Keyboarding speed
Finger dexterity, dominant R
Far vision acuity
Close/near vision acuity
Ambulation agility
Reaching overhead, dominant
Standing/walking
Sitting
Reaching overhead, other side
Fingering, other side
Fingering, dominant side R
Climbing ramps or stairs
Climbing ladders, etc.
Constant lift/carry >30x/hour
Frequent lift/carry 13-30x/hr.
Seldom high lift >54 in.
Seldom low lift <30 in.
Seldom middle lift 30-54 in.
Worker
Worker Name
Rick Wickstrom PT, DPT, CPE
Injury Date
Examiner Name
Exam Date
10/20/2020
Frank Sample
5/11/17
Materials Handling Demands
Job Match
Work Release Recommended
Worker
20
50
35
65
65
Physical Tolerances
Job Match
Worker
None
Occasional
Frequent
Occasional
Occasional
Extra time
Physical Aptitudes
Job Match
Medium
Medium
High
Low
Low
10
25
30
35
None
Frequent
Frequent
Frequent
Extra time
Extra time
Medium
Extra high
High
Medium
Very low
None: 0 h per shift, Seldom: <0.2 h, Occasional: 0.2<2.5 h,
Frequent: 2.5<5.5 h, Constant: 5.5-8 h, Extra time: >8 h
Functional Capacity Evaluation
Summary of WorkAbility
Constant
Occasional
Permanent Restrictions
Maximum Benefit
Recovery Progress
Further Explanation (WorkAbilities/Progress)
Mr. Sample was fully cooperative. He reported that his
functional performance was primarily limited by right
upper arm pain. This pain was localized over the region
of repair of his long head of biceps tenodesis. He
demonstrates full shoulder range-of-motion. His residual
deficits consists primarily of right biceps and right grip
weakness that is limited by pain localized over the
region of the right biceps tenodesis. He has mild
atrophy of his dominant right upper arm and forearm
that is consistent with his history of injury, having three
surgeries. There is no obvious Popeye deficit. He
expresses interest in return to a suitable job with his
employer of record, Sample Company. This is a HEAVY
job; therefore his prognosis would be considered poor
for return to his usual duties unless this job can be
modified to use a materials handling device such as a
ceiling track lift to greatly reduce or eliminate lifting and
carrying of buckets of flavor and the 65 lb. pump. He
should target a different job goal that does not exceed
MEDIUM job strength demands, with the support of
vocational rehab services for job search to leverage his
transferable skills related to production or driving
positions. Mr. Sample would like to receive
accommodation or affirmative action assistance to
continue his employment with Sample Company, based
on consideration of his qualifying disability, veteran, and
minority status. Additionally, he would benefit from
authorization of up to 6 physical therapy visits over a
period of 3 months to progress to a safe program of
exercise at Planet Fitness that emphasizes endurance
training his right upper arm muscles (e.g., 1-2 sets of 20
-25 reps before advancing weights for incline over grip
curls and other appropriate movements).
Extra time
Occasional
lb.
lb.
lb.
lb.
lb.
lb.
lb.
lb.
lb.
lb.
Occasional lift/carry 2-12x/hr.
40
lb.
65
Clinic: Sample Reports
Bending/stooping
Frequent
Frequent
Low work at or below knees
Occasional
Frequent
20/30 factors
Sample Company
Most Recent Employer
Flavor Deck Operator
Job Match Title
Dec 2017
Last Worked
Seldom carry 30-36 in.
Traditional keyboarding
Reaching forward, dominant R
Reaching forward, other side
Finger dexterity, other side
20/30 factors
# of Matches
lb.
lb.
lb.
30
Handling, dominant side R
Constant
Handling, other side
Extra time
Extra time
Extra time
Medium
Constant
Occasional
Extra time
40
65
Low
Frequent
Occasional
Seldom
Foot controls, left leg
Extra time
Foot controls, right leg
Extra time
None
Occasional
Exam Certification
Signed electronically by Rick Wickstrom PT, DPT, CPE on 10/21/2020
Review By Healthcare Provider
Sample Orthopod, MD | Orthopaedic Surgeon
Signature of agreement __________________________________________ Date ______________
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 1
17-XXXXXX
WorkAbility Systems
Functional Capacity Evaluation
Sample Reports
Worker Name
Rick Wickstrom PT, DPT, CPE
Examiner Name
Age
Exam Date
10/20/2020
51 yr
Birth Date
12/16/1968
Gender
Male
Education
He went to Sample College to play football for one year
after graduation from high school in 1986 and then left
to join the Marines. He served from 1988 to 1993 as a
scout sniper for recon overseas. He took data
processing and accounting vocational classes when in
high school.
Some College
Claim #
His BWC Claim is allowed for allowed for right shoulder conditions that include S46.911A Unspecified right
shoulder upper arm strain, M75.51 Subacromial bursitis of the right shoulder, M67.911 unspecified synovial
disorder of the shoulder, and S46.211A right biceps tendon rupture.
