Search Results
You are looking at 21 - 30 of 78 items for
- Author or Editor: Charles N Brooks x
- Refine by Access: All content x
Abstract
Like all multi-authored texts, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) presents some challenges and inconsistencies, and in March 2002 AMA published an errata. The latter has only one correction for Chapter 17, The Lower Extremities, and this article reviews some additional problems and inconsistencies in Chapter 17. For example, the AMA Guides, Fifth Edition, gives inconsistent instructions about measurements of muscle atrophy, and this article recommends simple, unambiguous directions such as measuring thigh and leg circumferences 15 cm superior and inferior to the medial joint line of the knee, respectively. One could argue that no goniometer should be included in Figure 17-1a, Using a Goniometer to Measure Flexion of the Right Hip; in Figure 17-1b, the goniometer should be placed with its axis at the center of rotation of the right hip. In Figure 17-1c, the limb of the goniometer overlying the left femur should instead be parallel to the tabletop. Additional sections of the article discuss joint ankylosis; peripheral nerve injuries; causalgia, complex regional pain syndrome, and reflex sympathetic dystrophy. A careful reading of Chapter 17 uncovers some problems, none of which is critical, but all should be noted by frequent users of the AMA Guides.
Abstract
Maximum medical improvement (MMI) and its multiple synonyms are important terms to understand because one cannot determine permanent impairment until a condition has resolved or reached a stable plateau with respect to improvement. Further, in many jurisdictions MMI represents the date beyond which temporary or all benefits cease or time-loss compensation (temporary disability benefits) may be terminated. Because each arena is to some extent unique, evaluating physicians should become familiar with MMI or the term used and its definition in the applicable federal, state, or provincial law or insurance policy. A table shows the terminology used by various US workers’ compensation jurisdictions, but there is no universal definition for MMI. The fourth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) says only that “an impairment should not be considered ‘permanent’ until the clinical findings, determined during a period of months, indicate that the medical condition is static and well stabilized. The AMA Guides, Fifth Edition, defines MMI as “a condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment” but acknowledges the possibility of “some change.” Similarly the sixth edition states that MMI is the “point at which a condition has stabilized and is unlikely to change (improve or worsen) substantially in the next year, with or without treatment”; signs and symptoms may wax and wane, but further recovery or deterioration is not anticipated.
Abstract
The presence of multiple ratable entities, including symptoms, physical findings, test results, diagnoses, and/or procedures, complicates impairment evaluation; further, patients may have several findings in the same anatomic area and/or findings unrelated to the condition being rated. In complex cases involving a final extremity or whole person impairment (WPI), the examining physician must consider all possible ratable impairments, discarding duplicative or mutually exclusive ratings and converting, adding, or combining to obtain the final rating. Failure to follow the instructions detailed in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is a common source of error in impairment rating. The AMA Guides provides multipliers and, for the upper extremity, tables to convert a body part impairment to an extremity and then to a whole person rating. Jurisdictional requirements vary, but rating physicians commonly are asked to provide a single impairment percentage for the limb or whole person; when two or more impairments are involved, the rater must add or combine the percentages, carefully following the specific instructions in the AMA Guides. Adding two ratings is no different than deriving any other arithmetic sum, but impairment percentages much more commonly are combined than added to ensure that, no matter how many impairments are present, the total is never greater than 100% loss of an extremity or 100% WPI.
