Toyota Job Site Analysis & Job Description

Job Site Analysis Report

Weight Checking/Barcoding Station

FTS California – Hayward, CA

Prepared by:

Dr. Allen S. Miller

Date of Analysis:

February 12, 2004

411 E. Huntington Dr. 107-285 Arcadia CA 91006  · E-Mail Drasmiller@Earthlink.net ·

COMPANY	FTS California-Hayward, CA	JOB TITLE
CONTACT PERSON	Mr. Peter Ingenhutt	D.O.T. EQUIVALENT
POSITION	HR/Safety Manager	D.O.T. NUMBER
OTHER CONTACT		DEPARTMENT
POSITION		BREAKS	60 Min.
ADDRESS	18231 Murphy Parkway	SHIFT DURATION	8.0 Hrs.
CITY, STATE	Hayward, CA	REAL WORK TIME	8 Hrs.
ZIP	95330	DAYS WORKED	Monday to Friday
TELEPHONE	(209) 858-0400 ext 130	HOURS PER WEEK	40 Hrs.
FACSIMILE	(209) 858-9293	SHIFT	1
		PHYSICAL DEMAND LEVEL (UPPER BODY)	Medium
E-MAIL	Peter.Ingenhutt@Fueltotalsystems.com	PHYSICAL DEMAND LEVEL (LOWER BODY)	Sedentary – Light
DATE	2/10/04	UNION PLANT?	No

JOB DESCRIPTION

FUNCTIONAL JOB DESCRIPTION:

Weight Bar-coding Station

KEY JOB TASKS:

Employee must inspect and weigh freshly manufactured tank and place barcode on it. The employee must additionally place parts and work machinery in a safe manner.

DATA:

Information, knowledge and conceptions related to data, people or things obtained by observation and mental creation.

Synthesizing Coordinating Analyzing Compiling Computing Copying Comparing

Yes Yes Yes Yes Yes Yes Yes

INFREQUENT TASKS: None

WORK PACE:

Self-paced to accomplish and finish 60 parts per hour, or in accordance with the demands of the employer.

PERSONAL TRAITS:

Ability to comprehend and follow instructions. Ability to perform simple and repetitive tasks. Ability to maintain a work pace appropriate to a given work load. Ability to relate to other people beyond giving and receiving instructions. Ability to influence people. Ability to perform complex or varied tasks. Ability to make generalizations, evaluations or decisions without immediate supervision. Ability to accept and carry out responsibility for direction, control and planning.

Yes Yes Yes Yes Yes Yes Yes Yes

POSTURE AND MOVEMENT

SUSTAINED POSTURE OVERVIEW	Max. Consec. Min. Per Hour	Total Daily Hours	Possible Change Optional	Further Description
Sitting	0	0	No	N/A
Static Standing	20	2	No	Line Dependent
Dynamic Standing	40	4	No	Line Dependent
Walking	10	2	No	Line Dependent
Driving	0			N/A

STATIC STANDING
Maximum Consecutive Minutes Per Hour	55
Total Daily Hours	8.0
Possible Change Optional?	No
Floor Surface	Cement, rubber mats
Step Available?	N/A
Further Description

DYNAMIC STANDING
Maximum Consecutive Minutes Per Hour	55
Total Daily Hours	8.0
Possible Change Optional?	Yes
Floor Surface	Cement, rubber mats
Further Description

WORK STATION

WORKSTATION LAYOUT	SURFACE 1 (See Below)	SURFACE 2 (See Below)
Surface	Roller Track
Height	39 in.
Depth	13 in.
Length	36 in.
Surface	Steel
Debris	No
Floor Surface	Cement with rubber mat
Comments

ERGONOMIC RISK FACTORS RISK FACTOR	IDENTIFIED?	COMMENTS
Awkward Posture	Yes	Must bend waist at 45 degrees to weight and place bar code on the tank.
Static Posture	Yes	Standing over a part for 20 seconds.
Repetition	Yes	Job task cycle is 1 part per minute
Forceful Exertion	No
Localized Mechanical Stress	Yes	Hands and low back.
Vibration	No
Extreme Cold	No

Strain Index (SI)

Hand: Right Side

Job Factors                              Level                            SI Score

Intensity of exertion                   Somewhat Hard             3.0

Duration of exertion (%)             33.0                              1.5

Efforts/Minute                           1.0                                0.5

Hand/Wrist Posture                   Good                            1.0

Speed of work                          Fair                               1.0

Duration per Day (hr)                 8.0                                1.0

Strain Index Score: 2.2

Recommendation:

Risk Level = Low

NOTE: Preliminary testing has revealed that jobs associated with distal upper extremity disorders had SI Scores greater than 5.  SI Scores less than or equal to 3 are probably safe.  SI Scores greater than or equal to 7 are probably hazardous.  The Strain Index does not consider stresses related to localized mechanical compression.  This risk factor should be considered separately. For additional information see Moore & Garg (1995).

