Case Study: Back

Mr. Rivera is a 58-year old Spanish-speaking man. He injured his low back and left ankle in a motor vehicle accident. Mr. Rivera worked for five years as a Machine Operator/Laborer upon coming to the United States. Following his accident, Mr. Rivera attempted an unsuccessful and brief return to work, but was unable to perform the required or modified job duties, e.g. sit for three hours during production processing or push the barrels.

Medical Information

Medical reports indicate herniated lumbar disc, lumbar spinal stenosis, lumbosacral derangement and severe muscle spasm; traumatic arthritis subtalar joint and fracture medial malleoulus right ankle.

MRI showed degenerative changes with spinal stenosis at L4-5, posterior disc bulges at L3-4 and L4-5. EMG’s showed abnormal findings of partial denervation along S1 nerve root distribution and supported evidence of severe left S1 lumbar radiculopathy.

Key Evaluation Findings

• Limited lumbar flexion (to 40 degrees; reduced about 50%)
• Left leg radicular symptoms
• Very limited abilities to perform brief or light lifting / carrying tasks
     • Frequent lift and carry capacities of 5 pounds or less
     • Occasional lift capacities of 8-10 pounds, at floor to nuckle and waist to shoulder level
• Increased heart rate with brief exertion
• Avoidance of full weight bearing on the left side
• Walk tolerance of < 7 minutes
• Painful cervical motion, particularly for rotation and lateral bending
• Weak hand grip, bilaterally
• Consistency of effort on repeated hand gripping
• Reduced sit tolerance; frequent weight shifting while seated
• Increased back pain when sitting to perform repeated reaching or hand manipulation

Summary

Mr. Rivera has limited and painful lumbar flexion that is associated with radicular symptoms. Left ankle motion is painful and limited in all planes. Upper extremity motion and gross strength patterns are within functional limits. Mr. Rivera can use his hands for fine and medium manipulation, but is limited by standing tolerances of <10 minutes and sit tolerances of an hour or less.

During the Functional Capacity Evaluation, Mr. Rivera preferred to sit whenever possible. When sitting an hour, periodic weight shifting was noted and Mr. Rivera stood periodically to relieve pressure on the left buttock and leg, particularly after sitting 30 minutes. When standing, he avoided weight bearing on the left foot.

In summary, Mr. Rivera’s current lift tolerances are at less than a sedentary level (occasional lift/carry 10 pounds, frequent lift/carry < 5 pounds). Further, he lacks transferable job skills, has a limited education and very limited English communication skills.

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Mr. Rivera has very limited standing tolerances on his left leg because of radicular symptoms and lift/carry capacities of < 10 pounds.

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