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AMA Guides 5th Ed. Case Studies SyllabusMohammed I Ranavaya MD, MS, FRCP, FFOM

1© 2011 Format only ACDM Inc.

American Board of Independent Medical ExaminersAnd

American College of Dis/Ability MedicinePRESENTS

AMA Guides 5th Ed. Training Program

Format © 2007 Mohammed I. Ranavaya, M.D., M.S.

Introduction

This Teaching program was created

by Prof. Ranavaya MD,JD, MS, FRCP, forAmerican College of Dis/Ability Medicineto teach physicians and others how touse the Guides to the Evaluation ofPermanent Impairment, 5th ed. publishedby the American Medical Association.

It is essential to have theAMA Guides to theEvaluation of PermanentImpairment 5th ed for thebest learning experiencefrom this program



Mohammed I. Ranavaya, MD, JD, MS, FRCPI, FFOM, CIME

Professor, Marshall Univ. School of Medicine

WEST VIRGINIA

Appalachian Institute of Occupational and Environmental Medicine100 Constitutional Avenue, Chapmanville, WV 25508. USA

PHONE: (304)733-0095 EMAIL: [email protected]

AMA Guides 5TH Edition

Advanced Case Studies

CASE STUDIESThe AMA Guides to the Evaluation of

Permanent Impairment, 5th Edition

SpineCASE STUDY #1



Cervical Spine

Ms Brown is a 35 Y/O Flight attendant.

Previously in excellent health with nomedical history of illness, operations, orinjuries of any significance.

Aerobic exercise enthusiast, involved inregular swimming, aerobics, and walking.

Case of pain in the Neck

She was driving home from work 12 months ago

and was stopped at a stop sign.

She was wearing her seat belt and recalls

hearing the screech of brakes and then a crash in

the rear of her car.

The impact threw her body backward and then

forward, but no direct trauma to her body

Cervical Spine


No further impact of vehicles.

She recalls soreness in her neck almost

immediately after she had the accident but

was preoccupied with the business of getting

the other driver’s details, speaking to the

police, and then getting her car towed to a

body shop.

Cervical SpineCase of pain in the Neck



By the time she got home her neck was very

painful and stiff, and her right arm was aching.

She did not have loss of sensation in the

arm or dysthesia (OWS).

She went to ER that evening and had

C-spine X-rays, which showed some early

degenerative disease but no acute injury

ER Doc gave her a soft cervical collar, NSAID,

physical therapy and follow up with PCP.


After continued soreness and a stiff neck forweeks, her family doctor decided to obtainflexion and extension cervical x-rays.

X-rays reported as normal, apart from someflattening of normal lordosis, i.e. muscle spasm.

She continued her NSAID medications andphysical therapy, but felt that neither of thesewere helpful in relieving her symptoms, howeverher right arm pain had resolved.

Cervical Spine


She discontinued treatment after 3 months.

4 months after the accident, she went to

Orthopedist, still complaining of pain &stiffness in the neck,

Orthopod ordered an MRI of the neck,which was reportedly normal.




Orthopedist diagnosed resolving Cervical strain/sprain “a whiplash injury to the neck”.

Recommended that she continue walking andswimming, but avoid aerobics.

Orthopedist saw nothing further to test or treat

He said “she would probably be better within next6 to 12 months.”


On IME for Impairment rating a year later:– She says that over the last 9 months there has

been a lot of improvement.

– Occasionally she feels stiffness in the neckbut only when she is tired or after a hardday’s work. she finds that stiffness getsbetter with rest.

– She has no symptoms that suggest cervicalnerve root irritation or cervical radiculopathy.


Cervical Spine


Examination– Cervical range of motion found normal

– No evidence of spasm or muscle guarding.

Rest of the physical exam is normal withoutany clinical evidence of neurologicalabnormality in the upper limbs (power,sensation, and reflexes all normal).

There is no muscular atrophy in the arms.



Cervical Spine

Impairment Rating

This is an example of an uncomplicatedneck injury that had been symptomatic,but has clearly improved with minorintermittent residual symptoms and noother clinical (objective) abnormalitysuggestive of a more serious injury orresidual impairment.

Cervical Spine

Impairment Rating

Acceleration/deceleration injuries to thecervical spine are relatively common events

Next Step: Determine the Appropriatemethod for Assessment under AMA5– “The DRE method is the principal methodology

used to evaluate an individual who has had adistinct injury” (AMA 5, pg. 379)

Cervical Spine

Impairment Rating

The diagnosis-related estimates methodmust be used to assess impairment inthis case, since the impairment is due toan injury, and none of the five clinicalsituations are present that would requirethe use of range-of-motion method.



Cervical Spine

Impairment Rating

To use the DRE method:

– obtain an individual’s history

– examine the individual

– review the results of appropriate diagnosticstudies

– place the individual in the appropriate category

Cervical SpineImpairment Rating

All findings must be carefullyassessed and documented, such as:

– The nature of the injury

– The clinical progress of the case

– The presence or absence of significantradiographic findings

– The presence or absence of clinicalabnormalities

Cervical Spine

Impairment Rating

The presence or absence of clinical

abnormalities are:

– cervical spinal mobility

– spasm and guarding

– peripheral nervous system findings

– central nervous system findings



Cervical Spine

Impairment Rating

These clinical findings provide thecriteria (including categorydifferentiators) that allow the evaluatingdoctor to be accurate and consistent inthe impairment assessment under theDRE model.

15.6 DRE: Cervical Spine

15.6

392-394

Cervical Spine

Impairment Rating

Almost all individuals will fall into oneof the first three DRE categories

The physician can assign an individualto DRE category I, II, or III.

An individual in category I has onlysubjective findings



392

5 Categories based

on Symptoms, signs,

Tests Fractures and/

or dislocations

Table 15-5 Criteria for Rating ImpairmentDue to Cervical Disorders (p. 392)

>50%compression fxone vert. Bodywith unilateralneurologicalcompromise

>50%compression fxone vert. Bodywithout residualneuralcompromise

1.25%-50%compression fxone vert. body;2.post. element fxwith displacement

1.<25%compression fxone vert. body;

2. post. element fx withoutdislocation;

3.spinous or transverse fxwith displacement

Significant UEimp. Requiringuse of UE ext.functional oradaptive devices;total loss at asingle level orsevere, multilevelneuro dysfunction

Loss or alterationof motionsegment integrity

Radiculopathy;

h/o radiculopathyimproved withsurgery

Non-radicular findings;

h/o documentedradiculopathy improvedwith nonoperativetreatment

Nofindings

35-38%25-28%15-18%5-8%0%

VIVIIIIII

Cervical Spine

Impairment Rating

The impairment rating in the DRE methodis based on the objective findings onceMMI is reached and not on prior symptomsor signs.




Cervical Spine

Impairment Rating

Ms Brown had no significant clinicalfindings when she was at MMI; therefore,she meets the definition of a DRE cervicalcategory I in Table 15-5 (AMA Guides 5th ed, p 392)

Impairment:

0% impairment of the whole person

SpineCASE STUDY #2


Back Injury Case StudyDocumented radiculopathy - resolved



Cervical Spine

Impairment Rating

A 40 year old construction worker hurthis back pulling on a drill bit that wasstuck in the ground.

He experienced severe back and rightsided leg and foot pain.

Diminished sensation in S1 distribution

No motor weakness found in foot/leg

Cervical Spine

Impairment Rating

Right ankle reflex somewhat diminished

Imaging studies revealed L5-S1 leveldisk herniation.

Right S1 radiculopathy was diagnosed.

He declined surgery and respondedwell to conservative care

Cervical Spine

Impairment Rating

He was back to light work in six weeks,and back to his usual work in 4 months.

One year later on IME, he had no legpain, occasional back pain mainly afterwork and some stiffness in back.

He was working regularly full duty



Cervical Spine

Impairment Rating

His back exam revealed no tenderness

on palpation

Lumbar range of motion normal

Neurological examination normal.

No motor weakness or sensory lossfound in foot/leg

He can walk on heels and toes well

15.2 Determining the AppropriateMethod for Assessment

Diagnosis-Related Estimate (DRE) VSRange-of-Motion (ROM) Method

15.2

379-381

Diagnosis-Related Estimate (DRE)VS

Range-of-Motion (ROM) Method

“The DRE method is the principalmethodology used to evaluate anindividual who has had a distinct injury”

WorkCover WA Guides 3rd Ed excludesRange of motion method in spine cases.



392

5 Categories based

on Symptoms, signs,


or dislocations

DRE Category II5 % - 8 % Whole Person

History and examination findings compatiblewith a specific injury.

“Clinical findings” (Box 15-1) when at MMI

No radiculopathy OR

Had (past tense) radiculopathy, imaging studyrevealed HNP “at the level and on the side thatwould be expected based on … radiculopathy,but no longer has the radiculopathy followingconservative treatment.”

15.4

385


• According to the 5th edition, at MMI hiscondition best fits into Lumbar DRE II,since radiculopathy has resolved.His impairment is 5% - 8% of the wholeperson. Since he is asymptomatic and hisphysical examination is normal, I wouldrate him at lower end-- 5% WPI.




Why is his condition not in DRE III?

Because….. At MMI

DRE category III requires…...


DRE Category III10 – 13 % Impairment

Significant Radiculopathy– “Significant Pain and/or” (Findings) …

Dermatomal sensory loss (undefined)

– Loss of relevant reflex(es)

– Loss of strength or Atrophy.

