CHAPTER EIGHT THE RATINGS

Transcription

1 CHAPTER EIGHT THE RATINGS 1. The Simplest--Look It Up In A Chart 2. Range of Motion 3. DRE (Diagnostic-Related Estimates) 4. Nerve 5. Special Cases 6. Combination

2 160 THE RATINGS There are 6 different types of ratings which appear in The AMA Guides: 1. The Simplest (Hearing Loss, Lower Extremity, Pain) 2. Range of Motion (Shoulder, Wrist, Elbow, Knee) 3. DRE (Diagnostic-Related Estimates) (Spine, The Majority) 4. Nerve (Carpal Tunnel) 5. Special Cases (Complex Regional Pain Syndrome) 6. Combination (Spine Range of Motion, Lower Extremity) We are going to learn each of them. The beauty of this is, even though The Guides is 606 pages long, once you have learned these 6 ways of rating, you will know everything you need to know to do all the ratings. All you will do is turn to a page in The Guides, look at the rating, and you will know exactly what type of rating it is. As soon as you recognize the type, you will know how to do it! Let's start with the easiest! I. THE SIMPLEST RATING OF ALL: JUST LOOK IT UP ON A CHART I think it always focuses the mind to have an actual case you are rating. So, here are all the facts you need to know to do your first rating. HEARING LOSS

3 161 Facts: Mrs. Oboe is a music teacher at a public school. She has developed hearing loss. She claims it is from listening to all of the children play their instruments (poorly) over the years (except for that darling Miriam, who went on to Julliard. Mrs. Oboe knew she would). Mrs. Oboe sees Doctor Aural who rates out her binaural hearing loss at 23.4%. He finds the hearing loss industrial. What is her AMA Guides rating? That's all you need to know. Steps in the Rating: 1. Turn to page 250 of The Guides. Read Table 11-3: Relationship of Binaural Hearing Impairment to Impairment of the Whole Person 2. Look up the % Binaural Hearing Impairment in the Left Column In our case, it's 23.4%. 3. Read across to the right column and find the Whole Person Impairment. It's 8% WPI. Rating: 8% WPI That's it. You probably did that in about 30 seconds. Not too bad. [If you are in California, the WPI percentage number will be plugged into the PD Rating formula to produce the PD percentage.]

4 162 LOWER EXTREMITY (MAJORITY OF INJURIES) Facts: Mr. Paisley is an usher at the Shrine Auditorium in Los Angeles. During the Emmy broadcast, he sees Halle Berry going by and twists his right knee as he stumbles down the stair. Dr. Palabi diagnoses a torn right medial meniscus. The doctor does surgery--a partial medial meniscectomy. Mr. Paisley completely recovers with no problems in his right knee and is able to return to work unrestricted and to continue his tryouts for the LA Lakers. Steps in the Rating: 1. Determine the diagnosis in the lower extremity. 2. Turn to p of The Guides. (This is known as the "Giant Buffet Line" of the Lower Extremity.) 3. Find the knee. 4. Read down until you find "partial medial meniscectomy." Rating: "Menisectomy, medial or lateral Partial" 1 (2) [Note: Look at the top of the chart on p It gives you the key. Whole Person Impairment (WPI) has no parentheses. Lower extremity (LE) has parentheses around it. Foot will have brackets around it.] So, 1% WPI 2% LE = 3% WPI or 7% LE

5 163 That probably took about a minute. Not too hard, huh? PAIN Remember, all normal pain is included within the ratings for the underlying diagnosis. P. 10 of The Guides states: "Subjective concerns, including fatigue, difficulty in concentraing, and pain, when not accompanied by demonstrable clinical signs or other independent, measurable abnormalities, are generally not given separate impairment ratings. Impairment ratings in the Guides already have accounted for commonly associated pain, including that which may be experienced in areas distant to the specific site of the pathology. Chronic pain is discussed in Chapter 18." (p. 10) Chapter 18 of The Guides addresses pain. It states: If the individual appears to have pain-related impairment that has increased the burden of his or her condition slightly, the examiner may increase the percentage [under the body part or organ rating system] by up to 3% [WPI] (p. 573, also see p. 584) Tables 18-1 and 18-2 list Conditions which are not adequately rated under the Guides and can be rated under this chapter. They include:

6 164 Headache Postherpetic neuralgia Tic douloreux Erythromelalgia Complex regional pain syndrome, type 1 (reflex sympathetic dystrophy) Any injury to the nervous system Postparaplegic pain Syringomyelia pain Thalmic syndrome Brachial plexus avulsion pain Nerve entrapment syndromes Peripheral neuropathy Complex regional pain syndrome, type 2 (causalgia) To give a pain rating for any other condition, the condition must meet the following criteria: 1. The condition is not adequately rated on the basis of the body and organ impairment systems in Chapters 1-17 of The Guides (p. 571, p. 573), AND 2. The pain is "excess" to that described in the other chapters (p. 570), AND

7 The physician has determined the extent to which the pain impairs the following: ADL's, socialization, recreation, work, sleep, sexuality, and cognition, AND 4. The physician determines the patient to be credible (p. 581, p. 583). The physician must ask this question: "Do the limitations that an individual describes and demonstrates accurately reflect the burden of illness which the individual bears during everyday activity?" (p. 581) The physician should address: a. Consistency of pain over time and situation (p. 582), b. Consistency of pain with anatomy and physiology (p. 582), c. Consistency with established conditions (p. 582), d. Observer agreement (p. 582), and e. Any inappropriate illness behavior (p. 583). 5. The patient DOES NOT HAVE an ambiguous or controversial syndrome, such as: a. Fibromyalgia (p. 568), b. Thoracic outlet syndrome (p. 568 and 569), or c. Myofascial pain syndrome (p. 569) "...the pain of individuals with ambiguous or controversial pain syndromes is considered unratable." (p. 571) CALIFORNIA ISSUE:

8 166 The AMA Guides specify the criteria listed above for giving an add-on for pain. The criteria must be met to give 1%, 2%, or 3% WPI for pain under Chapter 18. In California, the Disability Evaluation Unit has taken the position that there can be an add-on for pain anytime (with the one exception of no add-on for pain if the underlying rating is 0% WPI). The DEU does not require the patient to meet the criteria listed above for the add-on for pain. Interestingly, an add-on of 1-3% WPI for pain is given in less than 1% of cases in the 43 other than California which use The AMA Guides. The issue of whether the criteria of the AMA Guides listed above or the position of the DEU in California will prevail will be determined by California courts. II. RANGE OF MOTION RATING SHOULDER The second type of rating is called "Range of Motion" rating. This is used often in the upper and lower extremities (shoulders, elbows, wrists, hands, hips, knees, feet). To do this rating, The Guides will give you a series of motions which the patient must do under his own power. This is called "active" range of motion. The Guides do not have the doctor assist the patient in the motions-- "passive" range of motion--because the doctor could injure the patient (with a resulting lawsuit!). Always measure "active" motions. The doctor should measure the motions a minimum of 2 times, 3 times is preferable. He uses a goniometer to do this, not just eyeball it. He writes down the actual measurements. They need to fall within 10% of each

9 167 other to be consistent, reliable, reproducible, and used for the rating. (p. 20, p ) Then, the doctor picks the highest motion to use for the rating because this shows the patient's greatest ability. So, let's learn how to do this with a Shoulder. First, a little medicine: There are 6 motions you measure in the shoulder: 1. Flexion The motion of the arm away from the body (see picture at p. 475) 2. Extension The motion of the arm behind the body (see picture at p. 475) 3. Abduction The motion of the arm straight out sidewards and up from the body (see picture at p. 477) 4. Adduction The motion of the arm across the front of the body (see picture at p. 477) 5. External rotation The motion of the arm as the shoulder joint rotates upwards towards the ceiling (see picture at p. 478)

10 Internal rotation The motion of the arm as the shoulder joint rotates inwards toward the belt line (see picture at p. 478) Steps in the Physical Examination: 1. Have the patient do the 6 motions with the injured arm. Have him do the motions a minimum of 2 times (p. 20). Three times would be better. 2. Make sure the measurements fall within 10% of each other to be consistent. (p. 20) [Note: if they do not, they are not consistent and, therefore, cannot be used for an AMA impairment rating as AMA impairment ratings must be based upon measurements which are consistent and reliable. If the measurements are not consistent (meaning they do not fall within 10% of each other), then they cannot be used for rating. (p. 20) 3. The doctor should use a goniometer to do the readings as goniometer readings are called for. (p. 475, 477, 478) 4. The doctor should record the actual goniometer readings. (p. 476) 5. If the readings fall within 10% of each other, the doctor should select the measurement of the greatest motion for the rating. (p. 475, 477, 478) 6. Next, have the patient do the same 6 measurements with the uninjured extremity. Use those measurements to establish a baseline of normal and compare the measurements between the injured and uninjured sides. (p. 2) Now, let's work with an example:

11 169 Facts: Mr. Monet is a 40-year-old house painter. He is working one day and feels pain in his right shoulder. He hollers, "Ow!" He stops painting and goes to see his doctor, Dr. Pincher. The doctor tells him he has an impingement syndrome in the right shoulder. Injections are done to the right shoulder. They do no good. Finally, Dr. Pincher recommends surgery on the right shoulder. Mr. Monet undergoes an open anterior acromioplasty on the right shoulder. (This means they cut him open on the front of the right shoulder and rebuild his right shoulder.) He undergoes physical therapy and ultimately reaches maximum medical improvement. Now, he comes in to an evaluating physician for his mmi evaluation. On physical examination, Dr. Socrates finds the following active measurements of the right and left shoulders: Right Left Flexion 128/129/ /159/160 Extension 50/50/49 50/49/48 Abduction 160/159/ /178/179 Adduction 50/48/48 50/50/50 External Rotation 79/78/80 90/89/89 Internal Rotation 70/69/69 89/90/90

12 170 Steps in the Rating: 1. Select the highest measurement of each set of 3 measurements noted above. 2. For Flexion, go to Figure 16-40, p This is called a "Pie Chart." It looks a bit complicated at fist, but it's not. First, see how it says "Shoulder" in the middle. That means it's for the shoulder. Second, see how it says "Flexion" and "Extension." That means it's for flexion and extension. Third, see how there are 4 arcs? The first arc is called the "V" arc. "V" stands for "Value" or "Angle of Measurement." So, if I say, "Flexion is to 130 Degrees," 130 is the "Value." [There's a key in the lower left hand corner of the chart.] Now, see how there are 3 other arcs going out. Each has a letter "I" next to it. "I" stands for "Impairment." So, when you have "I" with a small "F", that's impairment due to loss of Flexion. "I" with a small "E," impairment due to loss of Extension. And "I" with a small "A," impairment due to Ankylosis. "Ankylosis" is the fancy medical term for a fusion. So, you only use

13 171 this arc if the shoulder is "fused" or "ankylosed." 3. Now, what was our measurement for Flexion? The highest measurement on the right was 130 degrees, so that is what we use for rating. Go to the section of the chart where the word "Flexion" appears. Find the 130 on the V scale. Circle it. Now, see how there is a bicycle spoke which goes out from the 130? Follow that spoke until you come to the I-F [Impairment of Flexion] arc, and when you get there, what number do you see? 3? Write that down: Flexion 3 4. Now, let's do Extension. Go the the section of the chart where you find the word, "Extension" (see the little pie piece?). What was our measurement for Extension? 50. Find the 50 on the V scale. Circle it. Trace out to the I-E or "Impairment of Extension" arc. When you get there, what number do you find? 0? Write that down: Extension 0 5. Now, turn to p. 477 for Abduction and Adduction. Same process: What was our measurement for Abduction? 160. Go to the section of the chart where the word "Abduction" appears. Find the 160 on the V Scale. Trace out to the Impairment of Abduction arc. When you get there, what number do you find? 1? Write that down.

14 172 Abduction 1 6. Now, let's do adduction. 50 degrees. Trace out: 0. Adduction 0 7. Now, turn the page to p. 479 for External and Internal Rotation. External Rotation: 80 degrees 0 Internal Rotation: 70 degrees 1 8. Now, all we have to do is add up the numbers we've got: Flexion 3 Extension 0 Abduction 1 Adduction 0 External Rotation 0 Internal Rotation 1 9. Now, all we have to do is add them up. (p. 474) = But 5 what? 5% Whole Person Impairment? 5% Brain Impairment? 5% Toe Impairment? 5% Hand Impairment? 5% Shoulder Impairment? 5% Upper Extremity Impairment? The answer is: "5% Upper Extremity Impairment."

15 173 But, how do we know that? By reading the name of the Charts from which we get the Impairment numbers. Example: Figure 16-40: "Pie Chart of Upper Extemity Motion Impairments Due to Lack of Flexion and Extension Of Shoulder" So, 5% Upper Extremity Impairment. 11 But now, what if we are in a state like California where we need a Whole Person Impairment Rating to plug into our Permanent Disability Rating Schedule? How can we turn an Upper Extremity Impairment into a Whole Person Impairment? Turn to page 439, and there you will find Table 16-3, the "Magic Decoder Ring" which turns arms into people. Use this chart to convert an Upper Extremity Impairment into a Whole Person Impairment. 5% Upper Extremity = 3% WPI. Not too bad, huh? That probably took 3 minutes, but this was your first time doing a Range of Motion rating. Once you get used to them, you'll be able to do them in about 2 minutes flat. But wait! We forgot something!

16 174 Because you are so good, now we are going to learn something "Advanced." Remember the "Matching Set Theory?" Whenever the patient has an impairment in something that comes in a matching set (arms, eyes, nostrils, buttocks, knees, shoulders), we have to measure the uninjured/other side to establish the baseline of normal. So, let's see if there is any impairment in Mr. Monet's uninjured shoulder. Left Shoulder Rating Let's do the same process for the Left Shoulder. Here's what we get: Flexion 1 Extension 0 Abduction 0 Adduction 0 External Rotation 0 Internal Rotation 0 Total 1% UE Look at that. Mr. Monet has 1% UE impairment in the uninjured left shoulder! What does that mean to us? If Mr. Monet has never had a previous injury to the left shoulder and he can only flex the left shoulder to 160%, The Guides presume that his other shoulder, the right one, the matching one, could only flex to 160% also. The Guides presume he was born that way. This is because we are usually born with matching sets of shoulders which can do the same things.

17 175 (If there were old medical records establishing the flexion measurements of both shoulders, those could be used to establish the baseline of normal.) Therefore, The AMA Guides presume that the Right Shoulder was only able to flex to 160 degrees prior to the injury because it is the match to the left shoulder (which can only flex to 160 degrees.) As such, that mean The Guides presume Mr. Monet was born with 1% UE impairment in his right shoulder and 1% UE impairment in his left shoulder. So, the impairment which Mr. Monet has suffered as a result of our injury must take into account the preexisting impairment with which Mr. Monet was born. To do this, we subtract out the preexisting 1% UE from our current impairment rating on the right shoulder: 3% UE (Right shoulder) - 1% UE (Right Shoulder) = 2% UE So, the final rating for the impairment in the Right Shoulder due to our injury is: 2% UE. This would convert to 1% WPI based on the chart on p Congratulations! You've now moved to the Advanced Level of AMA Ratings. That was the shoulder, which took 6 motions. So, let's do something even easier. How about the Wrist which has only 4 motions? WRIST

18 176 A little medicine first: There are 4 motions in the Wrist: 1. Flexion see picture at p Extension see picture at p Radial Deviation see picture at p Ulnar Deviation see picture at p. 468 Once again, measure the active motions 2 times at a minimum, 3 times is better. Make sure they fall within 10% of each other. Choose the highest measurement for the rating. (See Shoulder Section above for page citations.) Facts: Ms. Lubinski is a clerical worker. She comes out of her office to walk to another building. She slips and falls on her right wrist. She screams, "Ow!" She is raced to the ER. An x-ray is done which shows a fractured right wrist. Her right wrist is splinted. That does no good. She does not recover. Finally, her doctor, Dr. Pitengui, recommends she have a fusion of the right wrist. That is done.

19 177 Ms. Lubinski now returns for her mmi evaluation. Her wrist is fused. X-rays shows a solid fusion. Measurements are done: Right Left Flexion 10/10/10 60/61/62 Extension None 60/60/60 Radial Deviation 5/5/5 20/21/22 Ulnar Deviation None 30/30/30 The right wrist is "anklyosed" or fused in 10 degrees of flexion and 5 degrees of radial deviation. That means it is permanently in that position. Now, let's do the rating. Once again, turn to the Range of Motion charts for the Wrist on pages 467 and 469. Let's do Flexion first. Turn to the Chart on p. 467, Figure What was our value for flexion? 10 degrees. So, go to the chart where you find the word "Flexion" and find the 10 degrees on the "V" scale. But now, which arc do we trace out to? I-F for Impairment due to Loss of Flexion or I-A, Impairment due to Ankylosis? That's right! I-A because Mrs. Lubinski's right wrist is "ankylosed" or fused.

20 178 So, 10 on the V Scale. Trace out to I-A or Impairment due to Ankylosis, and what number do you find? 21? That's right. Write that down: 21% UE. Now, let's do Radial Deviation. Same Process. Radial Deviation of 5 degrees. Turn to the chart on p. 469, Figure Go the section of the chart where the words "Radial Deviation" appear. Place the 5 on the "V" scale. Trace out to the I- A or "Impairment due to Ankylosis" arc. And what number do you find? 12? That's right. Write that down: 12% UE. Now, all you have to do is add up the following numbers: Impairment due to Ankylosis (Flexion) 21 Impairment due to Ankylosis (Radial Deviation) 12 Total: 33% 33 what? 33% UE. Remember, this is Upper Extremity based on the title of the Charts from which we got our Impairment Numbers. If you need to convert to WPI, turn to page 439, Table % UE = 20% WPI. That's it! That's the wrist. Not too difficult, do you think? ELBOW The elbow works exactly the same as the Shoulder and the Wrist. So,

21 179 Just turn to pages 470 through 474 and follow The Recipe. The Magic Decoder Ring which turns Elbows into People (Upper Extremities into Whole Person Impairment) is at page 439, Table LOWER EXTREMITY RANGE OF MOTION The Lower Extremity Chapter also uses Range of Motion Rating. However, the Lower Extremity Chapter uses a different type of chart than the Pie Charts used in the Upper Extremity Chapter. [This is enough to make you run screaming through the streets, but it comes from having different chapters written by different committees of doctors who do not talk to each other. So, each committee writes its chapter using the methods it wants to use. Range of Motion in the Upper and Lower Extremity Chapters work the same way--they just use different types of charts!] Lower Extemity Range of Motion goes from pages 533 through 543. There are charts for Range of Motion measurements of the: Hip Knee Ankle Hindfoot Toe(s) So, once again, go to those pages and see what needs to be measured. Measure it 2 times at a minimum, 3 is better. Make sure the measurements fall within 10% of each other to be consistent and ratable. (p. 20) Then, pick the highest measurement for rating purposes. Let's use an example. Let's do a knee.

