Impairment Tutorial: Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating

2003 ◽  
Vol 8 (5) ◽  
pp. 4-12
Author(s):  
Lorne Direnfeld ◽  
James Talmage ◽  
Christopher Brigham
Keyword(s):  
Upper Extremity ◽  
Radicular Pain ◽  
Illness Behavior ◽  
Orthopedic Surgeon ◽  
First Case ◽  
Clinical Presentations ◽  
Whole Person ◽  
Physical Examinations ◽  
Upper Extremity Impairment ◽  
The Individual

Abstract This article was prompted by the submission of two challenging cases that exemplify the decision processes involved in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In both cases, the physical examinations were normal with no evidence of illness behavior, but, based on their histories and clinical presentations, the patients reported credible symptoms attributable to specific significant injuries. The dilemma for evaluators was whether to adhere to the AMA Guides, as written, or to attempt to rate impairment in these rare cases. In the first case, the evaluating neurologist used alternative approaches to define impairment based on the presence of thoracic outlet syndrome and upper extremity pain, as if there were a nerve injury. An orthopedic surgeon who evaluated the case did not base impairment on pain and used the upper extremity chapters in the AMA Guides. The impairment ratings determined using either the nervous system or upper extremity chapters of the AMA Guides resulted in almost the same rating (9% vs 8% upper extremity impairment), and either value converted to 5% whole person permanent impairment. In the second case, the neurologist evaluated the individual for neuropathic pain (9% WPI), and the orthopedic surgeon rated the patient as Diagnosis-related estimates Cervical Category II for nonverifiable radicular pain (5% to 8% WPI).

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.

To Combine or Not to Combine

2013 ◽  
Vol 18 (6) ◽  
pp. 9-9
Author(s):  
Mohammed I Ranavaya ◽  
Robert Rondinelli
Keyword(s):  
Upper Extremity ◽  
Single Case ◽  
General Rule ◽  
Lower Limbs ◽  
Limb Injuries ◽  
Whole Person ◽  
Sensory Motor ◽  
Common Unit ◽  
Upper Extremity Impairment ◽  
The Individual

Abstract Physicians must account for the effects of multiple impairments using a summary value. Sometimes, when dealing with multiple impairments in a single case, the evaluating physician may be confused about whether specific impairments are added or combined, particularly during the assessment of hand or limb injuries. Combining is accomplished by using the Combined Values Chart presented in the Appendix of each edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). With a few exceptions, the general rule is that all impairments should be combined. The combining must occur at the same hierarchal level (eg, upper extremity impairment can be combined only with another upper extremity impairment from the same limb), and whole person impairment (WPI) can be combined only with another WPI impairment. In case of impairments from a different limb (either from both upper or lower limbs) even though they may be expressed at the same hierarchal limb (eg, upper extremity or lower extremity), they should be combined at the WPI level only after the individual limb is fully rated and the final impairment for that limb is expressed at the WPI level. Evaluators should remember that impairing factors (sensory, motor, vascular, and so on) are combined at the smallest common unit (ie, digit < hand < upper extremity < whole person).

Combining Values Chart

2012 ◽  
Vol 17 (2) ◽  
pp. 7-9
Author(s):  
Christopher R. Brigham
Keyword(s):  
Lower Extremity ◽  
Upper Extremity ◽  
Sixth Edition ◽  
Whole Person ◽  
The Individual

Abstract Evaluating physicians may need to account for the effects of multiple impairments using a summary value. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, the Combined Values Chart provides a method to combine two or more impairment percentages based on the formula A + B(1 – A) = the combined value of A and B. Using the Combined Values Chart and this formula, physicians can combine multiple impairments so that the whole person impairment is equal to or less than the sum of all the individual impairment values. The AMA Guides, Sixth Edition, specifies that “impairments are successively combined by first combining the largest number with the next largest remaining number, and then further combining it with the next largest remaining number … until all given impairment numbers are combined.” Impairment values within a region generally are combined and converted to whole person permanent impairment before being combined with values from other regions. The article reviews the AMA Guides, Sixth Edition, approach to combining upper extremity impairments, lower extremity impairments, and combining spinal impairments.

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.

Quick Consult: Quick Consult: Acromioplasty

2002 ◽  
Vol 7 (3) ◽  
pp. 4-5
Keyword(s):  
Glasgow Coma Scale ◽  
Outcome Assessment ◽  
High Probability ◽  
Vegetative State ◽  
Behavioral Impairment ◽  
Whole Person ◽  
Ordinal Scales ◽  
Probability Of Death ◽  
The Individual ◽  
Assessment Scales

Abstract Different jurisdictions use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) for different purposes, and this article reviews a specific jurisdictional definition in the Province of Ontario of catastrophic impairment that incorporates the AMA Guides. In Ontario, a whole person impairment (WPI) exceeding 54% or a mental or behavioral impairment of Class 4 or 5 qualifies the individual for catastrophic benefits, and individuals who do not meet the test receive a lesser benefit. By inference, this establishes a parity threshold among dissimilar injuries and dissimilar outcome assessment scales for benefits. In Ontario, the Glasgow Coma Scale (GCS) identifies patients who have a high probability of death or of severely disabled survival. The GCS recognizes gradations of vegetative state and disability, but translating the gradations for rating individual impairment on ordinal scales into a method of assessing percentage impairments cannot be done reliably, as explained in the AMA Guides, Fifth Edition. The AMA Guides also notes that mental and behavioral impairment in Class 4 (marked impairment) or 5 (extreme impairment) indicates “catastrophic impairment” by significantly impeding useful functioning (Class 4) or significantly impeding useful functioning and implying complete dependency on another person for care (Class 5). Translating the AMA Guides guidelines into ordinal scales cannot be done reliably.