– May be verified by Electrodiagnositic Studies

OR: “Individuals who had surgery forradiculopathy but are now asymptomatic.”

15.4

386

SpineCASE STUDY # 3




Recurrent radiculopathy


Time Marches on……..

Five years later, the same individualin the preceding example, fell at workand re-injured his back. He hadsevere back and right leg pain, and a

diminished right ankle reflex.


When he failed to respond toconservative measures, a laminectomywas performed. He did not do wellafter surgery, and continued withsevere back pain and some moderate

residual leg pain.




One year after surgery, he had notreturned to work. He had gained 35pounds, and took 3-4 Vicodin and 6-8Tylenol a day to control his pain.


He reported some ADL difficulties.Driving long distance caused foot togo to sleep. Inability to mow thelawn. Mild sleep disturbance


His wife had gone to work, andhe did some light housework andtook care of his children.




Examination revealed motions asfollows:Hip flexion: 50 °Lumbar flexion 20 °Lumbar extension 10 °Right lateral bending 15 °Left lateral bending 15 °


There was still a diminished rightankle reflex. Strength of ankleflexion was normal, and sensibility inhis foot was normal. X-rays wereunremarkable.


MRI showed findings compatiblewith scarring, but no disc protrusioncausing compression.



Impairment Rating Low Back Injurywith Recurrent Radiculopathy

DRE vs. ROM

Which Method to use?WorkCover WA Guides 3rd Ed

excludes Range of motion method

in spine cases. So Use DRE method

392

5 Categories based

on Symptoms, signs,


or dislocations

DRE Category III ???10 – 13 % Impairment

AT MMISignificant Radiculopathy

– “Significant Pain and/or” (Findings) …Dermatomal sensory loss (undefined)

– Loss of relevant reflex(es)

– Loss of strength or Atrophy.

– May be verified by Electrodiagnositic Studies

OR: “Individuals who had surgery forradiculopathy but are now asymptomatic.”

15.4

386



Using the DRE Method……..

He is now in Lumbar category III.10% - 13% impairment of the wholeperson. Because of the severity ofsymptoms, I would rate him at thehigher value. 13% impairment of thewhole person


We can apportion between the twoinjuries, the first work related, and thesecond work related, the differenceaccording to the 5th edition is:13% - 5% = 8% whole person impairment

Apportionment??

SpineCASE STUDY # 4



A 49-year-old dock worker experiencedsudden low back pain and bilateral lowerextremity “numbness” after lifting a heavycrate at work.

Several episodes of Bladder incontinence

No prior history of similar episodes.

Low Back Injury withCauda Equina


Initial examination revealed:

– muscle guarding

– Dsymetria

– diminished strength of bilateral quadriceps

– full strength of his bilateral gastrocnemius ,

extensor hallucis longus, anterior tibialis


Examination con’t:

– diminished sensation of his perineum andbilateral proximal anterior calf

– absent patellar tendon reflexes bilaterally

– normal Achilles tendon reflexes

– normal anal sphincter tone




Examination con’t:

– Lumbar spine MRI revealed a large posterocentralherniated nucleus pulposus at L3-4 with a free diskfragment, resulting in multilevel nerve root compression

– Lumbar plain films with flexion and extension viewsrevealed no loss of motion segment integrity


Surgical treatment included decompressivelaminectomy at L3-4 with excision of theherniated disk material and free fragment.

One year after surgery, he reported mild residuallow back pain and difficulty with ADL mainlywalking limited to level surfaces. Can not climbstairs due to leg weakness.

He denied difficulty with bowel or bladdercontrol.


On examination 1 year after surgery:

– He reported diminished sensation in his anterio-lateral thigh/knee area bilaterally

– patellar deep tendon reflexes were absent

– muscular strength of his quadriceps femoris wasdiminished (4/5 - manual testing) but the remainderof his neurological examination was normal

– straight-leg raising was negative bilaterally

– Lumbar ROM were measured and found normal




Impairment Rating --What Method to Use?

DRE VS ROM ?

Determining the Appropriate Method

for Assessment: “The DRE method

is the principal methodology used to

evaluate an individual who has had a

distinct injury”



DRE VS ROM ?

Claimant’s injury was cauda equinasyndrome with initial bladdercompromise.

The residual bilateral leg weakness iscorticospinal tract involvement



DRE VS ROM ?The DRE method combined with a

rating for corticospinal tract damage isused to assess impairment in this case,because instruction on pg.380, #3 state

“use the DRE method forcorticospinal tract involvement”.




According to the GUIDES lumbar nerveroot injuries that result in cauda equinasyndrome are rated as Corticospinal Tractinvolvement as in cervical and thoracicinjuries that damage the corticospinal tractof the spinal cord.


Impairment Rating Corticospinal Tract injury

The recommended system is thatfrom the nervous system chapter,which has been reprinted in thespine chapter as Table 15-6, 396-7


Rating Corticospinal Tract Impairmentresulting from Station & Gait Disorders

Table 15-6, 396, Sec C





According to Table 15-6, RatingCorticospinal Tract Impairment, Sectionc, Criteria for Rating Impairments Dueto Station and Gait Disorders, this casemeets the definition of class 2.



This corresponds with a 10% to 19%impairment of whole person.

A higher value of 19% was selected due tosignificant effect on ADL.

This must be combined with applicableDRE impairments


Impairment Rating using DRE Method

DRE Method Classification:

– Lumbar (low back) injury in rated accordingto the Table 15-3, Criteria for RatingImpairment Due to Lumbar Disorders.



392

5 Categories based

on Symptoms, signs,


or dislocations



Claimant had surgery for radiculopathy;therefore, he meets the second definitionof DRE lumbar category III in Table 15-3.

This corresponds with a rating of 10% to13% impairment of the whole person.



The Guides’ states, “if residual symptoms orobjective findings impact the ability toperform ADL, despite treatment, the higherpercentage in each range should be assigned”

Therefore the claimant was assigned13% impairment of whole person





Final Impairment Calculation:

19% impairment from table 15-6combined with 13% impairment fromtable 15-5 (Cervical DRE table) comesto a total 30% of whole person

SpineCASE STUDY # 5

A 27 year old man fell from a building underconstruction, sustaining a fracture dislocationat the thoraco lumbar junction, with >50%T12 compression with immediate & completeparaplegia at this level. He had surgicaldecompression at T12 and fusion from T10 to

L2, but recovered no neurologic function.

Thoracic spine fracturewith paraplegia



One year later IME for rating:

He has no neurologic function below L2

He is wheel chair bound

Has intermittent bladder dribbling, novoluntary control and requires intermittentself catheterization.


One year later IME for rating:

His bowel function has reflex regulationbut no voluntary control-- requires enemas

He has no sexual functioning .

He has a deep ulcer 5 cm. in diameter overhis left ischial tuberosity.


15.5 DRE: Thoracic Spine

15.4

388-391



389

5 Categories based

on Symptoms, signs,


or dislocations

384

5 Categories, based on:

Symptoms, signs, tests

• Fractures and/ordislocations

According to the 5th edition, he is inDRE category V because of theradiculopathy and alteration of motionsegment integrity. This results in a25% - 28% impairment of the wholeperson. It is the same whether it isconsidered lumbar or thoracic.




Ischial ulcer

Loss of anorectal control

Loss of sexual function

Whole person impairment

Loss of bladder control

Gait disturbance

28%Spine injury DRE 5

% of WPImpairment


Impairment due to GaitDerangement 5th edition Table13-15, p. 336 Nervous system


He has Class 4 impairment of gaitaccording to table 15-6c, p. 396. Thisresults in a 40% - 60% impairment ofthe whole person. Since his impairmentis so severe, I would rate him at thehigher value.



Ischial ulcer




Loss of bladder control

60%Gait disturbance


% of WPImpairment


13-19, p. 341 Nervous systemNeurologic impairment of bladder(same as table 15-6, pp. 396-397)


He has Class 3 impairment of bladdercontrol according to table 15-6 d, P 397.This results in a 25% - 39% impairmentof the whole person. Since his impairmentis quite severe, I would rate him at thehigher value of 39%.



Ischial ulcer




39%Loss of bladder control

60%Gait disturbance


% of WPImpairment


13-20, p. 342 Nervous systemNeurologic impairment of Bowel(same as table 15-6, pp. 396-397)


He has Class 2 impairment ofanorectal control according to table15-6e, p. 397. This results in a 29% -39% impairment of the whole person.Since his impairment is quite severe, Iwould rate him at the higher value.



Ischial ulcer

39%Loss of anorectal control




60%Gait disturbance


% of WPImpairment


13-21, p. 342 Nervous systemNeurologic Sexual Dysfunction(same as table 15-6, pp. 396-397)


He has Class 3 impairment of sexualfunction according to table 15-6f, p. 397.

This results in a 20% impairment of thewhole person.



Ischial ulcer


20%Loss of sexual function



60%Gait disturbance


% of WPImpairment


Table 17-36 p. 550.(Lower extremity chapter)Impairments for Skin Loss.

