Transcription
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA GuidesGuide to t h e Gu id es:Evaluator’s Resource Algorithm to theAMA Gu id es t o t h eEv alu at ion of Per m an en t I m p air m en t , Fif t h Ed .Extremity RatingsSteven D. Feinberg, MDChristopher R. Brigham, MD 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.1
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides2This book is for information purposes only. It is not intended to constitute medical, legal or financial advice. Ifmedical, legal, financial, or other professional advice is required, the services of a competent professional should besought.No part of this publication may be reproduced, storied in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of theauthors. 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides3PrefaceThis resource is designed to simplify use of the AMA Guides to the Evaluation of Permanent Impairment andimprove the accuracy of ratings. The reality is that there is no easy way to learn the AMA Guides but this is anapproach at perhaps making it a little simpler. It is critical that you keep the AMA Guides 5th Edition available asyou review this resource. We have provided you with a format such that if the examiner answers the questions andfills out the integrated fill-in squares and check off boxes, the examiner should at least identify and address allpossible issues for an AMA Guides impairment evaluation. We welcome your feedback.AuthorsSteven Feinberg, MDFeinberg Medical Group, 825 El Camino Real, Palo Alto, CA 94301; 650-223-6400; [email protected];www.FeinbergMedical Group.comAmerican Board of Pain Medicine, American Board of Electrodiagnostic Medicine, American Board of PhysicalMedicine & Rehabilitation, Qualified Medical Evaluator, Adjunct Clinical Professor, Stanford University School ofMedicine, and Medical Director of Cedaron AMA Guides Impairment Rating software. Dr. Feinberg served on theACOEM Chronic Pain Guidelines Panel Chapter Update and also as Associate Editor, as a Medical Reviewer for theACOEM 2014 Opioid Guidelines and he also serves ongoing as a Medical Consultant to the Official DisabilityGuidelines (ODG) and on the Reed Group’s Medical Advisory Board. He served as a Reviewer for the AMA Guidesto the Evaluation of Permanent Impairment, 6th Edition.Christopher R. Brigham, MDPresident, Brigham and Associates, Inc., Brigham and Associates, Inc., Hilton Head, SC, 888-507-7920;[email protected]; https://www.cbrigham.comAmerican Board of Preventive Medicine – Occupational Medicine, Fellow American Academy of DisabilityEvaluating Physicians and Certification in Evaluation of Disability and impairment rating, Fellow American Collegeof Occupational and Environmental Medicine, Certified Independent Medical Examiner and Founder of AmericanBoard of Independent Medical Examiners, Editor-in-chief of the AMA Guides Newsletter and Guides Casebook andwas co-author of Understanding the AMA Guides in Workers’ Compensation. Senior Contributing Editor for theAMA Guides to the Evaluation of Permanent Impairment, Sixth Edition, and contributor/author for themusculoskeletal chapters. For the Fifth Edition, served on the Advisory Committee and as a contributor. 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides4Table of ContentsPREFACE 3AUTHORS 3TABLE OF CONTENTS 4ORIENTATION 5CHAPTER 16 – THE UPPER EXTREMITIES 6CHAPTER 17 – THE LOWER EXTREMITIES 27 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides5OrientationThe AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition is the standard for rating impairment.Physicians and others are trying to learn it and then apply it in a fair and equitable manner.It is imperative that the physician understand and follow the principles of the Guides. Chapter 1 Philosophy, Purposeand Appropriate Use of the Guides and Chapter 2 Practical Applications of the Guides define standards that apply toall ratings. The individual chapters define principles of assessment and the rating process.Maximal Medical Improvement (MMI) or Permanent and Stationary(P&S)The examinee must be at maximal medical improvement (MMI), the equivalent of Permanent and Stationary(P&S), to produce an impairment rating. It is necessary to determine that the patient is stable, and that no furtherrestoration of function is probable. If the examinee shows up and is in the middle of a flare-up or has had a newinjury that interferes with the examination, it is premature to do an impairment rating. In other words, the examineemust be stabilized medically for the physician to fairly assess the impairment rating. If the condition is changing orlikely to improve substantially with medical treatment, the impairment is not permanent and should not be rated. Forexample, an examinee has a known industrial injury problem, but the day before the examination is in an autoaccident and has increased complaints. An impairment rating examination that is a fair representation of theexaminee at MMI