Rapid Upper Limb Assessment (RULA)

Rapid Upper Limb Assessment (RULA)

Analyst: Allen S. Miller

Job Name: Pressure Test

Workstation ID:

Hand: Right Side

Body Parts                   Posture                                                 RULA Score

Wrist                             Neutral                                                  1

Wrist                             In mid-range of wrist twisting range        1

Upper Arms                  46 to 90                                                3

Lower Arms                   0 to 90                                                  1

Neck                             0 – 10                                                    1

Trunk                            0 – 20                                                    2

Legs                             Legs/feet well-supported                       1

Body Parts       Posture Score   Muscle Score    Force Score      Total

Arm+Wrist                     2                      0                      0          2

Neck+Leg+Trunk            1                      0                      0          1

RULA Grand Score: 2

Recommendation: The Posture is acceptable if it is not maintained or repeated for long periods.

Detailed Summary:

Job Task Requirements

As the tanks come from the robot Station the Tank # 635 for the Toyota Tacoma weighing 9.12 kg (20.06 lbs.) or tank # 930 for the Toyota Corolla weighing 7.56 kg (16.63 lbs.) come down the roller tracks to the weight station (see Diagram 1) the employee must remove two plastic tabs from the sides of the tank that the robot cannon remove.  Additionally, the employee must inspect the “O” ring and weight the tank (see diagram 2). Once the tank is weighed a bar code is printed and the employee must place the tag in its rightful place on the tank.

Diagram 1                                                         Diagram 2

Additionally, the employee must write the weight with a white chalk pen on the tank. This procedure may not be continued in regular production. This procedure requires the employee to stand and work within a neutral posture at a workstation height of 39 inched and reach of 13 inches. Once the tank is weighed it is rolled to a cooling station and then to the thickness station.

Conclusion:

In this case there are no recommendations to adjust body mechanics to work within the confines of this station. It would be advisable to have the robot remove the excess tabs from the tank. The employee will have to remove two (2) tabs per tank with an average force of less than one (1) pound of force. That equals 2 tabs per tank, 480 tanks per cycle that is 960 times a shift an employee must remove this material. There is no recommended remedy, as utilizing the robot would raise the production time to unacceptable levels.

Additionally, due to employee being required to stand and walk around, one recommendation is anti-fatigue mats or possibly a more cost-effective alternative Personal Anti-fatigue Mat™ Insoles (http://www.mega-comfort.com/ergonomic_personal_anti-fatigue_mat_insole.htm). These insoles act as if the employee walked on anti fatigue mats anywhere they walked. The retail cost of the insoles is $19.95 and reduces muscle fatigue and as well as prolongs performance.

One of the positive aspects of the job task is the employee is not required to lift the tank or utilize severe adverse body mechanics to complete the job task. They are also able to walk and move around in a defined area. This dynamic posture is advantageous, as it requires the employee to move all muscle groups, which inherently reduces fatigue, stress and injury. Because of factors that we cannot change i.e. robot mechanics, that are set and financial prohibitive to change, job rotation is crucial, and would delay the effects of ergonomic stress to one area. This would also allow other muscles to work reducing over fatigue and injury.

Post-Offer Employment testing Requirements:

We will concentrate on lumbar, hand, wrist strength and stability. These two areas are crucial in reducing costly injury and claims.

Please understand that when we evaluated these positions, the systems were still being worked out and procedures were still in flux. We will modify these recommendations as production starts and procedures are solidified. If there are any questions concerning the above information, please feel free to contact me.

Sincerely,

________________________________

Dr. Allen Miller

ASM/sd

CNA Peer Review

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 ·

May 3, 2008

Laureen Alvarez
CNA Claims
P.O. Box 6500
Brea, CA 92822

RE:

Patient:                         Jose Smith

Claim Number:            mmmmmm

Date of Birth:               May 5, 1965

SS#                              555-55-5555

Date of Injury:             May 18, 2005

Employer:                    Jensen Precast

Peer Review:                May 1, 2008

PEER REVIEW REPORT

The following is a Peer Review Evaluation based on medical records received from CNA on Jose Smith.  This evaluation was requested by CNA and will address the following issues in dispute:  Causality, Diagnosis, Excessive treatment, MMI, Necessity of treatment, Pre-existing condition, and Need for future medical care.  The following report contains my opinions and conclusions, in regard to this case.

It should be duly noted that all records reviewed, (as delineated in the following report), were done by myself without delegation of tasks to other parties or individuals.  Similarly, the entire body of this report was authorized solely by myself and all sources of historical facts mentioned in this report were obtained through a review of medical records as provided by CNA.  Further, let it be known that 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 and is reiterated at the end of this report.

RECORDS REVIEWED:

1. 5/28/2005-Doctors First Report; Mazin R. Sabri, MD

Doctor’s Hospital Medical Center of Montclair

1. 5/28/2005-Post-Operative Report; Mazin R. Sabri, MD

Doctor’s Hospital Medical Center of Montclair

1. 8/28/2005-Doctors First Report; Paul M. Umof, MD
2. 9/22/2005- Interim Progress Report; Mazin R. Sabri, MD
3. 5/29/2007 Primary Treating Physicians Request for Authorization; John B. Smith, MD Orthopaedic Medical Group of Riverside
4. 7/5/2007 EMG and Nerve Conduction Study Report; Filemon R. Quinio, Jr., MD.
5. 8/9/2007 Primary Treating Physicians Request for Authorization; John B. Smith, MD Orthopaedic Medical Group of Riverside.
6. 9/18/2007 Primary Treating Physicians Progress Report; John B. Smith, MD Orthopaedic Medical Group of Riverside.
7. 9/28/2007 Primary Treating Physicians Progress Report; John B. Smith, MD Orthopaedic Medical Group of Riverside.

