Examinee #:
123-45-6789
Sample Report Summary For Functional Capacity Evaluation (FCE)
Examinee:
Test Date:
John Doe
Hand Grip Strength Protocol
01/28/2004
(Standard Protocol, 5 positions, bell curve strength/reliability test):
Right Hand:
Left Hand:
Occupation: Detention Officer
Date of Birth:
09/13/1960
Date of Injury:
Examinee’s
Very Heavy - lifting
Stated Physical >100 lbs.
Demand Level: ocassionally.
ICD-9 1.
Codes:
2.
out of 5 valid, Bell Curve ✘ Yes
No
out of 5 valid, Bell Curve
Yes ✘ No
Five
Five
10/08/2003
724.4 3.
724.2 4.
847.1
Cross Validation Hand Grip Strength Protocol
(Rapid Exchange, 1 position, reliability test):
Positive REG, indicating a submaximal effort.
Functional Activity Summary
Activity
Attempted Completed Test Results
Observation
Axial Rotation Reach
YesRequired
No
Yes No [
Not
Crouching/Squat Reach
Yes No
Yes No [
Competitive
Examinee complained of bilateral knee and low back discomfort with this task.
Kneeling Reach
Yes No
Yes No [
Competitive
No complaints.
Kneeling to Standing & Back Reach Not
YesRequired
No
Yes No [
Kneeling Upper Level Reach
Yes
No
No [
Not Required Yes
Standing Position Reach
Yes No
Yes No [
Examinee complained of minor low back pain (3/10) with prolonged standing.
Competitive
Stooping 36“ Displacement
YesRequired
No
Yes No [
Not
Stooping Reach
Yes
No
Yes No [
Due to complaints of severe low back discomfort with this task / position.
Did not complete
Upper Level Reach
Yes No
Yes No [
No complaints.
Competitive
Static Strength/Reliability Protocol
Comments:
Vertical Height
Avg. Amount Demonstrated
98 lbs.
Above Shoulder (> 54 in.)
Knuckle to Shoulder (30-54 in.)
78 lbs.
Floor to Knuckle (0-30 in.)
121 lbs.
Dynamic Lifting Capacity
Moderate Duration
Vertical Height
Max. Lifted
Reliable
N/R
Above Shoulder (> 54 in.)
lbs.
Yes
No
N/R lbs.
Knuckle to Shoulder (30-54 in.)
Yes
No
N/R lbs.
Floor to Knuckle (0-30 in.)
Yes
No
Maximum Lbs.
Functional Activities
Carrying
40 lbs., (heaviest)
Cardio Respiratory Protocol
Cardio Respiratory Fitness Classification: Low
Cardio Respiratory Fitness Test: Kasch Step Test
Interpretation
Physical Effort:
Cooperation:
Symptom
mgmt./ control:
Body Mechanics:
Good
Average
Average
Fair
Licensed Therapist
Analysis reviewed by:
]
]
]
]
]
]
]
]
]
Reliable
✘ Yes
No
No
✘ Yes
Yes ✘ No
Short Duration
Max. Lifted
Reliable
40 lbs.
Yes ✘ No
50 lbs.
No
✘ Yes
No
60 lbs.
✘ Yes
Carry Cycles*
Reliable
8 # of cycles
No
✘ Yes
VO2 Submaximal
Heart Rate
ml/kg/min-1 Start
Stop
Mr. Doe did not meet his reported job
lifting requirements of >100 lbs. during
this evaluation. He was self limiting
with dynamic lifting due to complaints of
low back discomfort. It should be noted
that his heart rate (HR) remained
consistent with a positive pain response
throughout.
Lumbar ROM measurements are as
follows: flexion - 32, extension - 15, L
lateral flexion - 20, R - 22, L SLR - 57,
R - 50.
Defecits were noted in the following
areas: lumbar ROM, positional
tolerances (primarily with stooping), CV
fitness, and complaints of low back
discomfort with dynamic and static
activities.
N/T - not tested
N/R - not required
*1 cycle = 50 ft.
Vocational Implication
Examinee qualifies for the Light
work category with:
0 to 40 lbs. max. occasionally,
N/T to
lbs. max. frequently,
N/T to
lbs. max. constantly.
