Functional Capacity Evaluation

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Agatha Hunt
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S/P L4-L5 Fusion Referring Dr.: Joseph Smith, M.D. Other Doctors: Don Tee, M.D. Case Manager: Barb Smith Employer: Occupation: Job Title: U.S. Customs Patrol Police Officer Date of Injury: 10/5/2013

1 OccuPro - Woodstock 1118 N. Seminary Avenue Woodstock, IL (p) (815) (f)(815) Functional Capacity Evaluation Client: John Doe Gender: Male Date of Birth: 5/14/1962 Evaluation Date: 03/13/2015 Diagnosis: S/P L4-L5 Fusion Referring Dr.: Joseph Smith, M.D. Other Doctors: Don Tee, M.D. Case Manager: Barb Smith Employer: Occupation: Job Title: U.S. Customs Patrol Police Officer Date of Injury: 10/5/2013 Surgery Date(s): Evaluator: Law Enforcement Officer 7/12/2014 John Sample, MS, OTR/L Results Material Handling Abilities Bilateral Lifting: 50 pounds Frequent Bilateral Lifting: 25 pounds Bilateral Carrying: 40 pounds Bilateral Shoulder Lifting: 25 pounds Pushing: 50 horizontal force pounds Pulling: 45 horizontal force pounds Functional Abilities to Job Demands Match This job specific evaluation was performed in a 100% kinesiophysical approach and this client demonstrated the ability to perform 76.8% of the physical demands of their job as a Police Officer. The return to work test items this client was unable to achieve successfully during this evaluation include: Occasional Squat Lifting, Frequent Squat Lifting, Occasional Power Lifting, Frequent Power Lifting, Occasional Shoulder Lifting, Occasional Overhead Lifting, Occasional Bilateral Carrying, Frequent Bilateral Carrying, Occasional Unilateral Carrying, Occasional Pushing, Occasional Pulling, Bending, Squatting, Sustained Squatting, Walking and Suspect Tackling. Client/Occupation Physical Demand Category Client demonstrated the ability to perform within the MEDIUM Physical Demand Category based on the definitions developed by the US Department of Labor and outlined in the Dictionary of Occupational Titles. It should be noted that this client's job as a Police Officer is classified within the HEAVY Physical Demand Category. During objective functional testing, this client demonstrated consistent effort throughout 56.5% of this test which would suggest significant observational and evidenced based contradictions resulting in consistency of effort discrepancies, self-limiting behaviors, and/or sub-maximal effort. The overall results of this evaluation do not represent a true and OCCUPRO, LLC of 5

2 accurate representation of this client's overall physical capabilities. The functional results of this evaluation represent a minimal level of functioning for this client. During objective functional testing, the items that were inconsistent resulting in self limiting behavior/sub-maximal effort included range of motion inconsistencies, muscle testing inconsistencies, right hand grip strength inconsistencies, left hand grip strength inconsistencies, right five span versus right grip inconsistencies, right grip strength testing inconsistencies secondary to higher right rapid grip exchange results and biomechanical inconsistencies during floor to waist lifting. Reliability of Pain Ratings Throughout objective functional testing, this client reported reliable pain ratings 89.3% of the time which would suggest that pain could have been considered a limiting factor during functional testing. Recommendations Return to Work Recommendations Based on the results of objective functional testing this client demonstrated the ability to return to work on modified/light duty within the functional abilities outlined in this report over the course of 4 weeks until follow up with physician. Summary Limiting Factors Noted During Testing During this evaluation, the client was unable to achieve 100% of the physical demands of their job/occupation and the limiting factors noted during these objective functional tests include: compensatory techniques, evaluator stopped, general fatigue, heart rate exceeds aerobic limiter, increased pain, maximum effort, mechanical changes, mechanical deficits and substitution patterns. Assessment Purpose / Reason for Referral Mr. John Doe is being referred for a Job Specific Functional Capacity Evaluation to determine his feasibility to return to work as a Police officer, and to determine whether there are physical barriers that may exist which prevent him from returning to work. Job Demands Match Table Material Handling Client Abilities in this Evaluation Physical Demands Gathered From On-Site Job Demands Analysis Job Demand Match? Occasional Squat Lift 55 Pounds 75 Pounds No Frequent Squat Lift 20 Pounds 50 Pounds No Occasional Power Lift 50 Pounds 75 Pounds No Frequent Power Lift 25 Pounds 50 Pounds No Occasional Shoulder Lift 25 Pounds 30 Pounds No Occasional Overhead Lift 15 Pounds 20 Pounds No Occasional Unilateral Lift 25 Pounds 25 Pounds Yes Occasional Bilateral Carry 40 Pounds 50 Pounds No Frequent Bilateral Carry 20 Pounds 25 Pounds No Occasional Unilateral Carry 20 Pounds 25 Pounds No Frequent Unilateral Carry 10 Pounds 10 Pounds Yes Occasional Pushing 50 HFP 75 HFP No Occasional Pulling 45 HFP 75 HFP No Upper Extremity Gross Coordination Constant Constant Yes Fine Coordination Occasional Occasional Yes Simple Grasping Constant Constant Yes Firm Grasping Frequent Frequent Yes Pinching Frequent Occasional Yes Non-Material Handling Bending Avoid Frequent No Squatting Occasional Frequent No Sustained Squatting Avoid Occasional No Sustained Kneeling Occasional Occasional Yes OCCUPRO, LLC of 5

