• Rotator Cuff Tears
  • Rotator Cuff Tears: Surgical Treatment Options
  • SLAP Tears
  • Common Shoulder Injuries
  • Frozen Shoulder
  • Shoulder Arthroscopy
  • Biceps Tear at the Elbow
  • Elbow Fractures
  • How to use Crutches, Canes, and Walkers
  • Hip Arthroscopy
  • Anterior Cruciate Ligament (ACL) Injuries
  • Knee Arthroscopy
  • Total Knee Replacement

If you are injured at work, it is important to determine your functional capacity. If your Work Comp injury has resulted in a decrease in your ability to work, lift, carry, the most effective way to document the injury,and its effect on you, is a FUNCTIONAL CAPACITY EVALUATION. FOR AN APPOINTMENT,

The Labor Code defines medical necessity as that which is “reasonable required to cure or relieve from the effects of industrial injuries”. Treatment must also be consistent with published petitioner’s peer group. Presently, Senate Bill 228 amends the Labor Code §4604.5 to provide a presumption of correctness to the utilization guidelines of the American College of Occupational and Environmental Medicine (ACOEM).

The patient’s diagnosis is consistent with our objective findings, subjective complaints, symptomatology and the etiological factors of this case. The requested treatment for a functional capacity evaluation (FCE) is medically necessary and appropriate in relation to the industrial injury consistent with the American College of Occupational and Environmental Medicine (ACOEM) guidelines (2nd Ed., 2004) FCE results will also assist in translating medical impairment into functional limitations, and determine work capability (c.f. ACOEM 2004 OMPG: Chapter 1, page 12).

The following excerpts are taken from ACOEM Guidelines4 (additional formatting has been added for emphasis):

Chapter 7, Independent Medical Examinations and Consultations:
“The examiner is responsible for determining whether the impairment results in functional limitations and to inform the examinee and the employer about the examinee’s abilities and limitations. The employer or claims administrator may request functional ability evaluations, also known as Functional Capacity Evaluations, to further assess current work capability. These assessments also may be ordered by the treating or evaluating physician, if the physician feels information from such testing is crucial. …Functional capacity evaluations may establish physical abilities and also facilitate the examinee/employer relationship for return to work. However, FCE’s can be deliberately simplified evaluations based upon multiple assumptions and subjective factors, which are not always apparent to the requesting physician.”
Note: Chapter 7 goes on to say that “there is little scientific evidence confirming that FCE’s predict individual’s actual capacity to perform in the workplace;” which is precisely why we perform the EPIC1,2,3 Lift Capacity test (Employment Potential Improvement Corp., Santa Ana, CA).

Chapter 5, Cornerstone of Disability Prevention and Management, pages 75-103, states on page 81 (Step 4 of Formulating and Communicating a Work Prescription to the Employer/Insurer):
“It may be necessary to obtain a more precise delineation of patient capabilities than is available from routine physical examination. Under some circumstances, this can best be done by ordering a functional capacity evaluation of the patient.
“Whatever the basis of work capabilities or restrictions, it is necessary for physicians to state their source of information. In particular, avoid relying solely on the patient or the employer for input; instead, seek objective information or third-party corroboration, especially when controversy exists. This is particularly true when a patient may be asked to do work that may exceed his or her limitations and lead to further injury or create a hazard.”

Chapter 5, page 89, Managing Delayed Recovery, section A. Reassessing Function and Functional Recovery:
“The first step in managing delayed recovery is to document the patient’s current state of functional ability, including Activities of Daily Living (ADL) and the recovery trajectory to date as a time line. As starting point for this assessment, obtain a complete history from the patient and other objective observers, including the employer and the on-site occupational health professional with regard to the abilities or effectiveness at work. Goals for functional recovery can then be framed with a reference to this baseline. A number of functional assessment tools are available, including functional capacity exams and videotapes.”

As cited in the article by Jay, Marc A, et al.1: “Through use of standardized indicators of sincere effort, certified EPIC lift test evaluators were able to predict sincerity of effort with a high degree of reliability and validity. The rater’s systematic observational evaluation of effort was shown to be the single best indicator of sincere effort.” Another article by LN Matheson, et al. 2 concluded that “the safety and reliability of the EPIC Lift Capacity test was adequately demonstrated in a laboratory setting and across multiple field sites with evaluators who have varying types and degrees of professional preparation”. In “Part 2…” 3 it was found that “reactivity of the EPIC Lift Capacity test was negligible over an 8-week treatment regimen that did not include lifting tasks.”