5%Ischial ulcer





60%Gait disturbance


% of WPImpairment




60% combined with 39% = 76%76% combined with 39% = 85%85% combined with 28% = 89%89% combined with 20% = 91%91% combined with 5% = 91%

5%Ischial ulcer



91%Whole person impairment


60%Gait disturbance


% of WPImpairment

SpineCASE STUDY # 6



Low Back Injury withVertebral Fracture

35-year-old woman who worked as alibrarian in the public library fell froma ladder while putting away books

She sustained a mild burst fracture ofL1 with a 55% loss of height withoutneurologic deficits


History con’t:

–Treated with bracing

–Fracture healed

–6 months after the injury, was able to domost ADL


Current Complaints:

–Has back pain after heavy activity orwith weather changes

–No neurologic complaints




Physical Exam:

– Mild tenderness to palpation at thefracture site

– Neurologic examination : negative

– SLR : negative

– Range of motion is mildly decreased


Clinical Studies:

– Radiograph : fracture healed with 60% loss ofheight

Diagnosis:

– Burst fracture L1 > 50%

What is the Impairment Rating?


Impairment Rating

Analysis:

–Is she at MMI?

–What Method to Use?

–DRE Vs ROM

She is at MMI—Use DRE



384





Impairment Rating

Analysis:

–Individual qualifies for lumbar DREcategory IV based on the fracture.

–Neurologic deficit, if present, wouldwarrant category V or Section 15.7.

20% whole person impairment

SpineCASE STUDY # 7



Low Back Injury withDegenerative Disc Disease

28-year-old elementary school teacher fell onconcrete surface, while carrying a box full ofactivities for her class into the school.

Onset of back and left leg pain

Transported to ER via EMS


Examination in the ER:

muscle spasm of the back

SLR on the left side at 60°

Positive crossed SLR at 70°

An absent left Achilles tendon reflex

MRI : severely degenerated L5-S1disk with aherniation on the left side


History con’t:

– Treated conservatively by Neurosurgeon withmedication, physical therapy but did not improve

– Surgical diskectomy and arthrodesis of L5-S1Three months after injury

– After 9 months of rehabilitation, leg and backsymptoms were diminished but persistent




On IME a year after injury:

Current Symptoms:

– Back pain off and on—No lower limb pain

– Prolonged standing or walking, or performing herprior work, recreational and some householdactivities caused back pain

– Persistent numbness along the lateral side of thefoot one year after onset of symptoms


On IME a year after injury:

Physical Exam:

– mildly restricted range of motion

– Loss of Achilles reflex

– Numbness in the S1 nerve root distribution

– No motor loss in the lower limb

– Normal gait


Imaging Studies:

–Postoperative MRI with gadolinium :fibrosis, but no residual or recurrentherniation

–Fusion appears solid

–Electrodiagnostic study consistentwith current left S1 radiculopathy




Diagnosis:–Left posterolateral L5-S1 disk herniation

with S1 radiculopathy

–Unresolved radiculopathy status postdiskectomy with L5-S1 fusion



Impairment Rating

Analysis:– Symptoms, physical findings, and imaging

studies are all consistent with a symptomaticherniated disk and a persistent radiculopathy.

– Excision of the offending disk and a single-level fusion did not relieve all symptoms,which is supported by signs of a persistentradiculopathy.

384







Impairment Rating

Analysis con’t:

– Individual with persistent radiculopathy as wellas single-level alteration of motion segmentintegrity qualifies for lumbar DRE category V(25%-28% impairment of the whole person)

– Her Final whole person impairment is 28%because She has persistent ADL problems

SpineCASE STUDY # 8

Mid Back (Thoracic injury)

40-year-old electrician, worked for thepower company, fell from a power pole 30feet high and sustained a 55% compressionfracture of T12

– Conservative treatment for 8 months

– Able to perform most ADL, and walk withoutbraces or crutches, but is limited to levelsurfaces




Current Symptoms:

–Back pain with heavy physicalactivity

–Left extremity weakness, difficultywalking uphill

–Numbness in the left leg


Physical Exam:

–Spotty numbness in the left leg

–Grade 4/5 left leg weakness

–2 cm atrophy of left thigh and leg

–Left leg reflexes are hypoactive


Clinical Studies:

–Compression fracture of T8 -55%

Diagnosis:

–Compression fracture T8 with residual leftlower extremity neurologic involvement





Mid Back (Thoracic injury)Impairment Rating

Analysis:

–This individual qualifies for DREthoracic category V because of hisongoing unilateral neurologic deficits &structural inclusion of a compressionfracture with >50% loss of height.

389

5 Categories based

on Symptoms, signs,


or dislocations



Analysis:

– DRE thoracic category V is 25% -28%whole person impairment.

–Based on the effect on ADL, he wouldbe rated at 28% impairment of thewhole person






The recommended system is thatfrom the nervous system chapter,which has been reprinted in thespine chapter as Table 15-6, 396-7


What if he had bilateral leg weakness andlimited to walking surface only?

Then in addition to the Thoracic DRE V, hewould also be rated for Corticospinal Tractinjury Section c, Table 15-6, p 396-Criteria forRating Impairments Due to Station & Gait

This would be combined with the DRE. Iwould assign him lower limit for DRE as theStation & Gait number would account for ADL


Rating Corticospinal Tract Impairmentresulting from Station & Gait Disorders

Table 15-6, 396, Sec C





According to Table 15-6, RatingCorticospinal Tract Impairment, Sectionc, Criteria for Rating Impairments Dueto Station and Gait Disorders, this casemeets the definition of class 2.


This corresponds with a 10% to 19%impairment of whole person.

A higher value of 19% was selected.

This must be combined with 25%impairment of the whole person fromThoracic DRE V making it a 39%whole person impairment.

SpineCASE STUDY # 9




Thoracic spine Injury withVertebral Fracture

28-year dozer operator fell and struck hishead and neck while at work.

Had severe and persistent pain in the neck,radiating to lateral right upper limbextending into the thumb

MRI showed a herniated disk at C5-6 onthe right


History con’t:

–Failed nonoperative treatment

–Underwent a diskectomy of C5-6 level &Fusion of C5 to C6--Single level

–Underwent Physical therapy for 6 weeks


History at IME a year later:

– Has continued neck and right upperextremity pain

–Unable to perform most ADL

–Uses assistive devices for right sidegripping and turning objects




A year later, his current symptoms are:

– Severe neck and right upper extremity pain

– Aggravated by movements of the neck anduse of the right upper extremity

– Persistent numbness in the radial forearm,hand, and digits particularly of thumb

– requires the use of adaptive devices


Physical Exam:

– Mild loss of cervical motion

– Neurologic examination reveals decreasedsensation in the right thumb, index finger andthe Dosolateral aspect of the forearm

– weakness of bicep ans wrist extensors on right

– Diminished brachioradialis reflex on right


Clinical Studies:–Radiographs : healed fusion C5-C6





Diagnosis:

– Herniated C5-6 disk treated withdiskectomy and single level fusion withresidual right C6 radiculopathy

What is the Impairment rating?



Impairment Rating

Analysis:–Meets criteria for DRE cervical

category V because of objectivefindings supportive of significantupper extremity impairmentrequiring the use of adaptive devices

392

5 Categories based

on Symptoms, signs,


or dislocations





Impairment Rating

Conclusion:

– DRE cervical category V

–38% impairment of the whole person

Discussion

AMA Guides to the Evaluation ofPermanent Impairment - Fifth Edition

Chapter16_The Upper Extremities

Mohammed I Ranavaya MD, MS, FRCPI

16

433-521




Upper ExtremitiesCase studies


Upper ExtremitiesCase Study 1

Shoulder and Elbow Injury


A 48 year old file clerk fell down the stairsA 48 year old file clerk fell down the stairsat work sustaining a fracture of her rightat work sustaining a fracture of her rightdistal humerus. Open reduction of thedistal humerus. Open reduction of thefracture was necessary. Six months afterfracture was necessary. Six months afterinjury, healing of the fracture wasinjury, healing of the fracture wascomplete and serial measurements showedcomplete and serial measurements showedno further improvement in range ofno further improvement in range ofmotion.motion.




Her elbow flexed 120 degrees and lacked 40Her elbow flexed 120 degrees and lacked 40degrees from full extension. She had 60degrees from full extension. She had 60degrees of pronation and 20 degrees ofdegrees of pronation and 20 degrees ofsupination. Her shoulder would flex 150supination. Her shoulder would flex 150degrees and would extend 30 degrees. She haddegrees and would extend 30 degrees. She had40 degrees of adduction and 90 degrees of40 degrees of adduction and 90 degrees ofabduction. She had 30 degrees of internalabduction. She had 30 degrees of internalrotation and 40 degrees of external rotation.rotation and 40 degrees of external rotation.

Impairment due to loss of:

Combined upper extremity impairment

Upper extremityimpairment due tolimited shoulder motion

Upper extremityimpairment due tolimited elbow motion

external rotation

internal rotation

adductionsupination

abductionpronation

extensionextension

Shoulder flexionElbow flexion

Table 16-34, p. 472

ElbowFlexion120°

2% UEImpairment







external rotation

internal rotation

adductionsupination

abductionpronation

extensionextension

Shoulder flexion2Elbow flexion

Table 16-34, p. 472.40° Elbow Extension

ElbowExtension40° fromfull

4% UEImpairment





external rotation

internal rotation

adductionsupination

abductionpronation

extension4extension




Table 16-37, p. 47460° Forearm Pronation





external rotation

internal rotation

adductionsupination

abduction1pronation

extension4extension



Table 16-37, p. 47420° Forearm Supination







external rotation

internal rotation

adduction3supination

abduction1pronation

extension4extension





10


external rotation

internal rotation


abduction1pronation

extension4extension


Table 16Table 16--40, p 47640, p 476150150°° Shoulder FlexionShoulder Flexion






10


external rotation

internal rotation


abduction1pronation

extension4extension

2Shoulder flexion2Elbow flexion

Table 16Table 16--40, p 47640, p 4763030°° Shoulder ExtensionShoulder Extension




10


external rotation

internal rotation


abduction1pronation

1extension4extension




Table 16-43, p. 47790° Shoulder Abduction




10


external rotation

internal rotation


4abduction1pronation



Table 16-43, p. 477

40° Shoulder Adduction






10


external rotation

internal rotation

0adduction3supination




Table 16-46, p. 47930° Internal Rotation




10


external rotation

4internal rotation







Table 16-46, p. 47940° External Rotation




10


1external rotation

4internal rotation







12


10


1external rotation

4internal rotation








21Combined upper extremity impairment

12


10


1external rotation

4internal rotation





21% upper extremity impairment=

13%Impairment of whole personTable 16-3, Page 439


Tendon and Nerve Injury



A 27 year old right handed meatA 27 year old right handed meatpacking worker sustained apacking worker sustained alaceration of his right index fingerlaceration of his right index fingerwith tendon and nerve damage.with tendon and nerve damage.Surgical repairs were done, and heSurgical repairs were done, and heunderwent appropriateunderwent appropriaterehabilitation.rehabilitation.