17-XXXXXX
5/11/17
Injury Date
Claim Reference
Exam Service Type
Ohio BWC vs. Sample Company
Injury/Disease Management
Attending Health Provider
Name
Next Visit
How long?
2.0 yrs
Sample Orthopod, MD
Specialty
Send Report?
Orthopaedic Surgeon
Sample Orthopod has done 3 surgeries to the right shoulder.
Sample Family MD is his family physician with Sample Physicians who prescribes medications for hypertension
and type 2 Diabetes Mellitus.
Referral Issues/Consent/Intake (1-3)
He was referred by Dr. Orthopod for a functional capacity evaluation. We were contacted by his attorney to make
arrangements for this service. He has been off work since December of 2017. His employer sent him home after
only a short period of accommodation.
An informed consent was obtained prior to testing. The worker agreed to stop immediately and notify the examiner
in the event that any unacceptable symptoms occurred while performing any requested tasks.
He arrived at 8:55 AM to begin his appointment and completed the face to face exam at 12:35 PM. 60 minutes of
additional time was necessary to review his records, and integrate findings in his report.
97750 Physical Performance Testing
300 min
20
Time
Units
Procedure Coding
Evaluation Methodology (1-6)
He drove from his home in about an hour.
American Physical Therapy Association (APTA) defines Functional Capacity Evaluation (FCE) as “A
comprehensive performance-based medical assessment of an individual's physical and/or cognitive abilities to
safely participate in work and other major life activities. FCEs are designed, administered, and interpreted by
licensed healthcare examiners that demonstrate evidence of education, training, and compentencies to perform
FCEs." WorkAbility Systems, Inc. endorses use of 2018 Current Concepts in Functional Capacity Evaluation by the
Occupational Health SIG of the American Physical Therapy Association. Only therapy professionals trained to
administer the WorkAbility Systems FCE method are authorized to use this ExamFIT reporting template.
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 2
17-XXXXXX
Current Work Status
He is collecting Workers' Comp TTD benefits. He believes that he is still employed and is interested to getting back
to this job; however, he reports no longer receiving healthcare benefits.
This describes participation related to work, home, or school activities
Full time
Part time
Has job/not working
Unemployed/laid off
Disabled/unable to work
Retired
Homemaker/keeping house
Student
Other
Working with restrictions
He worked 3-5 12-hour shifts per week and handled items that ranged from 35-60 lb. (pumps, buckets of flavor).
Most Recent Employment
Seniority
Job Title
Company
Sample Company
5.0 yrs
Flavor Deck Operator
Hours/wk
40-60
Last Worked
Dec 2017
Stand
Strength
Heavy (51-100#)
Brief History of Injury/Disability
On 5/11/17, he was lifting and emptying a bucket of flavor into a vat and felt his right shoulder pop. He kept doing
his normal duties until November 2017 when he was put on work restrictions. Sample Company stopped
accommodating his work restrictions in Dec. 2017. He underwent three surgeries by Dr. Orthopod. The first surgery
was to repair his rotator cuff. He tore his right biceps tendon during post-op and had another surgery to repair. He
re-tore this again during post-op rehab and had another surgery. He had post-op therapy at Therapy Provider
3x/week for about 3-4 months that was last done in March of 2020. A functional capacity evaluation was requested,
but disputed by the employer. During a typical therapy session, 10 min. UBE, resistive bands to gray, ball exercises
using wall, dumbbell exercises with 10-12 lb. curls, pulley exercises, functional box lifts, wall push-ups, wall
reaches. He has been exercising at home by himself, but cancelled his Planet Fitness membership due to
concerns about COVID exposure with his and his wife's comorbidities.
This is a brief chronological summary of the worker's statements about the mechanism of injury or illness,
treatment received to date, and impact on employment.
Most Recent Job Activities
He reports that he would typically work 12-hour work shifts from 6am to 6pm, 3-5 days per week. He would get
briefed and operate a forklift to get pre-staged ingredients. He would hand carry items to 12 different vats. The
walkway was too narrow to use a cart to convey the items. Most bags are 25-50 lb. buckets of flavor weighing up to
35-60 lb. He is in the Food and Beverage Union. This was last reviewed in Jan 2016.
A job description was requested and did not arrive until the day after his participation in the FCE exam. The Hourly
Position Description for Flavor Operator was reasonably consistent with Mr. Sample's self-report of his duties and
physical demands. Only minor clarifications were necessary to this examiner's initial assessment of full duty job
demands. The purpose of this position is to pull mix from the wall tanks to the flavor vats and flavor them with the
correct flavor to match the specific formula. The flavor person is responsible for the mix quality, material control
and maintaining accurate records. This description states that The Flavor Operator must be able to lift various sizes
of flavor buckets and bottles. Buckets of flavor range from 32-53lbs and there can be as many as 100 buckets
each day that need to be lifted. They must also be able to lift the Graco Pump which weighs 65 lbs. The Flavor
Operator must climb stairs to reach the flavor deck working area. There are times when the operator must carry 5
gallon buckets up the stairs. The Flavor Operator must kneel down to hook up the air eliminators onto the piping for
the CIP process. They must also bend their knees each time they lift flavor buckets. The Flavor Operator will be
exposure to hot/cold temperatures, noise, fumes, cramped quarters, cold surfaces/tools, hot surfaces/tools, sharp
edges, and vibrations. The Flavor Operator must crawl and twist under deck platform to clean floors. While
performing the duties of this job, the employee is regularly required to stand; walk; sit; bend; swat; reach; push/pull;
use hands to finger, handle, or feel; reach with hands and arms. The employee must regularly work in hot / cold
temperature and noisy conditions. The employee must regularly lift and/or move 50 pounds and occasionally move
up to 100 pounds. The physical demands described here are representative of those that must be met by an
employee to successfully perform the essential functions of this job. Reasonable accommodations may be made
to enable individuals with disabilities to perform the essential functions.
