Part One: Essential Function Based on Ability and Agility
The first part of the examination, whether it is used for employment screening or postinjury screening, is the functional capacity/agility test.
Part Two: Functional and Physical Industrial Examination
The second part of the examination focuses on standard baseline physical findings, i.e., heart, lungs, vision, hearing, etc.
The crucial part of this examination is in the application of the orthopedic/neurological testing to establish a baseline of musculoskeletal information.
History of Musculoskeletal Injuries, Disorders, and Conditions
The history is a crucial part of determining the status of an individual. Make sure that the questions are specific and detailed so as not to miss any possible problem that will affect the future of the individual's health as relating to the job task required by the workplace.
Prior to giving the history in the doctors office, the physical exam of vision is tested, to include the correct reading of two questions from the "History of Musculoskeletal Form" by the individual. The same questions are used for everyone and there should be a place on the vision records where this is noted.
If the individuals can read the two questions properly, they certainly could read the rest of the history, and would be unable to say at a later date that they couldn't read or understand the questions. In those states that allow registering of pre-conditions, it has an obvious benefit: If the person neglects to tell of any injury or disorder and proves to have a problem, this information may be helpful in dealing with that situation.
If done correctly, the history will allow a measurement of the status that the individual presents at the time of beginning work.
The completed history is reviewed by a member of the doctor's staff and any prior or current problem is highlighted by that individual so that the doctor may specifically question (and document) that individual's response. If there is a problem detected in the examination, the individual must be questioned in the area of the history form as well, with notation as to what was said. This is time-consuming but crucial, and is done by the doctor's staff in a quiet place, not in the middle of a busy waiting room where an individual may claim to have been distracted.
Predisposing Radiological Factors
There are a number of factors that require the use of x-rays. The standard views that should be taken are:
Cervical series -- lateral and anterior-posterior views
Lumbar series -- lateral and a/p views to include L5/S1 disc level up to T12/L1 disc space
There are specific factors to be screened: disc degeneration, spondylosis (arthritic changes), or cervical transverse enlargement (that would restrict blood flow and nerves that pass through the area).
It may be seen there was a prior whiplash of the neck, for example, that could be related and brought up in the history. If the individual had treatment for this, the DC could get the records which would detail the permanency and prognosis, both very helpful if future contest develops concerning injury and employment.
In the low back there are 34 factors to be checked, that will be predictors and provide baseline. To only classify back I, II, III, IV is not sufficient, the functional factors must be checked.
Orthopedic Testing
Active and passive ranges of motion must be checked in all of the joints and muscle ligament/tendon structures (active range), and the integrity of the joint capsules and structures (passive range).
There are also specific tests to check for the functional status of blood flow and any structure particularly stressed by the job demands. There are more tests needed listed on the form and the DC should check those necessary based on biomechanical analysis of jobs. Anything that can be done to make the testing more specific and related to job function, the better.
The functional testing of the integrity of the joints is important. If a patient said everything was fine on the history, but during the assessment of the knees was very apprehensive about the joint movement of the right knee, which was restricted in several planes of motion, there is something that needs to be questioned. A little more investigation for documentation, another x-ray etc., will provide a base to compare and limit the liability.
To check active and passive ranges does not take that long, and can be done very effectively as well as time efficiently, even if the doctor may initially say this is too much, it is a learned sequence.
Neurological Testing
The testing by Semmes-Weinstein is an acceptable and accurate method to determine the neurological "map" of the individual's hand sensation. There are some doctors who promote EMGs instead, but these tests are expensive and painful to the employee. If there is an altered pattern of a dermatome (the specific surface pattern of the nerve that supplies it), it can be related to the corresponding nerve, the area that the nerve originates and the factor that is causing it.
An employee is much more apt to be truthful when confronted at this point than at a later date complaining of a compensable injury. Again, these disorders are detectable and can be related anatomically and to a reasonably accurate time of occurrence, which is then documented, and records obtained.
Examining Doctor's Skills
These skills can be taught, and if DCs do not know these techniques, they should.
The quality and direction of this examination needs to be specific for those conditions likely to occur because of the job demand. If the baseline is not established at the beginning, the work facility will pay for it at a later date with loss of control to limit the liability at time of injury.
If a quality examination is done, an employee's attorney will have to work hard to get a small or limited impairment, or to establish liability. By establishing this type of reputation, litigation will be minimized.
If the employee is injured, the employee is entitled to proper compensation. I believe the workplace would want to compensate the employee, and will feel better about doing so if it is evident that they are "paying for" their responsiblity.
Theodore Oslay, DC
Oregon, Illinois
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