Brown Box Employer FCE Sample
13
FUNCTIONAL CAPACITY EVALUATION NAME: Browne Box REFERRED BY: Case Manager EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548 I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965 SEX: MALE DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE 1: ROTATOR CUFF RUPTURE R Y 10/15/2011 VITAL SIGNS HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19 PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer SUMMARY The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet the demands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed a single stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain and weakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heart rate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities. PHYSICAL DEMAND LEVEL HEAVY Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate to contact us. Professionally, Evaluator: Katie McBee Title: Physical Therapist / LIC-04888 Date: 10/23/2012 cc: Remainder of page intentionally left blank FUNCTIONAL CAPACITY EVALUATION KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 1 / 13
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Transcript of Brown Box Employer FCE Sample
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 1 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 2 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 3 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 4 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 5 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 6 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 7 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 8 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 9 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 10 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 11 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 12 / 13
FUNCTIONAL CAPACITY EVALUATION
NAME: Browne Box REFERRED BY: Case Manager
EMPLOYER: Package Handling Company PHYSICIAN: Dr. Smith
DATE OF INJURY: 08/12/2011 INSURANCE CARRIER: W/C
DATE OF EVALUATION: 10/23/2012 INSURANCE REP: Jane Fonda
DATE OF REPORT: 10/23/2012 INSURANCE I.D. NO.: 402321548
I.D. NO.: 222111555 DATE OF BIRTH: 07/12/1965
SEX: MALE
DIAGNOSIS SIDE (L/R/B) SURGERY STATUS (Y/N) SURGERY DATE
1: ROTATOR CUFF RUPTURE R Y 10/15/2011
VITAL SIGNS
HEIGHT: 72 inches WEIGHT: 205 lbs. HAND DOMINANCE: RIGHT
RESTING HEART RATE: 78 bpm RESTING BLOOD PRESSURE: 120/65 (B/P) mmHg
STARTING TIME: 10/23/2012 08:14:33 ENDING TIME: 10/23/2012 12:04:19
PURPOSE OF ASSESSMENT: FCE Type: Work Related; Job Description for Package Handler Provided by Employer
SUMMARY
The results of this evaluation indicate that Browne Box did not demonstrate the ability to meet the physical demand requirements of a Package Handler based upon the job description provided by the employer. Specifically he did not meet thedemands for shoulder and overhead lifting up to 70# frequently, carrying up to 70# frequently and reaching overhead constantly. Browne Box demonstrated the ability to function in the Heavy Physical Demand Category, according to the US Department of Labor. Browne Box demonstrated the ability to occasionally lift up to 70 lbs. Floor to Waist, 65 lbs. Waist to Shoulder, carry up to 65 lbs., push 70 lbs. of force, and pull 70 lbs. of force. For positional tolerance see the chart on page 2. Browne Box completed asingle stage treadmill test at 3.5 mph and 5% grade. This was sufficient to predict Browne Box's functional aerobic capacity at 4.97 METS for an 8 hour time period. Deficits identified during testing include difficulty and increased pain with lifting up to shoulder and overhead levels, increased pain with sustained overhead reaching with his right upper extremity and difficulty with carrying tasks over 65# due to pain andweakness in hie right shoulder. Browne Box demonstrated consistent performance throughout testing. This, in combination with physiological responses (heartrate and respiratory rate), movement and muscle recruitment patterns both aware and unaware of observation, indicates that the results of this evaluation can be considered to be an accurate representation of Browne Box’s functional abilities.
PHYSICAL DEMAND LEVEL
HEAVY
Thank you for referring Browne Box to . If you have any further questions regarding this evaluation, please do not hesitate tocontact us.