Job Match Demands, Full Duty (6-7)
This section is used to clarify the specific occupational demands that the worker must demonstrate to justify a
release to perform the physical demands of the referenced Job Match Title without restrictions.
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 3
17-XXXXXX
Seldom: <0.2h, Occasional: 0.2<2.5h, Frequent: 2.5<5.5h,
Constant: 5.5-8h, and Extra time: >8h total per shift
Job Match Title
Flavor Deck Operator
Constant lift/carry >30x/hour
Frequent lift/carry 13-30x/hr.
Seldom high lift >54 in.
Seldom lower lift <30 in.
Seldom carry 30-36 in.
20
50
35
65
65
Physical Aptitudes
Ambulation Agility
Far vision acuity
Finger dexterity, dominant
Close/near vision acuity
Medium
High
Low
Medium
Physical Tolerances
Climbing ladders, etc.
Reaching forward, dominant
Reaching forward, other side
Sitting
None
Frequent
Frequent
Occasional
Verified by
Occupational Reference(s)
529.685-130 TITLE(s): FLAVOR ROOM WORKER (dairy products) - Tends
equipment, such as blenders, roasters and grinders, and performs any combination of
following tasks to prepare ice cream flavoring, coloring, and nut and fruit mixtures:
Weighs or measures specified quantities of ingredients, such as syrup, sugar, water,
butter, fruit pulp, fruit juice, salt, dye, and gelatin, using graduate. Dumps ingredients
into blending vat. Turns valve and starts agitator to heat and blend contents for
specified period. Opens valve to start flow of blend to storage vat, or moves it to
processing unit, using handtruck. Fills hopper of nut grinder and turns knob to adjust
teeth for desired grind. Dumps ground nuts into roaster and adjusts burner to roast
them. Dumps prepared fruits into sieve to remove juice. Observes ingredients and
removes foreign matter. Sprays containers and equipment with sterilizing solution to
clean them. Maintains inventory of supplies.
Standing/walking
Extra time
Occasional
Climbing ramps or stairs
Fingering, dominant side
Handling, dominant side
Occasional
Extra time
Foot controls, right leg
Occasional
Fingering, other side
Occasional
Handling, other side
Extra time
Keyboarding speed
Low
Worker
Employer
Observation
Comments
Occasional lift/carry 2-12x/hr.
65
Bending/stooping
Frequent
Occasional
Low work at or below knees
See Operational Definitions
See Operational Definitions
Seldom middle lift 30-54 in.
65
Finger dexterity, other side
Low
Reaching overhead, dominant
Reaching overhead, other side
Occasional
Occasional
Traditional keyboarding
Seldom
Foot controls, left leg
None
lb.
lb.
lb.
lb.
lb.
lb.
lb.
Prior Work Experience
He served a five year tour of duty in the Marines and was deployed overseas. Prior to working for the Sample
Company he worked as a Stader Core and Rotor Builder Assembly for Sample Energy for 5 years until layoff.
Before that, he had a Class B CDL and drove flat bed trucks to deliver building supplies for 13 years with Sample
Building Supplies until this company went out of business.
This is a description of past relevant work experience before the most recent employment.
Pending Injury or Disability Claims
Does the worker report having a pending claim for any type of injury or disability compensation?
No
Disability Benefits Received
Does the worker report receiving any type of disability benefits?
Yes
He receives temporary total disability benefits from his Ohio BWC Claim. He no longer has medical coverage
through Sample Company.
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 4
17-XXXXXX
Yes
Right neck, shoulder, elbow, and hand.
Do you have any health problems that may get worse with physical activity?
Limiting Health Problems
Head
Neck
Upper back
Shoulder(s)
Elbow(s)
Wrist(s)/hand(s)
Chest
Abdomen
Lower back
Hip(s)/thigh(s)
Knee(s)
Ankle(s)/feet
Recent Medications/Drugs/Supplements
Does the worker report taking any medications, drugs, or dietary supplements during the past month?
Yes
Atorvastatin 1x/day for high cholesterol, Metformin 500 mg. for DMII 2x/day, Lisinopril 1x/day for hypertension, and
Fenofibrate 1x/day.
Comorbidity Survey
The Comorbidity Survey is listing of health problems that relate to health status and utilization.
