AADEPAMA Guides 5th EditionUpper ExtremityRating MethodologyPaul S. Darby MD PhD MPH FACOEM with thanks toDouglas W Martin MD FAADEP FACOEM FAAFP

Upper Extremity: Sections 16.2 Amputation16 3 Sensory Loss (digital nerve)16.316.4 Range of Motion16 5 P16.5Peripherali h lNNerve DiDisordersd16.6 Vascular Disorders16.7 Other Disorders16 8 Strength16.8

Conversion Many impairments are stated as “Digit”. Table 16-1 converts “Digit”g to “Hand”. Table 16-2 converts “Hand” to “Upper Extremity”.((Same as multiplyingp y g byy 0.9)) Table 16-3 converts “Upper Extremity” to “Wholep y g byy 0.6))Person” ((Same as multiplying Figures 16-1a & b are worksheet to guide theg all steps,p , includingg conversion.evaluator through

Thumb portion of figure 16-1

Table 16-1

Testing two point Discrimination

Two-PointTwoImpairmentDiscriminationof Nerve6 mm. or less0%7 mm. to 15 mm.50%more than 15 mm. 100%

Table 16-10Grade Descriptionp%multiplier543210No loss of sensibility, abnormal sensation, or pain0Decreased light touch, sensations or pain forgotten 1 – 25during activityDecreased light touch and 2 PD,PD some abnormalsensations or slight pain, interferes with someActivitiesDecreased Protective Sensation, abnormalsensation or moderate pain, prevents someactivitiesNo protective sensibility, abnormal sensations orsevere pain prevents most activityNo sensibility, abnormal sensation or severe painprevents all activity26 – 6061 – 8081 – 99100

Measuring ROM & Impairment Each jjoint has Figuresgto show how to positionpandmeasure. Each joint has Figures to permit estimation ofimpairment for loss of motion, and in every direction ofnormal joint motion. “Pie Charts”: V Measurement in degreesIF Impairment for flexionIE ImpairmentIit forf extensiont iIA Impairment for Ankyolsis

Finger ROM Similar to thumb IP and MCP. Fingerg DIP,, PIP,, & MCP onlyy move inflexion and extension. Bone or jjoint injury,j y, measure with proximalpjoints in extension. If tendon injuryj y with adhesions,, mayymeasure in full simultaneous flexion andfull simultaneous extension.

Figure 16-22, p.463Measuring PIPwithMCP @ fullExtension.Traditional way ofMeasurement.

Elbow ROMO Measurement

Shoulder ROMMeasurement

16.5: Peripheral Nerve Disorders Rate:Loss of Sensation andMotor Weakness.Combine these. Active ROM loss secondaryy to nerve injuryj yis already in the rating. If Loss of ROM is due to separateppproblem(joint fracture, or CRPS), then it is ratedand combined.

Peripheral Nerve InjuryImpairment Rating Steps1. What nerve is involved?12. What is the maximum potential value of that nerve forloss of sensation and pain?3. What sensory severity multiplier is appropriate?p y “value” times “severity”.y4. Multiply5. What is the maximal potential value of that nerve forweakness (motor loss)?6. What weakness multiplier is appropriate?7. Multiply the “value” times the “severity”.8. Combine the motor rating with the sensory rating.

Table 16-10Grade Descriptionp%multiplier5432No loss of sensibility, abnormal sensation, or pain0Decreased light touch, sensations or pain forgotten 1 – 25during activityDecreased light touch and 2 PD,PD some abnormal26 – 60sensations or slight pain, interferes with someactivitiesDecreased protective sensation, abnormal sensation 61 – 80or moderate pain, prevents some activities1No protective sensibility, abnormal sensations orsevere pain prevents most activity81 – 990No sensibility, abnormal sensation or severe pain100prevents all activity

Huge Problem with Table 1616-1010 Assumes goodAd correlationl i betweenbseverityi offsensory loss and severity of pain.Grade 3: decreased light touchtouch, slight pain,pain interferes withsome activitiesGrade 2: decreased protective sensation, moderate pain,PPreventssome activitiesi iiGrade 1: no protective sensation, severe pain, prevents mostactivities. What if there is decreased protective sensation, yetminimal pain, and normal ADLs ?What if there is a normal sensory exam, yet severepain?(No Clear Guidance)