22 180 Facts: Mr. Kumquat is a Fed Ex Driver and Delivery Man. He slips on some spilled anchovy dip while delivering a Kwanzaa present to a home. He sprains his right knee. X-rays are normal. Swelling in the right knee abates after 1 week. He undergoes physical therapy. Ultimately, he reaches maximum medical improvement. He comes for his mmi evaluation. At the evaluation, the findings on Physical Examination are: Right Left Flexion 100/99/ /120/120 Flexion Contracture 0/0/0 0/0/0 What is his impairment? Go to page 537. Find Table Knee Impairment. Now, read down under Flexion. Read across. If Flexion is less than 110 degrees, then the rating is Mild: 4% (10%). Once again, this is the Lower Extremity Chapter so the first number is Whole Person Impairment while the second number in parentheses is Lower Extremity Impairment. (See the top of the chart for the key.) So, Flexion 4% WPI, 10% LE Flexion Contracture 0 Now, let's check the left side: Flexion 0

23 181 Flexion Contracture 0 So, the rating for the Right Knee Loss of Flexion is 4% WPI, 10% LE. And that is Range of Motion Rating! Not too bad, huh? III. DRE RATINGS (70% OF THE GUIDES RATINGS) Now, let's turn to the majority-type of rating under The AMA Guides. This type of rating is called "DRE Rating," and it makes up about 70% of the ratings under The Guides. DRE is a fancy medical term which stands for "Diagnostic-Related Estimates." What it means, simply, is that a doctor has a list of things he looks for in your body. When he finds one, he checks it off. Each item checked gets some impairment. So, for each "diagnosis" he makes, there is a "related impairment estimate," i.e. Diagnosis-Related [Impairment] Estimates. So, find the List, Check off What the Patient Has, Go to A Chart to Calculate the Impairment, and Total It! Now, let's start by learning this with the Spine. SPINE DRE

24 182 In the Spine, there are a series of things for which the evaluator looks. These things are included on a List of Things the Evaluator Looks for When Doing a Spine DRE Rating at pages 382 and 383 of The Guides. Let's turn there now. LIST OF THINGS THE EVALUATOR LOOKS FOR WHEN DOING A SPINE DRE RATING (P ) 1. Muscle spasm A hard muscle which the individual cannot relax. (p. 382) It is common after an acute spinal injury but rare in chronic back pain. (p. 382) 2. Muscle guarding Immobilization of an area by tightening the muscles. The Guides define it as " a contraction of muscle to minimize motion or agitation of the injured or diseased tissue." (p. 382) The contraction CAN be relaxed which is NOT POSSIBLE with muscle spasm. (p. 382) 3. Asymmetry of Spinal Motion Muscle spasm or muscle guarding may cause a patient to be unable to move the spine symmetrically. For example, if a patient attempts to flex (bend forward) from the lumbar spine, a muscle spasm on one side of the lumbar spine may cause his trunk to lean to one side (asymmetry). The same thing may happen with the head in the cervical spine (asymmetry). (p. 382)

25 183 The Guides specifically note: "To qualify as true asymmetric motion, the finding must be reproducible and consistent and the examiner must be convinced that the individual is cooperative and giving full effort." (emphasis added) (p. 382) Underline that! What does this mean? a. In the lumbar spine, asymmetric range of motion occurs when the patient bends from the waist and one shoulder goes forward further than another. b. In the cervical spine, asymmetric range of motion occurs when the patient is able to bend the head further to one side than another and able to turn the head further to one side than another 4. Nonverifiable Radicular Root Pain Pain that follows the pathway of a nerve root (i.e., a dermatomal distribution) but is not supported by objective physical, imaging, or electromyographic findings. (p. 382) The Nerve Pathways (or Dermatomal Distributions) are shown on p. 377 of The Guides, Figures 15-1 and These are great pictures to check out. They will help you a lot! From Wikipedia:

26 184 A Dermatome is an area of skin associated with a pair of dorsal roots from the spine. The significance of dermatomic regions is important as pain in a dermatomic area may indicate spinal damage or neurological stenosis. A compressed spinal nerve may show as pain elsewhere on the body, according to the dermatomic area covered by the compressed nerve. A similar area innervated by peripheral nerves is called a peripheral nerve field. The body can be divided into regions that are mainly supplied by a single spinal nerves.there are eight cervical (one for the head, and one for each cervical vertebra), twelve thoracic, five lumbar and five sacral spinal nerves. This innervates the body in a patterned form. Along the thorax and abdomen it is simply like a stack of discs forming a human, each supplied by a different spinal nerve. Along the arms and the legs, the

27 185 pattern is different: the dermatomes run longitudinally along the limbs. 5. Reflexes From Wikipedia: A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. [1] Human reflexes are tested as

28 186 part of a neurological examination to assess damage to and functioning of the central and peripheral nervous system. Tendon reflexes The deep tendon reflexes provide information on the integrity of the central and peripheral nervous system. Generally, decreased reflexes indicate a peripheral nervous system problem [out from the spinal cord], and lively or exaggerated reflexes a central one [within the spinal canal]. Biceps reflex (C5, C6) Brachioradialis reflex (C5, C6, C7) Extensor digitorum reflex (C6, C7) Triceps reflex (C6, C7, C8) Patellar reflex or knee-jerk reflex (L2, L3, L4) Ankle jerk reflex (Achilles reflex) (S1, S2) Plantar reflex or Babinski reflex (L5, S1, S2) 6. Weakness and Loss of Sensation The sensory findings must be in a strict anatomic distribution following a known nerve pathway. Weakness must be in muscles which correspond to the affected nerves. Long-term weakness is usually accompanied by atrophy. (p. 382) 7. Atrophy Muscle loss. It is measured with a tape measure at identical levels on both limbs. The difference in circumference indicating problems should be Thigh Arm Forearm 2 cm or greater 1 cm or greater 1 cm or greater

29 187 Leg 1 cm or greater (p. 382) Measurements that fall within the centimeter ranges above may be normal variants. 8. Radiculopathy Pain, numbness, or tingling in a known nerve pathway (dermatomal distribution). It is usually caused by pressure on one or several nerve roots. It produces a significant alteration in the function of the affected nerve(s). KEY: A diagnosis of herniated disc MUST BE SUBSTANIATED by an appropriate finding on an imaging study. FURTHER, just because someone has a herniated disc on imaging study does NOT mean he will have radiculopathy. [See discussion at p. 378.] 30% of people with no back pain have imaging studies which show herniated discs. (p. 378) 50% of people with no back pain have imaging studies which show bulging discs. (p. 378) As you get older, you get more bulges and herniations. (p. 378) An imaging result can confirm a diagnosis, but to get a diagnosis of radiculopathy, you need a positive EMG. (p. 378.)

30 Alteration of Motion Segment Integrity This is usually a loss of motion of the vertebrae in relation to each other due to a fusion. The most common example of this is a onelevel spinal fusion. (p. 383) Alteration of Motion Segment Integrity can also be seen in increased motion of the vertebrae (beyond normal) on top of each other or increased angles in relation to each other. (p. 383) KEY: You MUST have Flexion and Extension X-Rays to determine the motion of the individual spine segments. It cannot be done by Physical Examination. (p. 383) To have loss of motion segment integrity, the x-rays must meet the measurements prescribed on p. 378 through 379 of The Guides. 10. Cauda Equina Syndrome (means "the horse's tail") Loss of sphincter tone on rectal exam and diminished or absent bladder, bowel, or lower limb reflexes (p. 383) From Wikipedia: Cauda equina syndrome is a serious neurologic condition in which there is acute loss of function of the neurologic elements (nerve roots) of the spinal canal below the termination (conus) of the spinal cord. Signs include weakness of the muscles innervated by the compressed roots (often paraplegia), sphincter weaknesses causing urinary retention and post-void residual incontinence as assessed by catheterizing after the patient has voided. Also, there be decreased rectal tone; sexual

31 189 dysfunction; saddle anesthesia; bilateral leg pain and weakness; and bilateral absence of ankle reflexes. Diagnosis is usually confirmed by an MRI scan or CT scan, depending on availability. If cauda equina syndrome exists, surgery is an option depending on the etiology discovered and the patient's candidacy for major spine surgery. 11. Urodynamic Tests If the patient is suspected of having a "cauda equina syndrome," do a cystometrogram. If it is normal, it makes the presence of a nerverelated bladder dysfunction unlikely. (p. 383) Steps in the Physical Exam: 1. Determine if the patient has: a. Symptoms, signs, and diagnostic tests listed above in "The List of Things the Evaluator Looks For When Doing a Spine DRE", OR b. Fractures and/or dislocations with or without clinical symptoms (p. 381) Note: If a fracture exists, that places the patient into a DRE category with no other verification needed (p. 381) 2. If the patient does not have fractures and/or dislocations, check "The List" above to see which signs, symptoms, and/or diagnostic findings he has. 3. Check them off on The List. CERVICAL SPINE

32 190 Facts: Mrs. Pomposa is a Claims Examiner for a large insurance company in Southern California. She is driving on the 405 and gets rear-ended. She suffers a cervical whiplash. She undergoes chiropractic treatment. That does no good. She has massage therapy. That does not provide any permanent relief, but she has it at the Bel Air Hotel, and she usually has a margarita or two (or three) by the pool afterwards. That leaves her glowing and feeling good. She reaches mmi. She now comes in for her mmi evaluation, and Dr. Smythington finds the following: 1. History of specific injury: being rear-ended 2. Physical examination: a. Muscle spasm in the cervical paraspinal muscles b. Asymmetric range of motion in the cervical spine c. Complaints of pain and tingling along the C6-C7 nerve distribution in the left arm 3. Diagnostic tests a. X-rays normal b. EMG of the left arm: normal 4. Activities of Daily Living a. The pain in her neck makes it difficult to look behind her while driving b. No other impact on Activities of Daily Living

33 191 Now, let's rate her. Steps in the Rating: 1. Get the individual's history 2. Perform a physical examination looking for the things on "The List of Things the Evaluator Looks For in Doing A Spine DRE Evaluation" (pp ) 3. Do Diagnostic Tests, if indicated. 4. Turn to page 392 for the DRE Chart of the Cervical Spine a. You will see 5 columns. b. Read the words of each column. c. Place the patient in the appropriate category d. The Category will give you a WPI % range. 1) Question the patient on how the injury has affected her in her in the list of Activities of Daily Living at p. 4. If the injury has: 0 to Mild Impact: Give lowest numbers in WPI Range Significant Impact: Give highest number in WPI Range Moderate Impact: Give middle number(s) in

34 192 WPI Range (p. 381) 2) Reference: p. 381, paragraph 6: "If residual symptoms or objective findings impact the ability to perform ADL despite treatment, the higher percentage in each range should be assigned." Inconsistency: This appears to indicate that treatment is necessary to adjust the WPI number up based on residual symptoms or objective findings which have an impact on ADL's Here, Ms. Pomposa has muscle spasm in the cervical paraspinal muscles, asymmetric range of motion, and nonverifiable radicular root pain (EMG was normal). Therefore, she falls in DRE Category II, 5-8% WPI. Now, narrow down the range by picking a number based on the impact of the medical condition on the Activities of Daily Living. She has a bit of difficulty turning her neck when driving due to pain. That's it. This means she would probably get either 5% WPI (if you are conservative) or 6% WPI (if you are more generous). Facts: Rating: 5% or 6% WPI LUMBAR SPINE Mr. Jikes falls backwards off a ladder at work. He lands in a sitting position on a sawhorse. He has immediate pain in the low back. He has no pain down either leg.

35 193 He is rushed to the ER. An x-ray is taken which shows an L1 compression fracture of 40%. He has no neurological problems in any part of his body. He recovers. He returns for his mmi evaluation. He is having no symptoms. The x-ray done at the time of the injury shows an L1 compression fracture of 40%. Steps in the Rating: 1. Turn to page 384 for the DRE Chart of the Lumbar Spine. 2. Read the bottom paragraph in each column. 3. Place Mr. Jikes in the appropriate category. 4. Narrow down his rating to a specific number. Diagnosis: 40% compression fracture of L1 falls in DRE Category II. Category II is 5-8% WPI. Narrowing down could be done by ADL's. We have no information on impact of the injury on ADL's. However, in this case you can use an ADVANCED NARROWING TECHNIQUE: RATIO REASONING. Here is how Ratio Reasoning works: 1. The Range for the fractures is 25% %. 2. The Range for the Impairment %.

36 Our fracture is 40%. X (40%) 4. Applying the same ratio To the impairment scale X (12% WPI) This is called "Ratio Reasoning," and it is acceptable because 2 doctors applying the same method would come up with the same result. Rating: 12% WPI THORACIC SPINE Works exactly the same as Cervical and Lumbar DRE. See Thoracic Spine DRE Chart at p NOW, WHEN DO WE USE THE DRE METHOD VERSUS THE RANGE OF MOTION METHOD IN THE SPINE? a. Use the DRE if: (p. 379 of The AMA Guides) 1) Patient had a specific injury, or 2) Cause of the impairment is not easily determined, or 3) The impairment can be well characterized by the DRE method b. Use the ROM if: (p. 379 of The AMA Guides) 1) Fractures at more than one level in the same spinal Region (there are 3 spinal regions: cervical, thoracic,

37 195 And lumbar, so, there must be more than one fracture In a specific spinal region) 2) Fusions at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fusion in a specific spinal region) 3) Radiculopathy in the same spinal region a) Bilaterally, OR b) At multiple levels AMBIGUITY: The language above from p. 380, lower right paragraph #4 appears to be different from the following language below which appears at p. 380, upper left paragraph 4: "Recurrent Radiculopathy in the same spinal region, caused by a) A new (recurrent) Disc herniation, OR b) Recurrent injury" Note: In California, the phrase "recurrent injury" has been used to argue that all cumulative trauma spinal cases should be rated using the Range of Motion method because cumulative trauma constitutes thousands of tiny recurrent injuries.

38 196 The editors of the Guides Newsletter have clarified that cumulative trauma should be rated using the DRE method unless it produces one of the enumerated problems--fusions at multiple levels in the same spinal region; fractures at multiple levels in the same spinal region; radiculopathy which is bilateral or at multiple levels in the same spinal region; radiculopathy caused by recurrent disc herniation or stenosis or multiple episodes of other pathology at the same or a different level in the same spinal region; or alteration of motion segment integrity caused by multiple episodes of other pathology--and then it should be rated using the Range of Motion method. The determination of whether or not the phrase "recurrent injury" is interpreted to apply to all cumulative trauma spinal injuries will lie with the California courts. 4) Alteration of Motion Segment Integrity caused by a) Multiple episodes of other pathology 5) Radiculopathy caused by a) Multiple episodes of other pathology 6) The following 3 conditions are met: a) The impairment is not caused by an injury, and b) The cause of the condition is uncertain; and c) The DRE Method does not apply OR d) The patient cannot be easily categorized in a DRE category

39 197 e) AND, the evaluator gives his reasons for using the ROM under these circumstances in writing. c. If the patient qualifies to be rated under both the DRE and the ROM, 1) Rate him under both, AND 2) Give him the highest rating ALL OTHER DRE RATINGS Heart (Chapters 3 and 4) Hypertension (Chapter 4) Pulmonary (Chapter 5) Digestive System (Chapter 6) Urinary and Reproductive Systems (Chapter 7) Skin (Chapter 8) The Hematopoietic System (Blood) (Chapter 9) Endocrine System (Chapter 10) Vestibular Disorder, Face, Nasal, Speech (Chapter 11) Visual (Chapter 12) Neurology (Chapter 13) Psychological/Psychiatric (Chapter 14) [NO WPI% GIVEN] Spine (Chapter 15)--Note also RANGE OF MOTION METHOD Steps in the Recipe for the Rating:

40 198 Use the same process: 1. Turn to the section in The AMA Guides where the Diagnosis is rated. 2. Read the text first and follow the instructions given there. 3. Then, turn to the DRE Chart. You will see a number of different columns. Read the columns. Place the patient in an appropriate column based on his findings. a. Be sure to read all of the columns to ensure that you have selected the correct one. b. If there are findings or information required to place the patient in a category, and the evaluating doctor has not given you that information, write the doctor and ask for the necessary findings/information. c. ALWAYS CHECK THE PHYSICAL EXAMINATION RESULTS OF DIAGNOSTIC TESTS. (Phil's note: I would estimate that 50% of the reports I review contain conclusions by a doctor that a patient has certain findings which put the patient in a specific DRE Category, or has results on diagnostic testing which put the patient in a DRE Category, and, when I check the results of the Physical Examination or interpretation of the diagnostic tests, the Patient DOES NOT HAVE the findings or test results which the doctor claims are present. d. Once the patient is placed in a DRE Category, narrow down to a specific impairment percentage by questioning the patient on the impact of the injury or illness on the Activities of Daily Living (see list at p. 4 of The Guides.) 1) If questions arise as to why you narrow down using The List of Activities of Daily Living at p. 4,

41 199 you may wish to analogize to the DRE Method in the Spine: "If residual symptoms or objective findings impact the ability to perform ADL despite treatment, the higher percentage in each range should be assigned." (p. 381) IV. NERVE RATING This rating makes up about 5% of the AMA Guides. It is not difficult, but it works in the opposite way from other ratings. Other ratings start with the lowest impairment number and build up. This rating starts with the highest number and then works down. In this rating, the impairment charts will tell us what the maximum rating is if a nerve loses all feeling--sensation--or strength--motor strength. Now, that doesn't happen that often. Usually, a patient has something pinching on a nerve which causes loss of some percentage of that nerve function. Nerves do 2 things for us. They give us feeling--what doctors call "sensation"--and they give us strength--what doctors call "motor strength." When we lose feeling in areas of the body where a nerve goes, doctors call

42 200 that "sensory deficit." When we lose strength in a muscle where a nerve goes, doctors call that "motor deficit." Now, let's see how this works. "CARPAL TUNNEL SYNDROME" But first, let's learn a little medicine. We are going to learn nerve rating with "Carpal Tunnel Syndrome" because that is the most common type of nerve rating you will run into. In each of your wrists, you have a "carpal tunnel." Here's a picture: Carpal tunnel syndrome Classification and external resources

43 201 Transverse section across the wrist and digits. (The median nerve is the yellow dot near the center. The carpal tunnel is not labeled, but the circular structure surrounding the median nerve is visible.) From Wikipedia: Here is a picture of the Median Nerve which runs through the Carpal Tunnel:

44 202 Carpal tunnel syndrome (CTS), or median neuropathy at the wrist, is a medical condition in which the median nerve is compressed at the wrist, leading to paresthesias, numbness and muscle weakness in the hand. The diagnosis of CTS is often misapplied to patients who have activity-related arm pain. Most cases of CTS are idiopathic (without known cause), genetic factors determine most of the risk, and the role of arm use and other environmental factors is disputed. Night symptoms and waking at night--the hallmark of this illness--can be managed effectively with night-time wrist splinting in most patients. The role of medications, including corticosteroid injection into the carpal canal, is unclear. Surgery to cut the transverse carpal ligament is effective at relieving symptoms and preventing ongoing nerve damage, but established nerve dysfunction in the form of static (constant) numbness, atrophy, or weakness are usually permanent and do not respond predictably to surgery. History Although the condition was first noted in medical literature in the early 20th century, the first use of the term carpal tunnel syndrome was in The pathology was identified by physician Dr. George S. Phalen of the Cleveland Clinic after working with a group of patients in the 1950s and 1960s. CTS became widely known among the general public in the 1990s because of the rapid expansion of office jobs. Anatomy The median nerve passes through the carpal tunnel, a canal in the wrist that is surrounded by bone on three sides, and a transverse carpal ligament on the fourth. Nine tendons the flexor tendons of the hand pass through this canal. The median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both. Simply bending the wrist at 90 degrees will decrease the size of the canal. Compression of the median nerve as it runs deep to the Transverse Carpal Ligament causes wasting of the thenar eminence, weakness of the flexor pollicis brevis, adductor pollicis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the distribution of the median nerve distal to the transverse carpal ligament, sparing the superficial sensory branch given that its branch point is normally proximal to the Transverse Carpal Ligament and travels superficially thus avoiding compression.