At MMI, physical examination is as follows:At MMI, physical examination is as follows:

Transverse scar on the palmar side of theTransverse scar on the palmar side of the

finger at the level of the PIP joint.finger at the level of the PIP joint.

Radial side of the finger distal to the scar,Radial side of the finger distal to the scar,

the twothe two--point discrimination is 8 mm.point discrimination is 8 mm.

Ulnar side of the finger distal to the scar, theUlnar side of the finger distal to the scar, the

twotwo-- point discrimination is 18 mm.point discrimination is 18 mm.

Active ROM in the MP joint is 0 degreeActive ROM in the MP joint is 0 degreeextension to 80 degree flexion.extension to 80 degree flexion.

PIP flexion 100 deg, extensionPIP flexion 100 deg, extension toto ++1010 deg.deg.

DIP limited to flexion 10 to 20 degrees.DIP limited to flexion 10 to 20 degrees.




whole person

upper extremity

hand

Total finger impairment

Finger impairment dueto sensory loss

Finger impairment dueto limited motion

extension

DIP flexion

extension

PIP flexion

Ulnar side sensory lossdistal to PIP

extension

Radial sensory lossMP flexion

Figure 16-25, p. 464MP Motion 0/80

Active ROMActive ROMin the MPin the MPjoint is 0/80.joint is 0/80.


whole person

upper extremity

hand




extension

DIP flexion

extension

PIP flexion


6%extension

Radial sensory loss5%MP flexion




Figure 16-23, p. 463PIP Motion 10/100

PIP Flexion 100°

PIP Extension +10°

3% UEImpairment


whole person

upper extremity

hand




extension

DIP flexion

3%extension

0%PIP flexion


6%extension


Figure 16-21, p. 461.DIP Motion 10/20

DIP motion,DIP motion,10/20.10/20.




whole person

upper extremity

hand




2%extension

26%DIP flexion

3%extension

0%PIP flexion


6%extension


MP: 5% + 6% = 11%MP: 5% + 6% = 11%

PIP: 0% + 3% = 3%PIP: 0% + 3% = 3%

DIP: 26% + 2% = 28%DIP: 26% + 2% = 28%

28% combined with 11% = 36%28% combined with 11% = 36%

36% combined with 3% = 38%36% combined with 3% = 38%


whole person

upper extremity

hand



38%Finger impairment dueto limited motion

2%extension

26%DIP flexion

3%extension

0%PIP flexion


6%extension





whole person

upper extremity

hand




2%extension

26%DIP flexion

3%extension

0%PIP flexion


6%extension




Figure 16Figure 16--7, p. 4477, p. 447Transverse Sensory Loss of the FingersTransverse Sensory Loss of the Fingers




Table 16-7, p. 448 LongitudinalSensory Loss of the Fingers


whole person

upper extremity

hand




2%extension

26%DIP flexion

3%extension

0%PIP flexion


6%extension

12%Radial sensory loss5%MP flexion

Table 16-7, p. 448 LongitudinalSensory Loss of the Fingers




whole person

upper extremity

hand




2%extension

26%DIP flexion

3%extension

0%PIP flexion 16%

Maximum impairmentdue to sensory loss inthis area

6%extension

12%Degree of sensory loss5%MP flexion


whole person

upper extremity

hand


28%Finger impairment dueto sensory loss


2%extension

26%DIP flexion

3%extension

0%PIP flexion 16%


6%extension



whole person

upper extremity

hand

55%Total finger impairment– Combine 38% with 28%



2%extension

26%DIP flexion

3%extension

0%PIP flexion 16%


6%extension





Convert upper extremity impairment to whole person

Convert hand impairment to upper extremity – 16-1, pg.438

11%Convert finger impairment to hand – Table 16-1, pg.438

55%Total finger impairment



2%extension

26%DIP flexion

3%extension

0%PIP flexion 16%


6%extension



Convert upper extremity impairment to whole person

10%Convert hand impairment to upper extremity – 16-1, pg.438





2%extension

26%DIP flexion

3%extension

0%PIP flexion 16%


6%extension



6%Convert upper extremity impairment to whole person

10%Convert hand impairment to upper extremity – 16-1, pg.438





2%extension

26%DIP flexion

3%extension

0%PIP flexion 16%


6%extension





Shoulder Dislocation

A 54 year old construction worker injured his leftshoulder in a fall at work. Anterior dislocationwas confirmed by x-ray in the emergency room,and the shoulder was reduced by closedmanipulation. He was started on a rehabilitationprogram right away, and returned to light work intwo weeks and his usual work in a month.

Six months later, he dislocatedhis shoulder again in a ball game.Another player, who is aparamedic, put it back in place,and he did not see a doctor.



A year after his initial injury, he felt hisshoulder “came loose” while he wasreaching up to get some materials off ashelf at work. He was quite apprehensiveand went to ER. He was found to have thehumeral head sublux over the glenoid rimwhich reduced spontaneously when axialload was withdrawn (class II)

His orthopedist said that the recurrentshoulder instability was the result ofinadequate immobilization, and put himin a shoulder immobilizer for six weeks.Six months later he was evaluated.

Clinical shoulder instability test positiveMRI showed anterior glenoid labrum tear He refused surgery

At the time of his evaluation, sixmonths later, he had motions asfollows:Flexion 140°Extension 30°Adduction 30°Abduction 90°External rotation 50°Internal rotation 60°




Impairment of upper extremity

Upper extremity impairment due to limitation of:

Impairment of whole person

Upper extremity impairment due to instability

Upper extremity impairment due to limitedshoulder motion

external rotation

internal rotation

adduction

abduction

extension

3%Shoulder flexion









external rotation

internal rotation

adduction

abduction

1%extension

3%Shoulder flexion







external rotation

internal rotation

adduction

4%abduction

1%extension

3%Shoulder flexion



Table 16-43, p. 477







external rotation

internal rotation

1%adduction

4%abduction

1%extension

3%Shoulder flexion









external rotation

2%internal rotation

1%adduction

4%abduction

1%extension

3%Shoulder flexion






12%Upper extremity impairment due to limitedshoulder motion

1%external rotation

2%internal rotation

1%adduction

4%abduction

1%extension

3%Shoulder flexion



Table 16-26, p. 505. UE Impairment

Due to Shoulder Instability

23%Impairment of upper extremity



12%Upper extremity impairment due to instability


1%external rotation

2%internal rotation

1%adduction

4%abduction

1%extension

3%Shoulder flexion



14%Impairment of whole person

12%Upper extremity impairment due to instability


1%external rotation

2%internal rotation

1%adduction

4%abduction

1%extension

3%Shoulder flexion




Upper ExtremitiesCase Study 4Nerve Injury


A right handed operating room nursesustained a penetrating wound of his leftupper arm, when a rushed Co workeraccidentally stabbed him with the scalpel

damaging his musculo-cutaneous nerve.


One year later, he has full activeelbow flexion against gravity withsome resistance. He can detectpinprick on the radial side of hisforearm most of the time, but itdoesn't "feel right" in this area. Hehas no pain.




Upper extremity impairment due to nerve deficit

Upper extremityimpairment due tomotor loss

Upper extremityimpairment due tosensory loss

Maximum impairmentdue to motor loss ofthis nerve

Maximum impairmentdue to sensory loss ofthis nerve

Degree of motor lossDegree of sensory loss

Determination of ImpairmentDetermination of ImpairmentDue to Nerve InjuryDue to Nerve Injury


Table 16Table 16--10, p. 482. Determination10, p. 482. Determinationof Percent of Sensory Deficitof Percent of Sensory Deficit







Degree of motor loss25%Degree of sensory loss





Excerpt from Table 16-15, p. 492.Maximum Percent Impairments ofThe Upper Extremity Due to Injuryof Specific Nerves

Sensory MotorSensory Motor






5%







1%



5%







Table 16Table 16--11, p. 484.11, p. 484.Determination of Percent of Motor DeficitDetermination of Percent of Motor Deficit




1%



5%


25%Degree of motor loss25%Degree of sensory loss



Excerpt from Table 16-15, p. 492.Maximum Percent Impairments ofthe Upper Extremity Due to Injuryof Specific Nerves







1%


25%


5%






6%


1%


25%


5%





7%Upper extremity impairment due to nerve deficit

6%


1%


25%


5%







7% upper extremity impairment=

4%Impairment of whole personTable 16-3, Page 439


Upper ExtremitiesCase study 5

Amputations and otherinjuries


A 54 year old right handed carpentersustained a partial amputation of hisleft hand with a power saw. The sawcut began between the middle and ringfingers and came proximally andmedially to exit at the base of his

hypothenar eminence near the wrist.



