Functional Capacity Evaluation
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1 Functional Capacity Evaluation To: Mary G Jones ABC Insurance 1000 Main Street, Suite A Anytown, US Phone: Fax: Re: Mark Smith Case Number: Sample Social Security Number: Evaluation Date: Onset of Injury or Illness: Job Information Employer: WebMasters, Inc. Hired: Last Worked: DOT #: Job Title: Webmaster Job Description: Keyboarding up to 6 hours per day to design and deploy web sites. Required PDC: Physical Demand Level Light Clinical Information Occasional Frequent Constant 0-33% of workday 34-66% of workday % of workday lbs lbs. Negligible Energy Required METS Sex: Height: Male BP: 120/80 Dominant Side: Right Injured Side: Left 5'11 Weight: 170 Resting Heart Rate: 75 Medications: The patient does not take any prescription medications. Medical History: Here is some medical history on Mr. Smith... Complaints Chief Complaints: Patients states that he has numbness and tingling in the thumb and forefinger of his left hand. Symptoms Aggravated By: Patient states that his symptoms are aggravated by repetive keyboard use. Symptoms Alleviated By: Patient states that his symptoms are relieved by taking frequent breaks. Diagnosis Carpal tunnel syndrome Conclusions and Recommendations Functional Capacity Evaluation: Page 1 of 5
2 Here are my conclusions about Mr. Smith's functional capacity... Here are my recommendations for improving Mr. Smith's functional capacity... Current PDC: Physical Demand Level Occasional Frequent Constant 0-33% of workday 34-66% of workday % of workday Light lbs lbs. Negligible Energy Required METS Leonard H McCoy, MD Functional Capacity Evaluation: Page 2 of 5
3 Biomechanical Evaluation Key Muscle Testing Right/Left rated as Good, Fair or Poor Wrist flexors = Good/Good; Wrist extensors = Good/Good. Here are some notes about Mr. Smith's wrist muscle testing... Range of Motion Elbow Wrist Sensation Motion Left Right Flexion 35 deg 35 deg Extension 65 deg 65 deg Pronation 35 deg 35 deg Supination 30 deg 30 deg Motion Left Right Flexion 70 deg 80 deg Extension 35 deg 45 deg Radial Deviation 35 deg 40 deg Ulnar Deviation 40 deg 45 deg Two-Point Discrimination (Key = 2-Pt Value / % of Digit Length) Left Hand Right Hand Thumb - Radial: 7mm / 100% Ulnar: 7mm / 100% Thumb - Radial: 6mm / 100% Ulnar: 5mm / 100% Index - Radial: 7mm / 100% Ulnar: 7mm / 100% Index - Radial: 6mm / 100% Ulnar: 5mm / 100% Middle - Radial: 7mm / 100% Ulnar: 7mm / 100% Middle - Radial: 5mm / 100% Ulnar: 5mm / 100% Ring - Radial: 7mm / 100% Ulnar: 7mm / 100% Ring - Radial: 6mm / 100% Ulnar: 6mm / 100% Little - Radial: 7mm / 100% Ulnar: 7mm / 100% Little - Radial: 7mm / 100% Ulnar: 7mm / 100% Here are some notes about Mr. Smith's Two-Point Discrimination test... Physical Demands Evaluation Cardiovascular Endurance Screen Bike (10 Minutes) Heart Rate Pre-Test 71 bpm / Post-Test 95 bpm Blood Pressure Pre-Test 120/70 / Post-Test 130/80 Cardiac Recovery Regained Pre-Test Heart Rate in 9 minutes Treadmill (10 Minutes) Heart Rate Blood Pressure Cardiac Recovery Pre-Test 75 bpm / Post-Test 105 bpm Pre-Test 120/80 / Post-Test 130/80 Regained Pre-Test Heart Rate in 6 minutes Functional Capacity Evaluation: Page 3 of 5
4 Cardiovascular Profile Limiting Factors: Gross Mobility (check all that apply) Heart attack Heart surgery Abnormal ECG Heart disease Angina Heart palpitations Stroke BP has been 160/90 On BP Meds Pregnant (now) Profile/Score: 6 1. Age: (56 or over = 1 pt, 55 or under = 0 pts) 2. Sex: (Male = 1 pt, Female = 0 pts) 3. Blood Pressure Either number 160/100 or more = 10 pts Either number 140/90 or more = 5 pts Both numbers 140/90 or less = 0 pts 4. Weight 25 lbs or more overweight = 4 pts lbs overweight = 2 pts Less than 10 lbs overweight = 0 pts 5. Smoking 2 pks/day or more = 10 pts 1-2 pks/day or quit < 1 yr ago = 6 pts < 5 cigars/day, or regular pipe = 6 pts < 1 pk/day or quit > 1 yr ago = 3 pts Never smoked = 0 pts This portion of the evaluation was designed to observe the patient while performing certain key tasks. Lifting/Carrying was not restricted. During the lifting/carrying portion of the Gross Mobility Course, the patient was scored on the use of proper body mechanics. While lifting objects from the floor, he bent his hips and knees simultaneously, his feet were shoulder-distance apart, he held the object close to his body prior to rising. While lowering objects to the floor, he bent his hips and knees simultaneously, his feet were shoulder-distance apart, he held the object close to his body prior to lowering. While transferring objects, he held the object close to his body, he held the object at the midline, he turned as a unit. While pulling objects, he maintained proper foot placement, he bent his hips and knees simultaneously, he displayed no forward trunk flexion. For each item performed properly, one point was given. The patient's resulting score was 12 out of a possible 20. Here are some notes about Mr. Smith's gross mobility... Pinch Strength Lateral Pinch Side Trial 1 Trial 2 Trial 3 Average CofV Strength Loss Index Right Left % 7.5% 0% 26% Three pinch strength trials were evaluated using a pinch gauge. The three trials were averaged and a Strength Loss Index (SLI) was determined. SLI = (Normal Strength of Non-Injured Side - Abnormal Strength of Injured Side)/Normal Strength of Non-injured Side. Here are some notes about Mr. Smith's lateral pinch test... Physophysical Evaluation Functional Capacity Evaluation: Page 4 of 5
5 Modified Oswestry Questionnaire This test was used to gauge any limitations in the patient's ADL. When asked to complete the questionnaire, he selected the following statements to illustrate how his pain had affected his ability to manage everyday life: Pain Intensity - The pain comes and goes and is very mild. Personal Care - I would not have to change my way of washing or dressing in order to avoid pain. Lifting - I can lift heavy weights but it causes extra pain. Walking - I have no pain on walking. Sitting - I can sit in a chair as long as I like. Standing - I can stand as long as I want without pain. Sleeping - I get no pain in bed. Social Life - My social life is normal and gives me no pain. Traveling - I get no pain while traveling. Changing Degree of Pain - My pain fluctuates but overall is definitely getting better. The patient's score for this test was 2 points out of a possible 50 points (indicating a 4% disability.) Here are some notes about Mr. Smith's Oswestry Score... Functional Capacity Evaluation: Page 5 of 5
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