1. Back or other spine disorder
3. Osteoporosis
4. Asthma
6. Heart attack (myocardial infarction)
2. Arthritis or other joint disorder
7. Congestive heart failure
9. High blood pressure
10. Neurological disease (e.g. Parkinson's)
11. Stroke or mini-stroke (TIA)
12. Peripheral vascular disease
8. Pacemaker or other heart procedures
5. Chronic obstructive pulmonary disease
13. Blood clots or bleeding disorder
Health Condition/Problem Type
Based on self report of the following responses, the worker's total comorbitidy score is:
3 / 30
16. Eye problems (except glasses/contacts)
18. Diabetes or blood sugar problems
19. Kidney disease or urinary disorder
21. Lower gastrointestinal or bowel disorder
17. Ear problems or hearing difficulty
22. Liver disease (e.g. hepatitis)
24. Chronic infection or other immune disorder
25. Depression
26. Anxiety or panic disorder
27. Sleep disorder or dysfunction
23. Cancer
20. Upper gastrointestinal disorder (e.g. reflux)
28. Dementia or other cognitive impairment
14. Head/brain injury (e.g. concussion)
29. Emergency/hospital care within past year
30. Use of tobacco products
15. Seizures, epilepsy
Lifestyle Review
He is married and resides with his wife and four of six kids (16-25 years old). His wife is disabled due to Crohn's
Disease. They live in a two story house. He does light housework. A friend cuts his grass.
This is a brief summary of the subject's lifestyle at home.
Lifestyle Physical Function Screen (8-9)
This is a brief screen of the worker's perceived ability to perform a range of standardized lifestyle physical activities.
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 5
17-XXXXXX
1. Heavy lift/carry to 100lb
2. Walk more than 1 mile
3. Climb a flight of stairs
4. Lift or carry groceries
5. Bend, kneel, stoop
6. Vacuum or yard chores
7. Dress upper/lower body
8. Shampoo hair
9. Wash/dry your body
10. Toilet transfers
11. Hand wash dishes/pots
12. Get up from floor
13. Sitting for activities
14. Travel long distances
1-Unable to do
15. Walk block, flat ground
16. Run a short distance
17. Run or jog 2 miles
18. Lift 10lb above shoulder
19. Lift 25lb box off floor
20. Lift 50lb bag of sand
LIFESTYLE ACTIVITIES SCORE
58.75%
3-With some difficulty
5-Without any difficulty
2-With much difficulty
5-Without any difficulty
2-With much difficulty
4-With a little difficulty
4-With a little difficulty
4-With a little difficulty
5-Without any difficulty
3-With some difficulty
2-With much difficulty
5-Without any difficulty
3-With some difficulty
5-Without any difficulty
4-With a little difficulty
2-With much difficulty
3-With some difficulty
4-With a little difficulty
1-Unable to do
2. Strength Training
1. Maximum Strength Level
He walks the two small dogs frequently with his wife
and does wall pushups, stretching, and resistive
bands.
Very light (1-10 lb)
6-Moderate 150+ min/week
3. Cardio Activity Level
4 days/week
Recent Physical Activity
PROMIS Global-10 (10)
This is a brief 10-question survey to assess health care-related quality of life measures that include overall health,
pain, fatigue, social health, mental health, and physical health.
1. Overall Health
2. Overall Quality of Life
3. Overall Physical Health
4. Overall Mental Health
5. Relationships Satisfaction
6. Social Role Functioning
7. Daily Physical Functions
8. Emotional Difficulty
9. Average Fatigue Rating
10. Average Pain Level
6 / 10
Global Physical Health Score
Global Mental Health Score
12/20 points
12/20 points
3-Good
3-Good
5-Excellent
1-Poor
3-Sometimes
3-Good
1-Poor
3-Moderately
3-Moderate
Review of Recent Symptoms (11-12)
Lowest pain rating in past 24 hours
Highest pain rating in past 24 hours
8.0/10
2.0/10
Highest pain rating in past month
Lowest pain rating in past month
9.0/10
2.0/10
Right shoulder/upper arm pain ranges from 2/10 to 8/10 (2.5 now), right neck pain (0/10 to 6/10). He gets
numbness and tingling in his right hand. He reports weight loss (20 lb. over 2 months) that he attributes to less
appetite and worrying about his job and taking care of his family. He reports unusual fatigue, trouble sleeping,
stress headaches, feeling depressed.
Rating from 0 (No Pain) to 10 (Worst Imaginable Pain)
Communication/Affect/Cognition
1. Communication (age-appropriate?)
Normal
3. Orientation x 3 (person/place/time)
Normal
2. Affect/behavior
Normal
Pre-Exam Vitals (3-4)
Seated Heart Rate
60 bpm
Blood Pressure
114/78 mmHg
Right shoulder/upper arm pain
Stage 2 blood pressure is 160-199/100-109 mmHg at rest, and this usually warrants medication management.
2.5/10
Pain
Sp02%
96
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 6
17-XXXXXX
Anthropometric Measures (13)
Anthropometric measures identify obesity or underweight conditions that affect health and fitness.