Total Evaluation Time
Start Time: 10:00AM
Stop Time: 2:00PM Total: 4
Hrs.
Requesting
Doctor:
John Smith, D.O.
Deliver to:
Therapist name (printed): Mitch Winn, OTR #004690
02/09/2007Date:
©2001 OnSite Medtest, LLC & eBusiness1. All Rights Reserved. Use without expressed written permission prohibited. This copyrighted work and all goodwill pertaining thereto belong exclusively to the licensor and
it's authorized, contractual licensees. Any unauthorized use by any non-licensed entity is a violation of federal copyright laws. All violators can be criminally prosecuted under U.S. Title Code 17, Sections 501-506.
FUNCTIONAL ABILITIES EVALUATION
Client Information
Client Name: Mr. John Doe
PREPARED FOR:
Address: 858 Oakland St.
Grand Prarie, Texas
75052
Injury Date: May 21, 2002
Attn: Barbara Drake
CCS Consulting
PO Box 541387
Dallas, Texas
75354
Tel: (972) 554-1141
Dominant Hand: Right Hand
SSN: 452-37-3406
Employment Information
Occupation: Dentention Officer
Employer: Dallas County Sheriff's Office
Address: 501 Main St.
Dallas, Texas
75202
Insurance Information
Date of Birth:
Gender:
Height:
Weight:
Company: CCS Consulting
Address: Attn: Barbara Drake
PO Box 541387
Dallas, Texas
75354
(972) 554-1141
Start & Finish Date: Jan 28, 2004
Evaluator: Mitch Winn. OTR
Claim #: 10245
Work Status: Currently working
April 30, 1960
Male
69 inches
220 lbs
Areas of Complaint
Lower Back
General Location
Specific Location
Lower Back (Lumbosacral)
Plane
Side
Pain Type
Pain Scale
Posterior
Middle
Stiffness & Tingling
4 - Low Moderate
Mitch Winn. OTR
Occupational Therapist
Range of Motion
‡ Normals:
Trial 1:
Trial 2:
Trial 3:
Lumbar
True Lumbar
Flexion
60
41
48
46
Jan 28, 2004
True Lumbar
Extension
25
18
24
23
Left Lateral
Right Lateral
Flexion
Flexion
25
25
22
30
24
33
26
31
MOBILE ASSESSMENTS
Left Straight Leg
Raise
80
78
73
71
Right Straight
Leg Raise
80
77
75
78
400 Meandering Creek Dr. Argyle TX. 214-566-9013 (214) 566-9013
All testing was completed using the FOCUS System, Data Management was compiled through ODES products of Hanoun Medical Inc.
45.0
48.0
YES
75%
Average
Maximum
AMA Valid
% of Normal
180.0
144.0
108.0
72.0
36.0
0.0
1
2
Trial #
21.7
24.0
YES
87%
3
1
24.0
26.0
YES
96%
2
Trial #
3
1
2
Trial #
31.3
33.0
YES
125%
3
1
2
Trial #
74.0
78.0
YES
92%
3
1
2
Trial #
76.7
78.0
YES
96%
3
1
2
Trial #
3
Reference Information
American Medical Association Guides to the Evaluation of Permanent Impairment, Fifth Edition
Work Simulation
MPLC Knuckle to Shoulder Short Duration (Test 1)
Jan 28, 2004
The evaluee was required to lift a 30 X 30 centimetre crate weighing 10 pounds with progressively increased loads. The
evaluee was monitored with respect to heart rate (physiological), lifting mechanics (biomechanical) and perceived exertion
(psychophysical).
Starting Heart Rate: 126
Shoulder Height 54
Inches:
Knuckle Height Inches: 30
Initial Weight (Lb): 40
Ending Heart Rate Final Weight (Lb) Rate of Perceived
Load
145
7
90
Time
01:27
Evaluator Comments
Examinee complained of minor low back "tightness" with this task.
Reference Information
1) Dictionary of Occupational Titles, Vol. II, 4th Ed., Rev1991. 2) Matheson, 1996, et al. 3) Hanoun Medical, 2000
Work Simulation
MPLC Floor to Shoulder Short Duration (Test 3)
Jan 28, 2004
The evaluee was required to lift a 30 X 30 centimetre crate weighing 10 pounds from floor to shoulder level, with progressively
increased loads. The evaluee was monitored with respect to heart rate (physiological), lifting mechanics (biomechanical) and
perceived exertion (psychophysical).