At the time of final evaluation,the ring and little fingers, aswell as their metacarpals, havebeen amputated. There is acomplete ulnar nerve palsydistal to the wrist.


Impairment of upper extremity due to amputations


Combined impairment of upper extremity

Impairment of upper extremity due to nerve injury

Impairment due to motorloss

Impairment due tosensory loss

Maximum impairmentdue to motor loss at thislevel

Maximum impairmentdue to sensory loss atthis level


Impairment of hand due to amputation of both digits

Impairment of hand due to amputation of ring finger

Impairment of hand due to amputation of little finger




Figure 16Figure 16--3, p 442.3, p 442.Amputations of the fingersAmputations of the fingers


10% impairment of the hand for loss ofthe little finger added to 10% for lossof the ring finger = 20% impairmentof the hand or 18% of the UE.

18%Impairment of upper extremity due to amputations




Impairment due tomotor loss


Maximum impairmentdue to motor loss atthis level



20%Impairment of hand due to amputation of both digits

10%Impairment of hand due to amputation of ring finger

10%Impairment of hand due to amputation of little finger




Percent of DeficitPercent of Deficitof nerve functionof nerve function

is multiplied by theis multiplied by themaximum valuemaximum value

for that nerve function to givefor that nerve function to giveimpairment for that function.impairment for that function.














Maximum impairments ofMaximum impairments ofupper extremity for ulnar nerveupper extremity for ulnar nerve

taken from tabletaken from table


But he has amputation in Ulnar sensory distribution








0%Impairment due tosensory loss


0%







Table 16Table 16--11, p. 48411, p. 484Determination of PercentDetermination of Percent

of Motor Deficitof Motor Deficit


Maximum impairments ofMaximum impairments ofupper extremity for ulnarupper extremity for ulnar

nerve taken from table 16nerve taken from table 16--1515




18%*Impairment of upper extremity due to amputations

?Impairment of whole person

?Combined impairment of upper extremity

?Impairment of upper extremity due to nerve injury

35%Impairment due tomotor loss

0%Impairment due tosensory loss

35%


0%



10%Impairment of hand due to amputation of metacarpals





47%Combined impairment of upper extremity 18% C 35

35%Impairment of upper extremity due to nerve injury

35%Impairment due tomotor loss here

0%Impairment due tosensory loss here

35%


7%



20%Impairment of hand due to amputation of fingers





47%Combined impairment of upper extremity 18% C 35

35%Impairment of upper extremity due to nerve injury

35%Impairment due tomotor loss here

0%Impairment due tosensory loss here

35%


7%



20%Impairment of hand due to amputation of fingers







Carpal Tunnel Syndrome


A 48 year old worker in a meat packing plantcomplained of paresthesias in her right thumb,index, and ring fingers of six months duration.She was treated with oral medications andwrist splints, and was given temporary lightwork, but continued to have significantsymptoms which bothered her during the day,

and often awakened her at night.


Surgery was suggested, but since thesurgeon told her that she probablywould be unable to return to heroriginal job without symptoms aftersurgery, she decided not to havesurgery, and changed her Job.




A year later, she was self employed , andsymptoms were a little better, but still hadepisodic pain and numbness. Tinel’s test waspositive, but 2-point discrimination was5mm. in the pulps of all fingers, and thenarmuscles were normal. EMG was normal, butmotor and sensory latencies were delayed.


Table 16-5, p. 447Sensory Quality Impairment

100%more than 15 mm.

50%7 mm. to 15 mm.

0%6 mm. or less

Impairment

of Nerve

Two-Point

Discrimination


5th edition p. 495 Carpal Tunnel Syndrome.These criteria may be used whether or notsurgery has been performed

< 5%No physical findings of loss of nervefunction. Neuropathy confirmed byelectrodiagnostic tests

Rate same as anyother nerve lesion

Physical findings of loss of nervefunction

0%No clinical evidence of loss of nervefunction. Normal electrodiagnosticstudies

% impairment

Upper extremity

Physical findings



According to the Guidesher impairment may be up to5% of the upper extremity.

Since she still has significantsymptoms in spite of a changein her job, I would recommend5% impairment upper extremity


Case study 6…. continued.

Let us take the same scenario,except that she has two-pointdiscrimination of 12 mm. in themedian distribution and 5 mm.two-point in the ulnar distribution.These findings have beenconsistent on several examinations.


5th edition, table 16-5, p. 447Sensory Quality Impairment

100%more than 15 mm.

50%7 mm. to 15 mm.

0%6 mm. or less

Impairment

of Nerve

Two-Point

Discrimination




Percent of DeficitPercent of Deficitof nerve functionof nerve function

is multiplied by theis multiplied by themaximum valuemaximum value

for that nerve function to givefor that nerve function to giveimpairment for that function.impairment for that function.


5th edition, table 16-15, p. 492

Maximum percent impairments of theupper extremity from loss of sensoryor motor function

sensorysensory motormotor


39% of the UE is the maximumimpairment of sensory functionof the median nerve at the wrist.She has 50% impairment of thisfunction.39% X 50% = 20% of the UE12% of the Whole Person.




Upper ExtremitiesCase Study 7Carpal Injury


A 48 year old electriciansustained a dislocated lunate ofhis left wrist in a fall from aladder. After closed reduction,the lunate underwent asepticnecrosis, necessitating aproximal row carpectomy.


At MMI six months later, he hasflexion of 15°, extension of 30°,radial deviation of 10°, and ulnardeviation of 15°. There ispersistent moderate wrist swelling.




Upper extremityimpairment due tolimited motion

ulnar deviation

radial deviation

UE impairment due topersistent moderatewrist swelling

extension

Upper extremityimpairment due toresection arthroplasty

Impairment due tolimited:

Wrist flexion

Table 16-28.Wrist flexion 15°, Extension 30°



ulnar deviation

radial deviation


5%extension

Upper extremityimpairment due toresection arthroplasty8%

UE impairment due tolimited:

Wrist flexion



Table 16-31Radial deviation 10°Ulnar deviation 15°


18%


3%ulnar deviation

2%radial deviation


5%extension


UE Impairment due tolimited:

Wrist flexion

Table 16-27Upper Extremity Impairment Due to Arthroplasty




18%


3%ulnar deviation

2%radial deviation


5%extension

12%



Wrist flexion

Table 16-19Impairment Due to Joint Swelling

Table 16-18 (499)Table 18 (58)

Impairment Values for Digits,Hand, Upper Extremity, and theWhole Person for Disorders of

Specific Joints or Units

Never used alone, always usedwith a multiplier




According to table 16-7, p. 498, 5th

edition, the radio-carpal joint is40% of the upper extremity.

20% of the radio-carpal joint is 8%of the upper extremity.


18%


3%ulnar deviation

2%radial deviation 8%

Upper extremityimpairment due toswelling

5%extension

12%



Wrist flexion


Rules to Avoid Duplication

Joint swelling can not be rated separately

and combined with decreased jointmotion or other findings. (Pg. 500)

Take home lesson – Check carefully

Avoid Double Dipping




18%


3%ulnar deviation



5%extension

12%



Wrist flexion


18% impairment of the upperextremity due to limited motionis combined with 12%impairment of the UE due toresection arthroplasty.The result is 28% of the upperextremity.

28%Combined upper extremity impairment

OR 17% Whole Person impairment

18%


3%ulnar deviation



5%extension

12%



Wrist flexion





Rotator Cuff Injury


A 47 year old carpenter sustained amajor rotator cuff tear of his rightshoulder while at work. He hadsurgical repair and appropriaterehabilitation.


Six months later, he was back atwork as a carpenter, although heneeded help on some parts of hisjob that he used to do by himself.He had some aching pain afterwork, and occasionally had painat night.




At the time of his evaluation, six months aftersurgical repair, he had motions as follows:Flexion 120° Extension 20°Adduction 20° Abduction 90°External rotation 40° Internal rotation 60°Manual muscle testing showed a strength lossindex of between 10% and 20% in all shouldermotions.






Upper extremity impairment due to weakness


external rotation

internal rotation

adduction

abduction

extension

4%Shoulder flexion










external rotation

internal rotation

adduction

abduction

2%extension

4%Shoulder flexion










external rotation

internal rotation

adduction

4%abduction

2%extension

4%Shoulder flexion


Table 16-43, p. 477







external rotation

internal rotation

1%adduction

4%abduction

2%extension

4%Shoulder flexion










external rotation

2%internal rotation

1%adduction

4%abduction

2%extension

4%Shoulder flexion









1%external rotation

2%internal rotation

1%adduction

4%abduction

2%extension

4%Shoulder flexion

Table 16-35, p. 510Impairment of Upper Extremity due toWeakness of Shoulder or Elbow

3%

1%

2%

1%

1%

1%




9%Upper extremity impairment due to weakness


1%external rotation

2%internal rotation

1%adduction

4%abduction

2%extension

4%Shoulder flexion



we must not rate for weakness, becausewe are rating reduced ROM and it

would be double dipping.

If he had a normal range of motion, thenhe could be rated for weakness.