BMI
Waist to Height
30.9
55.6%
68.0 in (173.0 cm)
Height
203 lb (92.3 kg)
Weight
37.8 in (96.0 cm)
Waist Girth
Obese 1
Overweight
Near Vision Screen (14)
This is a test of close visual acuity using a hand-held Snellen Card at 14 inches from the eyes.
Corrected?
Both
Right
Left
Rating
20/20
20/20
20/20
Extra high
Far Vision Screen (14)
This is a test of distant vision acuity using a 10 foot wall chart.
Corrected?
Both
Right
Left
He was recommended to have glasses but could not afford them after his insurance was cancelled.
20/30
20/50
20/60
Rating
High
Active Movement Scale (AMS) (15)
2. Flex fingers 2-5
3. Extend wrists
4. Flex elbows back
5. Elevate shoulders
6. Diagonal neck bend
7. Extend neck up
11. Step up and over
9. Rotate torso in stand
10. Single leg stance
Right upper arm pain with shoulder elevation
and minor guarding.
1. Adduct thumbs
8. Forward bend over
Right
Left
Pain?
12. Heel walk forward
14. Active squat down
This is a series of rated movements to assess flexibility, coordination, strength, and balance.
13. Lunge back to kneel
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
3-Guarded
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
4-Normal
2-Fair
Total
97.0%
Upper Body
Lower Body
95.8%
98.1%
Right Arm
Left Arm
95.0%
100.0%
Spine and Pelvis Exam (16-18)
1. Inspection
Normal
5. Range Of Motion
a. Neck
b. Back
Normal
2. Reflexes
3. Sensation
Normal
4. Myotomes
Normal
Normal
Normal
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 7
17-XXXXXX
Upper Extremities Exam (16-18)
f. Wrists
g. Elbows
1. Inspection
a. Thumbs
Abnormal
3. Active Range Of Motion
Normal
Normal
Normal
Right biceps 31 left 31.5 cm. Right forearm 30.5 left 31 cm. This is consistent
with mild atrophy.
He has localized right biceps weakness
2. Sensory loss
Normal
b. Index fingers
c. Middle fingers
d. Ring fingers
e. Little fingers
h. Shoulders
Normal
Normal
Normal
Normal
Normal
Lower Extremities Exam (16-18)
1. Inspection
a. Hips
b. Knees
c. Ankles
d. Feet
Normal
Normal
Normal
Normal
Normal
2. Range Of Motion
Two Square Agility Test (TSAT) (20)
This is a test of dynamic agility. It involves stepping forward and back between two squares as quickly as safely
possible.
6.60
T1
6.00
T2
5.10
T3
CV
Best
Method
Right lead
M/sec
Rating
12.8%
5.10 s.
2.16 m/s
Practice
8.90 s.
Pain?
Medium
Grip Strength (24-27)
This is a test of grip strength using alternate hands at position 2 with the Jamar Hand Dynamometer.
T1
T2
T3
Mean
CV
%Norm
Pain?
Rating
39#
41#
48#
Right (Preferred)
42.7#
11%
46.4%
92#
90#
87#
89.7#
3%
100.0%
Left
Right upper arm pain
Very low
Medium
Tripod Pinch Strength (24-25)
This is a test of tripod pinch strength with up to 3 trials using alternate hands with the B & L Pinch Gauge.
T1
T2
T3
Mean
CV
%Norm
Pain?
13#
18#
13#
18#
14#
17#
13.3#
17.7#
4%
3%
Rating
56.0%
77.8%
Right (Preferred)
Left
Very low
Low
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 8
17-XXXXXX
5-Position Grip Strength (28)
T1
T2
T3
Right
Left
Right/Left Ratio
T4
T5
49#
55#
35#
25#
25#
Right upper arm pain
82#
92#
80#
73#
68#
0.60
0.60
0.44
0.34
0.37
This is a test of grip strength for a single trial at five different handle spans using alternate hands.
Pain?
Keyboarding Speed Test (29)
Results are based on best NET SPEED in words per minute.
Best
Pain?
T1
T2
T3
Mean
CV
Rating
17.5 wpm
19
16
19 wpm
13%
He uses only the index fingers of his right and left hand. We discussed that his performance would likely improve to
a high level with learning how to use all fingers to type.
Low
Grooved Pegboard Test (30-33)
Placing Test
Remove Test
T1
T2
Placing Test
Remove Test
AgeSex%
T1
T2
Best
Worker%
AgeSex%
Worker%
Rating
This finger dexterity test measures the ability to manipulate small pegs with the fingers rapidly and accurately.
Best
Rating
64.0
22.0
66.6
17.2
He reports primarily having right upper arm fatigue.
89.8
21.0
73.5
16.9
Right (Preferred)
Left
64.0 s.
17.2 s.
73.5 s.
16.9 s.
100.8%
105.2%
87.8%
107.1%
110.8%
102.2%
Pain?
Pain?