Professionally,
Evaluator: Katie McBee
Title: Physical Therapist / LIC-04888 Date: 10/23/2012
cc:
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL ABILITIES ASSESSMENT (PAA)
HEAVY
Occasional Frequent Constant Job Position Comments
Material Handling : (0 - 33%) (33% - 66%) (66% - 100%)
Lift - Floor to Waist 70 70 N/A Frequent Up to 70# Job Function Met
Lift - Waist to Shoulder 65 50 N/A Frequent Up to 70# Job Function Not Met
Lift - Floor to Shoulder 50 38 N/A Frequent Up to 70# Job Function Not Met
Carry - Bimanual 65 60 N/A Frequent Up to 70# Job Function Not Met
Push 70 70 N/A Frequent Up to 70# Job Function Met
Pull 70 70 N/A Frequent Up to 70# Job Function Met
Job Specific Lift Testing 45 35 N/A Job Function Not Met
Positional Tolerance : Frequency Job Position Comments
Sit Constant Frequent Job Function Met
Stand Constant Frequent Job Function Met
Walk Frequent Frequent Job Function Met
Climb Stairs Frequent Frequent Job Function Met
Climb Ladders Occasional Occasional Job Function Met
Reach Overhead Level Frequent Constant Job Function Not Met
Reach Desk Level Constant Frequent Job Function Met
Reach Floor Level Frequent Frequent Job Function Met
Balance Frequent Frequent Job Function Met
Stoop Frequent Frequent Job Function Met
Kneel Occasional Occasional Job Function Met
Crouch Frequent Frequent Job Function Met
Crawl Occasional Occasional Job Function Met
Manipulative Ability: Frequency Job Position Comments
Object Handling Right: Constant Left: Constant Constant R: Job Function Met / L: Job Function Met
Fingering Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Simple Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Firm Hand Grasp Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Fine/Gross Manipulation Right: Constant Left: Constant Frequent R: Job Function Met / L: Job Function Met
Consistency Profile: Consistent Test Performance
Maximal Voluntary Effort Consistent 10 of 10 CV Scores < 15%; 2 of 2 of Bell Shaped Curve Distributions
Pinch Strength Testing Consistent 6 of 6 CV Scores < 15%
Isometric Push / Pull Consistent 2 of 2 CV Scores < 15%
Dynamic Lift Test Consistent Expected Linear Heart Rate Increase
Observed Movement Patterns Consistent
Waddell's Testing Not Tested
Evaluator: Katie McBee Date: 10/23/2012
Title: Physical Therapist / LIC-04888 Evaluator Signature
Physician: Date: _______________ Title: Physician Signature
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
SUBJECTIVE HISTORY:
Browne Box is a 47 year old male with the current diagnosis of ROTATOR CUFF RUPTURE, onset 08/12/2011. Browne Box reports that the injury occurred when Mr. Box was lifting a package off of a high shelf in his work truck and he lost control of it.As he tried to stop it from falling he felt a sharp pain in his right shoulder. Present symptoms include: Stiffness and pain in his right shoulder with lifting and overhead reaching. Current medication includes: Ibuprofen as needed. Information obtained from Medical Records shows Browne Box with the following relevant past medical history: No other significant medical history. Previous testing for this injury/illness includes: MRI Torn supraspinatus per medical records. AND Previous treatment for this injury/illness includes: Physical Therapy, Mr. Box has been in physical therapy since the surgery and has been in a work conditioning program for the last 5 weeks. Browne Box reported aching and stiffness in his right shoulder at an intensity of 2 (0 = no pain; 1,2,3 = low; 4,5,6 = moderate;7,8,9 = severe; 10 = emergency pain). Browne Box reported that the pain ranges from 0 at best to 7 at its worst. Browne Box stated that lifting and reaching overhead aggravates Browne Box's symptoms, and that ice and rest provides relief. Perceived abilities include: sitting unlimited minutes, standing unlimited minutes, walking unlimited minutes, driving unlimited minutes, and lifting 50 lbs. Browne Box is independent with activities of daily living (ADLs) including: dressing, grooming, bathing, hygiene, cooking and laundry. He also reports that over the last two weeks he has been able to mow the lawn and rake leaves. Browne Box describes a typical day as: getting up around 8 am and driving to therapy for work conditioning program. He performs work conditioning for 4 hours and then goes home. He usually cooks dinner and gets his 7 and 10 year old children ready for bed. Then he watches television until he goes to bed at 11pm. Browne Box drove an automobile to/from the FCE appointment today. Mr. Box drove a manual transmission Ford 150 to his appointment today. He reports his drive took 30 minutes. Additional Subjective Information Includes: Dr. Smith performed rotator cuff repair in October 2011.
