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.