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- Author or Editor: Charles N Brooks x
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Abstract
The diagnosis, cause, and treatment of thoracic outlet syndrome (TOS) are challenging, and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) gives no specific instructions about rating impairments associated with this disorder. TOS is a group of symptoms and signs, including pain, weakness, paresthesias, numbness, swelling, and/or coldness arising at the base of the neck or superior chest but involving the upper limbs. Causes include compression of the brachial plexus (neurogenic TOS) or, less frequently, subclavian vein and/or artery (vascular TOS). Provocative tests for TOS attempt to induce symptoms and/or signs by compressing the subclavian artery or vein or brachial plexus, but palpitation of the radial pulse in various extremity positions is of limited diagnostic value. Diagnostic studies may include radiographs of the cervical spine, upper chest, and/or shoulder; MRI scans of the thoracic outlet; arteriography or venography, and electrodiagnostic testing. The differential diagnosis for TOS is broad and includes cervical radiculopathy, superior sulcus tumor, other peripheral nerve entrapment syndromes, complex regional pain syndrome, and psychiatric disease. The evaluator must determine if the symptoms, physical findings, and diagnostic study results support the diagnosis; the report should list the rating options considered, discuss the rationale for selecting the method(s) used, and explain how the percentage was calculated.
Abstract
To determine if an acromioplasty is impairing, an evaluator must know shoulder anatomy, the diagnosis or diagnoses, what treatment was provided, and the patient's present status. Over time, the earlier classification of shoulder impingement has been modified, and the current classification was adopted in 1994. At present, acromioplasty often is not the primary surgery but rather is one component of subacromial decompression with or without concomitant rotator cuff and/or intra-articular shoulder surgery. Until the sixth edition, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) did not address the question whether acromioplasty itself constitutes an impairment. In the fourth and fifth editions of the AMA Guides, although open or arthroscopic acromioplasty commonly results in temporary shoulder pain, stiffness, and weakness, the surgical procedure itself, barring complication, results in no permanent impairment. According to the AMA Guides, Sixth Edition, if an acromioplasty eliminated impingement and resulted in no pain or significant objective findings at maximal medical impairment, no impairment occurred. Diagnosis-based impairment is considered the rating method of choice, but range of motion is used primarily in the physical examination adjustment grid. Further, surgical error and/or complications may result in ratable motion and/or strength deficits. The AMA Guides, Fourth and Fifth Editions, also provide a means to rate impairment due to any concomitant distal clavicular resection.
Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, introduced the concept of diagnosis-based impairments (DBI), and a modified version of this method can be used in rating peripheral nerve injury in general (Section 5.4) and upper limb entrapment syndromes (Section 15.4f). The first portion of this article reviews the evaluation of upper extremity nerve impairment and summarizes inclusion criteria and causation correlation for carpal tunnel syndrome, Guyon's canal syndrome, cubital tunnel syndrome, anterior interosseous, Wartenberg's syndrome, and radial tunnel syndrome. Very mild nerve entrapments do exist and may fail to meet the AMA Guides criteria for impairment related to a diagnosis of nerve entrapment. Electrodiagnostic examination includes nerve conduction studies that assess the largest, most heavily myelinated axons, and needle electromyelography, which detects muscle membrane instability but not the sensory function of nerves. A case example from the AMA Guides, Sixth Edition, shows the process of permanent impairment rating in a case of carpal tunnel syndrome. Determination of impairment for peripheral nerve entrapments can be easily accomplished once one understands how to determine if the nerve under consideration from the electrodiagnostic evaluation demonstrates a conduction delay, a conduction block, or an axon loss. This establishes the test findings that usually are the only objective findings present.
Abstract
Repetitive illness sometimes is wrongly called repetitive injury or cumulative trauma, but the latter are misnomers because the employee cannot identify a specific injury as a cause of the symptoms. In workers’ compensation, such gradual illness claims may be compensable if the condition arises during the course of employment, which requires that it be caused by occupational duties, exposures, or equipment used on the employer's premises. Expert impairment evaluators face three requirements: they must know the best scientific evidence currently available regarding causation of the condition(s) in question, ie, generic causation; the facts of the individual case, ie, specific causation; and the legal threshold in the applicable jurisdiction for acceptance of a condition as work related. The AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, is an excellent resource and provides the physician a blueprint for the assessment of causation in occupational injury and illness claims. The book adopts the methodology developed by the National Institute for Occupational Safety and Health and the American College of Occupational and Environmental Medicine. When asked to render opinions regarding causation, a physician is wise to consider this methodology in determining the work relatedness of the condition. Medical opinions based on an accepted methodology and the best scientific evidence will result in better patient outcomes.
