith exhibited mild restriction and slight impairment of the Cervical, Thoracic and Lumbar range of motion during the examination.

During one part of the examination, Officer Smith was required to bend at the waist while keeping her legs straight. She was required to hold that position while we determined her ROM. She was able to perform this test without significant rise in her HR (101 to 109) or a change in her comfort level (2 to 2.5). The rise in her HR correlates to the movement activity she was performing during the testing and is consistent with the work she performed.  It should be noted that persons with back injury and or weakness cannot perform certain portions of this test due to pain and must be administered in a modified position. Officer Smith was able to perform these movements without an increase in pain or muscle spasms.

We also monitored Officer Smith’s HR and comfort level numerous times during every phase of the testing.  She did not portray a significant rise in comfort level or HR during this phase of the testing.

Following this ROM testing Officer Smith participated in Isometric Strength Testing. Officer Smith was tested utilizing NIOSH Isometric lift testing procedures including Push and Pull.  This testing required the participant to pull a non moving bar with maximum strength in six positions including bending, standing, and squatting. The patient exhibited significant strength consistent with her age and gender.  Her HR raised from 101 to an average of 158 during this portion of the testing.

Re:      Joan Smith

SS#:   000-00-0000

This is consistent as this type of testing is rigorous and difficult to perform. The patient did not exhibit dizziness or significant rise in comfort level during this phase of testing. Her comfort level rose from 2.5 to 3.0 during this phase, however, this is consistent with the rigors of testing. Officer Smith completed the testing and was examined immediately afterwards  for muscle spasms and or pain. Officer Smith did not exhibit a significant increase in pain or palpable muscle spasms before, during and after the examination.

One would expect a rise in muscle spasms pain and joint restriction from someone with the type of injury and restriction reported by Officer Smith.

During the examination process Officer Smith stated that she had pain and myospams around the medial border of the right scapula. However, during the isometric push/pull testing, Officer Smith exhibited significant strength and endurance. Her position and strength curves contradict her complaints of pain, reported restriction and associated spasms.

We utilized Dynamic Testing to correlate the data derived from Computerized Isometric Static Testing.  Officer Smith was asked to pick up an empty box weighing 12 lbs.  After completing this successfully, she was then asked to add weight to the box in increments she felt comfortable with and repeat the lifting procedure.  Officer Smith lifted the boxes in 4 different positions correlating with the NIOSH testing positions.  We did see a rise in her HR while performing this examination form 101 to a maximum of 160 with an average of 141. This rise in HR, is consistent with the amount of work required to perform this examination.  During the less strenuous portions of this testing, Officer Smith’s’ HR dropped from 158 to 141 again consistent with the work task. Officer Smith was able to lift the boxes without increased palpable spinal muscle spasms. Officer Smith stated that her comfort level increased from a 2 to a 3 respectively.

Because of the type of lifting Officer Smith was asked to perform, one would expect an increase in objective signs that occur involuntarily such as in palpable muscle spasms, pain and joint restriction. Physical examination could not detect any signs consistent with her complaints or that of her original injury.

During the entire examination process Officer Smith complained of pain and spasm around the medial border of the scapula, and sacral region. However, during all phases of testing, Officer Smith exhibited significant strength and endurance consistent with the activities involved. Physical Examination, testing position, and significant strength contradicts her current complaints of pain, restriction and spasm in these areas.

Re:      Joan Smith

SS#:   000-00-0000

Officer Smith’s subjective complaints of pain, spasm and restriction do not correlate with the physical examination, computerized hand/finger strength, range of motion, isometric and dynamic lift tests.

RECOMMENDATIONS:

With the information derived from computerized testing, physical examination, dynamic and isometric lift tests, the position and specific job functions consistent with a Police Patrol Officer are  for the participant to perform.  Officer Smith exhibited the ability and strength consistent with and even exceeding the ability to perform medium work which correlates with the DOT description 375.367-010, that of Police Officer. We did not find any physical reason Officer Smith cannot return to her job duties as a Police Patrol Officer.  She may return to her duties as a Police Patrol Officer immediately without restriction.

Officer Smith has received the gambit of treatment modalities Chiropractic, Medical, Physical Therapy and Rehabilitation. Officer Smith has reached a permanent and stationary plateau and has received maximum medical benefit.  I would recommend that Officer Smith continue with the  exercise program that she is currently performing at the Police Station. It is recommended that Officer Smith include cardiovascular training for overall health, fitness and job safety.

Without the records of the prior work related auto accidents it is difficult to apportion these injuries. Our computerized testing utilzies the AMA Guides to imparement 4^th. Edition to determine injury imparement. The rating source utilized in the State of Florida is the Florida Imparement Guides and is the proper sourse for rating work related injuries occuring after June 1993. The Following referenced section of The Florida Imparement Guide appropriately represents Officer Smith present status.

Under Specific Disorders of the Spine, the category C. Intervertebral Disc or Other Soft Tissue Lesions: 2 Pain associated with rigidity (loss of motion or postural abnormality) and chronic muscle spasm. The chronic muscle spasm and rigidity is substantiated by objective clinical findings but without associated demonstrable degenerative changes:

Cervical         3% Imparement of whole person.

Re:      Joan Smith

SS#:   000-00-0000

Officer Smith’s MRI studies revealed disc herniations at C4/C5 and C5/C6 disc levels. When both discs are considered, and the assigned percentage of impairment combined, they yield a 6% total impairment of the whole person. It is significant, and therefore predated the 05/29/98 accident. Therefore, her present level of impairment is not due solely to the 05/29/98 accident.

Thank you very much for considering this facility for your referral.  If there are any questions concerning this matter, please feel free to contact  me.

Sincerely,

Dr. Allen S. Miller

Enclosures

CC  Insurance Company

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)