VOCATIONAL/JOB HISTORY:
Browne Box is currently not working. Mr. Box is currently not working ecause his employer does not offer light duty. He hasbeen a package handler for the Package Handling Corporation for the last 15 years. This is his first injury. A Job Description was received. Information Regarding Job Description was obtained from the employer.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MUSCULOSKELETAL SCREENING SUMMARY
Gait:
No abnormalities noted. Mr. Box walked with no assistive device at a normal pace around clinic and outside whenaware and unaware of observation.
Posture:
Mr. Box has a mild forward head and shoulders and a mild increased thoracic kyphosis. He holds his right upperextremity in a mild protective position adducted and internally rotated against his trunk.
Soft Tissues:
3.7 cm scar noted over anterior surface of right shoulder from rotator cuff repair surgery. Wel healed with nosigns of atrophy or adherence. Mild tendnerness to palpation reported over long head of biceps tendon on right.
Flexibility:
Moderate restrictions were noted in his right Pectoralis Minor and Major and Upper Trapezius muscles. No othersignificant flexibility deficits were noted.
Range of Motion: Refer to Active Range of Motion / Strength Measurements Form
Strength: Refer to Active Range of Motion / Strength Measurements Form
Neurological:
Bilateral upper and lower extremity light touch sensation were equal and intact with no deficits noted. Bilateralupper extremity deep tendon reflexes were a 2+. Bilateral lower extremity reflexes were a 2+.
Additional Testing: N/A
ENDURANCE / AEROBIC CAPACITY
Sub-Maximal Treadmill Test Completed Test Incomplete Test Not Tested
Classification: Good 43 ml/kg/min 4.97 METS Moderate Work
HR Increase: YES Respiration Increase: YES Blood Pressure: 135/65 mmHg
Comments: Mr. Box completed the single stage treadmill test without complaints.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
MATERIAL HANDLING
Waist to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
65 lbs. 135 bpm 8 Max Lift 50 lbs. 141 bpm 8 Max Lift
Start Heart Rate 95 bpm HR Increase? YES Start Heart Rate: 102 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box demonstrated mild biomechanic breakdown and appropriate physiological changes consistent with a max effort uponcompletion of lift testing. He attempted 55# frequently but was unable to complete the lift with safe biomechanics so the test was terminated by the tester after 2 repetitions.
Floor to Waist Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
70 lbs. 125 bpm 6 Met Job Demand 70 lbs. 140 bpm 8 Max Lift
Start Heart Rate 85 bpm HR Increase? YES Start Heart Rate: 105 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box completed the occasional lift test without biomechanical breakdown but test was terminated since he met job demand,higher abilities may be possible. Frequent lift test demonstrated appropriate biomechanical breakdown and physiological responses consistent with a max effort, but ability was safe to perform for an 8 hour work day and meet job demand.
Floor to Shoulder Dynamic Lift Test
Occasional Lift Heart Rate RPL RFT Frequent Lift Heart Rate RPL RFT
50 lbs. 125 bpm 8 Max Lift 38 lbs. 135 bpm 7 Max Lift
Start Heart Rate 101 bpm HR Increase? YES Start Heart Rate: 103 bpm HR Increase? YES
Constant Lift N/A .lbs Heart Rate N/A bpm
Comments:
Mr. box demonstrated appropriate biomechanical breakdown and physiological changes consistent with a max effort atoccasional and frequent lift test terminations.
Lift Capacity Performance: Consistent
Carry Testing
Occasional Carry Heart Rate RPL RFT Frequent Carry Heart Rate RPL RFT
65 lbs. Bimanual 123 bpm 8 Max Carry 60 lbs. 132 bpm 7 Max Carry
N/A lbs Right N/A bpm N/A N/A lbs. N/A bpm N/A
N/A lbs Left N/A bpm N/A N/A lbs. N/A bpm N/A
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 101 bpm HR Increase? YES
Constant Carry N/A .lbs Heart Rate N/A bpm
Comments:
Mr. Box carried each load for a distance of 25'. Appropriate biomechnical and physiological changes were seen at thetermination of occasional and frequent lift tests indicating max effort.