HISTORY OF INJURY:

On May 18, 2005 the subject, Jose Smith, while working within the scope of his employment for Jensen Precast was “pulling cable” and “cut his pinky”. The subject presented to Doctor’s Hospital Medical center of Montclair via the emergency room with a complex laceration which was in a circular fashion across the distal portion of the right fifth finger at a level of the base of the nail. It was elected at that time to re-attach the torn tissue rather than amputate it. No information was documented how the accident occurred other than he was pulling cable. On 9/22/2007 Dr. Sabri, reported that the patient was doing well and presented with a healed right fifth finger tip. The finger was slightly contracted at the tip approximately 0.5 cm off the palmar aspect of the hand. The report states that the patient was to continue his regular work and scheduled for a re-examination in 6 weeks for release Permanent and Stationary.

HISTORY OF PRIOR INJURY AND/OR DISABILITY:

There is no history of prior injury and/or disability by way of recordation. However, x-rays taken by Dr. Smith on 5/29/2007 reveal a fracture of the right 3^rd phalanx. If any additional records become available concerning prior injuries and/or disability, I would be glad to review them and offer additional opinions if necessary as to whether or not there is a pre-existing condition.

SUBJECTIVE FINDINGS:

Subjective findings noted in Dr. Smith report, dated 5/29/2007 indicate that the patient noticed “numbness and tingling in the right hand and seems to be worsening since the time of original 5/18/2005 injury”. Dr. Smith at that time referred the patient for an EMG and Diagnostic Testing which was performed on 7/5/2007 by Filemon R. Quinio, Jr., MD. The testing revealed evidence of bilateral moderate carpal tunnel syndrome, with prolonged latencies of the median motor and sensory nerves across the wrist. There is no evidence of ulnar neuropathy, radial nerve injury or cervical radiculopathy. Note: Median-Ulnar/Martin Gruber anastomosis noted in both forearms.

On 8/9/2007 Dr. Smith makes note that the patient has bilateral moderate carpal tunnel syndrome, with prolonged latencies of the median motor and sensory nerves across the wrist. There is no evidence of ulnar neuropathy, radial nerve injury or cervical radiculopathy. The patient is noted to have a Median-Ulnar/Martin Gruber anastomosis noted in both forearms.  Dr. Smith with this information scheduled the patient for left carpal tunnel release of flexor tenosynovectomies. On 9/18/2007, Dr. Smith in his interim report acknowledges the patients arthritis of the 5^th proximal interphalangeal joint and right carpal tunnel syndrome. However, states the patient is progressing well with his left postoperative carpal tunnel release and did not want to proceed with carpal tunnel release of the right wrist. The patient was returned to his regular work on 9/18/2007. On 2/12/2008, Dr. Smith reports that the patient now wants to proceed with the right carpal tunnel release and states that he anticipated another left carpal tunnel release. The patient exhibits swollen volar aspects of both wrists, and positive Tinel’s and Phalen’s bilaterally. There is dryness and decreased moisture in the median distribution of both hands as compared to the ulnar distribution. Dr. Smith diagnoses the patient with bilateral carpal tunnel syndrome with flexor Tenosynovitis bilaterally.

OBJECTIVE TESTS:

X-ray Findings: May 29, 2007

Three views of the right hand and wrist reveal normal anatomy of the wrist with the exception of the fifth finger. We note there is a well healed middle phalanx fracture with contour changes to the articular surface at the PIP joint. Narrowing of the PIP joint is noted. We also note there is a middle finger distal phalanx old tuff fracture also on this middle finger on the ulnar side there is a large osteophye at the proximal phalanx of the PIP joint.

EMG and Nerve Conduction Study Report- July 5, 2007

Filemon R. Quinio, Jr., MD.

Patient has evidence of bilateral moderate carpal tunnel syndrome, with prolonged latencies of the median motor and sensory nerves across the wrist. There is no evidence of ulnar neuropathy, radial nerve or cervical radiculopathy. No radiographic studies were performed on the patient. Note: Median-Ulnar/Martin Gruber anastomosis noted in both forearms.

CAUSATION:

The patient was released Permanent and Stationary with a fully healed laceration of the right 5^th PIP joint in October of 2005. The patient presented May 29, 2007 complaining of bilateral numbness and tingling of his right hand. It was only upon EMG and Nerve Conduction Studies was it revealed the patient had latencies consistent with left carpal tunnel syndrome. The patient following left carpal tunnel release continued to present with symptomology consistent with bilateral median nerve entrapment. Dr. Smith at that time scheduled the patient for right carpal tunnel syndrome and was considering a second carpal tunnel release.