Nonspecific Chronic Back Pain: Sixth Edition Approaches

2019 ◽  
Vol 24 (5) ◽  
pp. 14-15
Author(s):  
Jay Blaisdell ◽  
James B. Talmage
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Intervertebral Disk ◽  
Key Factors ◽  
Sixth Edition ◽  
Whole Person ◽  
Class 1 ◽  
A Cell ◽  
Intervertebral Disk Herniation ◽  
The Individual

Abstract Ratings for “non-specific chronic, or chronic reoccurring, back pain” are based on the diagnosis-based impairment method whereby an impairment class, usually representing a range of impairment values within a cell of a grid, is selected by diagnosis and “specific criteria” (key factors). Within the impairment class, the default impairment value then can be modified using non-key factors or “grade modifiers” such as functional history, physical examination, and clinical studies using the net adjustment formula. The diagnosis of “nonspecific chronic, or chronic reoccurring, back pain” can be rated in class 0 and 1; the former has a default value of 0%, and the latter has a default value of 2% before any modifications. The key concept here is that the physician believes that the patient is experiencing pain, yet there are no related objective findings, most notably radiculopathy as distinguished from “nonverifiable radicular complaints.” If the individual is found not to have radiculopathy and the medical record shows that the patient has never had clinically verifiable radiculopathy, then the diagnosis of “intervertebral disk herniation and/or AOMSI [alteration of motion segment integrity] cannot be used.” If the patient is asymptomatic at maximum medical improvement, then impairment Class 0 should be chosen, not Class 1; a final whole person impairment rating of 1% indicates incorrect use of the methodology.

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.

scholarly journals Assessment of upper extremity movement performance of patients with obstetric brachial plexus palsy

2017 ◽  
Vol 3 (1) ◽  
pp. 1-5 ◽  
Author(s):  
Ligia C. S. Fonseca ◽  
Annika K. Nelke ◽  
Jörg Bahm ◽  
Catherine Disselhorst-Klug
Keyword(s):  
Brachial Plexus ◽  
Upper Extremity ◽  
Objective Data ◽  
Brachial Plexus Palsy ◽  
Obstetric Brachial Plexus Palsy ◽  
Movement Performance ◽  
Obstetric Brachial Plexus ◽  
The Individual ◽  
Acceleration Signals ◽  
Upper Extremity Movement

Abstract:Coping strategies of patients with obstetric brachial plexus palsy (OBPP) are highly individual. Up to now, individual movement performance is assessed by visual observations of physicians or therapists - a procedure, which is highly subjective and lacks objective data. However, objective data about the individual movement performance are the key to evidence-based and individualized treatment. In this paper, a new approach is presented, which provides objective information about the upper extremity movement performance of patients with OBPP. The approach is based on the use of accelerometers in combination with a classification procedure. The movement performance of 10 healthy volunteers and 41 patients with OBPP has been evaluated by experienced physiotherapists and has been assigned to one of 4 categories representing the Mallet Scale (MS) IV to I. Three triaxial-accelerometers were placed at chest, upper arm and wrist of the affected side of the patient. Acceleration signals have been recorded during repetitive movements with relevance regarding daily life. Here, especially the results from the “hand to mouth” task are presented. From the 9 recorded acceleration signals 13 relevant features were extracted. For each of the 13 features 4 thresholds have been determined distinguishing best between the 4 patient categories of the MS and the healthy subjects. With respect to the thresholds each feature value has been assigned to the discrete numbers 0, 1, 2, 3 or 4. Afterwards, each discrete number has been weighted by a factor regarding the correlation between the feature’s value and the MS score. The resulting weighted discrete numbers of all 13 features have been added resulting in a score, which quantifies the individual upper extremity movement performance. Based on this score the movement performance of each patient has been assigned to the classes “very good”, “good”, “regular” and “bad”. All movements of the 10 healthy volunteers were classified as “very good”. The movement performance of two patients MS IV were classified as “very good” as well and the movements of the other 16 patients as “good”. The movements of the entire group of MS III patients fell into the class “regular”. Just one MS II patient was assigned to the class “regular” while the others were classified as “bad”. It was not possible to classify the movements of MS I patients. This was mainly due to the fact that none of these patients MS I was able to complete the task successfully. The developed approach demonstrated its ability to quantify the movement performance of upper extremity movements based on accelerometers. This provides an easy to use tool to assess patient’s movement strategies during daily tasks for diagnosis and rehabilitation.

Sign in / Sign up

Export Citation Format

Share Document