Starting Heart Rate: 128
Job Demands: >100
Initial Weight (Lb): 85
Shoulder Height (In): 54
Ending Heart Rate Final Weight (Lb) Rate of Perceived
Load
Time
105
00:58
145
7
Evaluator Comments
Examinee complained of minor bilateral knee discomfort with this activity.
Reference Information
1) Dictionary of Occupational Titles, Vol. II, 4th Ed., Rev1991. 2) Matheson, 1996, et al. 3) Hanoun Medical, 2000
MOBILE ASSESSMENTS
400 Meandering Creek Dr. Argyle TX. 214-566-9013 (214) 566-9013
P. 2
Work Simulation
MPLC Floor to Knuckle Short Duration (Test 2)
Jan 28, 2004
The evaluee was required to lift a 30 X 30 centimetre crate weighing 10 pounds with progressively increased loads. The
evaluee was monitored with respect to heart rate (physiological), lifting mechanics (biomechanical) and perceived exertion
(psychophysical).
Initial Heart Rate: 135
Job Demands: >100
Initial Weight (Lb): 75
Knuckle Height (In): 30
Ending Heart Rate Final Weight (Lb) Rate of Perceived
Load
Time
105
01:04
146
7
Evaluator Comments
Examinee complained of minor bilateral knee discomfort with this task.
Reference Information
1) Dictionary of Occupational Titles, Vol. II, 4th Ed., Rev1991. 2) Matheson, 1996, et al. 3) Hanoun Medical, 2000
Work Simulation
Carrying Activity
Jan 28, 2004
The evaluee was required to carry a 30 X 30 centimetre crate weighing 5 pounds over a pre-determined distance, with
progressively increased loads. The evaluee was monitored with respect to heart rate (physiological), lifting mechanics
(biomechanical) and perceived exertion (psychophysical).
Starting Heart Rate: 138
Shelf Height: 30
Ending Heart Rate Maximal Weight
( lb)
169
105
Total Carries
Job Demands: >100
Rate of Perceived
Load
8
Evaluator Comments
Examinee complained of bilateral upper extremity fatigue with this task.
Reference Information
Dictionary of Occupational Titles, Vol. II, 4th Ed., Rev 1991
MOBILE ASSESSMENTS
P. 3
400 Meandering Creek Dr. Argyle TX. 214-566-9013 (214) 566-9013
Hand Grip
Strength
The JAMAR hand dynamometer was used in order to quantify grip strength and determine whether Mr. Gerardo
Aguayo exerted consistent effort during grip strength testing. Mr. Gerardo Aguayo was tested using the
maximum voluntary effort and rapid exchange hand grip protocols. Mr. Gerardo Aguayo is right hand
dominant. Normative data is based on the assumption that right and left hand dominant subjects, analyzed
separately show little functional difference between their mean scores.¹· ²·
Maximum Voluntary Effort (MVE)
Jan 28, 2004
The hand dynamometer is set
to each of the five available
positions which vary the
patient's grip size. The results
for each of the average
maximum forces during each
position are displayed by the
corresponding bar graphs.
Right
50
54
45
36
27
18
9
0
Force (Lbs)
Force (Lbs)
Left
Left
COV Right
COV
Pos #1 39.6 Lbs. 6.1% 41.5 Lbs. 1.7%
40
Pos #2
Pos #3
Pos #4
Pos #5
30
20
10
0
1
2
3
4
5
1
Hand Grip Setting
2
3
4
Hand Grip Setting
54.1 Lbs.
58.1 Lbs.
43.6 Lbs.
38.9 Lbs.
7.4%
5.8%
7.8%
10.5%
49.9 Lbs.
49.5 Lbs.
41.4 Lbs.
44.2 Lbs.
8.1%
7.8%
1.9%
7.8%
5
St. Dev. 7.8 Lbs.