1%external rotation

2%internal rotation

1%adduction

4%abduction

2%extension

4%Shoulder flexion






1%external rotation

2%internal rotation

1%adduction

4%abduction

2%extension

4%Shoulder flexion





Apportionment ofRotator Cuff Injury


Case 9: Rotator Cuff Tear

54 year old auto mechanic

Transmission repair, car on an overheadrack, strained right shoulder lifting thetransmission onto place (overhead heavylift)

No prior problems with right shoulder

Immediate shoulder pain

X-ray = normal, MRI = cuff tear


Case 9: Rotator Cuff Tear

Rx = open repair -

Op Note: compliant with Post-Op physical therapy

Evaluated 1 year later, @ MMI

Mild pain with overhead activity

Back at full duty

Exam: No atrophy, Normal neurologic and vascularexams. No tenderness. No weakness, but pain onresisted abduction. Neer and Hawkins impingementsigns Negative




Shoulder ROM

Motion Right () Left ()Flexion 140 170Extension 50 70

Abduction 120 160

Adduction 40 50

Internal Rotation 50 60

External Rotation 70 80


And theImpairmentRating Is ?


Key Principles:

Upper Extremity Section rates mainly byphysical exam findings, not usually byDiagnosis

No Table for “Rotator cuff rupture orrepair”

Usually rate by ROM (Active ROM) Loss




ROM: Key Principles

Upper Extremity Figures for ROM Impairment donot adjust for age

Many “normal” people do not have “normal”ROM by Guides criteria, especially in the shoulder

Principle: always measure the motion in the contralateral “normal” joint

Injury Impairment = ROM impairment of theinjured minus the uninjured joint


Right:

Flexion = 140°

Extension = 50°

Left:

Flexion = 170°

Extension = 70°


Right:

Flexion = 140°

Extension = 50°

Left:

Flexion = 170°

Extension = 70°

Right Impairment:

Flexion = 3 %

Extension = 0 %

Left Impairment:

Flexion = 1 %

Extension = 0 %




Right:

Abduction = 120°

Adduction = 40°

Left:

Abduction = 160°

Adduction = 50°


Right:

Abduction = 120°

Adduction = 40°

Left:

Abduction = 160°

Adduction = 50°

Right Impairment:

Abduction = 3 %

ADDuction = 0%

Left Impairment:

Abduction = 1 %

ADDuction = 0 %


Right:

Internal R. = 50°

External R. = 70°

Left:

Internal R. = 60°

External R. = 80°




Right:

Internal R. = 50°

External R. = 70°

Left:

Internal R. = 60°

External R. = 80°

Right Impairment:

Internal R. = 2%

External R.= 0%

Left Impairment:

Internal R. = 2 %

External R. = 0 %


Right Shoulder ROM8 % UE Impairment

Motion Right () Impairment

Flexion 140 3 %Extension 50 0

Abduction 120 3 %

Adduction 40 0

Internal Rotation 50 2 %



Left Shoulder ROM4 % UE Impairment

Motion Left () Impairment % UE

Flexion 170 1 %Extension 70 0

Abduction 160 1 %

Adduction 50 0

Internal Rotation 60 2 %





Case 9: Conclusion

ROM Impairment =Right shoulder = 8 % (injured)Left shoulder = 4 % (normal)

Injury Caused Impairment8% - 4% = 4 % upper extremity


4 % upper extremity

equals

2 % whole person


Case 9: Additional Thoughts

If surgery had been just arthroscopic debridementfor a partial thickness tear, or a smaller full thicknesstear, rate by ROM or weakness .

Arthroscopic debridement may result in normalmotion and minimal symptoms, thus no impairment

Guides does not have a rating for“having had an operation”

Surgery removes what “shouldn’t be there”




Yet Another ThoughtResection Arthroplasty

If, at the time of rotator cuff repair, orimpingement debridement, a resection ofthe distal clavicle was performed (not justremoval of osteophyte, but removal of thedistal 1 cm including the articular surface),use Table 16-27, pg. 506 “Arthroplasty” torate the resection, and then combine withthe rating for loss of motion


Upper ExtremitiesCase Study 10Crushed Thumb


Case 10: Crushed Thumb

22 year old newly hired factory worker

Right dominant thumb caught in and crushed by amachine at work

Fractures

Immediate surgery (Debridement), and stagedreconstructions

Never infected

Back at work 3 months after injury

@ MMI 1 year after injury




Case 10: Crushed ThumbExamination

IP Joint: Ankylosed @ 40°

MCP Joint: ROM = 0 - 60 °

CMC Joint: ADDuction = 6 cmRadial Abduction = 0 - 30°Opposition = 4 cm

Sensation, circulation and skin coverage:All normal

Fractures: All healed without infection or mal union

And the Impairment Is ?Thumb

Hand

Upper Extremity

Whole Person


ROM IP joint for the thumbFigure 16-12 (456)

ROM deficits:

IP joint ankylosed

at 40 degrees, which

equates to 10% of

the thumb –

Figure 16-12 (456)




Metacarpophalangeal (MP) Joint:Flexion - Extension

Figure Positions16-13 (456)


Metacarpophalangeal (MP)Joint: Flexion – ExtensionFigure 16-15 (457)

MP joint ROM = 0 - 60 °

equates to 0% of the thumb


Adduction

Measure and record thesmallest possible distancein centimeters from theflexor crease of the thumbIP joint to the distalpalmar crease over theMP joint of the littlefinger (Normal =0-1 cm.)

Note: % impairmentrelates to adduction losswhich is 20% thumb




Adduction

Table 16-8b (459)

ImpairmentValues


Radial Abduction

Measure and recordthe largest possibleangle in degreesformed by the firstand secondmetacarpals

30


Radial Abduction

Table 16-8a (459)

ImpairmentValues




Opposition

Measure and record thelargest possible distancein centimeters from theflexor crease of thethumb IP joint to thedistal palmar creasedirectly over the thirdMP joint

Figure 16-19 (460) LinearMeasurements

Note: Impairment refersto opposition loss whichis equal to 45% thumb


Opposition

Table 16-9 (460)

ThumbImpairmentsDue to Lack

of Oppositionand to

Ankylosis


Case 10: Crushed ThumbImpairment Summary

Add all the impairment because of the Thumb

IP Joint Ankylosis 10 %

MCP Joint ROM 0

CMC ADDuction 8 %Radial Abduction 3 %Opposition 9 %

Total thumb impairment 30 %




30 % Thumb Impairment =

12 % Hand Impairment

Page 438


12 % Hand Impairment =

11 % Upper Extremity

Page 439


11 % Upper ExtremityImpairment

Equivalent to:

7 % Whole Person Impairment

Page 439



AMA Guides to the Evaluationof Permanent Impairment

Fifth EditionCHAP 17

Lower Extremities


Lower Extremities Impairment Rating

Case Study 1


A construction workersustains a partial medialand lateral meniscustear. She has a partialmedial and lateralmeniscectomy, andundergoes appropriaterehabilitation. Youexamine her one yearlater and find:




- Gait is perhaps mildly antalgic- Thigh circumference is 1 cm. less- Strength appears normal- Knee flexion = 120o, extension full, no deformity- Cartilage intervals are 3 mm. bilaterally

WHAT IS THE IMPAIRMENT DUE TO THEINJURY?

A - 2% Whole Person

B - 4% Whole Person

C - 5% Whole Person

D - 7% Whole Person


Figure 17-10 (561)


Table 17-2 (526)




Table 17-5 (529)

Not preferred methodology, morespecific methods available,therefore do not use.


Table 17-6 (530) Impairmentsfrom leg muscle atrophy

1 cm. difference, therefore 1%whole person


Table 17-7 (531) Criteria for Grades ofMuscle Function of the Lower Extremity

No strength deficit, therefore noimpairment.





Range of motion normal,therefore no impairment.


Table 17-31 (544)

Joint space narrowing is present,however is bilateral and, “to areasonable degree of medicalcertainty is unrelated to the injury”,therefore not included in the rating.


Table 17-33 (546) Impairment Estimatesfor Certain Lower Extremity Impairments

“and” “partial” therefore 4%whole person




Table 17-2 (526)

Neither gait nor arthritisappropriate.

DBE = 4%, muscle atrophy =1%, however cannot combine.


Figure 17-10 (561)

120 0

43

4

1

B - 4% Whole Person



Case Study 2



A worker sustains a deep laceration tothe quadriceps. When at MMI, there is2.5 cm atrophy of the thigh (measured10 cm above the patella) and there isweakness on knee extension (activemovement against gravity with someresistance). What is the impairment?

Table 17-6 (530) Table 37 (77)Impairments from leg muscle atrophy

4%wholeperson




Table 17-8 (532) Impairment Due toLower Extremity Muscle Weakness

5% whole person

Atrophy = 4% whole person

Weakness = 5% whole person

Each measure a similar process, thereforeselect the greater impairment, e.g. 5%whole person

C - 5% Whole Person



The AMA Guides to theEvaluation of PermanentImpairment, 5th Edition

CASE STUDY 3

Lower Extremity

Below-Knee Amputation Case Study:– A 30-year-old mechanic who was working on a car

when the jack failed. His left leg was crushed underthe car.

– He underwent a left below-knee amputation (BKA).

Below-Knee Amputation

Lower Extremity

Below-Knee Amputation Case Study:– He underwent rehabilitation for 4 weeks.

– 12 weeks after the BKA a permanent below-kneeprosthesis was fitted.




Lower Extremity

Examination of the left lower extremity reveals:

– a residual limb 5 inches below knee

– sensation, skin and circulation to be intact

– range of knee motion is restricted from 10 to 100°

– muscle power is normal (5/5) in knee flexion/Extension

– suture site is well healed without evidence of neuroma orphantom limb pain.