It is also important to note that specific factors present in the patient or the patient’s case may have a significant influence on the patient’s recovery from industrial injury. Many factors are mentioned in Chapter 5 of ACOEM guidelines 4 as well as in evidence-based medicine. For example, LN Matheson, et al.6, compare aerobic fitness and back strength in relation to lift capacity. In short we wish to assure that all pertinent factors involved in our patients’ cure and relief are considered, both in our evaluation and treatment plan design.

ODG Guidelines also discusses the effectiveness (and cautions/limitations) of FCE’s. In the “Fitness for Duty” chapter, ODG states: “Functional capacity evaluation (FCE), as an objective resource for disability managers, is an invaluable tool in the return to work process. (Lyth, 2001).” Careful inspection of our FCE protocols shall prove that we have made all the necessary accommodations for the cautions and limitations addressed in these guidelines.

The goal of this FCE is to assess current work capability. Objective measurements, including visual analog scale (VAS), and pain drawing will be used to assess current status. This test will help provide indication of the individual’s ability to perform certain job tasks and return to work status. As previously noted, lifting, pushing, pulling, standing, carrying and other objective data will help translate medical impairment into functional limitations and determine work capabilities (required data for DWC Forms PR-4).

At NMCI, we have experienced Physiatrists and PM&R specialists available to perform EMG/NCV testing.

An electromyogram (EMG) measures the electrical activity of muscles when they’re at rest and when they’re being used. Nerve conduction studies measure how well and how fast the nerves can send electrical signals.

Nerves control the muscles in the body with electrical signals called impulses. These impulses make the muscles react in certain ways. Nerve and muscle problems cause the muscles to react in ways that aren’t normal.

If you have leg pain or numbness, you may have these tests to find out which nerves are being affected and how much they are affected. These tests check how well your spinal nerves are working. They also check the nerves in your arms and legs.


EMG: Recommended as an option (needle, not surface). EMGs (electromyography) may be useful to obtain unequivocal evidence of radiculopathy, after 1-month conservative therapy, but EMG’s are not necessary if radiculopathy is already clinically obvious.

EMG’s may be required by the AMA Guides for an impairment rating of radiculopathy.


When there’s failure to progress in a strengthening program attended to avoid surgery. Special studies are not needed unless a four-week program of conservative care and observation fails to improve symptoms. EMG/NCV study if cervical radiculopathy is suspected as a cause of lateral arm pain.

For possible Carpal Tunnel:

Recommended in patients with clinical signs of CTS who may be candidates for surgery. Appropriate electrodiagnostic studies (EDS) include nerve conduction studies (NCS). Carpal tunnel syndrome must be proved by positive findings on clinical examination and should be supported by nerve conduction tests before surgery is undertaken. Mild CTS with normal electrodiagnostic studies (EDS) exists, but moderate or severe CTS with normal EDS is very rare. Positive EDS in asymptomatic individuals is not CTS. There is minimal justification for performing nerve conduction studies when a patient is presumed to have symptoms on the basis of radiculopathy.

An EMG/NCV is done to:

  • Find problems that damage muscle tissue, nerves, or the spots where nerves and muscles join. These problems may include a
  • Find the cause of weakness, paralysis, or muscle twitching. Problems in a muscle or the nerves going to a muscle can cause these symptoms. So can problems in the spinal cord or the area of the brain that controls a muscle. The EMG does not show brain or spinal cord diseases.:
  • Find damage to the peripheral nervous system. This includes all the nerves that lead away from the brain and spinal cord. It also includes the smaller nerves that branch out from those nerves.

Physical therapists are evidence-based health care professionals who offer effective treatment to improve mobility and relieves pain. Physical Therapy may reduce the need for surgery, and allows individualized treatment plans designed for each patient.

Improving Motion And Mobility
Physical therapists
can teach patients how to prevent and manage their condition for long-term health benefits. PTs examine each individual and develop a personalized plan, using treatment techniques to promote Range Of Motion, reduce pain, restore function, and prevent disability.

Physical therapists address the injured patient and assesses their limitations, pain levels, ROM, strength and flexibility. Based on these evaluations, a treatment plan is made and each patient begins their path to the restoration of health.

Physical Therapists can utilize a variety of treatment techniques, massage, ultrasound, electrical muscle stimulation, traction, heat and/or cold therapy to relieve pain, exercise to strengthen muscles, improve coordination, balance and endurance, provide a HEP, home exercise program, and instruction on injury prevention.