3 Client Abilities in this Evaluation Physical Demands Gathered From On-Site Job Demands Analysis Job Demand Match? Repetitive Kneeling Occasional Occasional Yes Walking Occasional Frequent No Forward Reaching Constant Constant Yes Above Shoulder Reaching Frequent Occasional Yes Climbing Stair Climbing Occasional Occasional Yes Static Balance Occasional Occasional Yes Dynamic Balance Occasional Occasional Yes Job Specific Testing Suspect Tackling Avoid Occasional No Sprinting Occasional Occasional Yes Fence Climbing Occasional Occasional Yes Basic Diagnostics Medical History and Present Status History of Present Condition Mr. John Doe is a 43 y.o. (R) dominant Police Officer who reportedly sustained a work-related injury to his low back on 10/05/13 while lifting a heavy box at the station. He stated that "I thought I just pulled a muscle and it would go away". The client went to see his primary care physician, Dr. Tee, who ordered physical therapy for 3 months. In January, 2014, an MRI was ordered that revealed a herniated disc at L4-L-5. The client was then referred to a specialist, Dr. Smith, whom ordered a CT scan and performed a series of three steroid injections in conjunction with physical therapy from March to June, In July, 2014, the client underwent a lumbar fusion L4-L5. He participated in physical therapy and work hardening program for a total of 5 months. He does not participate in therapy at this time. Musculoskeletal Testing Lumbar Range of Motion (Inclinometric) OCCUPRO, LLC of 5

4 Movement Description Range Lumbar Flexion (60º) T12 ROM Sacral ROM Lumbar Flexion Angle Maximum Lumbar Flexion Angle = 60 Lumbar Extension (25º) T12 ROM Sacral ROM Lumbar Extension Angle Maximum Lumbar Extension Angle = 60 Straight Leg Raising (SLR), Left Left SLR Straight Leg Raising (SLR), Right Right SLR Straight Leg Raising (SLR), Validity Motion at Midsacrum SLR Validity No Maximum Midsacral Motion 17 Lumbar Left Lateral Bending Angle (25º) T12 ROM Sacral ROM Left Lateral Bending Angle Maximum Left Lateral Bending Angle = 25 Lumbar Right Lateral Bending Angle (25º) T12 ROM Sacral ROM Right Lateral Bending Angle Maximum Right Lateral Bending Angle = 25 Spine Musculoskeletal Testing Using spinal inclinameter, client displays 30 degrees of trunk flexion (60 degress WNL's), 10 degrees of extension (25 degrees WNL's), and 15 degrees (L) SB and 20 degrees of (R) SB (25 degrees WNL's). Special Tests: dural stretch, ASIS compression and distraction, lumbar compression & distraction, (B) Kernig, Laseque, Fabere, SI provocation, backward & forward torsion, and hip provocation. is determined based on this client demonstrating consistent or inconsistent biomechanical, observational, and evidence based consistency of effort criteria. The following items were deemed to be inconsistent during this assessment: - right five span grip strength testing inconsistencies secondary to higher right rapid grip exchange results - left five span grip strength testing inconsistencies secondary to higher left rapid grip exchange results - Static Strength Arm test - Static Strength Push test OCCUPRO, LLC of 5

5 - Static Strength Leg test - coefficient of variance for grip strength on the L Mr Doe exhibited consistent effort with spinal inclinameter testing for flexion, extension, and (B) side bend, Jamar hand grip for bell shaped curve, CV's for (R) grip strength, hand strength between the norms, comparison of functional performance with 1 and 2 hand lifting, 2 hand occasional and frequent lifting, etc. Reliability of Pain Reliability of Pain Reliability of Pain testing is performed to determine whether this clientʼs pain reports can be considered as limiting factors during functional testing. The following evidence based items were tested as unreliable pain reports: - Score of 3 on Waddell's Non-Organic Signs - Score of 35 on McGills Pain Questionaire Other testing that revealed reliable pain reports include: Ransford Pain Drawing, Oswestry, correlation of the client's perceived exertion and his heart rate on all occasional material handling, frequent material handling, and job simulation. The evidence of attempting all tasks and presence of clinical objective findings to support the reason for stopping. Joseph Smith, M.D., Barb Smith and U.S. Customs Patrol, thank you for the opportunity to work with your client. If I can be of assistance in interpreting the aforementioned data regarding this Functional Capacity Evaluation, please feel free to contact me at: OccuPro - Woodstock 1118 N. Seminary Avenue Woodstock, IL (815) FCE@occupro.net Sincerely, John Q Sample, MS, OTR/L John Q Sample, MS, OTR/L OCCUPRO, LLC of 5

Work Conditioning Evaluation

Client: Gender: OccuPro 3921 30th Ave Suite A Kenosha, WI 53144 (p) 866-470-4440 Work Conditioning Evaluation Jane Q Tees Female Date of Birth: 10/22/1970 Evaluation Date: 1/19/2015 Diagnosis: Referring