Evaluating Shoulder Impairment

1998 ◽  
Vol 3 (5) ◽  
pp. 1-3
Author(s):  
Richard T. Katz ◽  
Sankar Perraraju
Keyword(s):  
Peripheral Nerve ◽  
Upper Extremity ◽  
Sensory Loss ◽  
Motor Deficits ◽  
Nerve Lesion ◽  
Fourth Edition ◽  
Specific Patient ◽  
Industrial Medicine ◽  
Shoulder Motion ◽  
Upper Extremity Impairment

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, offers several categories to describe impairment in the shoulder, including shoulder amputation, abnormal shoulder motion, peripheral nerve disorders, subluxation/dislocation, and joint arthroplasty. This article clarifies appropriate methods for rating shoulder impairment in a specific patient, particularly with reference to the AMA Guides, Section 3.1j, Shoulder, Section 3.1k, Impairment of the Upper Extremity Due to Peripheral Nerve Disorders, and Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. A table shows shoulder motions and associated degrees of motion and can be used in assessing abnormal range of motion. Assessments of shoulder impairment due to peripheral nerve lesion also requires assessment of sensory loss (or presence of nerve pain) or motor deficits, and these may be categorized to the level of the spinal nerves (C5 to T1). Table 23 is useful regarding impairment from persistent joint subluxation or dislocation, and Table 27 can be helpful in assessing impairment of the upper extremity after arthroplasty of specific bones of joints. Although inter-rater reliability has been reasonably good, the validity of the upper extremity impairment rating has been questioned, and further research in industrial medicine and physical disability is required.

Upper Extremity Impairment Evaluation: Fifth Edition Revisions

2001 ◽  
Vol 6 (3) ◽  
pp. 1-5, 12
Author(s):  
Christopher R. Brigham ◽  
Charles N. Brooks
Keyword(s):  
Peripheral Nerve ◽  
Upper Extremity ◽  
Pain Syndrome ◽  
Upper Extremities ◽  
Fourth Edition ◽  
Strength Assessment ◽  
Sensory Deficits ◽  
Entrapment Neuropathies ◽  
New Process ◽  
Upper Extremity Impairment

Abstract Chapter 16, The Upper Extremities, in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, presents several changes from the Fourth Edition. The changes are minor compared to those in Chapter 15, The Spine, but are more significant than those in Chapter 17, The Lower Extremities. This article examines some of the most important revisions, notably the more rigorous standards for upper extremity evaluation, the requirement to compare motion findings to those of the contralateral extremity, entrapment neuropathies evaluation, and strength assessment. The principles of assessment are essentially unchanged in the AMA Guides, Fifth Edition, and Section 16.1c now clarifies the process of combining assessments. The Fifth Edition provides more direction about how to measure motion, but the values for motion deficits remain the same as in the Fourth Edition. Among important changes in the Fifth Edition regarding rating peripheral nerve impairment are: grading sensory deficits, rating entrapment neuropathies, and evaluating complex regional pain syndrome. The most noteworthy changes in assessing impairment due to other disorders are the following: explicit directions about how to rate these other disorders; elimination of rating for joint crepitation; inclusion of new radiographic criteria for rating carpal instability, and introduction of a new process for rating shoulder instability. The discussion of strength is expanded in the Fifth Edition of the AMA Guides.

Clinical Update: Measuring Shoulder Joint Motion

1998 ◽  
Vol 3 (5) ◽  
pp. 4-5
Author(s):  
Christopher R. Brigham
Keyword(s):  
External Rotation ◽  
Joint Motion ◽  
Fourth Edition ◽  
Single Plane ◽  
Reconstructive Procedures ◽  
Results Of Treatment ◽  
Shoulder Disorders ◽  
Shoulder Motion ◽  
Motion Measurements ◽  
Upper Extremity Impairment

Abstract Accurate measurement of shoulder motion is critical in assessing impairment following shoulder disorders. To this end, measuring and recording joint motion are important steps in diagnosing, determining the severity and progression of a disorder, assessing the results of treatment, and evaluating impairment. Shoulder movement usually is composite rather than in a single plane, so isolating single movements is challenging. Universal goniometers with long arms are used to measure shoulder motion, and testing must be performed and recorded consistently. Passive motion may be carried out cautiously by the examiner; two measurements of the same patient by the same examiner should lie within 10° of each other. Shoulder extension and flexion are illustrated. Maximal flexion of the shoulder also includes slight external rotation and abduction, and controlling or eliminating these components during evaluation is challenging. Abduction and adduction are illustrated. Deficits in external rotation may occur in patients who have undergone reconstructive procedures with an anterior approach; deficits in internal rotation may result from issues with shoulder instability. The authors recommend recording the shoulder's range of motion measurements according to the Upper Extremity Impairment Evaluation Record in the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition.