Abstract
The process of assessing lower extremity impairment described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, differs from that in previous editions. This article addresses common questions that arise in knee and hip impairment rating according to the new edition. Anatomic, diagnostic, or functional methods can be used to estimate lower extremity impairments. Functional methods include ratings based on diminished range of motion, weakness, or gait derangement. In general, only one method should be used to rate impairment associated with an injury or illness. Section 3.2i, Diagnosis-related Estimates, in the AMA Guides lists impairment ratings for many knee conditions and operative procedures. Decreased range of motion, ankylosis, diminished muscle function, and joint space narrowing are some rating methods for the knee. Similar anatomic, diagnostic, and functional methods may be used to rate impairment due to hip pathology, but most hip impairments are estimated by range-of-motion deficits. Assessing lower extremity impairments requires a thorough medical evaluation, careful analysis, experience, and clear judgment; evaluators must determine the applicable rating methods, use the methods to rate the impairment, and then decide which method or combination best describes the impairment, without overlooking or duplicating ratings. [A related Lower Extremity Impairment Checklist and Worksheet appears on page 4 of this issue of The Guides Newsletter. A related Quick Reference, Motion at the Wrist, Elbow, and Shoulder, appears on page 5.]
Abstract
The pain, numbness, and paresthesias of carpal tunnel syndrome generally are intermittent and are felt in the wrist, hand, thumb, and fingers, often in a distribution approximating that of the median nerve. No specific physical examination exists for carpal tunnel syndrome, and, in the impairment rating assessment, the physical examination focuses on detecting signs of permanent nerve damage (decreased sensation and thenar weakness on opposition). According to the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), provocative tests have no role in impairment rating. The AMA Guides, Fifth Edition, requires nerve conduction testing (NCT), even in “believable” instances, but no uniform definition of an abnormal NCT exists and examiners should realize the uses and limits of NCT. For example, if the NCT is normal, the symptoms, even if believable, do not rise to the level of an impairment. Impairment assessment must take place when the patient is at maximum medical improvement. If the NCT is grossly abnormal (axon loss) and/or degenerative changes are present on needle electromyography, and if physical exam shows sensory and/or thenar weakness, the examiner can use tables in the AMA Guides to rate the disability, combining sensory and motor impairments as appropriate. A one-page sidebar in this issue of The Guides Newsletter addresses the causes of carpal tunnel syndrome.
Abstract
The primary function of the acetabular labrum, like that of the glenoid, is to deepen the socket and improve joint stability. Tears of the acetabular labrum are common in older adults but occur in all age groups and with equal frequency in males and females. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, is silent about rating tears, partial or complete excision, or repair of the acetabular labrum. Provocative tests to detect acetabular labrum tears involve hip flexion and rotation; all rely on production of pain in the groin (typically), clicking, and/or locking with passive or active hip motions. Diagnostic tests or procedures rely on x-rays, conventional arthrography, computerized tomography, magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and hip arthroscopy. Hip arthroscopy is the gold standard for diagnosis but is the most invasive and most likely to result in complications, and MRA is about three times more sensitive and accurate in detecting acetabular labral tears than MRI alone. Surgical treatment for acetabular labrum tears usually consists of arthroscopic debridement; results tend to be better in younger patients. In general, an acetabular labral tear, partial labrectomy, or labral repair warrants a rating of 2% lower extremity impairment. Evaluators should avoid double dipping (eg, using both a Diagnosis-related estimates and limited range-of-motion tests).
Abstract
The terms subjective and objective often appear in health care records, and one commonly hears about “subjective symptoms” and “objective complaints”—yet the former is redundant and the latter an oxymoron. Objectively verifiable pathology may explain a patient's symptoms, but complaints themselves are never objective but rather, by definition, subjective. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, defines the terminology: Subjective information is more open to interpretation, but objective data are factual, reproducible, and often measurable or quantifiable. Objective findings generally have much higher inter-examiner reliability than subjective findings. Symptoms and most findings on physical (particularly neuromusculoskeletal) examination are subjective. Diagnostic study results and a minority of physical findings are objective. Some physical findings, such as strength and range of motion measurements, are both subjective and objective. Repeat testing, assessment of plausibility, and use of confirmatory physical findings can be used to validate or “objectify” subjective findings (eg, by determining if a weakness is corroborated by other neurologic or physical findings, imaging study results, and/or electrodiagnostic testing). The use of objective, or at least less subjective, findings in impairment rating should improve interrater reliability. Thus, evaluating physicians should not regard subjective complaints and findings, and they should lend greater weight to objective findings.