45 203 Symptoms Many people that have carpal tunnel syndrome have gradually increasing symptoms over time. The first symptoms of CTS may appear when sleeping and typically include numbness and paresthesia (a burning and tingling sensation) in the thumb, index, and iddle fingers, although some patients may experience symptoms in the palm as well. These symptoms appear at night because we tend to bend our wrists when we sleep, which further compresses the carpal tunnel. Patients may note that they "drop things". It is unclear if carpal tunnel syndrome creates problems holding things, but it does decrease sweating, which decreases friction between an object and the skin. In early stages of CTS individuals often mistakenly blame the tingling and numbness on restricted blood circulation. They may also be at ease and accepting of the symptoms and believe their hands are simply falling asleep. In chronic cases, there may be wasting of the thenar muscles (the body of muscles which are connected to the thumb), weakness of palmar abduction of the thumb (difficulty bringing the thumb away from the hand). Unless numbness or paresthesia are among the predominant symptoms, it is unlikely the symptoms are primarily caused by carpal tunnel syndrome. In effect, pain of any type, location, or severity with the absence of significant numbness or paresthesia is not likely to fall under this diagnosis. Causes Most cases of CTS are idiopathic. CTS is sometimes associated with trauma, pregnancy, multiple myeloma, amyloid, rhematoid arthritis, acromegaly, mucopolysaccharidoses, or hypothyroidism. Genetic The most important risk factors for carpal tunnel syndrome are structural and biological rather than environmental or activity-related. The strongest risk factor is genetic predisposition. Work-related The international debate regarding the relationship between CTS and repetitive motion and work is ongoing. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have been cited. However, the

46 204 American Society for Surgery of the Hand (ASSH) has issued a statement that the current literature does not support a causal relationship between specific work activities and the development of diseases such as CTS. (emphasis added) The relationship between work and CTS is controversial; in many locations workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation. Carpal tunnel syndrome results in billions of dollars of workers compensation claims every year. Some speculate that carpal tunnel syndrome is provoked by repetitive grasping and manipulating activities, and that the exposure can be cumulative. It has also been stated that symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations, but it is unclear if this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms. A review of available scientific data by the National Institute for Occupational Safety and Health (NIOSH) indicated that job tasks that involve highly repetitive manual acts or specific wrist postures were associated with incidents of CTS, but causation was not established, and the distinction from work-related arm pains that are not carpal tunnel syndrome was not clear. It has been proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. It has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. While addressing these factors has been found to improve comfort in some studies, there is no evidence that they affect the natural history of carpal tunnel syndrome. Psychosocial Factors Studies have related activity-related upper extremity pain with psychological and social factors, but most such pains are nonspecific but commonly mislabeled as carpal tunnel syndrome. Psychological distress correlates with increased pain at work, as do other psychosocial stressors such as job demands, poor support from colleagues, and work dissatisfaction. Carpal tunnel is characterized by numbness, not pain. Therefore, any associations between stress and carpal tunnel syndrome are debatable. Trauma related Fractures of one of the arm bones, particularly a Colles' fracture. Dislocation of one of the carpal bones of the wrist. Strong blunt trauma to the wrist or lower forearm, incurred for example by using arm extremity to cushion a fall or protecting oneself from falling heavy objects. Hematoma forming inside the wrist, because of internal hemorrhaging.

47 205 Deformities from abnormal healing of old bone fractures. Carpal Tunnel Syndrome Associated with Other Diseases Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging. Examples include: Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons can create median nerve compression at the carpal tunnel. With pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium. Acromegaly, a disorder of growth hormones, compresses the nerve by the abnormal growth of bones around the hand and wrist. Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the amount of space. This is exceedingly rare (less than 1%). Obesity also increases the risk of CTS with individuals who are classified as obese (BMI > 29) 2.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS. Double crush syndrome is a speculative and debated theory which postulates that when there is compression or irritation of nerve branches contributing to the median nerve in the neck or anywhere above the wrist, this then increases the sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really exists. (emphasis added) Diagnosis The reference standard for the diagnosis of carpal tunnel syndrome is electrophysiological testing Patients with intermittent numbness in the distribution of the median nerve and positive Phalen's and Durkan's tests, but normal electrophysiological testing have--at worst--very mild carpal tunnel syndrome. Phalen's Maneuver is a diagnostic test for carpal tunnel syndrome discovered by an American orthopedist named George S. Phalen. The patient is asked to hold his wrist in complete and forced flexion (pushing the dorsal [topside] surfaces of both hands together) for seconds. This maneuver moderately increases the pressure in the carpal tunnel and has the effect of pinching the median nerve between the proximal edge of the transverse carpal ligament and the anterior border of the distal end of the radius. By compressing the median nerve within the carpal tunnel, characteristic symptoms (such as

48 206 burning, tingling or numb sensation over the thumb, index, middle and ring fingers) conveys a positive test result and suggests carpal tunnel syndrome. Durkan test, carpal compression test, or applying firm pressure of the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed. A third test for carpal tunnel is: Tinel's sign, a classic, though less specific test, is a way to detect irritated nerves. Tinel's is performed by lightly tapping the area over the nerve to elicit a sensation of tingling or "pins and needles" in the nerve distribution. A predominance of pain rather than numbness is unlikely to be due to carpal tunnel syndrome no matter the result of electrophysiological testing. (Emphasis added.) Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will usually be tested electrodiagnostically with nerve conduction studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. When the median nerve is compressed, as in CTS, it will conduct more slowly than normal and more slowly than other nerves. The role of MRI or ultrasound imaging is the diagnosis of carpal tunnel syndrome is unclear. Prevention Current best evidence suggests that carpal tunnel syndrome is an inherent, structural disease determined primarily by one's genes. Therefore, carpal tunnel syndrome is probably not preventable. (Emphasis added.) Those who favor activity as a cause of carpal tunnel syndrome speculate that activitylimitation might limit the risk of developing carpal tunnel syndrome, but there is little or no data to support these concepts and they stigmatize and demonize arm use in way that risks increasing illness. Recommendations for preventing carpal tunnel syndrome have poor scientific support. Several are listed here:

49 207 Treatment Take frequent breaks from repetitive movement such as computer keyboard usage or use of browser based games that encourage the user for excessive finger movement. Reduce your force and relax your grip Take frequent breaks. Every 15 to 20 minutes give your hands and wrists a break by gently stretching and bending them. Alternate tasks when possible. Watch your form. Avoid bending your wrist all the way up or down. A relaxed middle position is best. If you use a keyboard, keep it at elbow height or slightly lower. Improve your posture. Incorrect posture can cause your shoulders to roll forward. When your shoulders are in this position, your neck and shoulder muscles are shortened, compressing nerves in your neck. This can affect your wrists, fingers and hands. Keep your hands warm. You're more likely to develop hand pain and stiffness if you work in a cold environment. If you can't control the temperature at work, put on fingerless gloves that keep your hands and wrists warm. There has been much discussion as to the most effective treatment for CTS. It is important to distinguish palliative treatments (treatments that control symptoms) from disease modifying treatments. The only treatment established to be disease modifying is operative release of the transverse carpal ligament. All other treatments seem palliative at best according to current best evidence. Reversible causes Some causes of CTS are secondary to other conditions metabolic disorders such as hypothyroidism, for example. Treatment of the primary disorder often resolves CTS symptoms. Immobilizing braces

50 208 A splint can keep the wrist straight. A wrist splint helps limit numbness by limiting wrist flexion. Night splinting helps patients sleep. There is no evidence that wrist splinting is disease modifying. The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but many people are unwilling to use braces. In 1993, The American Academy of Neurology recommended a non-invasive treatment for the CTS at the beginning (except for sensitive or motor deficit or grave report at EMG/ENG): a therapy using splints was indicated for light and moderate pathology. Current recommendations generally don't suggest immobilizing braces, but instead activity modification and non-steroidal antiinflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve. Many health professionals suggest that, for best results, one should wear braces at night and, if possible, during the activity primarily causing stress on the wrists. Localized steroid injections Steroid injections can be quite effective for temporary relief from symptoms of CTS for a short time frame while a patient develops a long-term strategy that fits with his/her lifestyle. In certain patients an injection may also be of diagnostic value. This treatment is not appropriate for extended periods, however. In general, medical professionals only prescribe localized steroid injections until other treatment options can be identified. For most patients, permanent relief requires surgery. Physiotherapy There is little evidence to support physiotherapy or occupational therapy as a disease modifying treatments. Medication

51 209 Using an over-the-counter anti-inflammatory such as aspirin, ibuprofen or naproxen can be effective as well for controlling symptoms. Pain relievers like paracetamol will only mask the pain, and only an anti-inflammatory will affect inflammation. Non-steroidal anti-inflammatory medications theoretically can treat the root swelling and thus the source of the problem. Oral steroids (prednisone) do the same, but are generally not used for this purpose because of significant side effects. The most common complications associated with long-term use of anti-inflammatory medications are gastrointestinal irritation and bleeding. Also, some anti-inflammatory medications have been linked to heart complications. Use of anti-inflammatory medication for chronic, long-term pain should be done with doctor supervision. A more aggressive pharmaceutical option is an injection of cortisone, to reduce swelling and nerve pressure within the carpal tunnel. Methylcobalamin (vitamin B12) has been helpful in some cases of CTS. Carpal tunnel release surgery Release of the Transverse Carpal Ligament ("carpal tunnel release" surgery) is recommended when there is static (ever-present, not just intermittent numbness), weakness of palmar abduction, or atrophy, and when night-splinting no longer controls intermittent symptoms. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Procedure In carpal tunnel release surgery, the goal is to divide the transverse carpal ligament in two. This is a wide ligament that runs across the hand, from the base of the thumb to the base of the fifth finger. It also forms the top of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the middle finger) it no longer presses down on the nerves inside, relieving the pressure. The two major types of surgery are open-hand surgery and endoscopic surgery. Most surgeons perform open surgery, widely considered to be the gold standard (test). However, many surgeons are now performing endoscopic techniques. Open surgery involves a small incision somewhere on the palm about an inch or two in length. Through this the ligament can be directly visualized and divided with relative safety. Endoscopic techniques involve one or two smaller incisions (less than half inch each) through which instrumentation is introduced including probes, knives and the scope used to visualize the operative field.

52 210 All of the surgical options typically have relatively rapid recovery profiles (days to weeks depending on the activity and technique), and all usually leave a cosmetically insignificant scar. (emphasis added) Efficacy Surgery to correct carpal tunnel syndrome has high success rate, especially using endoscopic surgery techniques. Up to 90% of patients were able to return to their same jobs after surgery. In general, endoscopic techniques are as effective as traditional open carpal surgeries, though the faster recovery time typically noted in endoscopic procedures may be offset by higher complication rates. Success is greatest in patients with the most typical symptoms. The most common cause of failure is incorrect diagnosis, and it should be noted that this surgery will only fix carpal tunnel syndrome, and will not relieve symptoms with alternative causes. (Emphasis added.) Recurrence is rare, and apparent recurrence usually results from a misdiagnosis of another problem. (Emphasis added.) Long term recovery Most people who find relief of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage." Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. symptoms of numbness, muscle wasting and weakness. While outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. One study showed that mental status parameters, alcohol use, yield much poorer overall results of treatment. While recurrence after surgery is a possibility, true recurrences are uncommon to rare. (Emphasis added.) Such recurrence can also be non-cts hand pain. Such hand pain may have existed prior to the surgery, which is one reason it is very important to get a proper diagnosis. See how much you can learn from Wikipedia! So the problem in Carpal Tunnel is that something--either the ligament or the tendons--presses on the median nerve.

53 211 This is called a "compression neuropathy." The pressure on the median nerve causes pain, numbness, or tingling where the median nerve goes. The AMA Guides state: Entrapment neuropathy is a nerve compression-type lesion that implies disproportion between the volume of the peripheral nerve and the space through which it passes. The underlying causes may be intrinsic or extrinsic, in that the nerve itself or the other contents of the passage may be enlarged or the passage space may be narrowed. Predisposing associated conditions can include diabetes, arthritis, alcoholism, renal disease, hormonal changes, malnutrition, or obesity The most frequently encountered entrapment is of the median nerve at the wrist, leading to the carpal tunnel syndrome, followed by the ulnar nerve at the elbow. (p ). Let's see where the median nerve goes in the wrist, hand, and fingers:

54 212 Branches in the hand The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus. From there it sends off several branches:

55 Recurrent branch to muscles of the thenar compartment (the recurrent branch is also called "the million dollar nerve" 2. Digital cutaneous branches to common palmar digital branch and proper palmar digital branch of the median nerve which supply the: o a) lateral (radial) three and a half digits on the palmar side o b) index, middle and ring finger on dorsum of the hand The median nerve supplies motor innervation to the first and second lumbricals. When something presses down or in on the nerve (ligament or tendons), it causes a "compression neuropathy." This means pain, numbness, or tingling where the nerve goes. We call this condition "Carpal Tunnel Syndrome." However, there is nothing the matter with the Carpal Tunnel. The problem is with something pressing in or around the median nerve causing the median nerve to lose feeling and/or lose strength, what the doctors would call producing "sensory deficit" or "motor deficit." Now, let's see how Carpal Tunnel Syndrome (that means "Problems with the Median Nerve") is rated. Steps in the Recipe of a Nerve Rating 1. Find the nerve you are dealing with on the Nerve Chart on p (In our case, it's the "median nerve.") 2. Find the section of the nerve you are dealing with. (As you can see from the picture above, the median nerve in the carpal tunnel is located "below the mid-forearm," so find "Median Nerve Below mid-forearm." See it on page 492? 3. Now, read to the right from "Median (below midforearm)." Do you see 3 numbers: ?

56 214 Cross out the "45." You will never need to know about that. Now, what are the "39" and the "10"? Remember I told you that nerves give us two things: feeling and strength? The "39" is the number for complete loss of feeling--what doctors call "100% sensory deficit," i.e., all of the feeling is lost. So, if the median nerve below the midforearm (from the carpal tunnel down to the tips of the thumb, index, middle, and 1 side of the ring finger) loses all feeling, your rating would be, according to the Chart on p. 492: "100% sensory deficit of median nerve below midforearm = 39% UE." (p. 492) The Chart just gives you that number. If there is no feeling in the median nerve below the mid-forearm, your rating is 39% UE. So, what is the "10?" That is the maximum for strength. Remember I told you that nerves give us two things: feeling and strength? The "10" is the number for complete loss of strength (or what doctors call "motor strength")--complete loss of strength is what doctors call "100% motor deficit," i.e., all of the strength is lost. So, if the median nerve below the midforearm (from the carpal tunnel down to the tips of the thumb, index, middle, and 1 side of the ring finger) loses all strength, your rating would be, according to the Chart on p. 492: "100% motor deficit of median nerve below midforearm = 10% UE." (p. 492)

57 215 The Chart just gives you that number. If there is no strength in the median nerve below the mid-forearm, your rating is 10% UE. 4. Grade the loss of feeling, i.e. "sensory deficit." To do this, turn to page 482, Table 16-10, where the Grading Chart For Sensory Deficit appears. There are 5 grades on the chart: You only need to know about Grades 5, 4, and 3. "Sensory deficit," i.e. loss of feeling, is graded by 2 tests: a. Monofilament Testing 6 pieces of monofilament are used. (Monofilament is nothing more than fising line.) They range from thick down to thin. The thickest one is about as thick as a broom straw; the thinnest is as thin as several human hairs together." People with healthy feeling along the median nerve can feel all 6--from thickest to thinnest--when you place the tip of the monofilaments over the median nerve. People who have lost feeling can only feel the thickest ones (the broom straw) but cannot feel the thinnest ones (several human hairs together). So, you measure loss of feeling by whether or not the person can feel all 6 or just the thicker ones. The doctor blindfolds the patient or has the patient turn his head away. He then places the various monafilaments all along the palm and fingers where the

58 216 median nerve goes. He measures which of the monofilaments the patient can feel and which he cannot. He records those notes. He alternates the monofilaments to make sure the answers are reliable. The answers must be consistent, reproducible, and reliable to be used for rating purposes under The Guides (p. 20). b. Two-Point Discrimination The physician places two points along the pathway of a nerve. The physician uses either a two-point discriminator or a paper clip. If the patient can feel the two points as close as 6 mm apart, then feeling is normal. If the patient can only feel the two points at a wider space than 6 mm, then the feeling is abnormal, patient has sensory deficit, and the two-point discrimination is "abnormal." So, let's use an example: Carpal Tunnel Example: Jane Hathaway, Secretary Ms. Hathaway is secretary to Millard Drysdale, President of the Beverly Hills Bank. Ms. Hathaway begins to notice her right hand falling asleep at night. She has numbness and tingling in the right hand.