On 7/5/2007 the Diagnostic Studies performed by Filemon Quinion, MD diagnosed the patient with Median-Ulnar/Martin Gruber anastomois in both forearms. Martin Gruber anastomois is a neural connection between the median and ulnar nerves in the forearm¹. This diagnosis is consistent with median nerve symptomology consistent with the patient’s complaints and is not a result of the 5/18/2007 injury involving the 5^th PIP joint. As discussed below Median-Ulnar Martin Gruber anastomosis is a genetically inherited condition.

DISCUSSION OF ISSUES IN DISPUTE:

The question of bilateral specifically left carpal tunnel syndrome and how it relates to a complex laceration to the right 5^th PIP suffered in the 5/18/2005 injury. First, it should be noted that the patients’ complaints of numbness and tingling in the right hand did not present until two years following the initial 5/18/2005 Injury. Secondly, the diagnosis of left carpal tunnel syndrome did not come until the electodignosistic studies were performed and discussed with the patient on 8/9/2007. Dr. Smith on 8/9/2007 upon his review of the EMG, consulted with the patient concerning his carpal tunnel syndrome and recognized the Martin-Gruber anastomosis bilaterally and subsequently recommended surgery to both wrists. The patient declined surgery to the right wrist consenting to surgery to the left wrist. Thirdly, Dr. Smith makes note in the radiologic exam contained within his 5/29/2007 report “there is a well healed fracture of the middle phalanx fracture of the right hand. However, there the patient denies any prior injuries to his right hand and wrist in prior reports dating back to 5/18/2005. Additionally, Dr. Sabri’s post-operative report dated 5/18/2005 do not make mention of any other injuries to the right hand other than the laceration. Furthermore, there are not reports of left hand symptomology, until after the 8/9/2007 examination by Dr. Smith following the diagnostic testing.

Following left wrist carpal tunnel surgery on 2/12/2008, Dr. Smith reports that the patient currently requests surgery to the right wrist and makes note that the patient has bilateral swelling of the volar aspect and positive Tinel’s and Phalen’s tests bilaterally. He diagnosis’s the patient with bilateral carpal tunnel syndrome. Dr. Smith, at that time agreed with the patient to relase the right flexor tenosynovectomies and is considering yet another surgery to the left wrist due to the patient’s complaints of numbness and tingling. On 7/05/2007, Dr. Quinio diagnosed the patient with Martin Gruber anastomosis of the forearms bilaterally. Martin-Gruber occurs in 10-30% of individuals and 60-70% of those affected show the anomaly bilaterally. In some families, an autosomal dominant inheritance is possible, although a gene controlling this occurrence has not been identified. Martin-Gruber anastomosis can be caused by a variety of indices none of which are a laceration to the a finger on the contralateral hand. Martin-Gruber anastomosis causes sensory changes in the nerves it involves and mimics carpal tunnel syndrome. Many patients complain of sensory changes in the fourth and fifth digits. Rarely, a patient actually notices that the unusual sensations are mainly in the medial side of the ring finger (fourth digit) rather than the lateral side, corresponding to the textbook sensory distribution. Sometimes the third digit is also involved, especially on the ulnar (ie, medial) side. The sensory changes can be a feeling of numbness or a tingling or burning as this patient exhibited. In this case the patient began to experience numbness and tingling of right hand, 2 years post surgery consistent with diagnosis of Martin Gruber anastomosis. As stated, it does not appear that the patient complained of numbness and tingling in the left hand however, when the EMG test results were brought to the patient’s attention he, consented to left carpal tunnel release, still not relieving the symptomology.  It appears that this syndrome was discarded and the diagnosis of carpal tunnel syndrome was embraced. The patient was scheduled and a surgical release of the left flexor tenosynovectomy was performed. The patient returns 6 months post surgical with increasing symptoms in his right hand and the same symptoms in the left hand even in the lite of surgery. Dr. Smith still scheduled the patient for right carpal tunnel release and was considering yet another surgery to the left hand still ignoring the diagnosis of bilateral Martin-Gruber anastomosis.

In assessing the diagnosis given of Median-Ulnar/Martin Gruber anastomosis and the subsequent treatment and surgeries for carpal tunnel syndrome received by the patient, it was not related to or a direct result of the 5/18/2007 injury. Martin-Gruber anastomois was properly diagnosed by Dr. Quinio on 7/5/2007 is a condition that is not related to the 5/18/2005 injury or even a work related injury for that matter. It is my opinion, supported by the documentation and medical fact, that the original diagnosis given was reasonable based on the findings, however the new diagnosis made in 2007 is one that is of genetic origin and the treatment rendered was not consistent with the diagnosis given or the examination findings recorded. Based on the findings recorded, the treatment rendered was excessive and not medically necessary to cure and/or relieve the effects of the condition sustained by this patient.  It is my opinion, given the minimal subjective and objective findings that the diagnosis of carpal tunnel syndrome is not work related and the carpal tunnel like symptoms are a direct result of the Martin-Gruber anastomosis, which is part of the patient’s genetic pathology and not work-related. We can deduce that the left carpal tunnel surgery failed as the patient was still symptomatic after the release of the left flexor tendon demonstrating that surgery was not successful in relieving the symptomology and further the objective signs were still present. There is no cause and effect relationship between the diagnosis carpal tunnel syndrome, Martin-Gruber anastomosis, all treatment rendered by Dr. Smith, and the 5/18/2005 injury.  As stated, there is no evidence to support that the patient’s Median-Ulnar/Martin Gruber anastomosis is even work related. The patient has the genetic marker for this syndrome and most likely would have developed it regardless of the type and frequency of work he performed. It is also evident that the left wrist carpal tunnel release did not resolve the carpal tunnel syndrome of the left hand and most likely will not when performed on the right if the Martin Gruber anastomosis is not addressed.