3.7 Lbs.
Using the Maximum Voluntary Effort (MVE) protocol over a range of five positions on the hand dynamometer, it
is expected that the strength graphs obtained results in a bell-shaped curve³·¹¹·¹²·¹³· even in a disabled population
or if the client's hand is injured³· ¹³· with at least 6 of the 10 coefficients of variation within the acceptable 15% or
less limit.²²
The graph obtained for Mr. John Doe did demonstrate a bell shaped curve which may be an indicator of
maximal effort and the coefficients of variation of the underlying data may be an indicator of consistent effort
with all 10 coefficients of variation within the 15% acceptable limit.
Rapid Exchange Grip (REG)
Jan 28, 2004
Right
Left
67
64
Trial #1
Force (Lbs)
The hand dynamometer is set
to position 3. The client
applies a maximum force for a
one second trial duration
quickly alternating between
hands. The average maximum
force for all six trials is
compared to the maximum
voluntary effort value in the
same position for reliability
purposes.¹³
Force (Lbs)
56
48
32
16
45
33
22
11
0
0
0
0.25
0.75
Time (s)
1
0
0.25
0.75
Trial #2
Trial #3
Trial #4
Trial #5
Trial #6
Average
Maximum
1
Time (s)
Diff L Vs. R
Left
Right
57.8 Lbs.
58.3 Lbs.
67.1 Lbs.
58.9 Lbs.
67.6 Lbs.
54.6 Lbs.
46.5 Lbs.
66.8 Lbs.
53.5 Lbs.
58.2 Lbs.
55.9 Lbs.
51.8 Lbs.
60.7 Lbs.
55.5 Lbs.
67.6 Lbs.
66.8 Lbs.
9.5%
The peak average force value recorded during the maximum voluntary effort protocol was 58.1 Lbs performed at
position 3. The Rapid Exchange Grip (REG) protocol was therefore administered at this position. A negative
rapid exchange grip (REG) occurs when the average of the values recorded during the rapid exchange grip
protocol are less than the average of the values recorded during the maximum voluntary effort protocol in the
same position and for the same hand. Conversely, a positive REG occurs when the average of the values recorded
during the rapid exchange grip protocol exceed the average of the values recorded during the maximum voluntary
effort protocol in the same position and for the same hand. A negative REG allows the evaluator to have more
confidence that the evaluee is performing maximally. A positive REG may be an indicator of submaximal
effort.¹³ Mr. Joh Doe produced an average value of 60.7 Lbs for the left hand and 55.5 Lbs for the right
hand during the rapid exchange protocol. He produced an average value of 58.1 Lbs for the left hand and 49.5
Lbs for the right hand during the maximum voluntary effort protocol. Mr. John Doe therefore
demonstrated a positive REG which may be an indicator of submaximal effort.
³ Stokes H. 1983. The seriously uninjured hand - weakness of grip. J Occup Med 25(9):683-684.
¹¹ Niebuhr B, Marion R. 1990. Voluntary control of submaximal grip strength. Am J Phys Med Rehabil 69(2): 96-101.
¹² Matheson L, Carlton R, Niemeyer L. 1988. Grip strength in a disabled sample: reliability and normative standards. Ind Rehabil Q 1(3):9,17-23.
¹³ Hildreth D, Breidenbach W, Lisiter G, Hodges A. 1989. Detection of submaximal effort by use of the rapid exchange grip. J Hand Surgery
14A(4): 742-745.
²² Klimek E, Strait J. 1997. Volition in impairment rating: the validity of effort assessment. J Occup Med 6(2) 9-18.
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 4
Static Pull Strength
Test Date: Jan. 28, 2004
Handle Type
Acc. Rot. Angle:
Accessory Angle
Foot Placement
Force (Lbs)
BPM
181
142
103
64
25
0
1
2
3
4
104.0
78.0
52.0
26.0
0.0
130.0
104.0
78.0
52.0
26.0
0.0
5
0
Time (min)
During Test
130.0
Static Strength (Lbs)
Static Strength (Lbs)
220
1.5
Time (s)
Trial 1: 121.8 Lbs Average:
Trial 2: 103.8 Lbs COV:
Trial 3: 95.1 Lbs
3
Time (s)
25%
106.9 Lbs
10.4% 75%
Mr. John Doe reached an average peak force of 106.9 Lbs. for the static pull strength. The co-efficient of variation was 10.4%
during the static pull strength. Values greater than 15% may be an indicator of submaximal effort.