59 217 She goes to see Dr. Ellie Mae Clampett of the Clampett Clinic. Dr. Clampett diagnoses carpal tunnel syndrome on the right. Dr. Clampett has an EMG performed on the right hand which is positive for carpal tunnel Syndrome. Dr. Clampett performs a carpal tunnel release on Ms. Hathaway's right carpal tunnel. Ms. Hathaway recovers. 1 year after the surgery, Ms. Hathaway comes in for her mmi evaluation. Dr. Bodine (no relation to Jethro), the evaluator, performs monofilament testing. It is abnormal. He performs two-point discrimination. It is intact. Now, that is what you need to know for the rating. Turn to the Grading Chart on p. 482, and here is the Cheat Sheet for the Chart: Grading Chart for Sensory Loss--Cheat Sheet (p. 482) Grade Monofilaments 2 Point % of Sensory Deficit 5 Normal Intact 0% 4 Abnormal Intact 0-25% 3 Abnomal Abnomal 26-60% So, Ms. Hathaway has Monofilaments Abnormal and 2 Point Intact. Which grade would she go in? That's right. Grade 4. Once the doctor places her in Grade 4, he then gets to select a percentage number from the right column between 0 and 25% for her "percentage of sensory deficit." The doctor simply gets to pick. The worse the sensory deficit is, the higher the percentage number should be.

60 218 Dr. Bodine picks 10% sensory deficit. So, we take that 10% sensory deficit and multiply it by the 39% UE-- the maximum for sensory deficit: 10% of 39% = 3.9% (this will round up to) 4% UE. That's the rating for "Sensory Deficit." 5. Grade the Loss of Strength or "Motor Deficit." Now, let's do the rating for "Motor Deficit." To do this, turn to the Grading Chart for "Motor Deficit" on p. 485 of the AMA Guides. This time, the doctor does a test called "Thumb to Middle Finger Opposition." He tests these two fingers because they get their strength from the Median Nerve. Dr. Bodine has the patient place the thumbs and middle fingers together (like a Zen meditation pose) on each hand. He then slips his palm between the thumb and middle finger on each hand. He then asks the patient to press as hard as she can with the carpal tunnel thumb and middle finger. Then, he asks her to do the same with the non-carpal tunnel thumb and middle finger. Ms. Hathaway presses. There is full strength of thumb to middle finger opposition on the non-carpal tunnel side. There is "some" strength of thumb to middle finger opposition on the Carpal Tunnel side. Here is the Cheat Sheet for the "Motor Deficit" Grading Chart: Grading Chart for Motor Deficit--Cheat Sheet (p. 485) Grade Thumb to Middle Finger Oppos. % of Motor Deficit 5 Full Strength 0%

61 219 4 "Some" Strength 0-25% 3 No Strength 26-60% Ms. Hathaway has "some" strength in thumb to middle finger opposition on the carpal tunnel side. So, Dr. Solomon places her in Grade 4. That means he gets to pick a percentage between 0 and 25% for her "Percentage of Motor Deficit." He picks 10%. So, we multiply the 10% Motor Deficit times the 10% Maximum for Motor Deficit given to us in the Chart on p. 492: 10% of 10% UE = 1% UE 6. Combine the Sensory Deficit Impairment and the Motor Deficit Impairment. (p. 494) And now, to get our total rating, all we have to do is combine the numbers for "Sensory Deficit" and "Motor Deficit" using the Combined Values Chart at p of The AMA Guides. (Just put the higher number on the left side, find the second highest number on the bottom, and read up to where they intersect. There, you will find your Impairment Number.): Sensory Deficit: Motor Deficit: 10% of 39% = 3.9% (this rounds up to) 4% UE 10% of 10% UE = 1% UE TOTAL: (Using Combined Values Chart at p. 604) 5% UE

62 Turn the Extremity Impairment into a Whole Person Impairment. If we need to convert this to Whole Person Impairment, turn to the Magic Decoder Ring at p. 439 of The Guides: 5% UE = 3% WPI CONGRATULATIONS! YOU HAVE JUST LEARNED NERVE RATING! NOW THAT YOU HAVE LEARNED IT, I WILL LET YOU IN ON A SECRET: You have just learned the most difficult rating in The Guides! (I never tell people that before I teach them because, if I do, their minds shut down.) You have now learned the most difficult rating in The Guides. It doesn't get harder than that. So, congratulations! You have just crossed into PhD territory, so, when I next see you, I will address you as "Doctor of The AMA Guides.

63 221 SOME SPECIAL THINGS TO KNOW ABOUT CARPAL TUNNEL Be sure to read the Text about Carpal Tunnel at pages 491 through 495 of The Guides. Those pages have some really important things in them: 1. You cannot diagnose Carpal Tunnel without a positive EMG. (pp. 492 and 493) 2. A patient will not be mmi until at least 6 to 9 to 12 months after surgery. (p. 493, p. 508) 3. Never use "grip strength" to rate carpal tunnel: "In compression neuropathies, additional impairment values are not given for decreased grip strength." (p. 494) 4. If, after surgery and an optimal recovery time, the patient still complains of pain, paresthesias, and/or difficulties in performing certain activities, and has the following: a. Normal monofilament testing, and

64 222 b. Normal 2-point discrimination, and c. Normal thumb to middle finger opposition, and EITHER: 1) Abnormal EMG testing of the Thenar Muscles From Wikipedia: The thenar eminence is the body of muscle on the palm of the human hand just beneath the thumb. The muscles in this location are usually innervated by the recurrent branch of the median nerve. They all control movement of the thumb. Or 2) Abnormal sensory and/or motor latencies THEN, THE PHYSICIAN MAY GIVE THAT PATIENT AN IMPAIRMENT OF UP TO 5% UE (WHICH WOULD EQUAL 3% WPI). (p. 495, lower left paragraph) 5. Risk factors for Carpal Tunnel Syndrome (please see my new book, Apportionment, Medicine, and Science in Workers' Compensation (coming out in 2009): a. Rheumatoid arthritis b. Diabetes c. Thyroid Disorder

65 223 d. Menopause e. Female gender: Women are 3 times as likely as men to get the condition. Incidence peaks after menopause. Genetics in women f. Repetitive flexing and extending of the tendons in the hands and wrists, particulary when done forcefully for prolonged periods of time without rest. g. Specific injury to the wrist h. Your carpal tunnel is smaller than average i. Pregnancy j. Obesity k. Women taking birth control pills l. Smoking m. Age of female o. Lack of conditioning p. Lack of conditioning q. Family history of carpal tunnel syndrome r. Osteoarthritis of the CMC joint of the thumb (this is also known as the basal joint of the thumb. Go to the following link for a good picture of the CMC Joint of the Thumb:

66 224 The basal joint or carpometacarpal joint (CMC) of The thumb is located at the base of the thumb. It Allows the thumb to pivot and swivel. It has a Tendency to wear out from normal use and will Then develop pain, stiffness, and symptoms of Arthritis. Further, this wearing out is most Common in women over 40. s. Lifetime Alcohol Intake And that is how all Nerve Ratings are done. Let's review. Steps in Doing a Nerve Rating: 1. Find the nerve you are dealing with on the Nerve Chart. 2. Find the section of the Nerve you are dealing with on the Nerve Chart. 3. Read across to find the Maximums for "Sensory Deficit" and "Motor Deficit." 4. Grade the Sensory Deficit from the Grading Chart. From the Grade, select a percentage, multiply that times the maximum for "Sensory Deficit." 5. Grade the Motor Deficit from the Grading Chart. From the Grade, select a percentage, multiply that times the maximum for "Motor Deficit." 6. Combine the Sensory Deficit Impairment Number with The Motor Deficit Impairment Number by using the

67 225 Combined Values Chart at pp of The Guides. 7. Convert the Extremity Impairment to Whole Person Impairment. V. SPECIAL CASES COMPLEX REGIONAL PAIN SYNDROME (FORMERLY KNOWN AS REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIA) Complex Regional Pain Syndrome (Types I and II) is a fancy name for conditions formerly known as "Reflex Sympathetic Dystrophy" and "Causalgia." These are real conditions which exist. However, there have been thousands of cases where people have claimed they had the conditions(s) when they did not. Further, the International Association for the Study of Pain notes that over 70% of all diagnoses of CRPS are incorrect (please see my new book, Apportionment, Medicine, and Science in Workers' Compensation (coming out in 2009). Therefore, The AMA Guides handles them in a special way.

68 226 Simply put, to have a diagnosis of CRPS under The Guides, and resulting impairment, the patient must have 8 findings present at the same time and observed by the physician at the same time. (p. 496) What are these conditions? From Wikipedia: Complex Regional Pain Syndrome (CRPS) is a chronic progressive disease characterized by severe pain, swelling and changes in the skin. The International Association for the Study of Pain has divided CRPS into two types based on the presence of nerve lesion following the injury. Type I, also known as Reflex Sympathetic Dystrophy (RSD), Sudeck's atrophy, Reflex Neurovascular Dystrophy (RND) or Algoneurodystrophy, does not have demonstrable nerve lesions. Type II, also known as Causalgia, has evidence of obvious nerve damage. The cause of this syndrome is currently unknown. Precipitating factors include illness, injury and surgery, although there are documented cases that have no documentable injury to the original site. History and nomenclature The condition currently known as CRPS was originally described by Silas Weir Mitchell during the American Civil War, who is sometimes also credited for inventing the name "causalgia." However, this term was actually coined by Mitchell's friend Robley Dunglison from the Greek words for heat and for pain. In the 1940s, the term reflex sympathetic dystrophy came into use to describe this condition, based on the theory that sympathetic hyperactivity was involved in the pathophysiology. Misuse of the terms, as well as doubts about the underlying pathophysiology, led to calls for better nomenclature. In 1993, a special consensus workshop held in Orlando, Florida, provided the umbrella term "complex regional pain syndrome," with causalgia and RSD as subtypes.

69 227 Severe CRPS of right arm Pathophysiology The pathophysiology of CRPS is not fully understood. Symptoms The symptoms of CRPS usually manifest near the site of an injury, either major or minor, and usually spread beyond the original area. Symptoms may spread to involve the entire limb and, rarely, the opposite limb. The most common symptom is burning pain. The patient may also experience muscle spasms, local swelling, increased sweating, softening of bones, joint tenderness or stiffness, restricted or painful movement, and changes in the nails and skin. The pain of CRPS is continuous and may be heightened by emotional stress. Moving or touching the limb is often intolerable. Eventually the joints become stiff from disuse, and the skin, muscles, and bone atrophy. The symptoms of CRPS vary in severity and duration. There are three variants of CRPS, previously thought of as stages. It is now believed that patients with CRPS do not progress through these stages sequentially and/or that these stages are not time-limited. Instead, patients are likely to have one of the three following types of disease progression: 1. Type one is characterized by severe, burning pain at the site of the injury. Muscle spasm, joint stiffness, restricted mobility, rapid hair and nail growth, and vasospasm (a constriction of the blood vessels) that affects color and temperature of the skin can also occur. 2. Type two is characterized by more intense pain. Swelling spreads, hair growth diminishes, nails become cracked, brittle, grooved, and spotty, osteoporosis becomes severe and diffuse, joints thicken, and muscles atrophy. 3. Type three is characterized by irreversible changes in the skin and bones, while the pain becomes unyielding and may involve the entire limb. There is marked muscle atrophy, severely limited mobility of the affected area, and flexor tendon contractions (contractions of the muscles and tendons that flex the joints).

70 228 Diagnosis Occasionally the limb is displaced from its normal position, and marked bone softening is more dispersed CRPS types I and II share the common diagnostic criteria shown below. 1. Spontaneous pain or allodynia/hyperalgesia is not limited to the territory of a single peripheral nerve, and is disproportionate to the inciting event. 2. There is a history of edema, skin blood flow abnormality, or abnormal sweating in the region of the pain since the inciting event. 3. No other conditions can account for the degree of pain and dysfunction. The two types differ only in the nature of the inciting event. Type I CRPS develops following an initiating noxious event that may or may not have been traumatic, while type II CRPS develops after a nerve injury. No specific test is available for CRPS, which is diagnosed primarily through observation of the symptoms. Diagnosis is complicated by the fact that some patients improve without treatment. Radiography Patchy osteoporosis, which may be due to disuse of the affected extremity, can be detected through X-ray imagery as early as two weeks after the onset of CRPS. A bone scan of the affected limb may detect these changes even sooner. Bone densitometry can also be used to detect changes in bone mineral density. It can also be used to monitor the results of treatment, as bone densitometry parameters improve with treatment. Electrodiagnostic testing The nerve injury that characterizes type II CRPS can be detected by electromyography. In contrast to peripheral mononeuropathy, the symptoms of type 2 CRPS extend beyond the distribution of the affected peripheral nerve. Prevention Vitamin C has been shown to reduce the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended.

71 229 Treatment The general strategy in CRPS treatment is often multi-disciplinary, with the use of different types of medications combined with distinct physical therapies. Physicians use a variety of drugs to treat CRPS, including antidepressants, antiinflammatories such as corticosteroids and COX-inhibitors such as piroxicam, bisphosphonates, vasodilators, GABA analogs such gabapentin and pregabalin, and alpha- or beta-adrenergic-blocking compounds. Elevation of the extremity and physical/occupational therapy are also used to treat CRPS. Injection of a local anesthetic such as lidocaine is often the first step in treatment. Injections are repeated as needed. However, early intervention with non-invasive management may be preferred to repeated nerve blockade. The use of topical lidocaine patches has been shown to be of use in the treatment of CRPS-1 and -2. Neurostimulation (spinal cord stimulators) may also be surgically implanted to reduce the pain by directly stimulating the spinal cord. These devices place electrodes either in the epidural space (space above the spinal cord) or directly over nerves located outside the central nervous system. Implantable drug pumps may also be used to deliver pain medication directly to the cerebrospinal fluid which allows powerful opioids to be used in a much smaller dose than when taken orally. Physical therapy is the most important part of treatment, though it should be noted that many patients are incapable of participating in physical therapy due to muscular and bone problems. People struggling with CRPS often develop guarding behaviors where they avoid using or touching the affected limb. Unfortunately, inactivity exacerbates the disease and perpetuate the pain cycle. Physical therapy works best for most patients, especially goal-directed therapy, where the patient begins from an initial point, regardless of how minimal, and then endeavors to increase activity each week. Therapy should be directed at facilitating the patient to engage in physical therapy, movement and stimulation of the affected areas. Prognosis Good progress can be made in treating CRPS if treatment is begun early, ideally within 3 months of the first symptoms. If treatment is delayed, however, the disorder can quickly spread to the entire limb and changes in bone, nerve, and muscle may become irreversible.

72 230 The AMA Guides specify that, in order to have a diagnosis of Complex Regional Pain Syndrome in the Upper Extremity, you must have 8 objective findings present at the same time and observed by the physician. The 8 findings are: Vasomotor changes (action on a blood vessel which alters its diameter): 1. Skin color a. Mottled: Skin having colored spots or blotches b. Cyanotic: Skin blue or purplish from lack of oxygen 2. Skin temperature: cool 3. Edema: Swelling Sudomotor changes (relating to nerve fibers controlling sweat glands): 4. Skin is dry or overly moist Trophic changes: (promoting cellular growth, differentiation, and Survival) 5. Skin texture is smooth and non-elastic 6. Soft tissue atrophy: especially in the fingertips

73 Joint stiffness and decreased passive motion 8. Nail changes: blemished, curved talon-like 9. Hair Growth changes: fall out or longer, finer Radiographic (x-ray) signs: 10. Radiographs show trophic bone changes or osteoporosis [decrease in bone mass with decreased density and enlargement of bone spaces producing pores and brittleness] 11. Bone scan: findings consistent with CRPS (increased periarticular uptake, lowered bone mineral density, bone demineralization) (p. 496 of The Guides.) In order to get a diagnosis of CRPS under The Guides, the patient must have 8 of these findings observed by the physician on physical examination: (p. 496) "At least eight of these findings must be present concurrently for a diagnosis of CRPS. Signs are objective evidence of disease perceptible to the examiner, as opposed to symptoms, which are subjective sensations of the individual." Upper Extremity Once you have the 8 objective findings, then CRPS of an Upper Extremity is rated in one of 2 ways: 1. Either using Range of Motion and Sensory (Nerve) Rating

74 232 Facts: noted above (see p. 497), OR 2. Under the Neurology Chapter, rate based on the Chart at p [Please note: This is the only place in The Guides where hand dominance is taken into consideration.] Mrs. Wilborn is a 30 year old woman. She is right handed. She underwent a right carpal tunnel release one year ago. During her recovery from surgery, she developed diffuse burning pain in the right hand, extending to the forearm, accompanied by swelling of the right hand. She underwent ganglion blocks which relieved the pain and reduced the swelling, temporarily. Over time, she noted color changes in her hand and increased sweating. Her hand was always cold. Movement of the fingers and waist was limited. A. TENS unit was used constantly, along with medication, to control the pain. At present, she has deep burning pain in the right hand, increased sweating of the hand, right arm weakness, and an inability to use the hand for any of the Activities of Daily Living listed on p. 4 of The Guides. On examination, she holds the right arm close to her body in a protected fashion. Her right hand is dusky with a sweaty palm. The skin on the right hand is thinned. The fingers on the right hand are tightly adducted and cannot be separated. The nails have grown and have the appearance of an eagle's talons. Attempts to move her right wrist produce pain. Her proximal muscles have poor tone and disuse atrophy. The hair on her right hand has grown long and unruly. The right hand feels significantly cooler than the left hand, when touched by the examiner. A three phase bone scan is done which is unremarkable. A plain x-ray shows diffuse demineralization.