Lower Extremity

Examination of the left lower extremity reveals:

– He is independent with donning/doffing theprosthesis as well as self-care skills

– evaluation of left hip and non affected right lowerextremity is normal

– He uses a straight cane routinely for gait stability


Lower Extremity

Permanent impairment evaluation is based onSection 17.2i, Amputations; Table 17-32,Impairment Estimates for Amputations;Section 17.2f, Range of Motion; and Table17-10, Knee Impairment.


Fifth Edition Rating



Lower Extremity

BKA with a residual limb more than 3 incheslong qualifies for a 28% whole personimpairment or 70% lower extremity rating.

10° knee flexion contracture as a moderateimpairment of 8% of the whole person or20% of the lower extremity.



Lower Extremity

Limited flexion to 100° is listed as a mildimpairment with a 4% whole person or 10%lower extremity impairment rating.

Range-of-motion restrictions in multipledirections do increase the impairment.



Lower Extremity

Add range-of-motion impairments for a singlejoint to determine the total joint range-of-motion impairments.

The impairment form loss of motion andflexion contracture is 30% of the lowerextremity or 12% of the whole person .





Lower Extremity

The Fifth contains a table to determine whenmultiple impairments can be combined andwhen they cannot (to avoid “double rating”the same condition).



Lower Extremity

Impairment Calculation:

The 70% of LE impairment fromBKA is combined with 30% of theLE impairment from knee loss ofmotion and flexion contracturecomes to 79% of LE impairment

32% impairment of whole person per


Lower Extremity

No additional impairment rating was givenfor the routine use of a cane.

The routine use of a cane is listed as 20%whole person impairment - Lower LimbImpairment From Gait Derangement.




Lower Extremity

Based on 3.2b (4th ed, p75) or Section17.2c (5thed, p529), Gait Derangement is a stand-aloneimpairment not combined with any otherimpairments method, and, whenever possible, theevaluator should use a more specific method.

In this case, the below-knee amputation withrestricted knee range of motion is the specificcondition determining the impairment.


Lower Extremity

To combine these 2 ratings would beinappropriate and only inflate theimpairment rating unjustifiably.


Discussion




Lower ExtremitiesImpairment Rating

Femur fracture and sciaticnerve injuryCASE STUDY 4


A 27 year old electrician sustained acomminuted open subtrochantericfracture of his femur, with injury tohis sciatic nerve. He was treated withopen reduction and internal fixationof the fracture.


One year later, he walked with a significantlimp, and wore a short leg brace. There was acomplete sciatic nerve palsy at the level ofthe upper thigh. Because of his anestheticfoot, he had an ulcer on his heel. There was 2cm. atrophy of his thigh, and 3cm. atrophy ofhis calf.




He had 2 cm. shortening of hisLE. Hip motions were asfollows: flexion 135°, extension0°, adduction 10°, abduction 20°,internal rotation 0°, externalrotation 50°.


Table 17-4 (528)

Limb length discrepancy


Calculation of Impairment

5% LELeg length discrepancy (2 cm.)

Limited hip motion

Calf atrophy

Thigh atrophy

whole person

Total impairment of lower extremity

Nerve deficit (complete sciatic palsy)

Skin loss (ulcer on heel)

Gait derangement (use of SL brace)




WP Impairment %Clinical signs

30

Full time cane or crutch

and short leg brace

20


or long leg brace

15Full time short leg brace

15Part time cane or crutch

10Positive Trendelenberg

7Antalgic limp

From Table 17-5 (529)

Gait Derangement




Limited hip motion

Calf atrophy

Thigh atrophy

whole person




15%Gait derangement (use of SL brace)


Table 17-6 (530)

Impairment From Leg Muscle Atrophy






Limited hip motion

13%Calf atrophy

8%Thigh atrophy

whole person






Table 17-9 (537)

Hip ROM Impairments


Impairment Due toLimited Motion

Limited hip motion:

20%Impairment due to limited hip motion

0%external rotation 50°

10%internal rotation 0°

5%Abduction 20°

5%Adduction 10°

0%extension 0°

0%flexion 135°






20%Limited hip motion

13%Calf atrophy

8%Thigh atrophy

whole person






Table 17-36 (550)

Impairments for Skin Loss





13%Calf atrophy

8%Thigh atrophy

whole person



25%Skin loss (ulcer on heel)





Table 17-37 (552)

Impairment from Nerve Deficits





13%Calf atrophy

8%Thigh atrophy

whole person


79%Nerve deficit (complete sciatic palsy)




Excerptfrom table17-2, p. 526guide tocombinationof methods







13%Calf atrophy

8%Thigh atrophy

whole person






79% combined with 25%= 84%84% combined with 20% = 87%87% combined with 5% =88%

88% of LE =35% of WP





13%Calf atrophy

8%Thigh atrophy

35%whole person

88%Total impairment of lower extremity








Fracture dislocation hip with fusion.

Case Study 5


At age 28, a man sustained a fracture-dislocation of his hip in a fall at work. Hedeveloped a severe post traumatic arthritis ofhis hip. Since he was not a candidate for ahip replacement, a fusion was performed atage 33. While drinking with some friends, heconvinced them to help him cut the spica castoff, and he did not return for follow up for sixmonths.


At MMI one year after surgery, X-raysshowed a solid hip fusion. Cartilage spacewas 0 mm. He had no pain, but had a severelimp, and used one crutch full time. Hipmotions were as follows:Flexion 45°Adduction 10°External rotation 15°




Calculation of Impairment ofLower Extremity

Impairment due to loss of cartilage space


Impairment due to gait derangement

Impairment due to nonfunctional position inadduction

Impairment due to nonfunctional position inrotation

Impairment due to nonfunctional position inflexion

Impairment of LE due to ankylosis of the hip


Ankylosis (total loss of motion) of the hip in themost functional position (25° - 40° flexion, < 5°internal rotation, adduction or abduction, < 10°external rotation) results in an impairment of 50%of the lower extremity or 20% of the whole person.If the joint is ankylosed in a less than optimumposition, additional impairments are combined andthe result is added to this percentage.







Impairment due to nonfunctional position inflexion

50%Impairment of LE due to ankylosis of the hip




4th Table 46, p. 79. 5th Table 17-15, p. 538.Additional impairments due to ankylosis of the hip

in flexed nonfunctional position (45°)







12%Impairment due to nonfunctional position inflexion



Tables 17Tables 17--18 and 1718 and 17--1919 (539)(539)

Impairment from Ankylosis in MalpositionImpairment from Ankylosis in Malpositionof Rotation (10of Rotation (10°° ER)ER)








12%Impairment due to nonfunctional position inrotation




Tables 49 and 50, p. 79. Impairment fromAnkylosis in Malposition of Adduction or

Abduction (add. 10°)

(adduction)





37%Impairment due to nonfunctional position inadduction







37% combined with 12% = 45%

45% combined with 12% = 52%


Calculation of Impairment of LE

37%Impairment due to nonfunctional position inadduction

52%Combined impairment due to malposition







WP Impairment %Clinical signs

30


and short leg brace

20


or long leg brace

15Full time short leg brace

15Part time cane or crutch

10Positive Trendelenberg

7Antalgic limp

Gait Derangement4th Table 36, p. 76,

5th Table 17-5, p.529







Total impairment of LE

20%Impairment due to gait derangement



4th Table 62, p. 83,5th Table 17-31, p. 544

Impairment Due to Arthritis of theLower Extremity



50%Impairment due to loss of cartilage space


















102%Total impairment of LE







100%Total impairment of LE





AMA Guides to the Evaluation of PermanentImpairment V

Chapter 13The Central and Peripheral Nervous System

Example 1

• 25 year old male involved in a head-on MVA with LOC.Now MMI

• Moderate difficulty finding his own room at home,difficulty following commands, often gets lost in familiarsurroundings, and lacks interest in home chores orcurrent events. Needs reminders to shower. Not activeout of the house, few friends. Often agitated, impulsive,and frustrated when given new tasks. Falls asleepfrequently when left alone, can’t drive for more than 1hour without excessive tiredness.

• On exam: MMST = 21/30, oriented to name not date orplace

• Normal cranial nerves, motor, sensory exam.