Evaluator Comments
Push / pull - no complaints.
Static Push Strength
Test Date: Jan. 28, 2004
Handle Type
Acc. Rot. Angle:
Accessory Angle
Foot Placement
Force (Lbs)
BPM
181
142
103
64
25
0
During Test
1
2
3
Time (min)
4
130.0
Static Strength (Lbs)
Static Strength (Lbs)
220
104.0
78.0
52.0
26.0
0.0
130.0
104.0
78.0
52.0
26.0
0.0
5
0
1.5
Time (s)
Trial 1: 102.3 Lbs Average:
Trial 2: 104.3 Lbs COV:
Trial 3: 94.7 Lbs
3
25%
Time (s)
100.4 Lbs
4.1%
75%
Mr. John Doe reached an average force of 100.4 Lbs. for the static push strength. The co-efficient of variation was 4.1%
during the static push strength. Values greater than 15% may be an indicator of submaximal effort.
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 5
Mr. John Does's ability to lift, push or pull was assessed using the FOCUS Standard NIOSH strength
test. It is predictable that leg strength will be greater than either torso or arm strength.† Mr. John Doe
did not demonstrate this predictable decrease in isometric strength.
Force (Lbs)
130
100
Trial #1
117.4 Lbs.
104
Trial #2
108.7 Lbs.
78
Trial #3
87.7 Lbs.
52
Average
104.6 Lbs.
Maximum 117.4 Lbs.
26
The client pulls up for a five
second trial duration. A rest
period of 15 seconds is given in
between the three trials.
COV
0
0
Jan 28, 2004
Force
Leg Lift
Heart Rate (BPM)
Standard
NIOSH
80
60
40
20
0
12.0%
0
2.5
Time (s)
1
5
Final:
2
3
Peak:
Min:
4
5
During
Prior/After
An average force of 104.6 Lbs. was exerted by Mr. John Doe during the leg lift. The coefficient of
variation for this test was 12%. Values greater than 15% may be an indicator of inconsistent effort.
Force
Trial #1
118.3 Lbs.
Trial #2
145.3 Lbs.
Trial #3
113.8 Lbs.
72
Average
125.8 Lbs.
36
Maximum 145.3 Lbs.
11.0%
COV
Force (Lbs)
144
The client pulls up for a five
second trial duration. A rest
period of 15 seconds is given in
between the three trials.
108
0
0
2.5
Time (s)
100
Heart Rate (BPM)
Torso Lift
80
60
40
20
0
0
5
1
Final:
2
3
Peak:
Min:
4
5
During
Prior/After
An average force of 125.8 Lbs. was exerted by Mr. John Doe during the torso lift. The coefficient of
variation for this test was 11%. Values greater than 15% may be an indicator of inconsistent effort.
Force
The client pulls up for a five
second trial duration. A rest
period of 15 seconds is given in
between the three trials.
61
50
40
30
20
10
0
Trial #1
50.6 Lbs.
Trial #2
61.6 Lbs.
Trial #3
48.4 Lbs.
Average
53.5 Lbs.
Maximum
61.6 Lbs.
COV
0
2.5
Time (s)
100
Heart Rate (BPM)
Force (Lbs)
Arm Lift
80
60
40
20
0
0
11.0%
1
5
Final:
2
3
Peak:
Min:
4
5
During
Prior/After
The client pushes up for a five
second trial duration. A rest
period of 15 seconds is given in
between the three trials.
112
98
84
70
56
42
28
14
0
0
High Near Lift
Force
Trial #1
101.9 Lbs.
Trial #2
92.8 Lbs.
Trial #3
92.8 Lbs.
Average
95.8 Lbs.
100
Heart Rate (BPM)
Force (Lbs)
An average force of 53.5 Lbs. was exerted by Mr. John Doe during the arm lift. The coefficient of
variation for this test was 11%. Values greater than 15% may be an indicator of inconsistent effort.
Maximum 101.9 Lbs.
2.5
Time (s)
5
COV
04.0%
80
60
40
20
0
0
Final:
1
2
3
Peak:
Min:
4
5
During
Prior/After
An average force of 95.8 Lbs. was exerted by Mr. John Doe during the high near lift. The coefficient
of variation for this test was 4%. Values greater than 15% may be an indicator of inconsistent effort.
