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- Author or Editor: James J. Mangraviti Jr x
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Abstract
The AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition, includes two methods of evaluating low back impairment following injury, the Diagnosis-related estimates (DRE) method and the Range of Motion (ROM) method. The DRE method should be used first, and the ROM method should be used only when the patient's injury is difficult to categorize or when two examiners disagree about how to categorize a patient. The final rating always comes from the DRE category, never from the ROM method. Two groups of findings help determine into which DRE category to place the patient: First are structural inclusions (eg, fracture patterns on an x-ray) that are objective and automatically place a patient into a DRE category. Second are differentiators such as guarding, loss of reflexes, or loss of bowel or bladder control. In addition, unlisted objective findings may help categorize a patient but may require interpretation; examples include muscle spasm, nonverifiable root pain, anatomical numbness, anatomical weakness, and straight-leg raising. This article discusses the interpretation of sometimes partially subjective findings, thus objectifying them: guarding; muscle spasm; dysmetria; nonverifiable root pain; loss of reflexes; atrophy; straight-leg raising; anatomical numbness; weakness; EMG; loss of motion segment integrity; loss of bowel or bladder control, bladder studies; and range of motion.
Abstract
The accurate measurement of hip motion is critical when one rates impairments of this joint, makes an initial diagnosis, assesses progression over time, and evaluates treatment outcome. The hip permits all motions typical of a ball-and-socket joint. The hip sacrifices some motion but gains stability and strength. Figures 52 to 54 in AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, illustrate techniques for measuring hip flexion, loss of extension, abduction, adduction, and external and internal rotation. Figure 53 in the AMA Guides, Fourth Edition, illustrates neutral, abducted, and adducted positions of the hip and proper alignment of the goniometer arms, and Figure 52 illustrates use of a goniometer to measure flexion of the right hip. In terms of impairment rating, hip extension (at least any beyond neutral) is irrelevant, and the AMA Guides contains no figures describing its measurement. Figure 54, Measuring Internal and External Hip Rotation, demonstrates proper positioning and measurement techniques for rotary movements of this joint. The difference between measured and actual hip rotation probably is minimal and is irrelevant for impairment rating. The normal internal rotation varies from 30° to 40°, and the external rotation ranges from 40° to 60°.
Abstract
How should an individual with pain arising from muscle be rated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides)? Syndromes of muscle pain include simple muscle strains and two controversial conditions, myofascial pain and fibromyalgia. Tables in the AMA Guides can be used for rating forearm injuries that affect grip or pinch strength; a separate set of tables can be used to rate the injury in a lower extremity. Injuries to some muscles (deltoid, biceps, and triceps) are not described in these sections but almost always test as grade 4. Major injury to muscle is well understood and noncontroversial, but terms such as myofascial pain syndrome and fibromyalgia describe controversial muscle pains. Some physicians attempt to differentiate myofascial pain and fibromyalgia on the basis of taut bands in myofascial pain and tender points in fibromyalgia, but the interrater reliability of these findings is low and the consensus view suggests that the cause of these two conditions is unknown. Muscle pain, like muscle contraction headache, irritable bowel syndrome, and dysmenorrhea, are real symptoms for which no impairment rating is provided. Our understanding of these conditions should improve with future research, enabling us to define criteria for evaluating impairment.