Types of Conditions Physical Therapists Treat:

  • Arthritis Pain
  • Back and Neck Pain
  • Dizziness and balance deficits
  • Acute, Subacute and Chronic conditions
  • Knee, Hip, and Ankle dysfunction and pain
  • Shoulder, elbow, and wrist/hand dysfunction and pain
  • Repetitive Stress Injuries
  • Pre and Post-Surgical Conditions
  • Sports Injuries

At NMCI, our Chiropractors provide treatment that helps relieve pain suffered from an injury, muscle spasm, accident, and/or trauma . Our Doctors of Chiropractic are skilled in low force, instrumentation, and/or manual osseous adjustments of the spine and extremities.

When you visit a Doctor of Chiropractic, you will receive a consultation, case history, physical examination, and X-ray examination when appropriate. In addition, you will receive a careful chiropractic structural examination, with particular attention paid to the spine.

The intention of a chiropractic adjustment is to affect or correct the alignment, motion and/or function of a vertebral joint. Specifically, they are intended to correct vertebral subluxations.

Since we have a multidisciplinary team at NMCI, our Chiropractors can refer patients for a full complement of medical treatment as well.

Low Back Pain and Neck Pain

In a study published in the British Medical Journal 2003, the clinical outcome measures showed that chiropractic adjustments resulted in faster recovery than physiotherapy and general practitioner care. Moreover, total costs of the chiropractic-treated patients were about one-third of the costs of physiotherapy or general practitioner care.


Chiropractors can also help patients with the symptoms of Cervicogenic headaches. A Chiropractor can help patients find relief and reduce muscle spasm from basic Chiropractic adjustments. Second only to back pain, headaches are one of the most common conditions regularly managed by Chiropractors.

Chiropractic treatment for work injuries is supported in the ACOEM, ODG, and MTUS GUIDELINES:

They Recommend Chiropractic Treatment as follows, “a trial of 6 visits, and then 12 more visits (for a total of 18) based on the results of the trial, except that the Delphi recommendations in effect incorporate two trials, with a total of up to 12 trial visits with a re-evaluation in the middle, before also continuing up to 12 more visits (for a total of up to 24).”

At NMCI, our Acupuncturists have years of experience in providing treatment that relieves pain from injuries to the spine, extremities.

Acupuncture is the practice of placing very thin needles through the skin in specific locations of the body for the purpose of healing and relief of symptoms. This practice is several thousand years old and is part of Traditional Chinese Medicine. As practiced today it is often combined with other interventions, such as sending a small current of electricity through the needles or burning herbs on the acupuncture points.

Acupuncture is based upon the Eastern philosophy of chi (also spelled qi), which is the Chinese term for the life force or vital energy. In Traditional Chinese Medicine (TCM) chi flows through pathways in the body known as meridians. Illness results from the flow of chi through the meridians being blocked, or by the two types of chi (yin and yang) being out of balance. Acupuncture is the practice of placing thin needles at acupuncture points, which are said to coincide with points at which meridians cross, to improve the flow and restore the balance of chi.

These treatments are done in accordance with the MTUS GUIDELINES, and are only prescribed for our patients that will benefit from this type of treatment.

§ 9792.24.1. Acupuncture Medical Treatment Guidelines.

(a) As used in this section, the following definitions apply:

(1) “Acupuncture” is used as an option when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten functional recovery. It is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated, and retained for a period of time. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range of motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.

(2) “Acupuncture with electrical stimulation” is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation. It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites.

(3) “Chronic pain for purposes of acupuncture” means chronic pain as defined in section 9792.20(c).

(b) Application

(1) These guidelines apply to acupuncture or acupuncture with electrical stimulation when referenced in the clinical topic medical treatment guidelines in the series of sections commencing with 9792.23.1 et seq., or in the chronic pain medical treatment guidelines contained in section 9792.24.2.

(c) Frequency and duration of acupuncture or acupuncture with electrical stimulation may be performed as follows:

(1) Time to produce functional improvement: 3 to 6 treatments.

(2) Frequency: 1 to 3 times per week

(3) Optimum duration: 1 to 2 months

(d) Acupuncture treatments may be extended if functional improvement is documented as defined in Section 9792.20(e).

(e) It is beyond the scope of the Acupuncture Medical Treatment Guidelines to state the precautions, limitations, contraindications or adverse events resulting from acupuncture or acupuncture with electrical stimulations. These decisions are left up to the acupuncturist.

Note: Authority cited: Sections 133, 4603.5, 5307.3 and 5307.27, Labor Code. Reference: Sections 77.5, 4600, 4604.5 and 5307.27, Labor Code.