Evaluator Comments
Leg lift - examinee complained of bilateral knee discomfort with this task.
Torso lift - no complaints.
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 6
Arm lift - no complaints.
High near lift - examinee complained of minor parathesia behind the left knee with this task.
†
Atuahene, F and A. Freivalds (1987) Comparison of Dynamic Static and Psychophysical Evaluations of Human Strength
Capablities. Journal of Human Ergology, Vol. 16, No. 2: 17-191
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 7
Occasional - F.R.O.M.
Crouching/Squatting
Reach
The client while maintaining the
assigned posture moves five rows of
pegs from one panel to another and
back using a hand to hand transfer.
A total of five cycles are completed.
The Sustained Crouching Reach protocol was used to determine Mr. John Doe's ability to
perform crouching activities with functional reaching on a sustained basis. Mr. John Doe was
tested using the Functional Range of Motion (FROM) System and the performance was calculated
using the internationally-recognized MTM (methods-time measurement) standard. Methods-Time
Measurement (MTM) is the industrial engineering-based method for the determination of time-motion
performance in conjunction with work-related activities. The MTM standard score allows for the
means to determine an exact percentage score of performance against the most widely recognized
criteria for the assessment of time-motion activities. MTM scoring is based on a criterion referenced
time-motion standard to complete a task as opposed to an estimate of ability.
Test Date
Time (min)
Jan 28, 2004 5:25:45 PM
05:43
MTM Percentage
86%
MTM Rating
Competitive
The test scoring is based upon the total time necessary to complete five cycles of the task. The time
required to complete the test is converted automatically into the equivalent MTM (methods-time
measurement) standard score. Mr. John Doe had a MTM score of 86% which correlates to a
rating of competitive.
Evaluator Comments
Examinee complained of bilateral leg and calf fatigue with this task.
Occasional - F.R.O.M.
Kneeling Reach
The client while maintaining the
assigned posture moves five rows of
pegs from one panel to another and
back using a hand to hand transfer.
A total of five cycles are completed.
The Sustained Kneeling Reach protocol was used to determine Mr. John Doe's ability to
perform kneeling activities with functional reaching on a sustained basis. Mr. John Doe was
tested using the Functional Range of Motion (FROM) System and the performance was calculated
using the internationally-recognized MTM (methods-time measurement) standard. Methods-Time
Measurement (MTM) is the industrial engineering-based method for the determination of time-motion
performance in conjunction with work-related activities. The MTM standard score allows for the
means to determine an exact percentage score of performance against the most widely recognized
criteria for the assessment of time-motion activities. MTM scoring is based on a criterion referenced
time-motion standard to complete a task as opposed to an estimate of ability.
Test Date
Time (min)
Jan 28, 2004 5:26:51 PM
05:04
MTM Percentage
94%
MTM Rating
Competitive
The test scoring is based upon the total time necessary to complete five cycles of the task. The time
required to complete the test is converted automatically into the equivalent MTM (methods-time
measurement) standard score. Mr. John Doe had a MTM score of 94% which correlates to a
rating of competitive.
Evaluator Comments
No complaints.
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 8
Occasional - F.R.O.M.
Standing Position
Reach
The client while maintaining the
assigned posture moves five rows of
pegs from one panel to another and
back using a hand to hand transfer.
A total of four cycles are completed.
The Sustained Standing with Distance Reach Evaluation protocol was used to determine Mr. John
Doe's ability to perform activities requiring distance reaching in a standing position on a sustained
basis. Mr. John Doe was tested using the Functional Range of Motion (FROM) System and the
performance was calculated using the internationally-recognized MTM (methods-time measurement)
standard. Methods-Time Measurement (MTM) is the industrial engineering-based method for the
determination of time-motion performance in conjunction with work-related activities. The MTM
standard score allows for the means to determine an exact percentage score of performance against the
most widely recognized criteria for the assessment of time-motion activities. MTM scoring is based on
a criterion referenced time-motion standard to complete a task as opposed to an estimate of ability.