75 233 Rating: She is diagnosed with Reflex Sympathetic Dystrophy (CRPS 1). 1. Does she have 8 of the objective findings noted on p. 496 of The Guides? 2. Yes, then rate her using the Upper Extremity Range of Motion Charts and the Nerve Charts in the Upper Extremity Chapter OR 3. Rate her using the chart at p. 343 of The Guides in the Neurology Chapter. (This chart will usually produce a higher rating than the charts in #2 above, so this chart is the one used most frequently for rating CRPS in an upper extremity. Note: She cannot use the hand for any of the Activities of Daily Living. This would place her in Class 4 of Table 13-22: "Criteria for Rating Impairment Related to Chronic Pain in One Upper Extremity." She is right-handed. This is her dominant hand. Therefore, her rating would be 40-60% WPI. (Remember, amputation of an arm is 60% WPI. The patient can never receive a rating higher than an amputation.) Lower Extremity For the Lower Extremity, rate CRPS using the chart on p. 336 of The AMA Guides. Chapter 17, the Lower Extremity chapter of The Guides, states: "When causalgia or CRPS occurs in an extremity, the evaluator should use the method described in Chapter 13, The Central and Peripheral Nervous System. [p. 336]" (p. 553.) Facts:

76 234 Mrs. Johnson is a 32 year old woman. She jumped from a truck dock down to the ground, approximately 4.5 feet. When she did so, she fell and struck the front of her right knee and sustained a bruise with ecchymosis. She had no fracture. One month later, she reported terrible pain, swelling, and a red, warm leg that sweated when no other part of her was sweating. Two years after the injury, she presents for examination. She is walking with two crutches. She does not bear weight on her right leg. She complains of constant, severe pain in the right leg despite undergoing multiple forms of treatment. She cannot stand without help and the use of her crutches. Her right leg is swollen and pale. There is skin atrophy and atrophy of the toes equivalent to "fingerprints." On active range of motion testing, she does not cooperate due to pain. She has very little active motion in any joint in the leg. She does not cooperate with manual muscle testing as this testing provokes pain. On sensory examination, there is no loss of sensation; rather, any touching of the leg provokes severe pain (allodynia). A bone scan is done after the injury. It shows diffuse periarticular increased uptake at the knee, ankle, and foot on the third phase or 3 to 4 hour delayed images. Current xrays of the leg show extensive osteoporosis. Diagnosis is Complex Regional Pain Syndrome of the right leg. 1. Does she have 8 of the objective findings noted on p. 496 of The Guides? Answer: She does not. Therefore, she could not be rated for CRPS in the lower extremity, and her rating for CRPS in the lower extremity would be 0% WPI.

77 Let's change the facts and assume she does have 8 of the objective findings. If so, what would her rating be: Turn to the Chart at p. 336 of The Guides. She would fall in Class 4 because she cannot stand without help, mechanical support, and/or an assistive device. This rates as 40% to 60% WPI. What should the evaluator give her? 40% WPI? 50% WPI? 60% WPI? Answer: 40% WPI because that is the amputation value of the leg (see p. 527, 100% LE = 40% WPI. An individual can never receive a rating for an extremity higher than the amputation value of that extremity. So, her rating would be 40% WPI. [Please note this error in the Guides. Table 13-15, Class 4, p. 336, rates out Impairment due to Station and Gait Disorder. It indicates that if a patient cannot stand without help, mechanical support, and/or an assistive device, his rating is 40% WPI - 60% WPI. Remember, the amputation value of 1 leg is 40% WPI. Therefore, one leg with CRPS can never rate higher than 40% WPI.](See p. 527.) VI. COMBINATION RATINGS Now that you have learned the 5 different types of ratings under The AMA Guides, let's learn the final type of rating: Combination. In this method, you combine different Chart, Range of Motion, DRE, and Nerve ratings to produce a total. In the Lower Extremity, there is one additional step where you determine which ratings can be combined for a total using the "Joan Crawford Christmas Morning Chart." I'll explain that under the Lower Extremity section below.

78 236 SPINE RANGE OF MOTION First, we'll learn how to do the rating. Then, we'll learn when it is used (as opposed to the DRE method of rating in the Spine.) The Spine Range of Motion encompasses 3 different ratings: 1. Chart: Read the Major Diagnosis off a Chart to find the Impairment for that diagnosis 2. Range of Motion: Then, do Range of Motion measurements to calculate impairment for loss of motion, and 3. Nerve: rate out any nerve impairment in the affected Extremities, and finally 3. Combine the 3 numbers you get for Diagnosis, Motion, and Nerve to get the total impairment. Let's use an example to learn: Facts: Mr. Volare is a trapeze artist in the circus. He is climbing one of the trapeze poles one day to reach the platform for a rehearsal. He slips and falls backwards 14 feet. He lands in a seated position on a plywood clown car on the ground below. Mr. Volare has immediate pain in his lower back. He has no pain running down into either of his legs. He is taken by ambulance to the Clown Circus in Sarasota, Florida. An x-ray is taken of his spine which shows an L1 Compression Fracture of 40% and an L2 compression fracture of 20%.

79 237 Mr. Volare is taken off work for the rest of the Winter Season. He recovers at the Circus Physical Rehabilitation and Convalescent Home. He particularly enjoys his time with the clowns, although he finds them a bit sad. He undergoes a full course of physical therapy and reaches a point where he has mild tenderness in the low back but no other symptoms. He is able to resume his normal daily activities. Mr. Volare returns to his work as a trapeze artist. He is better than ever and returns to thunderous ovations. He comes to see Dr. Ringling one year after the injury for an mmi evaluation. When Dr. Ringling finds M. Volare mmi. He has a new x-ray taken of the lumbar spine which confirms the L1 compression fracture of 40% and the L2 compression fracture of 20%. Dr. Ringling has Mr. Volare do warmup exercises for the spine as follows: flexion and extension twice, left and right rotation twice, left and right lateral bending twice, and one additional flexion and extension." Dr. Ringling then takes out his dual inclinometer. He has Mr. Volare do flexion, extension, left lateral, and right lateral a total of 6 times. Here are the measurements he gets: Motion Set Sacral flexion: True lumbar spine flexion: True lumbar spine extension: Left lateral bending: Right lateral bending:

80 238 The neurological examination is completely normal. What is Mr. Volare's rating using the Spine Range of Motion method? As noted, there are 3 components to a Spine Range of Motion rating: 1. Impairment for the Disorder (i.e. Diagnosis) 2. Impairment for the Motion 3. Impairment for the Nerve Problems A. Disorder: Turn to the chart on p. 404, Table Find the patient's disorder. If there are 2 or more diagnoses within a spinal region, use that which is most significant. (p. 402, paragraph 15.8d, #3.) Mr. Volare has 2 diagnoses: L1 compression fracture of 40% L2 compression fracture of 20% The L1 compression fracture is greater and would, Therefore, be more significant. So, use that for the Diagnosis. Read down on the chart on p. 404 to: "Disorder: 1. Fractures A. Compression of one vertebral body:

81 239 26% to 50% (Mr. Volare's is 40%.)" Now, read across to the right where it says: "% Impairment for the Whole Person--Lumbar" Mr. Volare's fracture is in the lumbar spine. You will see "7%". This is WPI based on the Chart. So, for the Disorder, Mr. Volare has 7% WPI. Disorder: 7% WPI. B. Motion Now, turn to the chart on p. 407, Table Apply The measurements above. Use the greatest measurement For rating purposes. 1. The measurements were done with a dual Inclinometer (see p. 400: " an inclinometer is The preferred device for obtaining accurate, reproducible Measuremements in a simple, practical, and Inexpensive way.") 2. They were done 3 times. P. 399 gives us the Test for consistency and reliability for Spine Range of Motion: "The reproducibility (precision) of an individual's Performance is one (but not the sole) indicator of Optimum effort. When measuring range of motion, The examiner should obtain at least three consecutive Measurements and calculate the mean (average) of the

82 240 Three. Measurements should not change substantially With repeated efforts. If the average is less than 50 Degrees, three consecutive measurements must fall Within 5 degrees of the mean; if the average is Greater than 50 degrees, three consecutive measurements Must fall within 10% of the mean." "Motion testing may be repeated up to six times to obtain 3 consecutive measurements that meet these criteria. If after six measurements inconsistency persists, the spinal motions are considered invalid. The measurements and accompanying impairments may then be disallowed, in part or in their entirety." "When possible, the individual being evaluated should warm up prior to the ROM measurements; flexion and extension twice, left and right rotation twice, left and right lateral bending twice, and one additional flexion and extension." Dr. Ringling did 6 sets of measurements. He calculates the mean (average) of the measurements: Sacral flexion: True Lumbar Flexion: 19.5 True Lumbar Extension: Left lateral bending: 19.0 Right lateral bending: All of these measurements are less than 50 degrees. Therefore, The measurements taken must fall within 5 degrees of the mean To be deemed consistent, reliable, and to be used for rating

83 241 Purposes. All of the measurements above fall within 5 degrees of the Mean. Dr. Ringling then selects 3 consecutive sets where all of the Measurements fall within 5 degrees of the mean. Motion Set Sacral flexion: True lumbar spine flexion: True lumbar spine extension: Left lateral bending: Right lateral bending: He selects the first 3 sets and chooses the highest number of the 3 in each motion for purposes of rating (p. 403, #7, p. 406, #5.) His numbers are: Sacral Flexion 40 True Lumbar Flexion 20 True Lumbar Extension 15 Left Lateral Bending 20 Right Lateral Bending 20

84 242 Now, he turns to the chart on p. 407, Table 15-8: He reads: "Sacral Flexion, " He circles that Because Mr. Volare's Sacral Flexion is 40 degrees." He reads across: "True Lumbar Spine Flexion: 20 degrees." He Circles that because Mr. Volare's true lumbar spine flexion is 20 Degrees. Then, he draws a line from the "30-45" down to the "20" and then Straight across to "% Impairment of the Whole Person." He reads: 7% WPI. He writes that down. Next, True Lumbar Extension. He continues down the chart. He Reads: "20" because Mr. Volare's true lumbar extension is 20. He Reads straight across the chart to the column for "% impairment of The Whole Person." He reads: "2%" 2% WPI. He turns the page to p. 409, Table Left Lateral Bending. He reads: "20" because Mr. Volare's left Lateral bending was 20 degrees. He reads straight across to the Column for "% impairment of the Whole Person." He reads: "1%." Then, he continues down for Right Lateral Bending. He reads: "20" because Mr. Volare's right lateral bending was 20 degrees. He reads straight across to the Column for "% impairment of the Whole Person." He reads: "1%." And now, you've got the 4 numbers you need: Sacral Flexion/True Lumbar Spine Flexion: 7% True Lumbar Spine Extension: 2%

85 243 Left Lateral Bending: 1% Right Lateral Bending: 1% Now, add them together to get the total: p. 403, #7: "If there are impairments due to loss of motion in more than one plane in the same spinal region (extension, flexion, or rotation), the impairments are added To determine total impairment due to loss of motion in a Spinal region." 11% WPI C. Nerve Mr. Volare has no neurological problems. So, his rating for Nerve problems would be 0% WPI. If he had nerve problems, you would rate them using Tables for the Upper Extremity and for the Lower Extremity on p. 424 and the Grading Charts at Table and PLEASE NOTE: The values given on Tables and are Upper Extremity Impairment and Lower Extremity Impairment. They must be converted to WPI per the conversion charts on pages 439 and 527 of The Guides to produce the overall WPI %. D. Combine the Disorder, Motion, and Nerve WPI numbers to Get the total WPI %. Disorder: Motion: Nerve: 7% WPI 11% WPI 0% WPI Use Combining Values Chart at pp

86 244 WPI 17% WPI. And that, is the Spine Range of Motion Rating. AND NOW, SOMETHING ADVANCED: THE ACCESSORY VALIDITY TEST 1. Turn to p. 406, paragraph 6. This describes the Accessory Validity Test Essentially, this test has the doctor compare the patient's lumbar flexion and extension with his straight leg raising while lying down. Remember, the motions of bending forward from the waist and lifting the legs while lying on the back are very similar. Therefore, it there is a significant discrepancy between the angles achieved when doing the same motion (standing up or lying down), then the results are not reproducible, not consistent, and cannot be used for rating lumbosacral spine flexion and extension. (see p. 406, #6.) P. 406 states: "If the straight-leg-raising angle exceeds the sum of sacral flexion and extension angles by more than 15 degrees, the lumbosacral flexion test is invalid. Normally, the straight-leg-raising angle is about the same as the sum of the sacral flexion-extension angle. If the individual resists passive Straight Leg Raising without other evidence of radiculopathy, The accessory test is also invalid. If invalid, the examiner Should either repeat the flexion-extension test or disallow For lumbosacral spine flexion and extension." (p. 406) An example of the accessory validity test is given on p Please note the limitations on the usefulness of the accessory Validity test for men and women given on p. 406, upper right Paragraph.

87 245 Now, WHEN DO YOU USE THE RANGE OF MOTION METHOD FOR RATING THE SPINE, VERSUS THE DRE METHOD? a. Use the DRE if: (p. 379 of The AMA Guides) 1) Patient had a specific injury, or 2) Cause of the impairment is not easily determined, or 3) The impairment can be well characterized by the DRE method b. Use the ROM if: (p. 379 of The AMA Guides) 1) Fractures at more than one level in the same spinal Region (there are 3 spinal regions: cervical, thoracic, And lumbar, so, there must be more than one fracture In a specific spinal region) 2) Fusions at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fusion in a specific spinal region) 3) Radiculopathy in the same spinal region a) Bilaterally, OR b) At multiple levels

88 246 AMBIGUITY: The language above from p. 380, lower right paragraph #4 appears to be different from the following language below which appears at p. 380, upper left paragraph 4: "Recurrent Radiculopathy in the same spinal region, caused by a) A new (recurrent) Disc herniation, OR b) Recurrent injury" Note: In California, the phrase "recurrent injury" has been used by Applicant attorneys to argue that all cumulative trauma spinal cases should be rated using the Range of Motion method because cumulative trauma constitutes thousands of tiny recurrent injuries. The editors of the Guides Newsletter have clarified that cumulative trauma should be rated using the DRE method unless it produces one of the enumerated problems--fusions at multiple levels in the same spinal region; fractures at multiple levels in the same spinal region; radiculopathy which is bilateral or at multiple levels in the same spinal region; radiculopathy caused by recurrent disc herniation or stenosis or multiple episodes of other pathology at the same or a different level in the same spinal region; or alteration of motion segment integrity caused by multiple episodes of other pathology--and then it should be rated using the Range of Motion method.

89 247 The determination of whether or not the phrase "recurrent injury" is interpreted to apply to all cumulative trauma spinal injuries will lie with the California courts. 4) Alteration of Motion Segment Integrity caused by a) Multiple episodes of other pathology 5) Radiculopathy caused by a) Multiple episodes of other pathology 6) The following 3 conditions are met: a) The impairment is not caused by an injury, and b) The cause of the condition is uncertain; and c) The DRE Method does not apply OR d) The patient cannot be easily categorized in a DRE category e) AND, the evaluator gives his reasons for using the ROM under these circumstances in writing. c. If the patient qualifies to be rated under both the DRE and the ROM, 1) Rate him under both, AND 2) Give him the highest rating

90 248 LOWER EXTREMITY The Lower Extremity Chapter combines Read It Off a Chart, Range of Motion, and Nerve Rating methods. It then adds a final stop to determine which impairments you can COMBINE from each of the rating methods above. This final step is known as the "Joan Crawford Christmas Morning Chart." I'll explain. When doing a rating in the Lower Extremity chapter, you follow the following steps: 1. Turn to the Chart on p. 525, Table 17-1, to see the list of all the things which can go wrong in a leg. They include: a. Limb length discrepancy b. Muscle atrophy c. Ankylosis (fusion) d. Amputation e. Arthritis of the joints f. Skin loss g. Peripheral nerve injury h. Vascular i. CRPS (reflex sympathetic dystrophy and causalgia) j. Range of Motion k. Gait derangement

91 249 l. Muscle strength m. Fractures o. Ligament injuries p. Meniscectomies q. Foot deformities r. Hip and pelvic bursitis s. Lower extremity joint replacements. Find the diagnoses you have, then turn to the chart for each and calculate the impairment. The charts are "simply read it", range of motion, and nerve rating charts. Calculate the impairment for each diagnosis. 2. Then, once you have calculated the impairments, turn to the "Joan Crawford Christmas Morning Chart" at p. 526 to see which impairments can be COMBINED to get the TOTAL. Let's do an example. Facts: a. If none of the impairment types can be combined, YOU PICK THE HIGHEST FOR THE TOTAL RATING. Mr. Lockyer is a Forest Ranger. He slips down a waterfall one day and injures his right leg.

92 250 He is diagnosed with a torn right medial meniscus. He undergoes surgery and recovers. He comes in for his mmi evaluation, and Dr. Arbiter finds the following: Partial medial meniscectomy (patient has recovered) Calf atrophy in right leg of 2 cm compared to left leg Limp Range of Motion: Right Left Flexion 110, 112, , 121, 122 Flexion Contracture 6, 6, 6 0, 0, 0 No other problems in the right leg. Mr. Lockyer has returned to his work as a Forest Ranger without any problems. Now, let's do the rating: 1. Partial medical meniscectomy: p (2) 2. Calf atrophy : p (8) 3. Limp: p. 529 Does not qualify for a rating because he does not have a shortened stance phase and there is no evidence of documented moderate to advanced arthritic changes of the knee Further, you never use "Gait Derangement" when

93 251 you have any impairment you can measure more specifically [such as partial medical meniscectomy, calf atrophy, or range of motion] (p. 529), and If you ever use gait, you cannotcombine it with any other impairment method. (p. 529) 4. Range of Motion: Right Flexion 0 (0) Flexion Contracture 4 (10) Good. Now you've got the impairment for each problem. If we just added up the Whole Person Impairment number above, we would get 8% WPI (1% WPI + 3% WPI + 4% WPI). But wait a second. We've got one more step: The Lower Extremity Chapter (Chapter 17) is the only chapter where this occurs. Once you've calculated each impairment, you have to see which ones can be COMBINED to get the total. How do you do that? Use the "Joan Crawford Christmas Morning Chart" on p. 526, Table Why do we call this the "Joan Crawford Christmas Morning Chart?" Because it does just what Joan Crawford did on Christmas Morning! Remember the movie, Mommie Dearest? Remember the radio broadcast on Christmas Eve? Joan Crawford was interviewed about what Christmas morning was like in the Crawford home. She told the reporter that she let Christopher and Christina come downstairs to the Christmas tree (after Joan had untied them from their beds). She then let them open each Christmas present, and, when they had finished, she made them pick ONE!

94 252 This chart is just like being at the Crawford home on Christmas morning. You take each impairment and see if you can combine it with the others. In our example, we have 3 impairments: 1. Partial Medical Meniscectomy (this is known as a Diagnosis- Based Estimate), 2. Atrophy 3. Range of Motion. Can we combine any of these? Look at the chart. Find DBE on the left. Read across to the column for atrophy. What do you see? A big "X." That means you cannot combine them. Now, let's try DBE with Range of Motion. An "X" again. Can't combine. How about the final two: Atrophy and ROM? Nope, an "X" again. That means we cannot combine any of the impairments. If you cannot combine, then you simply pick the highest number. In this case, that would be 4% WPI for Range of Motion (Flexion Contracture). Rating: 4% WPI. AND THAT, MY FRIENDS, IS ALL SIX OF THE RATING TYPES YOU WILL FIND IN THE AMA GUIDES!