Push / Pull Testing
Occasional Push Occasional Pull Frequent Push/Pull Heart Rate RPL RFT
lbs.70 lbs.70 lbs. 70 bpm 125 8 Max Push
Peak Heart Rate: bpm113 Peak Heart Rate: bpm120 Start Heart Rate: bpm 89 HR Increase? YES
Constant Push/Pull N/A .lbs Heart Rate N/A bpm
Comments:Mr. Box demonstrated no biomechanical breakdown with occasional push/pull of dynamic cart for 25' but test was terminated due to meeting job demand. Mr. box demonstrated biomechanical and physiological changes consistent with a max effort on thefrequent push/pull test.
Job Specific Lift Testing
45 Heart Rate RPL RFT 35 Heart Rate RPL RFT
45 lbs. 125 bpm 8 Max Lift 35 lbs. 135 bpm 8 Max Lift
Start Heart Rate 89 bpm HR Increase? YES Start Heart Rate: 98 bpm HR Increase? YES
Constant N/A .lbs Heart Rate N/A bpm
Comments:
Shoulder to Overhead lifting. Mr. Box demonstrated appropriate biomechanical breakdown and physiological changesconsistent with a max effort at termination of both occasional and frequent lift tests.
* RPL - Rate of Perceived Load * RFT - Reason For Termination
Post Material Handling Blood Pressure:
145/65mmHg
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POSITIONAL TOLERANCE
Frequency Comments
Sitting Constant No Deficit Observed.
Standing Constant No Deficit Observed.
Walking Frequent
No Deficit Observed. Mr. Box tolerated level and unlevel surfaces at a good speed with nodeficits noted.
Stair Climbing Frequent No Deficit Observed.
Climb Ladders Occasional
Positional Change Observed. Mr. box would stabilize himself on the ladder with his right upperextremity but would only pull up with his left.
Reach Overhead Level Frequent
Elevated pain level. Mr. Box had increased pain with overhead reaching with right upperextremity. No deficits were noted on the left.
Reach Desk Level Constant No Deficit Observed.
Reach Floor Level Frequent No Deficit Observed.
Balance Frequent No Deficit Observed.
Stoop Frequent No Deficit Observed.
Kneel Occasional No Deficit Observed.
Crouch Frequent No Deficit Observed.
Crawl Occasional No Deficit Observed.
N/A N/A
MANIPULATIVE ABILITY
Frequency Comments
R Object Handling Constant No Deficit Observed.
L Object Handling Constant No Deficit Observed.
R Fingering Constant No Deficit Observed.
L Fingering Constant No Deficit Observed.
R Simple Hand Grasp Constant No Deficit Observed.
L Simple Hand Grasp Constant No Deficit Observed.
R Firm Hand Grasp Constant No Deficit Observed.
L Firm Hand Grasp Constant No Deficit Observed.
R Fine/Gross Manipulation Constant No Deficit Observed.
L Fine/Gross Manipulation Constant No Deficit Observed.
Observed Movement Patterns: Consistent
Additional Positional and Postural Tolerance Comments:
Mr. Box completed a 1 hour job simulation circuit consisting of stacking different sized packages on a dolley and rolling then to a set of shelvesand loading them at different heights for 5 minutes, climbing up and down a ladder for 2 repetitions, lifting and carrying boxes with weights ranging between 5-30# for a distance of 30' for 5 minutes, climbing up and down a 20" step while holding a rail simulating climbing in and out ofa truck for 10 repetitions and typing for 3 minutes in a seated position followed by crouching and filing for 2 minutes. He completed 4 repetitionsof this circuit with no difficulties or complaints and his heart rate at completion was 118 bpm.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
POST TEST VITAL SIGNS: Heart Rate: 89 bpm Blood Pressure: 120/65 mmHg
POST TEST PAIN LEVEL 6/10
MUSCULOSKELETON SCREENING POST-TEST SUMMARY
Gait Analysis:
No significant changes noted.
Posture Analysis:
No significant changes noted.
Soft Tissue Assessment:
No significant changes noted.