Clinical Update: Grip Strength: An Uncommon Impairment

2003 ◽  
Vol 8 (5) ◽  
pp. 6-11 ◽  
Author(s):  
Christopher R. Brigham
Keyword(s):  
Peripheral Nerve ◽  
Grip Strength ◽  
Time Of Day ◽  
Strength Testing ◽  
Nerve Lesion ◽  
Body Parts ◽  
Muscle Tear ◽  
Upper Extremity Impairment ◽  
Missing Digit ◽  
Loss Of Strength

Abstract Upper extremity impairment rarely is assessed using grip strength, according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), because results can be influenced by subjective factors that are difficult to control, including sex, age, comorbidities, fatigue, handedness, time of day, pain, and the individual's cooperation. The AMA Guides, Section 16.5b, Impairment Evaluation Methods, discusses the approach used for rating peripheral nerve injuries, but this section applies only to specific nerve lesions with resulting weakness of the muscles supplied or sensory changes. Strength correlates only poorly with performance of the activities of daily living, and grip strength testing using a dynamometer or other types of isometric strength testing has not been shown to reliably discriminate between submaximal and maximal efforts. Grip strength usually is not used in the presence of decreased motion, painful conditions, deformities, or absence of body parts (eg, missing digit), nor is it used to rate weakness from a peripheral nerve lesion. In rare cases, the AMA Guides allows the use of loss of strength (eg, due to a severe muscle tear that healed leaving a palpable muscle defect). Impairment ratings based on objective anatomic findings take precedence, and loss of strength is rarely combined and only if based on unrelated etiologic or pathomechanical causes.

Comparative Analysis of Third Edition, Revised; Fourth; and Fifth Edition Ratings: The State of Colorado Study

2004 ◽  
Vol 9 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Christopher R. Brigham ◽  
Kathryn Mueller ◽  
Douglas Van Zet ◽  
Debra J. Northrup ◽  
Edward B. Whitney ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Upper Extremity ◽  
Interrater Reliability ◽  
The State ◽  
Fourth Edition ◽  
Department Of Labor ◽  
Independent Expert ◽  
Whole Person ◽  
Impairment Ratings ◽  
Upper Extremity Impairment

Abstract In 2002, the Department of Labor and Employment, the State of Colorado, performed a study to identify changes among the Third Edition, Revised (December 1990); the Fourth Edition (June 1993); and the Fifth Edition (November 2000) of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This three-part article summarizes the differences found. The study was based on a random sample of 250 cases identified by the Division of Workers’ Compensation of the State of Colorado and stratified into three broad categories: 40 upper extremity cases, 60 lower extremity cases, and 150 whole person cases. Only case records with adequate documented evidence to enable rating among all three editions of the AMA Guides were included. The average age of the examinee was 42.9 years (SD, 11.1 years, range, 18 to 71 years, 171 [68%] male); equal percentages of men and women were present in the upper extremity impairment ratings (20 men, 20 women), but lower extremity and whole person impairments occurred primarily among males (73% and 71% men, respectively). Interrater reliability was obtained from an independent expert medical review of 20% of the cases. Three figures show percentages of upper extremity, lower extremity, and whole person impairment according to the edition used; ratings generally are lower with more recent editions.