Rate
23.4 ppm
87.2 ppm
Rate
20.4 ppm
88.8 ppm
Medium
Medium
Medium
Medium
Best Finger Dexterity, one hand:
Combined Finger Dexterity, both hands:
Medium
Medium
WorkAbility Rate of Manipulation - Turning Test (34-35)
This is a test of finger dexterity. It involves turning over 20 cylinders by finger manipulation with right and left hands.
T1
T2
T3
Worker%
Rating
Pain?
Right (Preferred)
Left
Sit
19.4
18.3
18.2
19.9
18.0
16.5
Best
18.2 s.
16.5 s.
99.2%
109.5%
CV
4%
9%
Rate
65.9 ppm
72.7 ppm
Medium
Medium
WorkAbility Rate of Manipulation - Placing Test (34-35)
This is a brief dexterity test that involves moving 20 cylinders between the top and bottom boards using the right
versus left hands.
T1
T2
T3
Worker%
Rating
Pain?
Right (Preferred)
Left
Sit
18.2
18.3
20.3
19.5
20.5
18.2
Best
18.2 s.
18.2 s.
127.6%
127.6%
CV
6%
6%
He reports primarily right upper arm fatigue.
Rate
65.9 ppm
65.9 ppm
High
High
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 9
17-XXXXXX
Horizontal Push Strength (36-37)
This is a test of static pushing strength using both arms while alternating with the right and left legs forward. The
50th percentile performance is 69# for females and 117# for males. Weaker workers on a similar test called push
out strength were determined to have significantly higher amount of medical visits than workers with strength that
exceeded job force requirements.
T1
T2
Right Leg Lead
Left Leg Lead
55#
72#
95#
86#
Mean
63.5#
90.5#
Weight %
31%
45%
Pain?
Practice Trial
58#
104#
Both arms
He reports that it hurt more in the right shoulder to push when his right foot was forward. This performance was
inconsistent, because the test requires a symmetrical push with both arms and should not be affected much by
which foot was placed forward.
WorkAbility High Lift Strength (36, 40-44)
The standard method involves lifting progressive weights in a 16 x 12 x 10 inch tote without handles using both
hands from a table, pivoting and raising the entire tote above a tape mark on the wall at head height before
returning it to the table. This requires reaching up with both hands above head level.
Method
Other
Safe Limit
RPE
HR
7.5/10
/min.
30 lb
Pain?
Endpoint
Mechanics limit
Medium
Strength Rating
He reports right upper arm pain. His performance improved after he was instructed how to support the load more
predominantly using his unaffected left arm.
Mechanics
3-Guarded
Time
sec.
WorkAbility Low Lift Strength (36, 40-44)
The standard method involves lifting progressive weights in a 16 x 12 x 10 inch tote by its handles with both hands
from a table, pivoting 90 deg. to lower the tote to the floor and returning it to the table. This requires lower reaching
with both hands to 9 inches above the floor.
He reports right upper arm pain.
Method
Standard
Safe Limit
RPE
HR
7.0/10
/min.
30 lb
Pain?
Endpoint
Mechanics limit
Mechanics
Medium
Strength Rating
Time
sec.
3-Guarded
WorkAbility Chest Lift Strength (36, 40-44)
The standard method involves lifting progressive weights in a 16 x 12 x 10 inch tote without handles using both
hands from a table, pivoting and raising the top of the tote above a tape mark on the wall to 62 inches before
returning it to the table. This involves lifting in the mid-range with both hands to a vertical height of 52 inches above
the floor.
He reports right upper arm pain. His performance improved after he was instructed how to support the load more
predominantly using his unaffected left arm.
Method
Other
Safe Limit
RPE
HR
7.0/10
/min.
40 lb
Pain?
Endpoint
Mechanics limit
Mechanics
Medium
Strength Rating
Time
sec.
3-Guarded
WorkAbility Short Carry Strength (36, 40-44)
For the standard test method, the worker carries a 16-inch x 12-inch x 10-inch tote with progressive weights by the
handles with both hands along a short, 20-foot path.
He reports right upper arm pain. His performance improved after he was instructed how to support the load more
predominantly using his unaffected left arm.
Method
Other
Safe Limit
RPE
HR
7.0/10
/min.
40 lb
Pain?
Endpoint
Mechanics limit
Mechanics
Medium
Strength Rating
Time
sec.
3-Guarded
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 10
17-XXXXXX
WorkAbility Chest Lift Frequent (36,40-44)
For the standard test method, the worker performs 4 cycles of lifting a tote with progressive weights to and from
chest level within 20 seconds. Each cycle begins by lifting a 16-inch x 12-inch x 10-inch tote with both hands
without handles from a table, pivoting and raising the tote to just above a tape mark placed at a 62-inch height on
the wall before returning it to the table. This puts the knuckles of both hands at a vertical destination height of 52
inches above the ground (chest level).
Method
Safe Limit
RPE
HR
Endpoint
Standard
25 lb
7.0/10
/min.
Mechanics limit
Mechanics
He reports right upper arm pain. He supports the load by pressing against the side of the tote with the palms of
both arms symmetrically.
Pain?
Medium
Frequent Rating
Time
16.0 sec.