FUTURE MEDICAL CARE:

The patient does have arthritis and oteophytic growth of the 5^th PIP as identified by x-ray. This is an expected sequella of the laceration and 5/18/2005 injury. Dr. Sabri, did an exceptional job in saving the tip of the patient’s 5^th finger. However, in that surgery, Dr. Sabri had to sacrifice the extensor tendon as Dr. Sabri notes, “reattaching it would have involved stabilization of the finger, possible compromising the blood supply and the finger”. This would have compromised the reattachment of the finger tip. In this process the finger lost some movement, due to Dr. Sabri’s inability to reattach the extensor tendon during the initial surgery 5/18/2007. The arthritis and oteophytic growth and any minimal loss of movement, if any, is a natural sequella and has minimal impact on the patient if any. The patient has returned to work full time unrestricted consistent with this injury and is in no need of future medical treatment. Additionally, the issue of future care is not a factor in this case as the patient was released permanent and stationary in 2005 for injuries sustained in the May 18, 2005 injury.

However, the patient does have diagnosed bilateral Martin-Gruber anastomois. That patient has one failed surgery to the left wrist and unless intervened will undergo another surgery to the right wrist without addressing the most likely cause Martin-Gruber anastomosis. The current symptoms and resulting left carpal tunnel surgery, and impending right carpal tunnel syndrome are not related to the 5/18/2007 injury or incident and are a sole and separate issue to be evaluated.

PROGNOSIS:

The patient’s prognosis is considered good as it results to the 5/18/2005 injury. The patient returned and continued to work full time unrestricted until he was evaluated by Dr. Smith.

REASONS FOR OPINIONS:

I have derived the above opinions from review of the medical records/diagnostic testing provided to me by CNA and clinical experience both in evaluating and treating individuals with the same or similar conditions.

COMPLIANCE STATEMENT:

“I personally 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.”

Thank you for allowing me to participate in the evaluation of this individual’s records.  Should you have any additional questions or require any additional information, please do not hesitate to contact me directly.

Signed in Los Angeles County by:

5/3/2008

_____________________________________                      _____________________

Dr. Allen S. Miller, DC, DACBSP                                            Date

License Number 19031

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

References:

1. The median-ulnar anastomosis (Martin-Gruber) in normal and congenitally abnormal fetuses. R Srinivasan and J Rhodes Archives of Neurology Vol. 38 No.7 July 1981
2. Ulnar Neuropathy, Article Last Updated: Jun 25, 2007 Stephen A Berman, MD, PhD

//

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.

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)

New Penn Employee FCE

This is the report of the New Penn employee that was injured lifting 100 lb bags of coffee. This report led to his conviction and later incarceration for workers compensation fraud.

Mr. Andrew Kerlik
VP Risk Management Human Resources
New Penn Motor Express Inc.
P.O. Box 630
Lebanon, PA 17042-0630

Re: Timothy Sham
SS#: 000-00-0000
DOB: 1/2/63
Claim #: 97007976
Employer: New Penn Motor Express Inc.
Job Description: Truck Driver
Date of Injury: 10/21/1997

Peer Review Record Review and Report

Dear Mr. Kerlik,

We were contacted to perform a peer review of medical records and all other pertinent information and compare those findings to the demands of the job task to determine:

1. Ability to perform job task.
2. Estimate a date of return to job task.
3. Functional capabilities of the above named individual.

The results of this review are discussed below.

HISTORY:

Mr. Sham is a 37-year-old male who stated, on 10/21/97, that he injured his low back in the course of his occupation as a truck driver, including lifting and moving heavy objects. He also states that he had an onset of sudden pain in the right buttock, radiating to the posterior heal. He states that he received an evaluation and eventual treatment at Exeter Hospital Emergency Room. Mr. Sham reported to Dr. Hepner that he returned to work wearing a lumbar support, and

PAST MEDICAL/SURGICAL HISTORY:

1. A/C Separation age 17 1.
2. Rt. Clavicle Fracture Age 17 1
3. Mr. Sham denies any contributory or past pertinent medical history 1.

PERSONAL ACTIVITES, HOBBIES:

1. Mr. Sham states that he is unmarried and residing with his girlfriend and two minor children.
2. The representative for Mr. Sham, Billy Carnes, states that he is a professional skydiver 2.
3. Mr. Sham stated in his deposition that, when he skydives, he exits the plane at a height upwards of 13,500 feet, and accelerates to speeds in excess of 150 mph .
4. Mr. Sham stated that he is training for the ESPN Extreme Games as a “sky surfer “3.