95 253 CONGRATULATIONS! NOW YOU KNOW ALL OF THE RATINGS.

96 254 CHECKLISTS FOR RATINGS I. READ FROM A CHART A. HEARING LOSS (MONAURAL AND BINAURAL) 1. Monaural Chart: p Binaural Chart: p B. LOWER EXTREMITY (DIAGNOSIS- BASED ESTIMATES) C. Pain 1. Chart (Giant "Buffet Line" of the Lower Extremity): pp

97 Most pain is included in the ratings from Chapters Add-on for pain under Chapter 18 is 1% WPI, 2% WPI, or 3% WPI 3. Please see discussion at pp of This Book regarding conditions for add-on for pain under Chapter 18 and position of the DEU in California II. RANGE OF MOTION SHOULDER, ELBOW, WRIST, HAND, FINGERS LOWER EXTREMITY (NOT INCLUDING SPINE) 1. The patient must do the motions of the subject area specified in the text describing the physical examination for the body part involved a minimum of: a. Two times (p. 20), and b. Under his own power (active motion) (p. 475), and c. The measurements must fall within 10% of each other to be deemed reliable, consistent, and to be used for rating purposes (p. 20). 1) If the measurements do not fall within 10%, then they are not reliable, and the impairment for that motion is 0% UE (see p. 20). 2. The necessary motions and measurements for each body part are listed in the chapter for rating that body part.

98 The physician should use a goniometer to measure the actual angles of each of the motions. (p. 475, p. 451) a. The physician should record the actual goniometer readings (p. 475), and b. The physician should use the highest measurement for rating purposes. (p. 475) 4. The motion measurements are then applied to the pie charts/range of motion charts for impairment calculation. (p. 461) a. Measurements of motion which fall between those shown on a pie chart are adjusted or interpolated proportionally to the corresponding inverval (p. 461) 5. The physician uses the I-A (Impairment for Ankylosis) arc in calculating impairment if the subject body part is ankylosed (i.e. fused in a permanent position) 6. The physician should measure the contralateral (opposite) body part and use those measurements to establish the baseline of normal. (p. 453) a. If the uninvolved ("contralateral") "normal" joint has a less than average mobility, the impairment value(s) which correspond to the uninvolved joint serve as a baseline (p. 453), and b. They are subtracted from the calculated impairment for the involved joint (p. 453), and c. The physician should explain the rationale for this decision in his report. (p. 453) 7. Whether the upper extremity impairment percentages derived from the angle measurements of the specified motions are added together or

99 257 combined to get the total impairment is specified in the formula for doing the rating found in the Chapter for the subject body part. 8. The total upper extremity impairment in the body part is converted to whole person impairment using charts provided in the chapter for that specific body part. III. DRE (DIAGNOSTIC-RELATED ESTIMATES) SPINE (CERVICAL, THORACIC, LUMBAR) 1. Determine if the DRE Method or the Range of Motion (ROM) should be used for rating: a. Use the DRE if: (p. 379 of The AMA Guides) 1) Patient had a specific injury, or 2) Cause of the impairment is not easily determined, or 3) The impairment can be well characterized by the DRE method b. Use the ROM if: (p. 379 of The AMA Guides) 1) Fractures at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fracture in a specific spinal region) 2) Fusions at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fusion in a specific spinal region)

100 258 3) Radiculopathy in the same spinal region a) Bilaterally, OR b) At multiple levels AMBIGUITY: The language above from p. 380, lower right paragraph #4 appears to be different from the following language below which appears at p. 380, paragraph 4. "Recurrent Radiculopathy in the same spinal region, caused by a) Disc herniation, OR b) Recurrent injury" 4) Alteration of Motion Segment Integrity caused by a) Multiple episodes of other pathology 5) Radiculopathy caused by a) Multiple episodes of other pathology 6) The following 3 conditions are met: a) The impairment is not caused by an injury, and

101 259 b) The cause of the condition is uncertain; and c) The DRE Method does not apply OR d) The patient cannot be easily categorized in a DRE category e) AND, the evaluator gives his reasons for using the ROM under these circumstances in writing. c. If the patient qualifies to be rated under both the DRE and the ROM, 1) Rate him under both, AND 2) Give him the higher rating B. Things to Look For in the Physical Examination (Go to "THE LIST OF THINGS THE EVALUATOR LOOKS FOR" at pp of The Guides and pp of This Book. 1. Muscle spasm A hard muscle which the individual cannot relax. (p. 382) It is common after an acute spinal injury but rare in chronic back pain. (p. 382) 2. Muscle guarding Immobilization of an area by tightening the muscles. The Guides define this as " a contraction of muscle to minimize motion or agitation of the injured or diseased tissue." (p. 382) The contraction CAN be relaxed which is NOT POSSIBLE with muscle spasm. (p. 382)

102 Asymmetry of Spinal Motion Muscle spasm or muscle guarding may cause a patient to be unable to move the spine symmetrically. For example, if a patient attempts to flex from the lumbar spine, a muscle spasm on one side of the lumbar spine may cause his trunk to lean to one side (asymmetry). The same thing may happen with the head in the cervical spine (asymmetry). (p. 382) See explanation at p. of This Book The Guides specifically note: "To qualify as true asymmetric motion, the finding must be reproducible and consistent and the examiner must be convinced that the individual is cooperative and giving full effort." (emphasis added) (p. 382) 4. Nonverifiable Radicular Root Pain Pain that follows the pathway of a nerve root (i.e., a dermatomal distribution) but is not supported by objective physical, imaging, or electromyographic findings. (p. 382) The Nerve Pathways (or Dermatomal Distributions) are shown on p. 377, Figures 15-1 and Reflexes From Wikipedia: A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. Human reflexes are tested as part of a neurological examination to assess damage to and functioning of the central and peripheral nervous system.

103 Weakness and Loss of Sensation The sensory findings must be in a strict anatomic distribution following a known nerve pathway. Weakness must be in muscles which correspond to the affected nerves. Long-term weakness is usually accompanied by atrophy. (p. 382) 7. Atrophy Muscle loss. It is measured with at tape measure at identical levels on both limbs. The difference in circumference indicating problems should be Thigh Arm Forearm Leg 2 cm or greater 1 cm or greater 1 cm or greater 1 cm or greater (p. 382) Measurements that fall within the centimeter ranges above may be normal variants. 8. Radiculopathy Pain, numbness, or tingling in a known nerve pathway (dermatomal distribution). It is usually caused by pressure on one or several nerve roots. It produces a significant alteration in the function of the affected nerve(s). KEY: A diagnosis of herniated disc MUST BE SUBSTANIATED by an appropriate finding on an imaging study.

104 262 FURTHER, just because someone has a herniated disc on imaging study does NOT mean he will have radiculopathy. [See discussion at p. 378.] 30% of people with no back pain have imaging studies which show herniated discs. (p. 378) 50% of people with no back pain have imaging studies which show bulging discs. (p. 378) As you get older, you get more bulges and herniations. (p. 378) An imaging result can confirm a diagnosis, but to get a diagnosis of radiculopathy, you need a positive EMG. (p. 378.) 9. Alteration of Motion Segment Integrity This is usually a loss of motion of the vertebrae in relation to each other due to a fusion. The most common example of this is a one-level spinal fusion. (p. 383) Alteration of Motion Segment Integrity can also be seen in increased motion of the vertebrae (beyond normal) on top of each other or increased angles in relation to each other. (p. 383) KEY: You MUST have flexion and extension x-rays to determine the motion of the individual spine segments. It cannot be done by Physical Examination. (p. 383) To have loss of motion segment integrity, the x-rays must meet the measurements prescribed on p. 378 through 379 of The Guides. 10. Cauda Equina Syndrome (means "the horse's tail")

105 263 Loss of sphincter tone on rectal exam and diminished or absent bladder, bowel, or lower limb reflexes (p. 383) 11. Urodynamic Tests If the patient is suspected of having a "cauda equina syndrome," do a cystometrogram. If it is normal, it makes the presence of a nerve-related bladder dysfunction unlikely. (p. 383) C. Steps in the MMI Evaluation: 1. Get the individual's history 2. Perform a physical examination looking for the things on "The List of Things the Evaluator Looks For in Doing A Spine DRE Evaluation" (pp ) 3. Do Diagnostic Tests, if indicated. 4. Turn to the DRE Chart of the Section of the Spine with which you are dealing (Cervical, p. 392, Thoracic, p. 388, Lumbar, p. 384). a. You will see 5 columns. b. Read the words of each column. c. Place the patient in the appropriate Column, i.e., "Category" d. The Category will give you a WPI % range. 1) Question the patient on how the injury

106 264 has affected her in the list of Activities of Daily Living at p. 4. If the injury has: 0 to Mild Impact: Give lowest number(s) in WPI Range Significant Impact: Give highest number in WPI Range Moderate Impact: Give middle number(s) in WPI Range 2) Reference: p. 381, paragraph 6: "If residual symptoms or objective findings impact the ability to perform ADL despite treatment, the higher percentage in each range should be assigned." (Note: This appears to indicate that treatment is necessary to adjust the WPI number up based on residual symptoms or objective findings which have an impact on ADL's.) 6. Select the appropriate Impairment Number based on the Patient's Category and the Impact of the injury or illness on the Activities of Daily Living. 7. Convert to Whole Person Impairment. 8. Be sure to list all pages and charts referenced. 9. Write an Essay Answer: a. Calculate the Impairment Rating (Sec. 2.6b)

107 265 1) Compare medical findings with impairment criteria--calculate appropriate impairment rating 2) Show how findings compare with the criteria 3) Explain the absence of any data not included 4) Explain how impairment was calculated if data was limited b. Discuss how Impairment Rating was Calculated (Sec. 2.6c) (Essay Question) 1) Explain each impairment value with a reference to the applicable criteria of The Guides [Best practice: Include page and Chart number in The AMA Guides (Sec. 2.6c.1) 2) Combine multiple impairments for a whole person impairment (Sec. 2.6c.1) [In California, each body part should be Converted to WPI] 3) Include a summary list of impairments and their ratings by percentage (include whole person impairment) (Sec. 2.6c.2) 10. Review Chapter 2 of The Guides and Chapter 6 in This Book: "What Needs to Be Included in Medical Reports Under The Guides" to ensure you have included all the required elements.

108 Extended Checklist for DRE Rating of Lumbar Spine (Because this is very common) CHECKLIST FOR LUMBAR SPINE--DRE 1. Prior to evaluating the patient, read Chapters 1 and 2 of The AMA Guides and the Glossary. 2. The evaluation should include (per p. 374 of The Guides): a. Medical History: comprehensive and accurate b. Medical Record Review: review all pertinent records c. Current Symptoms and their relationship to daily activities: comprehensive description of the individual's current symptoms and their relationship to daily activities Phil's Interpretation: This section does not specifically refer to the List of the Activities of Daily Living at page 4 of The Guides. However, p. 381 of The Guides tells us that, in adjusting the numbers within a DRE range, "[i]f residual symptoms or objective findings impact the ability to perform ADL despite treatment, the higher percentage in each range should be assigned." 1) The List of the Activities of Daily Living appears at p. 4 of The AMA Guides. LIST OF THE ACTIVITIES OF DAILY LIVING

109 267 (p. 4 of The AMA Guides) a) Self-care and personal hygiene 1) Urinating 2) Defecating 3) Brushing teeth 4) Combing hair 5) Bathing 6) Dressing oneself 7) Eating b) Communication 1) Writing 2) Typing 3) Seeing 4) Hearing 5) Speaking c) Physical activity 1) Standing 2) Sitting 3) Reclining 4) Walking 5) Climbing stairs d) Senses 1) Hearing 2) Seeing 3) Tactile feeling (feeling with your fingers) 4) Tasting 5) Smelling e) Nonspecialized hand activities

110 268 1) Grasping 2) Lifting 3) Tactile discrimination (using your fingers to tell what something is) f) Travel 1) Riding 2) Driving 3) Flying g) Sexual function h) Sleep 1) Orgasm 2) Ejaculation 3) Lubrication 4) Erection 1) Restful, nocturnal sleep pattern d. Physical examination (careful and thorough) e. Testing results 1) Laboratory 2) Imaging (radiologic) 3) Electrodiagnostic 4) Ancillary f. Description of how the impairment was calculated

111 Take a History from the Patient a. Based primarily on the patient's statements b. Patient's integrity 1) The AMA Guides state: "It is not appropriate to question the individual's integrity. If information from the individual is inconsistent with what is known about the medical condition, circumstances, or written records, the physician should report and comment on the inconsistencies." a) Sample language: (1) The patient states:. (2) The patient's statement is inconsistent with the following information in the medical records of Dr.. [Give citation to page and line in medical records.] (3) I will leave it to the trier of fact to resolve this inconsistency. c. Chief complaint (describe in detail) 1) When the condition started 2) How the condition started 3) Precipitating event or factors 4) Relationship to any previous spine problems d. Symptoms

112 270 1) Quality 2) Severity 3) Anatomic location 4) Frequency 5) Duration 6) In the patient's own words: a) How the symptoms developed b) The assumed cause e. Are any of the following noted by the patient: 1) Pain 2) Numbness 3) Paresthesia (see p. 602 of The Guides: "A sensation of pricking, tingling, or creeping on the skin, usually associated with injury or irritation of a sensory nerve or nerve root." 4) Weakness f. Does the condition interfere with Activities of Daily Living (for reference, use List of Activities of Daily Living at page 4 of The Guides) 1) What factors exacerbate interference? 2) What factors alleviate interference? g. Response to treatment h. Results of Special Studies 1) Imaging studies a) Evaluator should either review them himself

113 271 and report findings, OR b) Report the findings as based on review by another reviewer i. Review of organ systems j. General medical history k. Any complicating medical problems which could affect the 1) Diagnosis 2) Treatment plan 3) Prognosis 4) Disability AND 1) Evaluator should either review them himself and report findings, OR 2) Refer to a Specialist. 4. Has the patient reached maximum medical improvement as defined on page 374 of The AMA Guides? a. Is his condition stable, meaning, is The condition unlikely to change within the next year with or without further medical treatment? b. When did the condition become mmi? c. The patient is only evaluated for permanent impairment

114 272 when he has reached mmi. (p. 374 of The Guides). d. Page 380 of The Guides tells us: "If the impairment is resolving, changing, unstable, or expected to change significantly with or without medical treatment within 12 months, it is not considered a permanent (stable) impairment and should not be rated under the Guides criteria." e. Page 383 of The Guides tells us: "The impairment rating is based on the condition once MMI is reached, not on prior symptoms or signs." 5. Evaluate the patient based on his medical findings which are present on the examination at mmi. (p. 374 of The Guides.) 6. Perform a Physical Exam. Look for spine-related physical findings: a. Range of motion b. Reflexes c. Muscle strength d. Muscle atrophy e. Sensory deficits f. Root tension signs g. Gait h. Need for assistive devices

115 273 The List ofclinical Findings to look for appear at pages 382 and 383 of The Guides: 1. Muscle spasm in the affected area of the spine 2. Muscle guarding in the affected area of the spine 3. Asymmetry of Spinal Motion 4. Nonverifiable Radicular Root Pain 5. Reflexes 6. Weakness and Loss of Sensation 7. Atrophy 8. Radiculopathy 9. Electrodiagnostic Verification of Radiculopathy 10. Alteration of Motion Segment Integrity 11. Cauda Equina Syndrome 12. Urodynamic Tests 7. Determine if any other medical conditions affect the findings in No. 6 above.

116 274 a. Distinguish these from spine-related findings 8. Physical findings which are inconsistent with the history a. Record these b. Discuss their significance 9. Specific physical examinations regarding the spine a. Sciatic Nerve Tension signs (p. 375 of The Guides)-- Straight Leg Raising 1) P. 375 of The Guides tells us: "Root tension signs are most reliable when the pain is elicited in a dermatomal distribution (that means, in the path where a nerve is known to go)." 2) "Back pain on straight leg raising is not a positive test." (p. 376 of The Guides.) 3) Have the patient do straight leg raising while sitting and while lying down: a) P. 376 of The Guides tells us: "Since sitting knee extension and supine hip flexion culminate in essentially identical positions, symptomatic responses to the two types of SLR should be similar, although the angle at which pain is elicited may vary." b. Neurologic Tests (pp of The Guides) 1) Measure reflexes at a) Knees

117 275 b) Ankles 2) Measure sensory and motor functions at a) Knees b) Ankles 3) Look for a) Decreased or absent knee reflex--may be L4 nerve root compromise b) Quadriceps weakness--may be pathology at L3-4 Note: The quadriceps muscle is the large muscle group which contains the four main muscles on the front of the Thigh. It is the great extensor muscle of the knee and forms the flesh on the front and sides of the leg above the knee.

