1. Work Capacity Evaluation & Chronic Pain Work Restoration Experience
Presented by Samir Sharma, MD.
Orthopedic Surgeon
Board Certified Orthopedic Surgery & Sports Medicine; Qualified Medical Evaluator
Alliance Occupational Medicine
315 S. Abbott Ave. Milpitas, CA
2737 Walsh Ave. Santa Clara. CA
1901 Monterey Rd. Ste. 10 San Jose, CA
Copyright 2016 Alliance Occupational Medicine

2. Why Do We Need WCEs & Chronic Pain Work Restoration?
To separate pathology, muscle strength & endurance, pain behaviors, suffering reactions & motivational interferences
Are indispensible tools for identifying and correcting the “true” barriers to recovery
To prevent injured worker job loss, replacement worker costs, and to reduce settlement & impairment costs
Guessing at work capability is not an option; at the end of a claim accuracy is needed to minimize impairment costs
Chronic pain behavior is complex and poorly understood; it needs to be objectively separated from strength & endurance capabilities (the ability to do work)
They give us our best defensible position, particularly in a disability dispute, for returning injured workers back to work
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When To Use WCEs?
Lost Work Time > 30 Days / Modified Duty > 90 Days
Full Duty Not Reached In 6 Month From DOI / Surgery
Permanent Impairment Is Expected
Subjective Complaints Are Not Supported By Objective Findings
Patient Is Resistant To Progressing Work Status / Poor Patient Compliance With Treatment
When Emotional Reactions To Pain Delay Recovery
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Case # 1
Mr. IR; Age 53; Foreman - tree & utility service company; HEAVY job demand – lifting large chain saw (50+ lbs) over shoulder & heavy tree trunks (80 lbs) on “frequent” work basis
Dx: Right Bicep Tendon Rupture & Repair; Adhesive Capsulitis - DOI: 4/15/15 - SX: 6/16/15; referred for WCE due to limited ROM & shoulder weakness
WCE Results: MODERATE biomechanical work deficiencies; Severe muscle fatigue (poor endurance), muscle guarding, offloading of shoulder motions (harm avoidance reactions) & physio-behavioral pain responses (mixed pain & pathology reactions to motion)
Psychosocial: Had NO significant psychosocial issues but had poor pain-motion integration
Motivation: gave “excellent” effort during test & demonstrated no significant negative predictors of success causing delayed recovery
Recommendation: Chronic Pain Work Restoration (CPWR) program which was subsequently authorized
Copyright 2016 Alliance Occupational Medicine

