AADEPAMA Guides 5th Edition

Upper ExtremityUpper Extremity Rating Methodology

Paul S. Darby MD PhD MPH FACOEM with thanks toDouglas W Martin MD FAADEP FACOEM FAAFP

Upper Extremity: Sections

• 16.2 Amputation• 16 3 Sensory Loss (digital nerve)16.3 Sensory Loss (digital nerve)• 16.4 Range of Motion

16 5 P i h l N Di d• 16.5 Peripheral Nerve Disorders• 16.6 Vascular Disorders• 16.7 Other Disorders• 16 8 Strength16.8 Strength

Conversion

• Many impairments are stated as “Digit”.• Table 16-1 converts “Digit” to “Hand”.g• Table 16-2 converts “Hand” to “Upper Extremity”.

(Same as multiplying by 0.9)( p y g y )• Table 16-3 converts “Upper Extremity” to “Whole

Person” (Same as multiplying by 0.6)( p y g y )• Figures 16-1a & b are worksheet to guide the

evaluator through all steps, including conversion.g p , g

Thumb portion of figure 16-1

Table 16-1

Testing two point DiscriminationTesting two point Discrimination

TwoTwo--Point Point ImpairmentImpairmentDiscriminationDiscrimination of Nerveof Nerve6 mm. or less6 mm. or less 0%0%7 mm. to 15 mm.7 mm. to 15 mm. 50%50%more than 15 mm. more than 15 mm. 100%100%

Grade Description %

Table 16-10

pmultiplier

5 No loss of sensibility, abnormal sensation, or pain 04 Decreased light touch, sensations or pain forgotten

during activity1 – 25

3 Decreased light touch and 2 PD some abnormal 26 603 Decreased light touch and 2 PD, some abnormal sensations or slight pain, interferes with some Activities

26 – 60

2 Decreased Protective Sensation, abnormal sensation or moderate pain, prevents some activities

61 – 80

activities

1 No protective sensibility, abnormal sensations or severe pain prevents most activity

81 – 99

0 No sensibility, abnormal sensation or severe painprevents all activity

100

Measuring ROM & ImpairmentMeasuring ROM & Impairment• Each joint has Figures to show how to position and j g p

measure.• Each joint has Figures to permit estimation of

impairment for loss of motion, and in every direction of normal joint motion.

• “Pie Charts”: V = Measurement in degreesIF = Impairment for flexionI I i t f t iIE = Impairment for extensionIA = Impairment for Ankyolsis

Finger ROM

• Similar to thumb IP and MCP.• Finger DIP, PIP, & MCP only move in g , , y

flexion and extension.• Bone or joint injury, measure with proximal j j y, p

joints in extension.• If tendon injury with adhesions, may j y , y

measure in full simultaneous flexion and full simultaneous extension.

Figure 16-22, p.463

Measuring PIPMeasuring PIP with MCP @ fullMCP @ full Extension.Traditional way ofTraditional way ofMeasurement.

Elbow ROM MeasurementO

Shoulder ROM Measurement

16.5: Peripheral Nerve Disorders

• Rate: Loss of Sensation and Motor Weakness.Combine these.

• Active ROM loss secondary to nerve injury y j yis already in the rating.

• If Loss of ROM is due to separate problem p p(joint fracture, or CRPS), then it is rated and combined.

Peripheral Nerve Injury Impairment Rating Steps

1 What nerve is involved?1. What nerve is involved?2. What is the maximum potential value of that nerve for

loss of sensation and pain?loss of sensation and pain?3. What sensory severity multiplier is appropriate?4. Multiply “value” times “severity”.p y y5. What is the maximal potential value of that nerve for

weakness (motor loss)?6. What weakness multiplier is appropriate?7. Multiply the “value” times the “severity”.8. Combine the motor rating with the sensory rating.

Grade Description %

Table 16-10

pmultiplier

5 No loss of sensibility, abnormal sensation, or pain 04 Decreased light touch, sensations or pain forgotten

during activity1 – 25

3 Decreased light touch and 2 PD some abnormal 26 603 Decreased light touch and 2 PD, some abnormal sensations or slight pain, interferes with some activities

26 – 60

2 Decreased protective sensation, abnormal sensation or moderate pain, prevents some activities

61 – 80

1 No protective sensibility, abnormal sensations or severe pain prevents most activity

81 – 99

0 No sensibility, abnormal sensation or severe painprevents all activity

100

Huge Problem with Table 16-10Huge Problem with Table 16 10

A d l i b i f• Assumes good correlation between severity of sensory loss and severity of pain.

Grade 3: decreased light touch slight pain interferes withGrade 3: decreased light touch, slight pain, interferes with some activities

Grade 2: decreased protective sensation, moderate pain, P i i iPrevents some activities

Grade 1: no protective sensation, severe pain, prevents most activities.

• What if there is decreased protective sensation, yet minimal pain, and normal ADLs ?