118 276 c) Weak extensor hallucis longus muscle--may be L5 nerve root compromise

119 277 d) Decrease or absence of ankle reflex--may be S1 nerve root involvement e) Difficulty walking--may be S1 nerve root involvement f) Weakness in foot plantar flexion (that is, pressing the foot downward, like pressing on an automobile pedal)-- may be S1 nerve root involvement 4) Check for evidence of corticospinal involvement, noted by a) Babinski sign: Inside of the sole of the foot is rubbed with a blunt instrument from the heel along a curve to

120 278 the toes. If the big toe points upward to the shin and the other toes fan out, you have a positive Babinski which indicates damage to the central nervous system, (See Wikipedia.) b) Clonus means violent or confused motion. It is a series o rapid muscle contractions most commonly seen in the ankles after rapidly flexing the foot upward towards the shin or in the knee after rapidly pushing the kneecap towards the toes. There must be sustained clonus of 5 beats or more to be considered abnormal. (See Wikipedia.) c) Hyperflexia: overactive or overresponsive reflexes seen through twitching or spasm. (See Wikipedia.) d) Changes in balance or gait: may signify myelopathy 5) Evaluate sensation by a) Touch b) Pinprick c) Light touch d) Vibrating fork 6) Compare extremities (p. 377 of The Guides) a) Reflexes (1) Should always be compared between extremities AND (2) Should be elicited several times to determine reproducibility. (3) If the reflex was previously lost due to a prior

121 279 b) Strength injury or disease, it will rarely return. (1) Should always be compared between extremities AND (2) May need repeat testing to determine effort and reproducibility 10. Review Test Results (p. 378 of The Guides) a. Identify all tests (include a separate paragraph in report) 1) Done by whom? 2) Done where? 3) Interpretation? 4) Who did the interpretation? b. Physician should personally review the tests, if possible 1) Indicate if he agrees or disagrees with conclusions of other evaluators c. NOTE: The AMA Guides tell us that a positive imaging test does NOT, by itself, make the diagnosis. (p. 378 of The Guides) 1) Specifically, studies show that 30% of people have studies positive for a herniated disc but have never had any back pain (p. 378) 2) 50% of people will have studies showing bulging discs

122 280 3) So, the signs and symptoms must agree with the imaging findings 4) An imaging test alone is insufficient to qualify for a DRE category. (p. 378 of The Guides) 5) However, people with a positive EMG fall in DRE Category III because this clearly supports a diagnosis of radiculopathy. 11. Now, determine if the DRE Method or the Range of Motion (ROM) should be used a. Use the DRE if: (p. 379 of The AMA Guides) 1) Patient had a specific injury, or 2) Cause of the impairment is not easily determined, or 3) The impairment can be well characterized by the DRE method b. Use the ROM if: (p. 379 of The AMA Guides) 1) Fractures at more than one level in the same spinal Region (there are 3 spinal regions: cervical, thoracic, And lumbar, so, there must be more than one fracture In a specific spinal region) 2) Fusions at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fusion in a specific spinal region) 3) Radiculopathy in the same spinal region

123 281 a) Bilaterally, OR b) At multiple levels AMBIGUITY: The language above from p. 380, lower right paragraph #4 appears to be different from the following language below which appears at p. 380, upper left paragraph 4: "Recurrent Radiculopathy in the same spinal region, caused by a) Disc herniation, OR b) Recurrent injury" 4) Alteration of Motion Segment Integrity caused by a) Multiple episodes of other pathology 5) Radiculopathy caused by a) Multiple episodes of other pathology 6) The following 3 conditions are met: a) The impairment is not caused by an injury, and b) The cause of the condition is uncertain; and

124 282 c) The DRE Method does not apply OR d) The patient cannot be easily categorized in a DRE category e) AND, the evaluator gives his reasons for using the ROM under these circumstances in writing. c. If the patient qualifies to be rated under both the DRE and the ROM, 1) Rate him under both, AND 2) Give him the highest rating 12. If using the DRE, the patient will likely fall in Category I, II, or III. (p. 381 of The Guides) 13. Has the patient had medical treatment (surgery or any other modality)? If yes, determine: a. Result b. Extent of improvement c. Impact on the ability to perform Activities of Daily Living 14. Place the patient in a DRE Category based on his physical findings 15. Once he is in a Category, you will need to narrow down the range to a specific impairment number. a. Question the patient on the impact of the injury or condition on the List of Activities of Daily Living at page 4 of The AMA Guides. (see p. 381 of The AMA Guides)

125 283 1) If injury/condition has had little or no impact on ADL's, then give the patient the low end of the range. 2) If the injury/condition has had sever impact on the ADL's, give the patient the high end of the range. 3) If the injury falls in between, give the patient one of the middle numbers. 16. Determine if there was a prior impairment. Should this be apportioned out? a. If so, rate both conditions using the Guides (in the same fashion, i.e. both as DRE or both as ROM) and subtract the former from the latter. b. The AMA Guides tell us: "In cases where the abnormalities are present in imaging studies and are known or assumed to have preexisted an injury being rated, physicians should acknowledge these preexisting conditions." (p. 384 of The Guides.) 17. The DRE method recommends: a. Document physiologic and structural impairments relating to injuries or diseases other than common developmental findings, such as 1) spondylolisis (a condition in which the back part of the vertebra is not formed in one continuous piece of bone with the frontal, donut-like portion of the vertebra. The back part of the vertebra may be attached to the front part of the vertebra with

126 284 cartilage, scar, or ligament. It may be totally connected, partially connected, or totally disconnected, that is, detached.) (This condition is found normally in 7% of adults. In one group of Eskimos, 40% have spondylolisis.) is a condition in which the back part of the vertebra is not formed in one continuous piece of bone with the frontal, 2) spondylolisthesis (forward slippage of one vertebra on another) (found normally in 3% of adults) 3) herniated disk without radiculopathy (found in approximately 30% of individuals age 40 and up) 4) aging changes (present in 40% of adults 35 and nearly 100% in individuals 50 and up) 18. Calculate the DRE impairment using the chart at page 384 of The Guides: a. Place the patient in a DRE Category (I - V) based on the findings on Physical Examination from the List of Clinical Findings Used to Place an Individual in a DRE Category At pp of The AMA Guides. b. Use the information regarding the impact of the specific injury or medical condition to select a WPI% number within the DRE Category (little or no impact--low number; high or severe impact--highest number; medium impact--middle numbers) c. List all pages and charts used in calculating your WPI%

127 285 CHECKLIST FOR DRE RATINGS FOR ALL AREAS OTHER THAN THE SPINE Heart (Chapters 3 and 4) Hypertension (Chapter 4) Pulmonary (Chapter 5) Digestive System (Chapter 6) Urinary and Reproductive Systems (Chapter 7) Skin (Chapter 8) The Hematopoietic System (Blood) (Chapter 9) Endocrine System (Chapter 10) Vestibular Disorder, Face, Nasal, Speech (Chapter 11) Visual (Chapter 12) Neurology (Chapter 13) Psychological/Psychiatric (Chapter 14) [NO WPI% GIVEN] Spine (Chapter 15)--Note also RANGE OF MOTION METHOD Steps in the Recipe for the Rating: 1. Turn to the section in The AMA Guides where the Diagnosis is rated. 2. Read the text first and follow the instructions given there. 3. Then, turn to the DRE Chart. You will see a number of different columns. Read the columns. Place the patient in an appropriate column based on his findings. a. Be sure to read all of the columns to ensure that you have selected the correct one.

128 286 b. If there are findings or information required to place the patient in a category, and the evaluating doctor has not given you that information, write the doctor and ask for the necessary findings/information. c. ALWAYS CHECK THE PHYSICAL EXAMINATION RESULTS OF DIAGNOSTIC TESTS. (Phil's note: I would estimate that 50% of the reports I review contain conclusions by a doctor that a patient has certain findings which put the patient in a specific DRE Category, or has results on diagnostic testing which put the patient in a DRE Category, and, when I check the results of the Physical Examination or interpretation of the diagnostic tests, the Patient DOES NOT HAVE the findings or test results which the doctor claims are present. d. Once the patient is placed in a DRE Category, narrow down to a specific impairment percentage by questioning the patient on the impact of the injury or illness on the Activities of Daily Living (see list at p. 4 of The Guides.) 1) If questions arise as to why you narrow down using The List of Activities of Daily Living at p. 4, you may wish to analogize to the DRE Method in the Spine: "If residual symptoms or objective findings impact the ability to perform ADL despite treatment, the higher percentage in each range should be assigned." (p. 381) IV. NERVE RATING

129 287 CARPAL TUNNEL SYNDROME AND ALL NERVES 1. Find the nerve you are dealing with on the Nerve Chart. 2. Find the section of the nerve you are dealing with on the Nerve Chart. 3. Now, read to the right from the name and section of the nerve. Find the maximums for "sensory loss" and "motor deficit 4. Grade the "Sensory Deficit" using the Grading Chart. Multiply the percentage "Sensory Deficit" by the maximum for "Sensory Deficit." 5. Grade the "Motor Deficit" using the Grading Chart. Multiply the percentage "Motor Deficit" by the maximum for "Motor Deficit." 6. Combine the Sensory Deficit Impairment and the Motor Deficit Impairment. 7. Turn the Component Impairment into a Whole Person Impairment. V. SPECIAL CASES COMPLEX REGIONAL PAIN SYNDROME 1. Does the patient have 8 of the objective findings listed below at

130 288 The time of the physical examination and observed by the physician? A. Vasomotor changes (action on a blood vessel which alters its diameter): 1) Skin color a. Mottled: Skin having colored spots or blotches b. Cyanotic: Skin blue or purplish from lack of oxygen 2) Skin temperature: cool 3) Edema: Swelling B. Sudomotor (relating to nerve fibers controlling sweat glands) changes: 4) Skin is dry or overly moist C. Trophic (promoting cellular growth, differentiation, and survival) changes: 5) Skin texture is smooth and non-elastic 6) Soft tissue atrophy: especially in the fingertips 7) Joint stiffness and decreased passive motion 8) Nail changes: blemished, curved talon-like 9) Hair Growth changes: fall out or longer, finer D. Radiographic (x-ray) signs:

131 289 10) Radiographs show trophic bone changes or osteoporosis [decrease in bone mass with decreased density and enlargement of bone spaces producing pores and brittleness] 11) Bone scan: findings consistent with CRPS (increased periarticular uptake, lowered bone mineral density, bone demineralization) (p. 496 of The Guides.) 2. For Upper Extremity, rate using either range of motion and nerve Rating in the upper extremity (p. 497) or rate using the Neurology Chapter, p For Lower Extremity, rate using the Neurology Chapter, p VI. COMBINATION RATINGS A. SPINE RANGE OF MOTION The Spine Range of Motion encompasses 3 different ratings: 1. Chart: Read the Major Diagnosis off a Chart to find the Impairment for that diagnosis 2. Range of Motion: Then, do Range of Motion measurements to calculate impairment for loss of motion, and 3. Nerve: rate out any nerve impairment in the affected Extremities, and finally 3. Combine the 3 numbers you get for Diagnosis, Motion, and

132 290 Nerve to get the total impairment. STEPS IN THE RATING: First, determine whether you should use the Range of Motion method for the Spine or the DRE: Now, WHEN DO YOU USE THE RANGE OF MOTION METHOD FOR RATING THE SPINE, VERSUS THE DRE METHOD? a. Use the DRE if: (p. 379 of The AMA Guides) 1) Patient had a specific injury, or 2) Cause of the impairment is not easily determined, or 3) The impairment can be well characterized by the DRE method b. Use the ROM if: (p. 379 of The AMA Guides) 1) Fractures at more than one level in the same spinal Region (there are 3 spinal regions: cervical, thoracic, And lumbar, so, there must be more than one fracture In a specific spinal region) 2) Fusions at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fusion in a specific spinal region) 3) Radiculopathy in the same spinal region a) Bilaterally, OR

133 291 b) At multiple levels AMBIGUITY: The language above from p. 380, lower right paragraph #4 appears to be different from the following language below which appears at p. 380, upper left paragraph 4: "Recurrent Radiculopathy in the same spinal region, caused by a) A new (recurrent) Disc herniation, OR b) Recurrent injury" Note: In California, the phrase "recurrent injury" has been used by Applicant attorneys to argue that all cumulative trauma spinal cases should be rated using the Range of Motion method because cumulative trauma constitutes thousands of tiny recurrent injuries. The editors of the Guides Newsletter have clarified that cumulative trauma should be rated using the DRE method unless it produces one of the enumerated problems--fusions at multiple levels in the same spinal region, fractures at multiple levels in the same spinal region, radiculopathy which is bilateral or at multiple levels in the same spinal region, radiculopathy caused by recurrent disc herniation or stenosis at the same or a different level in the same spinal region, or alteration of motion segment integrity caused by multiple episodes of other pathology--and then it should be rated using the Range of Motion method.

134 292 The determination of whether or not the phrase "recurrent injury" is interpreted to apply to all cumulative trauma spinal injuries will lie with the California courts. 4) Alteration of Motion Segment Integrity caused by a) Multiple episodes of other pathology 5) Radiculopathy caused by a) Multiple episodes of other pathology 6) The following 3 conditions are met: a) The impairment is not caused by an injury, and b) The cause of the condition is uncertain; and c) The DRE Method does not apply OR d) The patient cannot be easily categorized in a DRE category e) AND, the evaluator gives his reasons for using the ROM under these circumstances in writing. c. If the patient qualifies to be rated under both the DRE and the ROM, 1) Rate him under both, AND 2) Give him the highest rating Example: The patient suffers a specific injury which Results in fractures at more than one level in the same

135 293 Spinal region. In that case, he would qualify for the DRE Because he suffered a specific injury AND he would Qualify for the Range of Motion because he has fractures At more than one level in the same spinal region. In that case, rate him under the DRE and the Range of Motion and give him the higher rating. 1. Have the patient do the warm-up exercises specified on p Identify the most significant diagnosis per p. 406, Table Use Dual Inclinometers for measuring spinal motions. (p. 400) 4. Have the patient perform flexion, extension, left lateral bending, right Lateral bending 6 times (for cervical and thoracic spines, add in left and right rotaton). (p. 403, 406) 5. Calculate the mean (average of the measurements). (p. 399, p. 403) Ensure that the measurements fall within either 5 degrees or 10% of The mean per p Select 3 consecutive sets of measurements where the measurements Fall within the criteria under #5 above. 7. Choose the highest motion measurement from the 3 sets for rating Purposes. (p. 403) 8. Apply the measurements to the charts for Flexion, Extension, Left Lateral, Right Lateral, Left Rotation (Cervical and Thoracic), and Right Lateral (Cervical and Thoracic) in the ROM Section for the Cervical Spine (pp ), Thoracic (pp ), and Lumbar Spine (pp ). 9. Add together the impairment measurements from the charts noted

136 294 In #8 above for a total % WPI. 10. Rate out any Nerve Impairment per p Remember, the values Given on Table are for Upper Extremity and must be converted To WPI. The values given on Table are for Lower Extremity And must be converted to WPI. 11. Combine the % WPI for Disorder, Motion, and Nerve to get the Total % WPI. 12. If performing a ROM rating of the Lumbar Spine, perform the Accessory validity test noted at p. 406, #6, to ensure that the Flexion and extension values are consistent, reproducible, and can Be used for rating purposes. (p. 406) B. LOWER EXTREMITY 1. Turn to the Chart on p. 525, Table 17-1, to see the list of all the things which can go wrong in a leg. They include: a. Limb length discrepancy b. Muscle atrophy c. Ankylosis (fusion) d. Amputation e. Arthritis of the joints f. Skin loss g. Peripheral nerve injury h. Vascular

137 295 i. CRPS (reflex sympathetic dystrophy and causalgia) j. Range of Motion k. Gait derangement l. Muscle strength m. Fractures o. Ligament injuries p. Meniscectomies q. Foot deformities r. Hip and pelvic bursitis s. Lower extremity joint replacements. Find the diagnoses you have, then turn to the chart for each and calculate the impairment. The charts are "simply read it", range of motion, and nerve rating charts. Calculate the impairment for each diagnosis. 2. Then, once you have calculated the impairments, turn to the "Joan Crawford Christmas Morning Chart" at p. 526 to see which impairments can be COMBINED to get the TOTAL. a. If none of the impairment types can be combined, YOU PICK THE HIGHEST FOR THE TOTAL RATING.

138 296 SAMPLE LETTERS TO PHYSICIANS TO GET CORRECT AMA RATINGS (INITIAL LETTERS) I. JUST READ IT OFF A CHART (HEARING LOSS, LOWER EXTREMITY--DIAGNOSIS BASED ESTIMATES, AND ADD-ON FOR PAIN) Dear Dr. : Thank you for agreeing to evaluate the Claimant's claim of injury to the. INSERT ALL BACKGROUND INFORMAITON LIST MEDICAL RECORDS FORWARDED LIST ALL OTHER MATERIALS FORWARDED This case falls under The AMA Guides to the Evaluation of Permanent Impairment [5th Edition] for purposes of rating permanent impairment and permanent disability under the [insert name of state, Federal, our country] workers' compensation system. Therefore, please use The AMA Guides [Fifth Edition] in performing your impairment evaluation. In calculating the patient's impairment, if any, please address the following: 1. What is/are the patient's diagnosis/diagnoses?

139 Has the patient reached maximum medical improvement as that term is defined by The Guides: "...a date from which further recovery or deterioration is not anticipated...the clinical findings indicate that the medical condition is static and well stabilized." (p. 19) a. If so, when did the patient reach that point? (p. 21) b. If not, when do you expect the patient to reach that point? c. Please provide the basis for your opinion in that regard. (p. 21) 3. It appears that this patient would be rated under the Chapter. a. The chart for calculating impairment appears at p.. b. Please read Chapters 1 and 2 prior to completing the impairment calculation. c. Please read the "text" of the AMA Guides applicable to rating this condition. d. Please perform the Physical Examination as outlined in the text. e. Please rate the impairment per the chart noted at 3a above. f. If you feel that the patient should be rated per other or additional sections of The Guides, please indicate the sections, charts and tables used, pages, and your basis for using such sections in writing as required by The Guides.

140 298 II. RANGE OF MOTION A. SHOULDER (INITIAL LETTER TO PHYSICIAN FOR SHOULDER RANGE OF MOTION IMPAIRMENT RATING [CAN BE MODIFIED FOR ANY RANGE OF MOTION RATING IN THE UPPER EXTREMITY--ELBOW, WRIST, FINGERS]) Dear Dr., Thank you for agreeing to evaluate the Claimant's shoulder for an injury on. INSERT ALL BACKGROUND INFORMATION LIST MEDICAL RECORDS FORWARDED LIST ALL OTHER MATERIALS FORWARDED This case falls under The AMA Guides to the Evaluation of Permanent Impairment [5th Edition] for purposes of rating permanent impairment and permanent disability under the [insert name of state] workers' compensation system. Therefore, please use The AMA Guides [Fifth Edition] in performing your impairment evaluation.