Table 1616-11:11: Motor DeficitG d DescriptionGradeDi ti%Multiplier5Normal04Full ROM against gravity plus resistance32Full ROM against gravity, but not with any 26 – 50resistanceMotion when gravity is eliminated51 – 751Slight contraction, NO movement0No Contraction1 – 2576 – 99100


Entrapment Instructions p.p 493 “Onlyy individuals with an objectivelyjy verifiablefdiagnosis should qualify for a permanentimpairment rating. The diagnosis is made not onlyon the basis of believable symptoms but, moreimportant, on the presence of positive clinicalfindings and loss of functionfunction. The diagnosis shouldbe documented by electromyography as well assensory and motor nerve conduction studies.studies.”

Translation Very Mild CTS or other entrapment thatcauses “believable symptoms”,y p, but normalphysical exam of strength and sensation,with normal EDx,, DOES NOT QQUALIFYfor an impairment rating. Pg.494Pg 494 “InIn compression neuropathies,neuropathiesadditional impairment values are NOTgiven for decreased grip strength.strength ”

Nerve Entrapment: EMG tests “ 5 % of individuals with CTS mayy have normalelectrophysiologic studies.” p. 495 “The severity of conduction slowing has nocorrelation with the severity of clinical symptoms,such as weakness or static large-fiber sensory loss. Ifthesehare present, substantialbi l amounts off eitherihconduction block, axon loss, or a combination of bothmust be present.present ” p.p 493

p. 493 Translation Can have Very Mild CTS((or other entrapment)p) with normal exam,,and either normal or abnormalg(EDx).()Electrodiagnostics BUT, if Either weakness or abnormalsensation is present,present EDx will be abnormal will detect the entrapment.

Carpal Tunnel SyndromeInstructions p. 493 Tinel’s sign not useful. Reserved for followingpost operative status of sion. Exam: May have normal 2 point discrimination,b t decreasedbutdd lightli ht touch-deept hdpressurerecognition,HHenceSSemmes-WeinsteinW i t i monofilamentfilttesting can be indicated.

Semmes-WeinsteinSemmesWeinstein Monofilaments

Nerve Entrapment 5th Edition “If after an optimal recovery time followingsurgicalgdecompression*pan individual continuesto complain of pain, paresthesias, and/ordifficulties in performing certain activities, threepossible scenarios can be present.”* Authors are hand surgeons and forgot that not allCTS patients choose surgery.

Carpalp Tunnel Syndromey(Patient remains symptomatic at MMI)Ph i l findingsPhysicalfi di% impairmentiiUpper extremityNNormall sensationti andd oppositioniti strengthtthwith normal Edx0%%Normal sensation and opposition strengthwith abnormal EDx (NCV and/or EMG)NTE 5%Positive clinical findings of median nerve Rate same as anydysfunction and abnormal EDxother nerve lesion

16.7 b: Arthroplasty With or Without Joint Replacement. Can rate and combine impairmentpfor loss ofROM. Can NOT rate with instability,y, subluxation,, ordislocation. A severe symptomaticy pfailure of an implantpprocedure (eg, symptomatic breakage orsubluxation of the device) is given 100 % of thejoint value listed in Table 16-18. %s changed, Implant no longer “automaticallyworth more” than resection arthroplasty.

16.7 d: Tendinitis (p. 507) Several upper extremity syndromes are attributed totendinitis, fascitis, or epicondylitis. Although mayAlthhbeb persistent.i t t NotN t givenia permanenttimpairment rating unless there is some other factor thatmust be considered. Tendon rupture, surgical release of flexor or extensororigins, or has excision of an epicondyle, there may besome permanent weaknesskoff gripi as a resultl off thehrupture or surgery. Rate grip strength, probably when 1 year from rupture or surgery.

16.8 Strength Evaluation “Many subjective or non-measurablefactors, including fatigue, handedness, timeof day, age, nutritional state, pain, and theindividual’s cooperation further influencestrength measurements.” “It should be noted that the correlation ofstrength with performance of activities ofdaily living is poor ”

AMA Guides 5th Edition Upper ExtremityUpper Extremity Rating Methodology Paul S. Darby MD PhD MPH FACOEM with thanks to Douglas W Martin MD FAADEP FACOEM FAAFP. Upper Extremity: Sections 16.2 Amputation 16 3 Sensory File Size: 6MB