The Challenge of Evaluating RSD Impairment and Disability (Part II)

1998 ◽  
Vol 3 (1) ◽  
pp. 1-4 ◽  
Author(s):  
Leon H. Ensalada
Keyword(s):  
Peripheral Nerve ◽  
Reflex Sympathetic Dystrophy ◽  
Evaluation Method ◽  
Pain Syndrome ◽  
Current Approach ◽  
Motor Deficits ◽  
Type I ◽  
Type Ii ◽  
Fourth Edition ◽  
Peripheral Nerve Disorder

Abstract Part II of this two-part series continues the discussion of diagnostic and treatment issues related to reflex sympathetic dystrophy (RSD) and presents approaches to assessing pain and disability associated with complex regional pain syndrome (CRPS). CRPS encompasses CRPS Type I (RSD) and CRPS Type II (causalgia), but the approach of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition is problematic. The current approach may not account for the complete impairment, and RSD/CRPS I by definition does not involve a specific peripheral nerve disorder. Causalgia/CRPS II by definition involves a specific peripheral nerve disorder, and the physician can assess impairment due to pain and sensory deficit or loss of power and motor deficits by multiplying the graded percent deficit with the maximum allowable impairment for the specific peripheral nerve. RSD/CRPS I by definition does not involve disruption of a peripheral nerve, but the criteria recommended by the AMA Guides may be difficult to use. The fourth edition of the AMA Guides advises that, in general, only one evaluation method should be used to evaluate a specific impairment, and a table specifies which tests should not be used together, those that may be used in combination, if appropriate, and those for which combination is not specified.

Impairment Tutorial: Rating Peripheral Nerve Disorders of the Upper Extremity

1996 ◽  
Vol 1 (1) ◽  
pp. 2-4
Author(s):  
Kathryn Mueller
Keyword(s):  
Peripheral Nerve ◽  
Upper Extremity ◽  
Motor Impairment ◽  
Sixth Grade ◽  
Sensory Function ◽  
Sensory Loss ◽  
Motor Deficit ◽  
Sensory Deficits ◽  
Maximum Loss ◽  
Whole Person

Abstract The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) Fourth Edition, states that peripheral nerve impairments are determined by determining the percentage of the patient's motor and sensory loss. This article discusses the six steps necessary to rate a peripheral nerve impairment of the upper extremity: First, identify the nerve or nerves affected using relevant tables and figures. Second, locate the table that lists the nerve identified, and record the maximum loss attributed to that nerve for motor and sensory function. A table lists peripheral nerve charts in the AMA Guides, including nerves rated, table and page numbers, and type of rating (upper or lower extremity, foot, and so on). Third, grade the motor deficit of the nerve, and, using the appropriate table, find the percentage range and choose a number within the range that is appropriate for the patient; multiply the graded percentage by the total motor impairment found in step two. Fourth, determine the total deficit for the nerve by combining the motor and sensory deficits using the Combined Values Chart. Fifth, combine the total nerve deficit with other appropriate impairments. A table instructs raters how to convert to a whole person impairment. Sixth, grade the sensory deficit of the nerve. An example illustrates application of the six steps.

Tools and Resources: Instrumentation for Upper Extremity Impairment Assessment

1999 ◽  
Vol 4 (3) ◽  
pp. 7-8
Author(s):  
James B. Talmage
Keyword(s):  
Upper Extremity ◽  
Resection Arthroplasty ◽  
Neurological Deficits ◽  
Large Role ◽  
Fourth Edition ◽  
Primary Methods ◽  
Radiographic Findings ◽  
Relative Value ◽  
Strength Tests ◽  
Upper Extremity Impairment

Abstract The primary methods of evaluating impairment in the upper extremity are range of motion testing and neurological examination. For certain conditions that do not cause motion or neurological deficits yet leave the extremity significantly impaired, the editors of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, provided Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. The AMA Guides emphasizes that the criteria described in these “other disorders” should be applied only when the other criteria have not adequately encompassed the extent of the impairments. The evaluator must carefully read the criteria for rating each derangement to ensure the rating is correct and not duplicative. Table 26, Upper Extremity Impairment Due to Carpal Instability Patterns, includes values based on radiographic findings, and Table 27, Impairment of the Upper Extremity after Arthroplasty of Specific Bones or Joints, features ratings for resection arthroplasty and implant arthroplasty. Tables 28, 29, and 30 for musculotendinous impairments require that the percent of digit impairment be multiplied by the relative value of the digit according to Table 18. The AMA Guides does not assign a large role to functional measurements such as pinch and grip strength tests because they are influenced by subjective factors that are difficult to control.