• What if there is a normal sensory exam, yet severe pain? (No Clear Guidance)

Table 16-11: Motor DeficitTable 16 11: Motor Deficit

G d D i ti %Grade Description % Multiplier

5 Normal 05 Normal 0

4 Full ROM against gravity plus resistance 1 – 25

3 Full ROM against gravity, but not with any resistance

26 – 50

2 Motion when gravity is eliminated 51 – 751 Slight contraction, NO movement 76 – 99

0 No Contraction 100

Carpal Tunnel

SyndromeSyndrome

Nerve EntrapmentEntrapment

16.5d

Entrapment Instructions p 493Entrapment Instructions p. 493• “Only individuals with an objectively verifiable y j y f

diagnosis should qualify for a permanent impairment rating. The diagnosis is made not only on the basis of believable symptoms but, more important, on the presence of positive clinical findings and loss of function The diagnosis shouldfindings and loss of function. The diagnosis should be documented by electromyography as well as sensory and motor nerve conduction studies.”sensory and motor nerve conduction studies.

Translation

• Very Mild CTS or other entrapment that causes “believable symptoms”, but normal y p ,physical exam of strength and sensation, with normal EDx, DOES NOT QUALIFY , Qfor an impairment rating.

• Pg 494 “In compression neuropathiesPg.494 In compression neuropathies, additional impairment values are NOT given for decreased grip strength ”given for decreased grip strength.

Nerve Entrapment: EMG testsNerve Entrapment: EMG tests• “…5 % of individuals with CTS may have normal y

electrophysiologic studies.” p. 495• “The severity of conduction slowing has no

correlation with the severity of clinical symptoms, such as weakness or static large-fiber sensory loss. If h b i l f i hthese are present, substantial amounts of either

conduction block, axon loss, or a combination of both must be present ” p 493must be present. p. 493

p. 493 Translation

• Can have Very Mild CTS (or other entrapment) with normal exam, ( p ) ,and either normal or abnormal Electrodiagnostics (EDx).g ( )

• BUT, if Either weakness or abnormal sensation is present EDx will be abnormal -sensation is present, EDx will be abnormalwill detect the entrapment.

Carpal Tunnel SyndromeInstructions p. 493

• Tinel’s sign not useful. Reserved for following post operative status of repair/decompressionpost-operative status of repair/decompression.

• Exam: May have normal 2 point discrimination, b t d d li ht t h dbut decreased light touch-deep pressure recognition,

H S W i t i fil tHence Semmes-Weinstein monofilamenttesting can be indicated.

Semmes-Weinstein MonofilamentsSemmes Weinstein Monofilaments

Nerve Entrapment 5th EditionNerve Entrapment 5th Edition

• “If after an optimal recovery time following surgical decompression* an individual continues g pto complain of pain, paresthesias, and/or difficulties in performing certain activities, three possible scenarios can be present.”

* Authors are hand surgeons and forgot that not all CTS patients choose surgery.

Carpal Tunnel SyndromeCarpal Tunnel Syndromep yp y(Patient remains symptomatic at MMI)(Patient remains symptomatic at MMI)

Ph i l fi diPh i l fi di % i i% i iPhysical findingsPhysical findings % impairment% impairmentUpper extremityUpper extremity

N l ti d iti t thN l ti d iti t th %%Normal sensation and opposition strength Normal sensation and opposition strength with normal with normal EdxEdx

0%0%

Normal sensation and opposition strength Normal sensation and opposition strength with abnormalwith abnormal EDxEDx (NCV and/or EMG)(NCV and/or EMG)

NTE 5%NTE 5%with abnormal with abnormal EDxEDx (NCV and/or EMG)(NCV and/or EMG)

Positive clinical findings of median nervePositive clinical findings of median nerve Rate same as anyRate same as anyPositive clinical findings of median nerve Positive clinical findings of median nerve dysfunction and abnormal dysfunction and abnormal EDxEDx

Rate same as any Rate same as any other nerve lesionother nerve lesion

16.7 b: Arthroplasty• With or Without Joint Replacement.• Can rate and combine impairment for loss of p

ROM.• Can NOT rate with instability, subluxation, or y, ,

dislocation. • A severe symptomatic failure of an implant y p p

procedure (eg, symptomatic breakage or subluxation of the device) is given 100 % of the joint value listed in Table 16-18.

• %s changed, Implant no longer “automatically worth more” than resection arthroplasty.

16.7 d: Tendinitis (p. 507)

• Several upper extremity syndromes are attributed to tendinitis, fascitis, or epicondylitis.Alth h b i t t N t i t• Although…may be persistent.. Not given a permanent impairment rating unless there is some other factor that must be considered.

• Tendon rupture, surgical release of flexor or extensor origins, or has excision of an epicondyle, there may be

k f i l f hsome permanent weakness of grip as a result of the rupture or surgery. Rate grip strength, probably when > 1 year from rupture or surgery.1 year from rupture or surgery.

16.8 Strength Evaluation

• “Many subjective or non-measurable factors, including fatigue, handedness, time of day, age, nutritional state, pain, and the individual’s cooperation further influence strength measurements.”

• “It should be noted that the correlation of strength with performance of activities of daily living is poor…”