EXAMINATION FINDINGS:

Negative orthopedic and neurological findings to support a recent lumbar disc protrusion, or prolapse 1. Trunk flexion to reach within five inches of the floor with dimished extension. There is mild tenderness across the lumber spine. The subject displayed no atrophy or loss of reflexes 1.

RADIOLOGICAL FINDINGS:

1. Herniated disc at L5 of the protrusion type, with disc material protruding through the annulus extending to the right and lateral towards the neural foramen, touching the L5 nerve root 4.
2. There is a bulging at the L4disc 4.

REVIEW OF APPLICABLE DATA:

On 3/30/98, Mr. Sham participated in rehabilitation exercises, including seated rowing 4 sets of 50 lbs from 10-15 repetitions. He was also able to perform lat pull downs of 4 sets of 62 pounds for 10-12 repetitions; leg curls of 4 sets of 50 lbs for 10-12 repetitions 5. These exercises continued through 6/26/98 with the weight utilized escalating to 75 lbs for rowing, 62 lbs for lat pull downs, and 100 lbs for leg curls, respectively 6.

On, 8/05/98 3, a private investigator observed Mr. Sham working on an addition to a building at his skydiving “drop zone,” New England Adventures. These activities required repeated bending, stooping, squatting, reaching, walking, crawling, standing, sitting, fine hand motor control and lifting. These activities are consistent with his job task as a truck driver 7.

Upon evaluation of videotape and testimony, Mr. Sham, along with his representative Billy Carnes, admitted he participated in repeated freestyle skydiving activities from April 1998 through August 5, 1998 3. Additionally, it is depicted in the August 5, 1998 videotape and by statements made by Mr. Sham that he is a “professional skydiver” 2. These activities require repeated bending, stooping, squatting, reaching, walking, crawling, standing, sitting and fine hand motor control. These activities are more strenuous if the diver is “packing” his own chute. Mr. Sham also states that he exits the plane at speeds of 120 mph. He also states that when the canopy opens, he “goes from 150 mph to 0 mph in one second” 2.

Mr. Sham was able to perform these activities voluntarily without apparent restriction while carrying a 30-35 lb. parachute pack. Mr. Sham performs these activities in preparation for and following a jump. The intervals for which this activity is performed, by admission of Mr. Sham, is between 8-10 times during an outing 2for a total of 8 hours. Once prepared, Mr. Sham puts the pack on his back and voluntarily boards a plane on which he sits until the plane reaches an altitude of 13,500 feet. As the divers ascend to the agreed-upon altitude, the ambient temperature decreases, to an average of 25 degrees Farenheight (depending on region and meteorological factors). When he exits the aircraft, he is moving horizontally at the same speed as the aircraft, typically 90-110 mph. During the first 10 seconds, a skydiver accelerates up to about 115-130 mph straight down. In a standard face-to-earth position, the diver can change his fall rate up or down a few (i.e., 10-20) miles per hour 8. However, by diving or “standing up” in freefall, any experienced skydiver can learn to reach speeds of over 160-180 mph. Speeds of over 200 mph require significant practice to achieve 8. By admission, Mr. Sham states that he reaches speeds in excess of 200 mph. The actual freestyle flying lasts approximately 2-3 minutes. Upon deployment of the chute, 2-3 G-forces are enacted on the body of the diver. These forces can be so severe in some cases as to cause unconsciousness 9. Once under parachute, descent rates of 1000 ft/min are typical, and a heavier person may have a somewhat faster descent than a lighter person. Mr. Sham is 6’0”, 185 lbs. Experienced jumpers can descend (in normal glide) at up to 1500 ft/min. During radical turns, the descent rate can go well over 2000 ft/min.10 The diver continues to decelerate and hit the ground, if all is controlled, at an average speed of 20 mph, causing significant compression forces on the lower extremities and spine. By admission, Mr. Sham repeated this activity 8-10 times during an outing 2.

On 8/11/1998, Mr. Sham submitted to a Physical Capacity Evaluation, that utilized isometric strength-testing that is compared to the National Institute of Occupational Safety & Health Standards (NIOSH).10 This testing was utilized to determine Mr. Sham’s physical demand level and ability to return to work in his previous job task. This testing consisted of computerized range of motion, computerized isometric lift tasks, along with a routine physical exam. The protocol consisted of lifting isometrically within the NIOSH 6-position protocol. The protocol is to instruct the subject to lift normally and in any way he felt best, and to stop if his comfort level changed. The objective of this testing was to determine the participant’s Physical Demand Level (PDL) for return into a suitable job task.

During testing, Mr. Sham was required to bend, squat, reach, walk, stand and sit for varying intervals of time, which are activities that coincide with his duties as a truck driver. These activities also involved pushing, pulling, lifting and straining against a non-moveable object to measure strength. This testing is quite rigorous and physically demanding. One of the most important aspects of this testing is that, if there is disability, impairment or injury, this testing would aggravate it immediately along with the accompanying symptoms. However, in this case, I cannot find evidence of Mr. Sham’s inability to perform or complete the testing, or any increase in objective medical signs/symptoms. This type of testing involves very objective protocols and anonymous tests; know as “distraction testing”. Specifically, there is no feedback from the equipment to tell the subject how he is performing. The built-in coefficient of variance ensures both subject and evaluator accuracy along with consistency. In Mr. Sham’s case, he was able to produce strength consistent with the Dictionary of Titles (DOT), Very Heavy Lifting,10 which is consistent with his described job task as a truck driver 5.