Flexibility:
No significant changes noted.
Range Of Motion:
R shoulder ROM was 156 degrees flexion, 147 degrees abduction, 76 degrees external rotation and 82 degrees internal rotation.
Strength:
No significant changes noted.
Neurological:
No significant changes noted.
Additional Tests:
N/A
ADDITIONAL INFORMATION N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PERFORMANCE CONSISTENCY
Maximal Voluntary Effort Computerized Data Collection - see attached report
Grip Test Grip Position
1 2 3 4 5
Right Hand 78 84 78 88 89 90 95 94 93 86 85 86 71 71 71
Average 80.00 89.00 94.00 85.67 71.00
Coefficient of Variation * 4% 1% 1% 1% 0%
Left Hand 67 72 69 75 75 76 82 81 82 75 75 75 65 65 65
Average 69.33 75.33 81.67 75.00 65.00
Coefficient of Variation * 3% 1% 1% 0% 0%
10 of 10 CV Scores < 15% Consistent Test Performance 2 of 2 of Bell Shaped Curve Distributions
HR(s): 89
Comments:
Pinch Strength Testing Computerized Data Collection - see attached report
Pinch Test Tip Pinch Palmar Pinch Key Pinch
Right Hand 15 16 17 23 22 21 19 18 18
Average 16.00 22.00 18.33
Coefficient of Variation * 5% 4% 3%
Left Hand 12 11 12 19 18 19 16 17 16
Average 11.67 18.67 16.33
Coefficient of Variation * 4% 3% 3%
6 of 6 CV Scores < 15% Consistent Test Performance
HR(s): 92
Comments:
Isometric Push / Pull Computerized Data Collection - see attached report
Test Heart Trials(Pounds of Force) Average Standard Coefficient of
Rate Trial 1 Trial 2 Trial 3 Deviation Variation*
Isometric Push 102 110 115 112 112.33 2.05 2%
Isometric Pull 105 105 102 107 104.67 2.05 2%
2 of 2 CV Scores < 15% Consistent Test Performance
Comments:
Performance Consistency Summary: Consistent Test Performance
Additional Performance Consistency Testing N/A
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH
N/A
SPINE NORM AROM (Degrees)
Cervical Flexion 50° WNL
Extension 60° WNL
Right Lateral Flexion 45° 30
Left Lateral Flexion 45° WNL
Right Rotation 80° WNL
Left Rotation 80° 53
Thoracic Flexion 60° WNL
Right Rotation 30° 15
Left Rotation 30° WNL
Lumbar Flexion 60° WNL
Extension 25° WNL
Right Lateral Flexion 25° WNL
Left Lateral Flexion 25° WNL
Right SLR 80° WNL
Left SLR 80° WNL
N/A
UPPER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Shoulder Flexion 180° 152 WNL 4/5 5/5
Extension 50° WNL WNL 5/5 5/5
Abduction 180° 148 WNL 4/5 5/5
Adduction 40° WNL WNL 5/5 5/5
Internal Rotation 90° 65 WNL 5/5 5/5
External Rotation 90° 71 WNL 4/5 5/5
Elbow Flexion 140° WNL WNL 5/5 5/5
Extension 0° WNL WNL 5/5 5/5
Supination 80° WNL WNL 5/5 5/5
Pronation 80° WNL WNL 5/5 5/5
Wrist Flexion 80° * WNL WNL 5/5 5/5
Extension 70° * WNL WNL 5/5 5/5
Radial Deviation 20° WNL WNL 5/5 5/5
Ulnar Deviation 30° WNL WNL 5/5 5/5
N/A
LOWER EXTREMITY NORM Right AROM Left AROM Right Strength Left Strength
Hip Flexion 120° ** WNL WNL 5/5 5/5
Extension 30° ** WNL WNL 5/5 5/5
Abduction 45° ** WNL WNL 5/5 5/5
Adduction 30° ** WNL WNL 5/5 5/5
Internal Rotation 45° ** WNL WNL 5/5 5/5
External Rotation 45° ** WNL WNL 5/5 5/5
Knee Flexion 135° ** WNL WNL 5/5 5/5
Extension 0° ** WNL WNL 5/5 5/5
Ankle Plantar Flexion 50° ** WNL WNL 5/5 5/5
Dorsiflexion 20° ** WNL WNL 5/5 5/5
Inversion 35° ** WNL WNL 5/5 5/5
Eversion 15° ** WNL WNL 5/5 5/5
Normative Data - AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
* Normative Data - Rehabilitation of the Hand: Survey and Therapy, 4th Edition
** Normative Data - American Academy of Orthopedic Surgeons
FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