141 299 In calculating the patient's impairment in the shoulder, please address the following: 1. What is/are the patient's diagnosis/diagnoses? 2. Has the patient reached maximum medical improvement as that term is defined by The Guides: "...a date from which further recovery or deterioration is not anticipated...the clinical findings indicate that the medical condition is static and well stabilized." (p. 19) a. If so, when did the patient reach that point? (p. 21) b. If not, when do you expect the patient to reach that point? c. Please provide the basis for your opinion in that regard. (p. 21) 3. It appears that this patient would be rated under the "range of motion" method of rating the shoulder. To that end, a. Please have the patient do the six motions of the shoulder listed below a minimum of: 1) Two times (p. 20), and 2) Under his own power (active motion) (p. 475), and 3) Ensure that the measurements used for rating purposes fall within 10% of each other to be deemed reliable, consistent, and to be used for rating purposes (p. 20). If they do not fall within 10% of each other, then they would not be deemed reliable for purposes of rating impairment. (p. 20)

142 300 b. The six motions of the shoulder are (p. 474): 1) Flexion 2) Extension 3) Abduction 4) Adduction 5) Internal Rotation 6) External Rotation c. Please use a goniometer to measure the actual angles of each of the six motions. (p. 475, p. 451) 1) Please record the actual goniometer readings in your report (p. 475), and 2) Please use the highest measurement for rating purposes. (p. 475) d. Please apply the motion measurements to the pie charts at pages 476, 477, and 479 of The Guides for impairment calculation. (p. 461) 1) Measurements of motion which fall between those shown on a pie chart are adjusted or interpolated proportionally to the corresponding inverval (p. 461) e. If the patient's shoulder is ankylosed, please use the I-A (Impairment for Ankylosis) arc in calculating impairment. f. Please measure the contralateral shoulder and use

143 301 those measurements to establish the baseline of normal. (p. 453) 1) If the contralateral shoulder has a less than average mobility, the impairment value(s) which correspond to the contralateral shoulder serve as a baseline (p. 453), and 2) They are subtracted from the calculated impairment for the involved shoulder (p. 453), and 3) Please explain your rationale for this decision in your report. (p. 453) g. Please add together the upper extremity impairment percentages derived from the angle measurements of the six motions to get the total upper extremity impairment. (p. 474) h. Please, then, convert the total Upper Extremity Impairment in the shoulder to Whole Person Impairment using the chart at p. 439 of The Guides. III. DRE A. SPINE (CERVICAL, THORACIC, LUMBAR) INITIAL LETTER TO THE EVALUATING DOCTOR LUMBAR SPINE--DRE (Can be modified for Cervical and/or

144 302 Thoracic Spine) First, determine whether you should use the Range of Motion method for the Spine or the DRE. WHEN DO YOU USE THE RANGE OF MOTION METHOD FOR RATING THE SPINE, VERSUS THE DRE METHOD? a. Use the DRE if: (p. 379 of The AMA Guides) 1) Patient had a specific injury, or 2) Cause of the impairment is not easily determined, or 3) The impairment can be well characterized by the DRE method b. Use the ROM if: (p. 379 of The AMA Guides) 1) Fractures at more than one level in the same spinal Region (there are 3 spinal regions: cervical, thoracic, And lumbar, so, there must be more than one fracture In a specific spinal region) 2) Fusions at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fusion in a specific spinal region) 3) Radiculopathy in the same spinal region a) Bilaterally, OR b) At multiple levels

145 303 AMBIGUITY: The language above from p. 380, lower right paragraph #4 appears to be different from the following language below which appears at p. 380, upper left paragraph 4: "Recurrent Radiculopathy in the same spinal region, caused by a) A new (recurrent) Disc herniation, OR b) Recurrent injury" Note: In California, the phrase "recurrent injury" has been used by Applicant attorneys to argue that all cumulative trauma spinal cases should be rated using the Range of Motion method because cumulative trauma constitutes thousands of tiny recurrent injuries. The editors of the Guides Newsletter have clarified that cumulative trauma should be rated using the DRE method unless it produces one of the enumerated problems--fusions at multiple levels in the same spinal region, fractures at multiple levels in the same spinal region, radiculopathy which is bilateral or at multiple levels in the same spinal region, radiculopathy caused by recurrent disc herniation or stenosis at the same or a different level in the same spinal region, or alteration of motion segment integrity caused by multiple episodes of other pathology--and then it should be rated using the Range of Motion method.

146 304 The determination of whether or not the phrase "recurrent injury" is interpreted to apply to all cumulative trauma spinal injuries will lie with the California courts. 4) Alteration of Motion Segment Integrity caused by a) Multiple episodes of other pathology 5) Radiculopathy caused by a) Multiple episodes of other pathology 6) The following 3 conditions are met: a) The impairment is not caused by an injury, and b) The cause of the condition is uncertain; and c) The DRE Method does not apply OR d) The patient cannot be easily categorized in a DRE category e) AND, the evaluator gives his reasons for using the ROM under these circumstances in writing. c. If the patient qualifies to be rated under both the DRE and the ROM, 1) Rate him under both, AND 2) Give him the highest rating Example: The patient suffers a specific injury which Results in fractures at more than one level in the same

147 305 Spinal region. In that case, he would qualify for the DRE Because he suffered a specific injury AND he would Qualify for the Range of Motion because he has fractures At more than one level in the same spinal region. In that case, rate him under the DRE and the Range of Motion and give him the higher rating. Dear Doctor, Thank you for agreeing to evaluate On. Enclosed, please find the following: 1. A Memorandum on the Background of this Case 2. All of the Medical Reports in our possession regarding This evaluee 3. The following Medical Records: LIST MEDICAL RECORDS 4. A Job Description of the Evaluee's Position (if appropriate) 5. The Deposition of the Evaluee taken 6. The following additional Depositions: LIST DEPOSITIONS 7. Witness Statements LIST NAMES OF WITNESSES AND ATTACH STATEMENTS

148 Relevant Personnel Documents Mr./Mrs./Ms. has claimed the following injury: 1. Date of injury: 2. Body parts claimed injured: 3. Occupation at time of injury: 4. Age at time of injury: 5. How the injury allegedly occurred: a. Per Evaluee: FILL IN DETAILS b. Per Others: FILL IN NAMES AND DETAILS In completing your evaluation, please address each of the following (if an item is not applicable, please indicate "Not Applicable"): 1. During your evaluation, please address the following items on the attached CHECKLIST(S): LUMBAR SPINE--DRE 2. During your evaluation, please address each of the items on the attached STEPS IN THE RATING:

149 307 LUMBAR SPINE--DRE 3. Please provide your DIAGNOSIS for each and every diagnosis which you make, and address: a. Criteria for Diagnosis 1) Criteria for diagnosis which are MET --Identify each and every criteria met 2) Criteria for diagnosis NOT MET --Identify each and every criteria NOT met 3) Are sufficient criteria MET to support the Diagnosis b. Is the Diagnosis supported by the Scientific Literature? 1) If the diagnosis is controversial, please provide Citations to peer-reviewed scientific studies in the Medical Literature which support the diagnosis (please note that "Letters to the Editor" are interesting but do not constitute peer-reviewed scientific studies) 4. Please provide your Whole Person Impairment Rating for a. Each involved body part or system, and a. Each involved medical condition 5. Then, please answer each of the following questions: a. Do you believe the evaluee has experienced a valid injury?

150 308 1) If so, please indicate what information supports That conclusion. 2) If not, please indicate what information does not Support that conclusion. b. Do you believe the evaluee has experienced periods of temporary disability as a result of the subject injury? 1) Temporary total or partial disability 2) Starting and ending dates c. Your AMA rating d. Medical treatment 1) Through the date of your evaluation a) Appropriate, or not b) Did it result in improvement in patient's condition (1) If not, why not? c) Is it consistent with the medical treatment guidelines controlling this case [for example, the ACOEM Treatment Guidelines in California] (1) If consistent, please provide citation(s) to applicable Guidelines (2) If inconsistent, please provide Citations to applicable Guidelines

151 309 2) After your evaluation (Future medical) a) Do you believe further treatment is necessary or appropriate? (1) What type of treatment? (2) How long should such treatment Be provided? e. Return to Work 1) Can the patient return to her/his usual and Customary work? (a) (b) If so, why? If not, why? 2) Can the patient return to modified or alternate Work? (a) What type? 3) What work limitations (preclusions) would you Place on the evaluee? (a) For how long? Please attach your bill with your report. Thank you very much for agreeing to evaluate. We will look forward to receiving your report. Sincerely,

152 310 ALL DRE RATINGS OTHER THAN THE SPINE Dear Dr., Thank you for agreeing to evaluate the Claimant's claim of injury to the. INSERT ALL BACKGROUND INFORMAITON LIST MEDICAL RECORDS FORWARDED LIST ALL OTHER MATERIALS FORWARDED This case falls under The AMA Guides to the Evaluation of Permanent Impairment [5th Edition] for purposes of rating permanent impairment and permanent disability under the [insert name of state, Federal, our country] workers' compensation system. Therefore, please use The AMA Guides [Fifth Edition] in performing your impairment evaluation. In calculating the patient's impairment, if any, please address the following: 1. What is/are the patient's diagnosis/diagnoses? 2. Has the patient reached maximum medical improvement as that term is defined by The Guides: "...a date from which further recovery or deterioration is not anticipated...the clinical

153 311 findings indicate that the medical condition is static and well stabilized." (p. 19) a. If so, when did the patient reach that point? (p. 21) b. If not, when do you expect the patient to reach that point? c. Please provide the basis for your opinion in that regard. (p. 21) 3. Please do the following: a. Please provide your DIAGNOSIS for each and every diagnosis which you make, and address: 1) Criteria for Diagnosis a) Criteria for diagnosis which are MET --Identify each and every criteria met b) Criteria for diagnosis NOT MET --Identify each and every criteria NOT met c) Are sufficient criteria MET to support the Diagnosis b. Is the Diagnosis supported by the Scientific Literature? 1) If the diagnosis is controversial, please provide Citations to peer-reviewed scientific studies in the Medical Literature which support the diagnosis (please note that "Letters to the Editor" are interesting but do not constitute peer-reviewed scientific studies)

154 Please follow the Steps in the Rating listed below: Steps in the Recipe for the Rating: 1. Turn to the section in The AMA Guides where the Diagnosis is rated. 2. Read the text first and follow the instructions given there. 3. Then, turn to the DRE Chart. You will see a number of different columns. Read the columns. Place the patient in an appropriate column based on his findings. a. Be sure to read all of the columns to ensure that you have selected the correct one. b. Please give all information necessary to place the patient in a category. c. Please ensure that the findings on Physical Examination and the results of Diagnostic Tests are consistent with the requirements of the DRE category. d. Once the patient is placed in a DRE Category, narrow down to a specific impairment percentage by questioning the patient on the impact of the injury or illness on the Activities of Daily Living (see list at p. 4 of The Guides.) 1) You may wish to analogize to the DRE Method in the Spine: "If residual symptoms or objective findings impact the ability to perform ADL despite treatment, the higher percentage in each range should be assigned."

155 313 (p. 381) e. Ensure that the impairment calculation is expressed as a Whole Person Impairment percentage. IV. NERVE RATING Dear Dr., Thank you for agreeing to evaluate the Claimant's claim of injury to the. INSERT ALL BACKGROUND INFORMAITON LIST MEDICAL RECORDS FORWARDED LIST ALL OTHER MATERIALS FORWARDED This case falls under The AMA Guides to the Evaluation of Permanent Impairment [5th Edition] for purposes of rating permanent impairment and permanent disability under the [insert name of state, Federal, our country] workers' compensation system. Therefore, please use The AMA Guides [Fifth Edition] in performing your impairment evaluation. In calculating the patient's impairment, if any, please address the following: 1. What is/are the patient's diagnosis/diagnoses? 2. Has the patient reached maximum medical improvement as that term is defined by The Guides: "...a date from which further recovery or deterioration is not anticipated...the clinical findings indicate that the medical condition is static and well stabilized." (p. 19)

156 314 a. If so, when did the patient reach that point? (p. 21) b. If not, when do you expect the patient to reach that point? c. Please provide the basis for your opinion in that regard. (p. 21) 3. Please do the following: a. Please provide your DIAGNOSIS for each and every diagnosis which you make, and address: 1) Criteria for Diagnosis a) Criteria for diagnosis which are MET --Identify each and every criteria met b) Criteria for diagnosis NOT MET --Identify each and every criteria NOT met c) Are sufficient criteria MET to support the Diagnosis b. Is the Diagnosis supported by the Scientific Literature? 1) If the diagnosis is controversial, please provide Citations to peer-reviewed scientific studies in the Medical Literature which support the diagnosis (please note that "Letters to the Editor" are interesting but do not constitute peer-reviewed scientific studies) 4. Please follow the steps below in performing the rating:

157 315 a. Find the nerve you are dealing with on the Nerve Chart. b. Find the section of the nerve you are dealing with on the Nerve Chart. c. Read to the right from the name and section of the nerve. Find the maximums for "sensory deficit" and "motor deficit" d. Grade the "Sensory Deficit" using the Grading Chart. Multiply the percentage "Sensory Deficit" by the maximum for "Sensory Deficit." e. Grade the "Motor Deficit" using the Grading Chart. Multiply the percentage "Motor Deficit" by the maximum for "Motor Deficit." f. Combine the Sensory Deficit Impairment and the Motor Deficit Impairment. g. Turn the Component Impairment into a Whole Person Impairment. V. COMPLEX REGIONAL PAIN SYNDROME Dear Dr., Thank you for agreeing to evaluate the Claimant's claim of injury to the.

158 316 INSERT ALL BACKGROUND INFORMAITON LIST MEDICAL RECORDS FORWARDED LIST ALL OTHER MATERIALS FORWARDED This case falls under The AMA Guides to the Evaluation of Permanent Impairment [5th Edition] for purposes of rating permanent impairment and permanent disability under the [insert name of state, Federal, our country] workers' compensation system. Therefore, please use The AMA Guides [Fifth Edition] in performing your impairment evaluation. In calculating the patient's impairment, if any, please address the following: 1. What is/are the patient's diagnosis/diagnoses? 2. Has the patient reached maximum medical improvement as that term is defined by The Guides: "...a date from which further recovery or deterioration is not anticipated...the clinical findings indicate that the medical condition is static and well stabilized." (p. 19) a. If so, when did the patient reach that point? (p. 21) b. If not, when do you expect the patient to reach that point? c. Please provide the basis for your opinion in that regard. (p. 21) 3. Please do the following: a. Please provide your DIAGNOSIS for each and every diagnosis which you make, and address: 1) Criteria for Diagnosis

159 317 a) Criteria for diagnosis which are MET --Identify each and every criteria met b) Criteria for diagnosis NOT MET --Identify each and every criteria NOT met c) Are sufficient criteria MET to support the Diagnosis b. Is the Diagnosis supported by the Scientific Literature? 1) If the diagnosis is controversial, please provide Citations to peer-reviewed scientific studies in the Medical Literature which support the diagnosis (please note that "Letters to the Editor" are interesting but do not constitute peer-reviewed scientific studies) 4. Please follow the steps below in performing the rating: Does the patient have 8 of the objective findings listed below at the time of the physical examination and observed by the physician? A. Vasomotor changes (action on a blood vessel which alters its diameter): 1) Skin color a. Mottled: Skin having colored spots or blotches b. Cyanotic: Skin blue or purplish from lack of oxygen

160 318 2) Skin temperature: cool 3) Edema: Swelling B. Sudomotor (relating to nerve fibers controlling sweat glands) changes: 4) Skin is dry or overly moist C. Trophic (promoting cellular growth, differentiation, and survival) changes: 5) Skin texture is smooth and non-elastic 6) Soft tissue atrophy: especially in the fingertips 7) Joint stiffness and decreased passive motion 8) Nail changes: blemished, curved talon-like 9) Hair Growth changes: fall out or longer, finer D. Radiographic (x-ray) signs: 10) Radiographs show trophic bone changes or osteoporosis [decrease in bone mass with decreased density and enlargement of bone spaces producing pores and brittleness] 11) Bone scan: findings consistent with CRPS (increased periarticular uptake, lowered bone mineral density, bone demineralization) (p. 496 of The Guides.) 2. For Upper Extremity, rate using either range of motion and nerve

161 319 Rating in the upper extremity (p. 497) or rate using the Neurology Chapter, p For Lower Extremity, rate using the Neurology Chapter, p VI. COMBINATION A. SPINE RANGE OF MOTION Dear Dr., Thank you for agreeing to evaluate the Claimant's claim of injury to the. INSERT ALL BACKGROUND INFORMAITON LIST MEDICAL RECORDS FORWARDED LIST ALL OTHER MATERIALS FORWARDED This case falls under The AMA Guides to the Evaluation of Permanent Impairment [5th Edition] for purposes of rating permanent impairment and permanent disability under the [insert name of state, Federal, our country] workers' compensation system. Therefore, please use The AMA Guides [Fifth Edition] in performing your impairment evaluation. In calculating the patient's impairment, if any, please address the following: 1. What is/are the patient's diagnosis/diagnoses? 2. Has the patient reached maximum medical improvement as that term is defined by The Guides: "...a date from which

162 320 further recovery or deterioration is not anticipated...the clinical findings indicate that the medical condition is static and well stabilized." (p. 19) a. If so, when did the patient reach that point? (p. 21) b. If not, when do you expect the patient to reach that point? c. Please provide the basis for your opinion in that regard. (p. 21) 3. Please do the following: a. Please provide your DIAGNOSIS for each and every diagnosis which you make, and address: 1) Criteria for Diagnosis a) Criteria for diagnosis which are MET --Identify each and every criteria met b) Criteria for diagnosis NOT MET --Identify each and every criteria NOT met c) Are sufficient criteria MET to support the Diagnosis b. Is the Diagnosis supported by the Scientific Literature? 1) If the diagnosis is controversial, please provide Citations to peer-reviewed scientific studies in the Medical Literature which support the diagnosis (please note that "Letters to the Editor" are

163 321 interesting but do not constitute peer-reviewed scientific studies) 4. Please follow the steps below in performing the rating: STEPS IN THE RATING: First, determine whether you should use the Range of Motion method for the Spine or the DRE: Now, WHEN DO YOU USE THE RANGE OF MOTION METHOD FOR RATING THE SPINE, VERSUS THE DRE METHOD? a. Use the DRE if: (p. 379 of The AMA Guides) 1) Patient had a specific injury, or 2) Cause of the impairment is not easily determined, or 3) The impairment can be well characterized by the DRE method b. Use the ROM if: (p. 379 of The AMA Guides) 1) Fractures at more than one level in the same spinal Region (there are 3 spinal regions: cervical, thoracic, And lumbar, so, there must be more than one fracture In a specific spinal region) 2) Fusions at more than one level in the same spinal region (there are 3 spinal regions: cervical, thoracic, and lumbar, so, there must be more than one fusion in a specific spinal region) 3) Radiculopathy in the same spinal region

164 322 a) Bilaterally, OR b) At multiple levels AMBIGUITY: The language above from p. 380, lower right paragraph #4 appears to be different from the following language below which appears at p. 380, upper left paragraph 4: "Recurrent Radiculopathy in the same spinal region, caused by a) A new (recurrent) Disc herniation, OR b) Recurrent injury" Note: In California, the phrase "recurrent injury" has been used by Applicant attorneys to argue that all cumulative trauma spinal cases should be rated using the Range of Motion method because cumulative trauma constitutes thousands of tiny recurrent injuries. The editors of the Guides Newsletter have clarified that cumulative trauma should be rated using the DRE method unless it produces one of the enumerated problems--fusions at multiple levels in the same spinal region, fractures at multiple levels in the same spinal region, radiculopathy which is bilateral or at multiple levels in the same spinal region, radiculopathy caused by recurrent disc herniation or stenosis at the same or a different level in the same spinal region, or alteration of motion segment integrity caused by multiple episodes of other pathology--and then it should be rated using the Range of Motion method.