CONCLUSIONS AND RECOMMENDATIONS:

With the information derived from documentation pertaining to the computerized testing, physical examination, rehabilitation reports, videotapes and statements made by Mr. Sham, we can make the following conclusions.

In March of 1998, Mr. Sham participated in rehabilitation exercises, consisting of seated rows, squats, lat pull downs and leg curls. He utilized weights in excess of 50 lbs increasing to 100 lbs . The forces that these exercises produce on the lumbar spine, directly at the L5/SI disc space, are significant. Injured persons with lumbar spine involvement, in most cases, are unable to start and maintain exercises of this magnitude without exacerbating their symptoms. Mr. Sham complains of only slight increases in pain and symtomogly when performing these activities. These exercises mimic the type of activities, forces and strength consistent with performing his job description as truck driver.

In addition, Mr. Sham consistently and repeatedly participated in activities that produced forces and stress to his body that far exceeded those consistent with his job task. In most cases, it is normal for an injured individual to attempt to continue, activities they enjoyed prior to injury. In this case, thoe activities are skydiving and sky surfing. Once the activities are attempted and the symptoms increase, the injured person stops the activity, as it is too painful and debilitating. What is important to realize is that Mr. Sham was able to perform these activities repeatedly without aggravating his symptoms or injury. For example, the video clearly shows Mr. Sham landing after a jump involving sky surfing. He is clearly visible descending and, at the last moment, pushes off the board with his foot and then impacting the ground.15, 16. Mr. Sham then gathers up his chute, along with the board weighing 10 lbs. Carrying these items, he then walks over to the investigators filming his activities. The investigators engage him in a conversation about his activities. This tape depicts several biomechanical attributes. Mr. Sham is able to walk, bend, stoop, and carry items without difficulty or antalgic (pain) posture.
He is able to stand erect holding these items and speak without inflection or obvious pain. This is all done after impacting the ground, 15, 16 with a visibly hard landing at an estimated speed of 15-20 mph. This leads to the following conclusions:

1. Mr. Sham’s body mechanics are not consistent with his reported degree of disability.
2. Mr. Sham’s movement patterns are not consistent with his reported degree of disability.
3. Mr. Sham’s diagnosistic-based limitations are not consistent.

The forces from his voluntary hobby and the construction work would not only have exacerbated his injuries, but most likely would have resulted in a more severe injury and disability, if Mr. Sham was physically impaired or the injury was “active”. As stated, the forces enacted on his body during these activities are so excessive that they would exacerbate and flare-up an active injury, especially the lumbar spine, if the individual was impaired.

For example, astronauts Neil Armstrong (commander) and David Scott (pilot), of the Gemini VIII, received similar forces that Mr. Sham experienced. The Gemini VIII astronauts experienced Gz force of 0.89 G-units from the waist up, Gz of 0.05 from the waist down, and were momentarily incapacitated.11 This was so disturbing to NASA that they redesigned the space capsule for re-entry to prevent this from recurring. Mr. Sham sustains and repeats forces in excess of 1-2 Gz and tolerates these activities consistent with a professional skydiver, again without hesitation or injuring his low back. Long-term stress and force causes significant long-term injury and changes to the human body, i.e., spinal stenois,12 disc disease and repeated micro tearing of the intervertebal discs, etc. These changes are represented in Mr. Sham’s medical data, indicative of long-term, continuous trauma due, in part, to his skydiving activities.

Mr. Sham also made statements that he was training for the ESPN Extreme Games in Sky Surfing.3, 13, 14 The requirements to enter this sport are physically demanding. They require multiple jumps exceeding speeds of 200 mph and Gz forces well exceeding 1.00. In addition, the competition requires the surfer/diver to twist, turn, rotate, and spin while traveling at speeds in excess of 150-200 mph. This, again, causes tremendous stress on the body that would have resulted in injury and incapacitation to an individual with an injury.11, 12 Mr. Sham practiced and performed for this competition multiple times, indicating his ability to return to work full time, unrestricted. Billy Carnes made the statement that skydiving is “not as strenuous as pushing twenty or thirty thousand pounds of freight around, it’s not quite the same thing.”2 He is, in essence, correct; it is not the same thing, it is worse. By definition, Very Heavy Lifting17 constitutes lifting greater than 100 lbs on an occasional basis, 50 lbs on a frequent basis, and 20 lbs on a constant basis. In his employment as a truck driver, Mr. Sham is able to utilize his own strength and body mechanics in performing lifting tasks. He is able to control the speed, force, direction, and all aspects of the job task. His own pain, fatigue, impairments, restrictions, and intelligence, along with the human guarding mechanism, limit him from injuring himself unless, of course, unforeseen circumstances occur.
In the case of skydiving, he knows the risks and is unable to affect and control the forces acted upon him. The diver cannot prepare for the forces that come from skydiving, as they come from variety of different directions at once and at different loads, causing extreme tearing, shearing, and loading on all parts of the body. An injured body cannot take this abuse and stress without breaking down, or the symptoms and impairments flaring-up. The fact that Mr. Sham was able to repeat this activity supports the conclusion that he could have returned to work full time unrestricted when he resumed or continued skydiving. Mr. Sham continued to perform these activities, resulting in stresses and forces more severe than he could possibly have caused himself performing the duties consistent with a truck driver during a typical day at work.