Individual functions associated with aninjury to the nervous system

NervousSystem

HigherCortical

Functions

CranialNerve

Functions

Station, Gaitand

MovementDisorders

ExtremitySpinalCord

Chronic

Pain

Peripheral

Nerve



HigherCortical

Functions

State ofconsciousness

and level ofawareness

Mental statusCognition

Language

T13-7; p323

Emotional &Behavioral

T13-8; p325

Permanent

T13-2; p309

Episodic

T13-3; p311

Sleep & Arousal

T13-4; p317

Clinical Dementia

Rating Scale

T13-5; p320

Mental Status

Impairment

T13-6; p320

Sleep and Arousal Disorders(T 13-4; p 317)

Class I

1 – 9% WB PPI

Reduced daytimealertness: sleep patternallows most ADL

Class II

10 – 29% WB PPI

Reduced daytime alertness:sleep pattern interferes withsome ADL

Class I

30 – 69% WB PPI

Reduced daytime alertness:sleep pattern significantlyinterferes with ADL

Class I

70 – 90% WB PPI

Severe reduction of daytimealertness: unable to care forself in any situation ormanner

Clinical Dementia Rating Scale(p 320)

Class II (mild) (CDR = 1.0)

15 – 29% PPI WB

Memory Marked memory loss, more for recentevents, interferes with everyday activities

Orientation Moderate difficulty with time, oriented X1,geographic disorientation at times

Judgment & problemsolving

Moderate difficulty handling problems,similarities vs. differences, social judgmentusually maintained

Community affairs Unable to function independently in somesituations, normal upon casual observation

Home & hobbies Mild difficulty at home, some chores andcomplicated hobbies abandoned

Personal care Needs prompting



Impairment due to Emotional & BehavioralDisorders (T 13-8; p 325)

Class I

0 -14% PPI WB

Mild limitation of ADL, daily socialand interpersonal functioning

Class II

15 – 29% PPI WB

Moderate limitation of someADL and some social andinterpersonal functioning

Class III

30 – 69% PPI WB

Severe limitation in most ADLimpeding useful function in mostdaily social and interpersonalfunctioning

Class IV

70 – 90% PPI WB

Severe limitation of all ADL,requires total dependence onothers

Calculation

Higher Cortical Functions →

1. State of Consciousness & Level of Awareness• Sleep and Arousal

• Class I impairment = 1 – 9% PPI

2. Mental Status & Cognition– Class II Impairment; 15 – 29% PPI

3. Emotional & Behavior– Class II = 15 – 29% PPI

• Choose the highest impairment due to“higher cortical dysfunction” and combinewith other nervous system impairments(no others)

• 20% PPI WB (15 – 29)



Example 2

• Example 1 plus

– Complains of unsteadiness, walks slowly butdoes go up & down stairs; doesn’t useladders or ride a bike.

– ENG is positive for peripheral vestibular lesion

Cranial

Nerve

Disorders

Smell

< 3%

Vision &

Visual

FieldsT13-9; p328

T13-10; p328

Diplopia

Chapter 12

Trigeminal

T13-11; p331

Facial

T13-13; p332

Vestibular

T13-3; P334

IX, X, XII

T13-4; p334

Impairment Rating of VIII Nerve(p 334)

Class I

1 – 9% PPI WB

Limitation of hazardousactivities, performs ADL withoutrestriction

Class II

10 – 29% PPI WB

Limitation of all ADLs except thoseinvolved in self care

Class III

30 – 49% PPI WB

Limitation of all ADLs includingthose involved in self care

Class III

50 – 70% PPI WB

Limitation of all ADLs requiringhelp with self care and ambulation



Calculation

Higher Cortical Functions →1. State of Consciousness & Level of Awareness

• Sleep and Arousal– Class I impairment = 1 – 9% PPI

2. Mental Status & Cognition– Class II Impairment; 15 – 29% PPI

3. Emotional & Behavior– Class II = 15 – 29% PPI

Cranial Nerves1. Vestibular

– Class I = 1 – 9% PPI WB

• Choose the highest impairment due to“higher cortical dysfunction” and combinewith other nervous system impairments(no others)

• Combine 20% with 5%– Combined Values Chart (p 604 – 606)

• 24% PPI WB

Example 3

• 46 year old woman suffered a T11 burstcompression fracture after falling off a ladderand striking her back on a guard rail. Now MMI.She is able to get out of bed or rise from a chairwith difficulty and walks with Canadian crutches.She has some voluntary bladder control butoften wets her self without warning. Normalbowel control. She has difficulty with orgasmand often can not become aroused.

• On exam she exhibits a spastic paraparesis witha T12 sensory level.

• Normal mentation & cranial nerves. Now MMI




NervousSystem

HigherCortical

Functions

CranialNerve

Functions

Station, Gaitand

MovementDisorders

ExtremitySpinalCord

Chronic

Pain

Peripheral

Nerve

Station and Gait, &

Movement

Disorders

Station & Gait

T13-15; p336

Movement

Disorders

Impairment due to Stationand Gait Disorders (p 346)

Class I

1 – 9% PPI

Rises to standing position, walks,difficulty elevations, grades, stairs,deep chairs, and long distances

Class II

10 – 19% PPI

Rises to standing position, walkssome distance without assistancebut with difficulty, limited to levelsurfaces

Class III

20 – 39% PPI

Rises and maintains standingposition with difficulty, can notwalk without assistance

Class IV

40 – 60% PPI

Can not stand without help,mechanical support or assistivedevices



Spinal Cord

Respiration

T13-18; p341

Bladder

T13-19; p341

Anorectal

T13-20; p342

Sexual

T13-21; p342

Neurologic Bladder Impairment(p341)

Class I

1 – 9% PPI

Some degree of voluntary controlwith urgency and frequency

Class II

10 – 24% PPI

Good bladder reflex activity,limited capacity withintermittent emptying withoutvoluntary control

Class III

25 – 39% PPI

Poor bladder reflex control,intermittent dribbling, no voluntarycontrol

Class IV

40 – 60% PPI

No reflex or voluntary bladdercontrol

Neurologic Sexual Impairment(p 342)

Class I

1 – 9% PPI

Sexual functioning is possible withdifficulty with difficulty in erectionor ejaculation in men or lack ofawareness, excitement orlubrication in women

Class II

10 – 19% PPI

Reflex sexual activity withoutawareness

Class III

20% PPI

No sexual functioning



Calculations

• Class III Impairment of Station and gait = 20 -39% PPI

• Class II Neurologic Impairment of the Bladder = 10 -24% PPI

• Class II Neurologic Sexual Impairment = 10 - 19% PPI

• Utilizing the CVC:

– Combine bladder (17%) and sexual dysfunction(24%) impairments to get the Spinal Cord impairment

– Combine Station & Gait (30%) and the Spinal Cord(%) impairments to get the whole body Impairment

• Combined with Spine Impairment due to the burstcompression vertebral fracture

Example 4

• A 57 year old right handed man suffered aleft thalamic stroke with limited recovery.He has a seizure disorder with the lastepisode 1 year ago. He has mild slurringof speech, a moderate right spastichemiparesis and mild RUE dysmetria. Hehas poor dexterity and walks without help.Climb stairs only with a rail. Mentation isnormal. Now MMI


NervousSystem

HigherCortical

Functions

CranialNerve

Functions

Station, Gaitand

MovementDisorders

ExtremitySpinalCord

Chronic

Pain

Peripheral

Nerve



HigherCortical

Functions

State ofconsciousness

and level ofawareness

Mental statusCognition

Language

T13-7; p323

Emotional &Behavioral

T13-8; p325

Permanent

T13-2; p309

Episodic

T13-3; p311

Sleep & Arousal

T13-4; p317

Clinical Dementia

Rating Scale

T13-5; p320

Mental Status

Impairment

T13-6; p320

Impairment due to Episodic Loss ofConsciousness or Awareness

(p 312)

Class I

0 – 14% PPI

Paroxysmal disorderwith predictablecharacteristics butunpredictableoccurrence that doesnot limit usualactivities but is a riskto the individual orlimits daily activities.

Impairment due to Language orDysphasia (p 323)

Class I

0 – 9% PPI

Minimal disturbance ofcomprehension and productionof language symbols of dailyliving.

Class II

10 – 24% PPI

Moderate limitation incomprehension and production oflanguage symbols of daily living.

Class III

25 – 39% PPI

Able to comprehend nonverbalcommunication, expressivespeech in unintelligible for ADL

Class IV

40 – 60% PPI

Completely unable tocommunicate or comprehendlanguage symbols



Station and Gait, &

Movement

Disorders

Station & Gait

T13-15; p336

Movement

Disorders

Impairment due to Stationand Gait Disorders (p 346)

Class I

1 – 9% PPI

Rises to standing position,walks, difficulty elevations,grades, stairs, deep chairs, andlong distances

Class II

10 – 19% PPI

Rises to standing position, walkssome distance without assistancebut with difficulty, limited to levelsurfaces

Class III

20 – 39% PPI

Rises and maintains standingposition with difficulty, can not walkwithout assistance

Class IV

40 – 60% PPI

Can not stand without help,mechanical support or assistivedevices

Upper

extremities

One

T13-16 p338

Both

T13-17 p340



Neurologic Impairment of One UpperExtremity (p 338)

Class I

Dominant: 1 – 9% PPI

Nondominant: 1 – 4% PPI

Can perform self care andholding activities but hasdifficulty with dexterity

Class II



Can perform self care, hold &grasps with difficulty, no digitaldexterity

Class III



Can use the extremity but hasdifficulty with self care

Class IV



Can not use the extremity for selfcare or daily activities

Calculations

1. Higher Cortical Functions →1. State of Consciousness & Level of Awareness

• Episodic• Class I impairment = 1 – 9% PPI

2. Language or Dysphasia• Class I Impairment = 5% PPI

2. Station and Gait Disorders• Class I Impairment = 1 - 9% PPI

3. Upper Extremity• Class I Impairment of the Dominant UE = 1 - 9% PPI

Choose the highest impairment related to “higher cortical function” andcombine with other nervous system impairments

• HCF - 5% combined with S&G - 5%combined with UE - 5% using theCombined Values Chart

• 15% PPI WB



Summary: 1

Higher

Cortical

FunctionsCranial

Nerves

Station

Gait

Movement

ExtremitySpinal

Cord

Chronic

Pain

Peripheral

Nerve &

Muscle

Nervous

System

Summary 2

• Choose the highest impairment of the“higher cortical functions”

• Combine all other nervous systemimpairments

• Keep the crib sheets ± Guides in the examroom

case studies ama5, 2011 wa f m - acdmed.org · ama guides 5th ed. case studies syllabus mohammed i...

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