Test Date
Time (min)
Jan 28, 2004 5:28:10 PM
05:11
MTM Percentage
89%
MTM Rating
Competitive
The test scoring is based upon the total time necessary to complete four cycles of the task. The time
required to complete the test is converted automatically into the equivalent MTM (methods-time
measurement) standard score. Mr. John Doe had a MTM score of 89% which correlates to a
rating of competitive.
Evaluator Comments
No complaints.
Occasional - F.R.O.M.
Stooping Reach
The client while maintaining the
assigned posture moves five rows of
pegs from one panel to another and
back using a hand to hand transfer.
A total of five cycles are completed.
The Sustained Stooping Reach protocol was used to determine Mr. John Doe's ability to
perform stooping activities with functional reaching on a sustained basis. Mr. John Doe was
tested using the Functional Range of Motion (FROM) System and the performance was calculated
using the internationally-recognized MTM (methods-time measurement) standard. Methods-Time
Measurement (MTM) is the industrial engineering-based method for the determination of time-motion
performance in conjunction with work-related activities. The MTM standard score allows for the
means to determine an exact percentage score of performance against the most widely recognized
criteria for the assessment of time-motion activities. MTM scoring is based on a criterion referenced
time-motion standard to complete a task as opposed to an estimate of ability.
Test Date
Time (min)
Jan 28, 2004 5:27:25 PM
05:21
MTM Percentage
92%
MTM Rating
Competitive
The test scoring is based upon the total time necessary to complete five cycles of the task. The time
required to complete the test is converted automatically into the equivalent MTM (methods-time
measurement) standard score. Mr. John Doe had a MTM score of 92% which correlates to a
rating of competitive.
Evaluator Comments
Examinee complained of minor low back "tightness" with this task.
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 9
Occasional - F.R.O.M.
Upper Level Reach
The client while maintaining the
assigned posture moves five rows of
pegs from one panel to another and
back using a hand to hand transfer.
A total of five cycles are completed.
The Sustained Upper Level Reach protocol was used to determine Mr. JOhn Doe's ability to
perform shoulder level and above reaching activities on a sustained basis. Mr. John Doe was
tested using the Functional Range of Motion (FROM) System and the performance was calculated
using the internationally-recognized MTM (methods-time measurement) standard. Methods-Time
Measurement (MTM) is the industrial engineering-based method for the determination of time-motion
performance in conjunction with work-related activities. The MTM standard score allows for the
means to determine an exact percentage score of performance against the most widely recognized
criteria for the assessment of time-motion activities. MTM scoring is based on a criterion referenced
time-motion standard to complete a task as opposed to an estimate of ability.
Test Date
Jan 28, 2004
Time (min)
05:22
MTM Percentage
89%
MTM Rating
Competitive
The test scoring is based upon the total time necessary to complete five cycles of the task. The time
required to complete the test is converted automatically into the equivalent MTM (methods-time
measurement) standard score. Mr. John Doe had a MTM score of 89% which correlates to a
rating of competitive.
Evaluator Comments
No complaints.
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 10
Dallas Pain Questionnaire
Please read:
This questionnaire has been designed to give the doctor information
as to how your pain has affected your life. Be sure that these are
your answers. Do not ask someone else to fill out the questionnaire
for you. Please click on the line in the position that expresses your
thoughts from 0 to 100% in each section.
0% Daily Activities
Scoring: Factor I:
Factor II: 10% Work/Leisure Activities
Factor III: 0% Anxiety/Depression
Factor IV: 15% Social Interest
Primary Approach: Conservative intervention
Jan 28, 2004
SECTION I: PAIN AND INTENSITY
To what degree do you rely on pain medications or pain relieving substances for you to be comfortable?
NONE
ALL THE TIME
SOME
X
0%(
*
*
*
*
)100%
*
SECTION II: PERSONAL CARE
How much does pain interfere with your personal care (getting out of bed, teeth brushing, dressing, etc)?
NONE (NO PAIN)
SOME
I CANNOT GET OUT OF BED
X
0
0%(
*
*
*
*
*
)100%
SECTION III: LIFTING
How much limitation do you notice in lifting?