The August 8, 1998 Physical Capacity Evaluation determined, objectively, Mr. Sham’s Physical Demand Level (PDL) to be Very Heavy Lifting17 consistent with and exceeding the New Penn Motor Express Inc. job description of Truck Driver. According to the records, Mr. Sham did not exhibit the following. His strength presentation was not consistent with his diagnosis. One would expect a significant increase in pain and restriction from someone with the type of injury and restriction reported by Mr. Sham. As stated above, this testing is rigorous and physically demanding. This testing is designed to aggravate an injury to determine a subject’s ability to do work. Mr. Sham was able to tolerate and excel in the testing process to levels far exceeding the average proportion of the population. This testing indicated that Mr. Sham was able to return to work as a truck driver full time and unrestricted.

The position and specific job functions as described by New Penn Motor Express, Inc.5 are safe for Mr. Sham to perform. Mr. Sham exhibited, in multiple ways, independent of one another, the ability and strength consistent with and exceeding the ability to perform very heavy work consistent with his job tasks at New Penn Motor Express, Inc. We did not find any physical reason why Mr. Sham could not return to his job duties5 as a truck driver as of March 30, 1998. This is the date Mr. Sham completed his rehabilitation routines consistent with his job description. It is also concluded that Mr. Sham could have returned to his job task full time, unrestricted, upon his first repeated freestyle skydiving activity, or whichever date came first. It is our opinion, based on the available subjective data provided, Mr. Sham could have been working in some capacity with modified duty from the date of injury. We cannot give an exact work level, as we do not have objective medical records or tests to determine the level of work for which he could have returned. However, the rehabilitation records of March 30, 1998 indicate that he was lifting weights in positions that mimicked his work activities as a truck driver, and could have returned to work full time unrestricted on that date.

In addition, Mr. Sham’s subjective complaints of pain, spasm, and restrictions do not correlate with his activities. They are inconsistent with the findings of the physical capacity evaluation, along with the physical requirements of sky surfing, skydiving, and/or construction work. In addition, Mr. Sham stated that his goal was “to return to work.” Specifically, he did not return to work but continued to misrepresent the facts regarding with his outside activities, severity of his injuries, and ability to return to work, to all medical personnel encountered.
All decisions made by the medical personnel were based on misleading statements and inaccurate subjective data provided by Mr. Sham. The medical personnel were unable to accurately determine the legitimacy of the claim and make recommendations as to the severity of injury, treatment, and return to work recommendations.

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,

Allen S. Miller, D.C., DACBSP
COO, Kinematic Solutions, LLC
Enclosures

Footnotes
Transcript Court Proceedings, Commonwealth of Massachusetts, Lowell District Court. Commonwealth of Massachusetts vs. Timothy Sham. April 11, 2001.
3 Transcript from Tape Recording: Case #:01-0533. Southern New England Joint Area Committee. May 24, 2001.
4 Diagnostic Imaging Department, Exeter Hospital, Inc. 12/30/1997.
5 Exercise: Worksheet, Exeter AthletiCare. 3/26/98-4/3/98
6 Exercise: Worksheet, Exeter AthletiCare. 6/12/98-6/26/98.
7 Job Description, 1-City Driver/Road Driver.
8 rec.skydiving FAQ Sheet. http://www.afn.org/skydive/faq/faq.html#physical ., Archive-name: sports/skydiving/faq. Last-modified: 8/13/97
9 Fong KL, Fan SW., An overview of the physiological effects of sustained high +Gz forces on human being. Ann Acad Med Singapore 1997 Jan;26(1):94-103.
10 Physical Capacity Evaluation, Debra McAuley, OTR/L 8/13/98
11 Mohler SR, Nicogossian AE, McCormack PD, Mohler SR Jr., Tumbling and space flight: the Gemini VIII experience. Aviat Space Environ Med 1990 Jan;61(1):62-6.
12 Hamalainen O, Toivakka-Hamalainen SK, Kuronen P. +Gz associated stenosis of the cervical spinal canal in fighter pilots. Aviat Space Environ Med 1999 Apr;70(4):330-4
13 BAP Qualifications. HTTP://www-user.york.ac.uk/~socs213/info/category.html .
14 Addendum-Sky surfing Compulsory Sequences 2001 Performance Requirements & Judgment Criteria. HTTP://members.aol.com/skysurfnj/page4.html.
15 VHS Videotape. Labeled MASS AG. Depicting Mr. Sham Sky surfing, landing and interviewed by investigators.
16 VHS Videotape. Labeled TV-25 Sham. Depicting Fox 25 new at Ten. Fox undercover exclusive of Timothy Sham sky surfing.
17 Dictionary of Occupational Titles, U.S. Department of Labor Employment and Training Administration 1991. Volume II Fourth Edition, Revised 1991