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ambulation, while Grade 3 strength (full ROM against gravity, but the addition of very minimal resistance no longer permits full motion) is rarely compatible with unassisted gait (ie, braces, crutches, etc, are necessary). Thus, if prior examiner(s) found Grade 4 strength but the examinee demonstrated Grade 3 strength during a subsequent IME, there probably is a medical explanation other than “day-to-day variation.” Ensuring reliability (consistency) requires the review of recent medical records to determine the results of manual muscle testing by other examiners and
The following tables are referenced in the article opposite, “Spinal Cord Impairments,” and have been included for quick and easy reference. Table 13 Station and Gait Impairment Criteria. Table 14 Criteria for One Impaired Upper Extremity. Table 15 Criteria for Two Impaired Upper Extremities. Table 16 Neurologic Impairment of Respiration. Table 17. Criteria for Neurologic Impairment of Bladder. Table 18 Criteria for Neurologic Anorectal Impairment. Table 19 Sexual Impairment Criteria.
required in his setting (4th ed., 75). No impairment for the lower extremity can exceed 40% of the whole person (which is equivalent to 100% of the lower extremity). This is an important benchmark to remember when calculating ratings to avoid duplication (4th ed., 84). For most diagnosis-based conditions, ranges of impairments are broad. The assessed impairment value should be made dependent on the patient's individual clinical manifestations (4th ed., 84). There are four ways to evaluate diminished muscle function. These are gait, atrophy, weakness, and
issue of The Guides Newsletter. Anatomic, diagnostic, and/or functional methods may be used to estimate lower extremity impairments. Limb length discrepancy and muscle atrophy are examples of the former (anatomic method). The diagnosis-based estimates section provides ratings not only for diagnoses per se (eg, lower extremity fractures or ligamentous laxity), but also provides ratings for surgical procedures, such as hip replacement, patellectomy, and meniscectomy. Examples of functional methods include ratings based on diminished range of motion, weakness, or gait
XII. The ratings range from 1% to 60% impairment of the whole person and are based on three levels of impairment related primarily to difficulty swallowing. Note that the first category includes the problem of mild dystonia and/or uncontrolled spasmodic torticollis. This condition affects cranial nerve XI (not IX or XII) and rates an impairment percentage between 1% to 14% of the whole person. The Spinal Cord The Guides divides impairment from spinal cord pathology into six categories: station and gait, use of the upper extremities, respiration, uri
total hand impairment derived from digits). Lower Extremity Impairment Evaluations □ Two or more methods are used, (eg, functional and diagnosis-based) and ratings are combined or added. □ Rating is based on sections 3.2a, “Limb Length Discrepancy” (4th ed., 75), 3.2b, “Gait Derangement” (4th ed., 75–767), 3.2g, “Arthritis” (4th ed., 82–83), or 3.2l, “Causalgia and Reflex Sympathetic Dystrophy” (4th ed., 89). □ Range of motion (ROM) deficits for the same joint are added or combined. □ Impairment values are added (other than for joint replacement
Abstract
Most impairment ratings for conditions affecting the cervical spine are relatively straightforward and can be addressed using the first three categories of the Injury Model in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This real-life case study illustrates how higher impairment categories are applied, including combining categories; the importance of rating the patient's condition based on the injury (as opposed to treatment outcome); and how apportionment is handled in different jurisdictions. Mr Smith, a 64-year-old high school principal, presented with numbness and burning pain from the chest to the feet, unsteadiness of gait, and difficulty maintaining an erection. Symptoms reportedly began two years earlier when he tripped and fell down a flight of stairs at work, striking his face. An MRI scan revealed marked spinal stenosis and cervical cord compression at C3 due to a combination of posterior C3-4 disc protrusion and osteophyte formation. Via an anterior approach, the orthopedic surgeon performed a C4 corpectomy, C3-4 and C4-5 discectomies, and then inserted a tricortical iliac bone graft between C3 and C5. Mr Smith improved postoperatively but still complained of numbness from upper chest to feet, mild unsteadiness of gait, and difficulty maintaining an erection. Evaluators can use the Injury Model, recalling that surgery to treat an impairment does not modify the original impairment, and in the jurisdiction in which Mr Smith was rated, if a claimant was asymptomatic before a work injury, the entire impairment is attributed thereto.
Anatomical, diagnostic, and functional methods are used in evaluating permanent impairment of the lower extremity. Section 3.2 advises, in general, only one evaluation method should be used to evaluate a specific impairment. In some circumstances … a combination of two or three methods may be required (4th ed., 75). The following grid summarizes which methods may be combined, dependent upon the specifics of the case. Short Leg Gait Atrophy Weakness ROM DJD Amputation Dx-based Skin Loss Neuro. RSD Vascular
