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Christopher R. Brigham

QUESTION: Are the multiple impairments added or combined for a patient with multiple peripheral nerve impairments in a lower extremity (LE) injury according to the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (AMA Guides) , Sixth Edition Does it automatically mean that the cited ratings should be added simply because the impairments are listed in the same rating chart May a peripheral nerve impairment be combined with a diagnosis-based impairment ANSWER: Multiple peripheral nerve injuries of the LE are combined

in AMA Guides® Newsletter
James B. Talmage
,
Jay Blaisdell
, and
Christopher R. Brigham

Introduction Peripheral nerve impairments of the lower extremity (LE) are rated using Section 16.4, Peripheral Nerve Impairment (6th ed, 531-538), and Table 16-12, Peripheral Nerve Impairment (6th ed, 534) in the sixth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Because complex regional pain syndrome, type II (CRPS II), formerly known as causalgia, involves an “unambiguous” lesion to a specific peripheral nerve, it is also rated using Section 16.4 and Table 16-12. Complex regional pain syndrome, type I (CRPS I

in AMA Guides® Newsletter
Kathryn Mueller

Peripheral nerve impairments are determined by clinically grading the percentage of motor and sensory loss experienced by the examinee. The Guides , fourth edition, discusses this method in detail on pp. 46-57 and pp. 150-152. The six steps required to rate a peripheral nerve impairment of the upper extremity are detailed below. 1. Identify the nerve or nerves affected . Many charts are available in the Guides to aid this determination. For example, upper extremity nerve charts include: Table 10 (4th ed., 47) – functions of brachial plexus nerves

in AMA Guides® Newsletter
Christopher R. Brigham
and
Charles N. Brooks

select the method that best reflects the impairment. 16.5 Impairment of the Upper Extremities Due to Peripheral Nerves The Fifth Edition contains several changes in rating peripheral nerve impairment. The most significant of these are: grading sensory deficits, rating entrapment neuropathies, and evaluating complex regional pain syndrome. There are significant discrepancies between this chapter and Chapter 13, The Central and Peripheral Nervous System, and Chapter 16, The Upper Extremities. Sensory grading is reversed in the Fifth Edition upper extremity

in AMA Guides® Newsletter
Christopher R. Brigham

Peripheral nerve injury or illness may occur at the level of the spinal nerve, brachial plexus, or the peripheral nerve. This article discusses peripheral nerve impairment evaluation with a focus on assessing peripheral polyneuropathies. Even though peripheral neuropathy is a common neurological disorder, there are no uniform criteria for its evaluation or for the establishment of a diagnosis. After a complete evaluation, 30% of cases remain idiopathic, particularly chronic axonal neuropathies of late onset. 1 The clinical presentation may be bilaterally

in AMA Guides® Newsletter
Christopher R. Brigham

permanent impairment less than ratings based on the Fifth Edition. Section 16.4 Peripheral Nerve Impairment (6th ed, 531-538) uses the same process defined in Chapter 15 for the assessment of peripheral nerve injury. Impairments are based on assignment to International Classification of Functioning, Disability, and Health (ICF) Classes dependent on the nerve involved and the extent of the sensory and motor deficits, with the final impairment based on Table 16-12 Peripheral Nerve Impairment: Lower Extremity Impairments (6th ed, 534-536). A separate approach to defining

in AMA Guides® Newsletter
Christopher R. Brigham
,
Craig Uejo
,
J. Mark Melhorn
, and
James B. Talmage

be observed, however the ratings obtained from the Fifth and the Sixth Editions typically are similar. Peripheral Nerve Impairment Section 15.4 Peripheral Nerve Impairment (6th ed, 419-450) assesses impairments of digital nerves, brachial plexus, peripheral nerves, and entrapment syndromes. Enhanced standards are provided for clinical evaluation and interpretation of electrodiagnostic studies. Brachial plexus and peripheral nerve traumatic injuries are rated on the basis of assignment to ICF Classes based on the nerve involved and the extent of the sensory

in AMA Guides® Newsletter
William Shaw
and
Lorne Direnfeld

impairment should be evaluated. If multiple conditions involving the nervous system exist, each condition should be evaluated separately and the impairment ratings combined. For example, if there is a cerebral impairment and a peripheral nerve impairment, these percentages are combined. Overlaps exist with other systems, including but not limited to respiratory; bowel, bladder, and sexual dysfunction; behavioral disorders; and special senses. Care should be taken to avoid duplication of impairment ratings. Complex and integrative cerebral functions are evaluated

in AMA Guides® Newsletter
Christopher R. Brigham

Peripheral Nerve Injuries It is helpful to first understand the methodology used in the Sixth Edition to rate for peripheral nerve impairment and how it relates to the Fifth Edition. The clinical assessment process is similar in the two editions; however, the approach to assessing impairment was modified in the Sixth Edition for consistency with the change in methodology. In the Fifth Edition the rating of upper extremity peripheral nerve injuries involved the use of 3 tables. Maximum losses are obtained by using Table 16-15, Maximum Upper Extremity Impairment Due to

in AMA Guides® Newsletter
Douglas W. Martin

most cases, if a peripheral nerve injury can be traced to a single traumatic event, it is rated using Table 15-21, Peripheral Nerve Impairment: Upper Extremity Impairments (6th ed, 436); if considered an entrapment neuropathy, it would be rated following the instructions in Sections 15.4f, Entrapment Neuropathy (6th ed, 432–450), and Table 15-23, Entrapment/Compression Neuropathy Impairments (6th ed, 449). Although most cases of quadrilateral space syndrome are due to compression or entrapment over time, in this case, there was a specific weightlifting injury that

in AMA Guides® Newsletter