HAND NORM * Right AROM Left AROM Right Strength Left Strength
(Degrees) (Degrees)
Thumb CMC Flexion 15° * n/a n/a n/a n/a
CMC Extension 20° * n/a n/a n/a n/a
CMC Abduction 70° * n/a n/a n/a n/a
MCP Flexion 50° * n/a n/a n/a n/a
MCP Extension 0° * n/a n/a n/a n/a
IP Flexion 80° * n/a n/a n/a n/a
IP Extension 0° * n/a n/a n/a n/a
Index MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Long MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Ring MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Small MCP Flexion 90° n/a n/a n/a n/a
MCP Extension Up to 45° n/a n/a n/a n/a
PIP Flexion 110° n/a n/a n/a n/a
PIP Extension 0° n/a n/a n/a n/a
DIP Flexion 60° n/a n/a n/a n/a
DIP Extension 0° n/a n/a n/a n/a
Normative Data - American Academy of Orthopedic Surgeons, Rehabilitation of the Hand: Surgery and Therapy, 4th Edition
N/A
Hand Volume Right Left
Pretest ml n/a Pretest ml n/a
Post Test ml n/a Post Test ml n/a
Difference + ml n/a Difference + ml n/a
* Rehabilitation of the Hand: Surgery and Therapy,4th Edition
- Fluid volume changes are often 30 to 50 ml or more between one measurement and the next if swelling is present.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
ACTIVE RANGE OF MOTION / STRENGTH (continued)
N/A
Circumference Right Left
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
n/a *R (Pretest) cm n/a Pretest cm n/a
*R - Right *R (Post Test) cm n/a Post Test cm n/a
*R (Difference) + cm n/a Difference + cm n/a
n/a Pretest cm n/a Pretest cm n/a
Post Test cm n/a Post Test cm n/a
Difference + cm n/a Difference + cm n/a
* Rehabilitation of the Hand: Survey and Therapy, 4th Edition - Circumference measurements of the hand and fingers or areas of swelling.
N/A
Opposition Right Index - n/a Long - n/a Ring - n/a Small - n/a
Left Index - n/a Long - n/a Ring - n/a Small - n/a
* American Academy of Orthopedic Surgeons - Tip of thumb to base or tip of small digit.
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FUNCTIONAL CAPACITY EVALUATION
Re: Browne Box DOB: 07/12/1965 INSURANCE I.D. NO.: 402321548
PHYSICAL DEMAND CATEGORY (U.S. Department of Labor, Dictionary of Occupational Titles)
Sedentary Exerting up to 10 lbs. of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/ora negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time to lift, carry, push, pull or otherwise move objects, including human body.
Light Exerting up to 20 lbs. of force occasionally, and/or up to 10 lbs. force frequently, and/or a negligible amount of
force constantly (Constantly: activity or condition exists from 2/3 or more of the time) to move objects. Physicaldemand requirements are in excess of those for Sedentary Work.
Medium Exerting 20 lbs. to 50 lbs. of force occasionally, and/or 10 lbs. to 25 lbs. of force frequently, and/or greater than
negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of thosefor Light Work.
Heavy Exerting 50 lbs. to 100 lbs. of force occasionally, and/or 25 lbs to 50 lbs. of force frequently, and/or 10 lbs. to 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally, and/or in excess of 50 lbs. of force frequently, and/or in
excess of 20 lbs.of force constantly to move objects. Physical Demand requirements are in excess of those forHeavy Work.
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KORT Goss Avenue, 1227 GOSS AVE. LOUISVILLE, KY. 40217; Clinic's phone # : (502) 636-1200 [FCE-3240] Page 13 / 13