5. Restoration Program Results 392% Strength & Endurance Gain
Case # 1 (cont)
Chronic Pain Work
Restoration Program Results
Completed ten (10) 4-Hr restoration sessions including aggressive mobilization exercises and full course of chronic pain coping skills training
Mobilization: Gross material handling – Avg. of 16,388 lbs per session / equal to 327 lifts of 50 lbs in 4-hours – over the shoulder); fully restored shoulder strength & endurance
Coping Skills: By end of program patient reported pain reduced by 50%; continued to have some harm avoidance behaviors but was actively confronting them & coping better with pain; returned to full duty work
CPWR – Progressive Performances
Gross Material Handling Loads: 8,280 – 32,438 Lbs
392% Strength & Endurance Gain
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Case # 2
Mr. MT; Age 49; Route sales rep - water company; MEDIUM (50 lbs) job demand – lifting, carrying and delivering 5 gallon water bottles; off work - employer unable to accommodate restrictions (10 lbs)
Dx: Left Meniscus Tear; Knee Sprain; Chondromalacia; Arthrofibrosis - DOI: 7/7/11 - SX: 8/8/14 (MUA); referred for WCE due to persistent stiffness, knee swelling & weakness
WCE Results: MILD biomechanical work deficiencies (lifting, carrying, kneeling & crouching)
Psychosocial: Moderate psychosocial issues noted; catastrophizing pain & functional inhibition reactions; using pain behaviors to avoid returning to work; reporting high pain levels (8+/10); unwilling to confront pain
Motivation: several poor work adjustment factors noted (unhappy with employer/supervisor; has litigated disability dispute; prolonged work absence – 1½ yrs; claim over 2 years old); pronounced negative predictors of success for work restoration
Recommendation: Poor candidate for Chronic Pain Work Restoration given permanent restrictions (40 lbs) based on WCE (MMI w/reduced impairment rating level)
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Case # 3
Mr. TD; Age 22; Inspection Tech - solar company; HEAVY (100 lbs) job demand – mounting equipment on roofs; lifting 100 lb tile boxes; off work – due to surgical repair of shoulder
Dx: Left Shoulder Impingement; Labrum Tear & Lesion - DOI: 11/12/14 - SX: 5/21/15; referred for WCE due to weakness of rotator cuff muscles, periscapular muscle pain & tenderness, had full range of motion
WCE Results: NO biomechanical work deficiencies
Psychosocial: SEVERE psychosocial issues; severely pain-focused – having some difficulty integrating pain & motion but had excellent pain-functional inhibition normalization; felt overwhelmed, hopeless & worn out
Motivation: functional disability mindedness (mixed primary & secondary gain motives); taking care of time-demanding alcoholic mother needing rehab; no social support other than girlfriend & best friend - both of whom were also dealing with alcoholic parents; disliked employer – too demanding; felt unfairly laid off; poor compliance with medication & HEP
Recommendation: Full duty capable; encouraged patient to talk to his personal physician to get help/counseling to improve social support systems & to get professional guidance in dealing with alcoholic parent; encouraged to look for a new job & re-engage in a normal productive lifestyle
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Case # 4
Mr. TL; Age 64; Cure Technician – satellite & spacecraft manufacturer ; HEAVY (75+ lbs) job demand – lifting & carrying beams; working on manufacturing line for satellite parts; working modified duty (30 lbs)
Dx: Left Rotator Cuff Repair; Adhesive Capsulitis - DOI: 3/21/14 - SX: 6/14/14; referred for WCE due shoulder stiffness & weakness, unable to progress modified duty restrictions, patient was significantly symptomatic, failed conservative treatment (medication, PT, HEP)
WCE Results: MODERATE biomechanical work deficiencies (lifting – above & below shoulder & carrying); safe at 50 lbs; had marked accelerated fatigue (accelerated 8-hour workday fatigue), ancillary muscle recruitment & transient disruptions in mobility occur when trying to work over 50 lbs below the shoulder, and 25 lbs over the shoulder, indicating biomechanical breakdown was approaching
Psychosocial: SEVERE psychosocial issues due to pain-related fear reactions causing loss of confidence in strength capabilities
Motivation: gave “excellent” effort during test
Recommendation: Chronic Pain Work Restoration (CPWR) program which was subsequently authorized
Copyright 2016 Alliance Occupational Medicine

9. Restoration Program Results 369% Strength & Endurance Gain
Case # 4 (cont)
Chronic Pain Work
Restoration Program Results
Completed ten (10) 2-hr restoration sessions including aggressive mobilization exercises and full course of chronic pain coping skills training
Session time was adjusted to allow him to remain at work doing modified duty simultaneously
Mobilization: Gross material handling – Avg. of 8,440 lbs per session / equal to 281 lifts of 30 lbs in 2-hours – over the shoulder); fully restored shoulder strength & endurance
Coping Skills: By end of program patient reported pain reduced by 75%; regained confidence in being able to do full duty work; released to full duty
CPWR – Progressive Performances
Gross Material Handling Loads: 3,660 – 13,500 Lbs
369% Strength & Endurance Gain
Copyright 2016 Alliance Occupational Medicine

10. SUMMARY Chronic Pain Cases Are Messy & Difficult To Manage!
Pain Reactions, Suffering Overlays & Motivational Interferences Need To Be Separated From Strength & Endurance So Delayed Recovery Issues Can Be Properly Addressed!
The Outcomes Speak For Themselves…
Case #1: Full Duty w/ Chronic Pain Work Restoration
Case #2: MMI w/ Objective Reduced Impairment Levels
Case #3: Full Duty – WCE Exam Only
Case #4: Full Duty w/ Chronic Pain Work Restoration
No Other Tools Do So Much!
Without These Tools All Of These Cases Would Have Been Lost!
Copyright 2016 Alliance Occupational Medicine

11. Questions? Thank You Samir Sharma M.D. Phone: (408) 228-8400
Alliance Occupational Medicine
2737 Walsh Ave. Santa Clara, CA
315 S. Abbott Ave. Milpitas, CA
1901 Monterey Rd. Ste 10 San Jose, CA
Copyright 2016 Alliance Occupational Medicine