Quick Reference: Measuring Impairment Due to Other Disorders of the Upper Extremity

1999 ◽  
Vol 4 (3) ◽  
pp. 5-6
Keyword(s):  
Upper Extremity ◽  
Sensory Quality ◽  
Tuning Fork ◽  
Sensory Testing ◽  
Fourth Edition ◽  
Reference Measuring ◽  
Paper Clip ◽  
Sensory Modalities ◽  
Hand Dynamometer ◽  
Upper Extremity Impairment

Abstract When performed according to criteria in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, upper extremity impairment assessment requires a thorough physical examination of the involved (and contralateral) upper limb. Observation and palpitation require no instrumentation, and much of the equipment necessary for the remainder of the examination may be present in the physician's office. According to the AMA Guides, sensory testing, particularly in the hand and digits, requires equipment and considers all sensory modalities, including perception of pain, heat, cold, and touch. For example, the two-point discrimination test of sensory quality can be performed using a paper clip or commercially available test disks. Traditionally, light touch is assessed using a cotton tipped swab, and sharp-dull discrimination can be assessed using a safety pin or needle (discard after use). Pressure and vibration sensibility can be assessed using the end of an initially still, then vibrating 128-Hz tuning fork. Deep tendon reflexes are tested with a reflex hammer; goniometers of various sizes are used for range-of-motion tests; and grip strength is assessed using a hand dynamometer. Other instruments are available to assess hand and upper extremity sensibility, coordination, strength, and motion but are not used by the AMA Guides for estimating impairment.

Combining Values

2002 ◽  
Vol 7 (2) ◽  
pp. 1-4, 12 ◽  
Author(s):  
Christopher R. Brigham
Keyword(s):  
Lower Extremity ◽  
Upper Extremity ◽  
Evaluation Method ◽  
Proximal Phalanx ◽  
Common Error ◽  
The Third ◽  
Whole Person ◽  
Impairment Ratings ◽  
Upper Extremity Impairment ◽  
The Individual

Abstract To account for the effects of multiple impairments, evaluating physicians must provide a summary value that combines multiple impairments so the whole person impairment is equal to or less than the sum of all the individual impairment values. A common error is to add values that should be combined and typically results in an inflated rating. The Combined Values Chart in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, includes instructions that guide physicians about combining impairment ratings. For example, impairment values within a region generally are combined and converted to a whole person permanent impairment before combination with the results from other regions (exceptions include certain impairments of the spine and extremities). When they combine three or more values, physicians should select and combine the two lowest values; this value is combined with the third value to yield the total value. Upper extremity impairment ratings are combined based on the principle that a second and each succeeding impairment applies not to the whole unit (eg, whole finger) but only to the part that remains (eg, proximal phalanx). Physicians who combine lower extremity impairments usually use only one evaluation method, but, if more than one method is used, the physician should use the Combined Values Chart.

Peripheral Nerve and Brachial Plexus Impairment, AMA Guides, Sixth Edition

2017 ◽  
Vol 22 (2) ◽  
pp. 3-5
Author(s):  
James B. Talmage ◽  
Jay Blaisdell
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Complex Regional Pain Syndrome ◽  
Lower Extremities ◽  
Pain Syndrome ◽  
Upper Extremities ◽  
Motor Deficits ◽  
Type I ◽  
Sixth Edition ◽  
Nerve Entrapments

Abstract Physicians use a variety of methodologies within the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, to rate nerve injuries depending on the type of injury and location of the nerve. Traumatic injuries that cause impairment to the peripheral or brachial plexus nerves are rated using Section 15.4e, Peripheral Nerve and Brachial Plexus Impairment, for upper extremities and Section 16.4c, Peripheral Nerve Rating Process, for lower extremities. Verifiable nerve lesions that incite the symptoms of complex regional pain syndrome, type II (similar to the former concept of causalgia), also are rated in these sections. Nerve entrapments, which are not isolated traumatic events, are rated using the methodology in Section 15.4f, Entrapment Neuropathy. Type I complex regional pain syndrome is rated using Section 15.5, Complex Regional Pain Syndrome for upper extremities or Section 16.5, Complex Regional Pain Syndrome for lower extremities. The method for grading the sensory and motor deficits is analogous to the method described in previous editions of AMA Guides. Rating the permanent impairment of the peripheral nerves or brachial plexus is similar to the methodology used in the diagnosis-based impairment scheme with the exceptions that the physical examination grade modifier is never used to adjust the default rating and the names of individual nerves or plexus trunks, as opposed to the names of diagnoses, appear in the far left column of the rating grids.

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