3-Guarded
WorkAbility Low Lift Frequent (36, 40-44)
The standard test method involves lifting progressive weights in a 16 x 12 x 10 inch tote with handles for 4 cycles of
lifting from the table to floor within 20 seconds. Each cycle involves lifting the tote with both hands from a table,
pivoting and lowering it to the floor and then returning it to the table. This requires repetitive bending and reaching
with both hands from 38 to 9 inches above the floor.
Method
Safe Limit
RPE
HR
Endpoint
Standard
25 lb
7.0/10
/min.
He reports right upper arm pain.
Mechanics limit
Mechanics
Pain?
Medium
Frequent Rating
Time
15.0 sec.
3-Guarded
Other Exam Findings
We discussed that he should do primarily endurance rep strengthening to build his confidence, progressing to a
minimum of 25 reps for box lifts and overgrip curls before adding weight.
Post Exam Vitals (4-5, 12)
Right shoulder/upper arm pain
Seated Heart Rate
72
Blood Pressure
118/82 mmHg
3.0
Pain
Sp02%
97
Consistency of Performance (19, 44)
This is an overall summary that identifies inconsistencies during functional capacity testing.
1. Dramatic symptoms reported
2. Non-anatomic or superficial tenderness
4. Strength inconsistencies
3. Movement inconsistencies
5. Cardiovascular signs inconsistencies
6. Excessive pain behaviors
7. Unaffected areas limitations
8. Refusal to attempt
9. Overestimates safe limits
Overall Consistency of Performance
Worker was cooperative and provided a consistent performance on functional capacity tests that did not stress
recent problem areas; however, some inconsistencies were identified for problems reported or exam findings.
10. Increased pain post exam
Relevant Diagnostics/Records Findings
6/1/2018 - Right shoulder surgery operative report by Sample Orthopod, MD: Diagnosis right shoulder partial
rotator cuff tear, type 2 SLAP tear. He performed a right shoulder arthroscopy, subacromial decompression, rotator
cuff debridement, and biceps tenodesis. There was no significant chrondromalacia within the humeral head over
the glenoid. He did have some partial tearing of his biceps tendon. He had significant fraying of the labrum and a
type 2 SLAP tear that involved the biceps anchor. He had some partial tearing of fraying of his rotator cuff near the
insertion side that was debrided.
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 11
17-XXXXXX
Operational Definitions
STRENGTH: To determine the physical exertion requirements of work in the national economy, Social Security Administration (SSA) uses
Strength level definitions (below) from the Dictionary of Occupational Titles, published by the United States Department of Labor. These
definitions are used by SSA to classify and match exertion levels of jobs with worker abilities when making disability determinations.
(a) Sedentary work. Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files,
ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often
necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met.
(b) Light work. Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds.
Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves
sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light
work, you must have the ability to do substantially all of these activities. If someone can do light work, we determine that he or she can also do
sedentary work, unless there are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of time.
(c) Medium work. Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25
pounds. Someone that can do medium work would also be capable of doing sedentary and light work.
(d) Heavy work. Heavy work involves lifting no more than 100 pounds at a time with frequent lifting or carrying of objects weighing up to 50
pounds. Someone that can do heavy work would also be capable of doing medium, light, and sedentary work.
(e) Very heavy work. Very heavy work involves lifting objects weighing more than 100 pounds at a time with frequent lifting or carrying of objects
weighing 50 pounds or more. Someone that can do very heavy work would also be capable of doing heavy, medium, light and sedentary work.
MATERIALS HANDLING FACTORS:
* Constant lift/carry >30x/hour: Average load of materials lifted or carried by one worker for more than a total duration of 5.5 hours (2/3) of the
shift. Include materials handling tasks that exceed 30x/hour during the shift. Average the 31 heaviest loads handled in a given hour for the job.
* Frequent lift/carry 13-30x/hr: Average load lifted or carried by one worker for a duration ranging from third (2.5 hrs) to less than two thirds (5.5
hrs) of the shift. Average the 13 heaviest loads handled in a given hour for the job.
* Occasional lift/carry 2-12x/hr: Average load lifted or carried by one worker for a total duration ranging from 0.2 hours to less than 2.5 total
hours (1/3) of the shift. Average the 2 heaviest loads handled in a given hour for the job.
* Seldom carry 30-36 in. (maximum): Heaviest load transported over short distances while walking and supporting load in one or both arms
near waist level.
* Seldom high lift >54 in. (maximum): Heaviest load raised with one or both hands from shoulder level to overhead.
* Seldom low lift <30 in. (maximum ): Heaviest load lifted with one or both hands positioned below table height.
* Seldom middle lift 30-54 in. (maximum): Maximum load lifting with one or both hands positioned from mid-range to chest level.
PHYSICAL APTITUDES: Factors are rated by skill level as None, Very low, Low, Medium, High, and Extra high based on functional definitions.
* Ambulation agility: Ability to move about on foot while walking, jogging, or running for a short time period. Examples - Low: Slow, unhurried
walk at 1.8 to < 3 mph on level ground; Medium: Brisk walk at 3 to 4.25 mph; High: Jog on level ground or walk brisk on uneven ground.
