Re:                     John Doe
Claim Number:  555555-22
D.O.I.:               05-13-2000
Allowances:      847.2-SPRAIN/STRAIN
                          722.10- HERNIATED DISC NUCLEUS PULPOSUS
                          724.02-SPINAL STENOSIS L4-L5
                          722.52- DEGENERATIVE DISC DISEASE
Employer:         BUCKEYE STEEL
Date of Birth:    4/07/1975
Social Security #:  123-45-6789

The following is in regards to your client, John Doe, who presented to our office on January 6, 2009, for examination in regards to the above-mentioned industrial related incident in reference to percentage of Whole Person Permanent Partial Impairment, utilizing AMA Guides, 5^th Edition.

John Doe presented with ongoing complaints of low back pain.  He states that these complaints have been present since being involved in an industrial related accident that occurred on the above-mentioned date.  He described the mechanism of the injury as when he was carrying a barrel of grease approximately 40 pounds up a long flight of steel stairs.   He reported slipping on pneumatic oil and falling backwards about 20 feet.  The first doctor he saw after the accident prescribed Tylenol and performed an ultrasound.  The next doctor Mr. Doe saw prescribed medication, an MRI, CT Scan, and x-rays.

John Doe explained that he no longer works for the above-mentioned employer.  Mr. Doe states that the pain is constant.  He describes the pain as a sharp, dull, tingling, throbbing, numbness, stiffness, aching, and shooting sensation.  The patient states that he has limited mobility of his low back pain.  He states that this injury interferes with his work, sleep, daily routine, and recreation.  With limited use of his low back, it is difficult or impossible for him to perform the following activities:  climbing stairs, doing laundry, doing dishes, running sweeper, cutting lawn, shoveling snow, raking leaves, gardening, driving a car, sitting too long, playing sports, playing with kids, lifting weights, exercising, running, swimming, water skiing, jogging, sleeping, standing, fishing, hiking, shopping with spouse, and grocery shopping.

All of the above mentioned complications fall under the chronic pain category where up to 3% impairment is given/added to this claim based on the ongoing burden of illness disrupting activities of daily living.  John is given 3% WPI today.  Reference AMA guides, 5^th edition, Chapter 18, Tables 18-1, 18-3, 18-4, 18-5, 18-6 and page 584 item 5b.

Deep tendon reflexes were +2 and symmetrical of the patella and Achilles. Bechterews test was positive.  Ely’s, Nachlas, and Hibbs test were positive.  Straight leg raise test was positive at 30 degrees.  Milgrams test was positive.  Kemps test was positive. Hypertonicity was palpated in the lumbar erector spinae muscles and quadratus lumborum bilaterally.  Motion palpation revealed fixations during flexion at L3, L4, and L5; during extension at L4 and L5; during right and left lateral bending at L4 and L5.  Postural analysis revealed an elevated hip on the right indicative of asymmetrical muscle tone in the gluteus medius and quadratus lumborum muscles. 

Total whole person impairment = 20% WPI, based on  AMA Guides, 5^th Edition, Chapter 15, Table 15-8, page 407 and Table 15-9, page 409.

Criteria for rating whole person impairment

Section II.  Intervertebral disc or other soft tissue lesion; L5/S1 herniated nucleus pulposus. Item E:  Surgically treated disc lesion with residual, medically documented pain and rigidity.  10% WPI

Section IV.  Spinal stenosis, segmental instability, spondylolisthesis, fracture, or dislocation, operated on.  Item B: Single-level without spinal fusion with residual signs and symptoms. Spinal stenosis at L4/L5: (No additional impairment allowed from this table).

Sensory Testing:  Patient was unable to discern between two sharp point of contact at a distance of 40 mm (<5mm is normal) over the back of the left and right legs and down into all of his toes (L4, L5 and S1 dermatomes bilaterally).  Reference AMA Guides, Chapter 15, page 424, Table 15-18, this equates to a 11% WPI.

36% WPI plus 3% WPI (Pain/ADL’s) = 39% WPI.

Mr. Does also suffers from a psychological condition related to this injury.  However, the examination that was performed on this day was strictly a musculoskeletal examination and his impairment was calculated based only on these finding.  Therefore, the following impairment rating has been given to Mr. Doe after a thorough history, orthopedics, neurological, muscle testing, and range of motion examinations were performed on January 6^th, 2009:  It is my professional opinion that Mr. Doe has sustained a 39% Whole Person Impairment.

This impairment rating falls into the Range of Motion category, November 2000, 5^th Edition AMA Guides to the Evaluation of Permanent Impairment.

Dr. Larry Van Such, D.C., B.E.
Chiropractic Physician