Functional Capacity Report

Patient Information

• Marcus Vance
• 14/08/1979
• Male
• 42 Stirling Hwy, Nedlands WA 6009 | 0412 345 678

Assessment Date

• 24/05/2024

Referring Physician

• Dr. Sarah Jenkins
• Swan River Medical Centre, 120 Broadway, Crawley WA 6009 | (08) 9386 1234

Medical History

• Chronic LBP secondary to L4/L5 disc prolapse (injured at work 12/01/2024), HTN, T2DM.
• L4/L5 microdiscectomy (15/02/2024).
• pregabalin (Lyrica®) 75 mg PO BID, celecoxib (Celebrex®) 200 mg PO OD, metformin 1,000 mg PO BID, perindopril 5 mg PO OD.
• Penicillin (rash).

Functional Assessment

• Independent with light self-care and short-duration domestic tasks. Bilateral floor-to-waist lift max 7.5 kg; waist-to-shoulder lift max 5 kg.
• Difficulty donning socks/shoes due to lumbar flexion restriction. Unable to perform heavy domestic duties (vacuuming, lawn mowing).
• Pre-injury role: Warehouse Storeman. Currently unfit for pre-injury duties. Unable to perform repetitive bending, twisting, or manual handling > 7.5 kg.
• Sitting tolerance: 30 mins. Standing tolerance: 20 mins. Walking tolerance: 15 mins (approx. 800 m) on flat ground before onset of R L5 radicular pain.
• Alert and oriented x3. Mildly anxious regarding RTW and financial stressors; K10 score 18 (moderate distress).

Objective Findings

• Lumbar AROM: Flexion 50% (reproduces LBP), Extension 25%, Lateral flexion L/R 75%. SLR positive on R at 45 degrees. L5 myotome (EHL) 4/5 on R; L4-S1 sensation intact bilaterally. Antalgic gait after 10 mins of ambulation.
• MRI Lumbar Spine (20/01/2024): Moderate R paracentral disc extrusion at L4/L5 contacting the traversing R L5 nerve root.

Recommendations

• 8-week work hardening and gym-based functional restoration program, 2x/week, focusing on core stability and graded lifting mechanics.
• Suitable for sedentary to light alternate duties, 4 hours/day, 3 days/week. Restrictions: No lifting > 7.5 kg, avoid repetitive lumbar flexion/rotation, ability to alternate sitting and standing every 20–30 mins.
• Good prognosis for graduated RTW to modified duties; guarded for full pre-injury heavy manual handling within the next 3 months.

Clinician's Signature

• Liam O'Connor
• Senior Physiotherapist
• 25/05/2024