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.
//
//
Dr. Allen S. Miller's Reports 