* Close/near vision acuity: Ability to see details at a close range, using one or both eyes (e.g., inspect items or read print). Ratings are based
on Snellen-equivalent (font size) results with or without corrective lenses with best eye. Examples - Low: 20/200 (26 pt) to < 20/70 (10 pt),
Medium: 20/70 (10 pt) to < 20/30 (5 pt), High: 20/30 (5 pt) to < 20/20 (3 pt).
* Far vision acuity: Ability to see details at a distance. Ratings are based on Snellen-equivalent results, with or without corrective lenses in best
eye. Examples - Low: 20/200 to < 20/70 (gross movements), Medium: 20/70 to < 20/30 (general observation), High: 20/30 to < 20/20 (drives).
* Finger dexterity, dominant: Ability to manipulate small items rapidly and skillfully with fingers of the DOMINANT (or preferred) hand. Examples
– Low: Slow/below normal pace, Medium: Normal pace, High: Fast/above normal pace.
* Finger dexterity, other side: Ability to manipulate small items rapidly and skillfully with fingers of the OTHER hand. Examples – Low:
Slow/below normal pace, Medium: Normal pace, High: Fast/above normal pace.
* Keyboarding speed: Ability to move the fingers rapidly and accurately to perform computer keyboarding tasks. Examples - Low: 15 to 24
wpm, Medium: 25-34 wpm, High: 35-44 wpm.
POSTURE TOLERANCES: Physical tolerances are measured as the total number of hours during a work shift and then rated as None, Seldom:
<0.2 hr, Occasional: 0.2<2.5 hr, Frequent: 2.5<5.5 hr, Constant:5.5-8 hr, and Extra time: > 8 hours per shift.
* Bending/stooping: Bending forward 45 deg. or more at the waist while standing to reach to a lower level.
Climbing ladders, etc.: Ascending or descending ladders, scaffolding, ropes, poles, etc. using both upper and lower body strength.
* Climbing ramps/stairs: Ascending or descending ramps or stairs using primarily the feet and legs.
* Fingering, dominant side: Using primarily the thumb and fingers of the DOMINANT (or preferred) hand to touch, pick, pinch, or otherwise
manipulate items. This does not include gross grasping or handling with the whole hand or arm to manipulate items. This includes time for hand
writing using electronic devices to enter data using touch screens.
* Fingering, other side: Using primarily the thumb and fingers of the OTHER hand to touch, pick, pinch, or otherwise manipulate items primarily
with the fingers. This does not include gross grasping or handling with the whole hand or arm. This includes using electronic devices to enter
data using touch screens.
* Foot controls, left leg: Making movements with the LEFT leg usually in a sitting posture to operate foot pedals that control machinery or
equipment. The upper leg muscles are not typically required to generate force.
* Foot controls, right leg: Making movements with the RIGHT leg usually in a sitting posture to operate foot pedals that control machinery or
equipment. The upper leg muscles are not typically required to generate force.
* Handling, dominant side: Using the DOMINANT (or preferred) hand and arm to seize, hold, grasp, turn or otherwise manipulate larger
objects. Fingers are involved only to the extent that they are an extension of the hand (e.g., to turn a switch or shift automobile gears).
* Handling, other side: Using the OTHER hand and arm to seize, hold, grasp, turn or otherwise manipulate larger objects. Fingers are involved
only to the extent that they are an extension of the hand (e.g., to turn a switch or shift automobile gears).
* Low work at or below knees: Working with hand(s) below knee level or to get closer to the ground. Include crawling, kneeling or crouching.
* Reaching forward, dominant: Reaching forward with the DOMINANT (or preferred) hand at shoulder level or below with the shoulder angle at
least 45 deg. If workers can adjust themselves or reposition items to avoid reaching at or below shoulder level, do not include time as reaching.
* Reaching forward, other side: Reaching forward with the OTHER hand at shoulder level or below, with the shoulder angle at least 45 deg.
* Reaching overhead, dominant: Reaching with the DOMINANT (or preferred) arm with the elbow above shoulder level (> 90 deg). Overhead
reaching includes 1) Bending the elbow with the shoulder angle 90 deg. or more to reach overhead with the hand and 2) Keeping the elbow
extended with the shoulder angle at 120 deg. or more.
* Reaching overhead, other side: Reaching with the OTHER arm with the elbow above shoulder level (> 90 deg).
* Sitting: Remaining in a seated position during work tasks. Includes driving done while sitting. Sitting is present when workers 1) remain in a
sitting posture, 2) recline or lie down, or 3) may choose to sit or stand for a given task. For example, office workers can choose a standing desk.
* Standing/walking: Remaining on one’s feet at a work station or to move about. Include stooping, crawling, kneeling, crouching, or climbing.
* Traditional keyboarding: Using a traditional keyboard to enter text or data into a computer or other machine. Although traditional keyboarding
requires fingering, it is collected as a separate factor.
Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 12
17-XXXXXX
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Ph (513) 772-1026 Fax (513) 672-2552
Sample, Frank - Pg 13
17-XXXXXX