NONE
(I CAN LIFT AS I DID)
I CANNOT LIFT
ANYTHING
SOME
X
0%(
0
*
*
*
*
*
)100%
SECTION IV: WALKING
Compared to how far you could walk before your injury or back trouble, how much does pain restrict your walking now
I CAN WALK
THE SAME
ALMOST
THE SAME
VERY LITTLE
I CANNOT
WALK
X
0%(
0
*
*
*
*
*
)100%
SECTION V: SITTING
Back pain limits my sitting in a chair to:
NONE
PAIN SAME AS BEFORE
SOME
I CANNOT
SIT AT ALL
0
X
0%(
*
*
*
*
*
)100%
SECTION VI: STANDING
How much does your pain interfere with your tolerance to stand for long periods?
NONE
SAME AS BEFORE
I CANNOT
STAND
SOME
0
X
0%(
*
*
*
*
*
)100%
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 11
SECTION VII: SLEEPING
How much does pain interfere with your sleeping?
NONE
SAME AS BEFORE
I CANNOT
SLEEP AT ALL
SOME
0
X
0%(
*
*
)100%
*
SECTION VIII: SOCIAL LIFE
How much does pain interfere with your social life (dancing, games, going out, eating with friends, etc)?
NONE
SAME AS BEFORE
SOME
NO ACTIVITIES
TOTAL LOSS
0
X
0%(
*
*
*
*
*
*
*
)100%
SECTION IX: TRAVELING
How much does pain interfere with traveling in a car?
NONE
SAME AS BEFORE
SOME
I CANNOT
TRAVEL
1
X
0%(
*
*
*
*
*
*
)100%
SECTION X: VOCATIONAL
How much does pain interfere with your job?
NONE
NO INTERFERENCES
I CANNOT
WORK
SOME
1
X
0%(
*
*
*
*
*
*
*
)100%
SECTION XI: ANXIETY/MOOD
How much control do you feel that you have over demands made on you?
(NO CHANGE)
TOTAL
SOME
NONE
0
X
0%(
*
*
*
*
*
*
)100%
SECTION XII: EMOTIONAL CONTROL
How much control do you feel you have over your emotions?
(NO CHANGE)
TOTAL
SOME
NONE
X
0%(
*
0
*
*
*
*
*
*
)100%
SECTION XIII: DEPRESSION
How depressed have you been since the onset of pain?
NOT DEPRESSED
SIGNIFICANTLY
OVERWHELMED
BY DEPRESSION
0
X
0%(
*
*
*
*
*
*
*
)100%
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
P. 12
SECTION XIV: INTERPERSONAL RELATIONSHIPS
How much do you think your pain has changed your relationships with others?
DRASTICALLY
CHANGED
NOT CHANGED
3
X
0%(
*
*
*
*
*
*
*
)100%
SECTION XV: SOCIAL SUPPORT
How much support do you need from others to help you during this onset of pain (taking over chores, fixing meals, etc.)?
NONE NEEDED
ALL THE TIME
X
0%(
0
*
*
*
*
*
*
)100%
SECTION XVI: PUNISHING RESPONSE
How much do you think others express irritation, frustration or anger toward you because of your pain?
NONE
ALL THE TIME
SOME
0
X
0%(
*
*
*
*
*
*
*
)100%
Kasch Step Test
The total number of heart beats is counted during recovery, and this count is compared with population norms to
determine the appropriate classification of cardiovascular condition
Jan 28, 2004 4:44:46 PM
111 BMP
143 BMP
142 BMP
29 %
122 BMP
Heart Rate (BPM)
Initial Heart Rate:
Peak Heart Rate:
Final Testing Heart Rate:
% Heart Rate Increase:
Final Recovery Heart Rate:
220
Elapsed Time: 04:05
Test Time: 03:00
Recovery Time: 01:00
176
132
88
During Testing
Before & After Testing
44
0
0
1
2
3
4
5
Time (Min)
Standard:: Very Poor
Advanced Fitness Assessment & Exercise Prescription, 2nd Ed. Vivian H Heyward. 1991.
Cardiovascular Intake
Jan 28, 2004
Result
Resting
Rate (Min)
Systolic
(mm Hg)
Diastolic
(mm Hg)
105
148
99
Fast Heart
Rate
Borderline
Hypertension
Mild
Hypertension
MOBILE ASSESSMENTS
1604 RIVER BIRCH FLOWER MOUND TX. 75028 (214) 566-9013
Mr. Gerardo Aguayo
P. 13