status in this situation cannot be done. Assuming the examinee has reached MMI and is nothaving a flare-up or other problem, the physician can go forward with the impairment rating.Activities of Daily Living (ADL)Impairment percentages or ratings are estimates that reflect the severity of the medical condition and the degree towhich the impairment decreases an individual’s ability to perform common activities of daily living (ADL),excluding work. Throughout the AMA Guides, the examiner is given the opportunity to adjust the ImpairmentRating based on the extent of any ADL deficits (5th ed., Table 1-2, 4). The following are typical ADLs. Self-care & personal hygiene– Urinating, defecating, brushing teeth, combing hair, bathing, dressing oneself, eatingCommunication– Writing, typing, seeing, hearing, speakingPhysical activity– Standing, sitting, reclining, walking, climbing stairsSensory function– Hearing, seeing, tactile feeling, tasting, smellingNonspecialized hand activities– Grasping, lifting, tactile discriminationTravel– Riding, driving, flyingSexual function– Orgasm, ejaculation, lubrication, erectionSleep– Restful, nocturnal sleep pattern 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides6Chapter 16 – The Upper ExtremitiesOverviewThis chapter provides criteria for evaluating permanent impairments due to anatomic impairments of the hand andthe upper extremity. The methods discussed in this chapter for evaluation of upper extremity impairment due toamputation, sensory loss, and abnormal motion or ankylosis were based on A. B. Swanson’s work and adapted fromthe fourth edition and updated with input from many of the specialty societies listed in the preface. It is comprised ofthe following sections:16.1Principles of Assessment16.2Amputations16.3Sensory Impairment Due to Digital Nerve Disorders16.4Evaluating Abnormal Motion16.5Impairment of the Upper Extremities Due to Peripheral Nerve Disorders16.6Impairment of the Upper Extremities Due to Vascular Disorders16.7Impairment of the Upper Extremities Due to Other Disorders16.8Impairment of the Upper Extremities Due to Other Disorders16.9Summary of Steps for Evaluating Impairments of the Upper Extremity16.10 Clinical ExamplesUpper Extremity Impairment Evaluation rve(16.3) 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.Vascular(16.6)
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides7Principles of AssessmentThe evaluation of anatomic impairment forms the basis for upper extremity assessment. The impairment ratings inthis chapter reflect the degree of impairment and its impact on the ability of the individual to perform activities ofdaily living.Impairment ratings in this chapter have not been adjusted for hand dominance, as is done in Chapter 13, The Centraland Peripheral Nervous System, but hand dominance should be considered in the determination of disability. If youbelieve that hand dominance has a significant impact on the ability to perform activities of daily living, this can bediscussed in the impairment evaluation report along with the resulting impairment rating. However, no additionalincrease is given in the final impairment rating.Assuming the examinee has reached MMI and is not having a flare-up or other problem that prevents you fromgoing forward with the impairment rating examination, you can proceed. It is necessary to measure findings of bothupper extremities to determine what is normal for that individual.This is one of the most difficult chapters due to issues that confuse many people regarding what can be added andwhat can be combined. Also, because the upper extremities and particularly the hands, are so important for ADLs,special care is needed in providing an impairment rating for these body parts. Let’s start with the concept ofcombining and then discuss adding.Combined ValuesA 0% whole person (WP) impairment rating is assigned when there are no significant organ or body systemfunctional consequences and no resulting limitations in the performance of the activities of daily living. At the otherextreme, a 90% - 100% whole person rating suggests very severe organ or body system impairment that results inthe individual being fully dependent on others for self-care, approaching death. Typically the highest ratings arewith catastrophic head and spinal cord injuries.The AMA Guides provide weighted percentages for various body parts but since the total impairment cannot exceed100%, a Combined Values Chart (p. 604) accounts for the effects of multiple impairments with a summary value.Regardless of the number of impairments, the summary value cannot exceed 100% of the whole person. Using thecombined values chart, multiple impairments are combined so that the whole person impairment value is equal to orless than the sum of all the individual impairment values.In Chapter 16, The Upper Extremities, the examiner is advised when combining multiple impairments to combinethe two smallest values first. In California, however in keeping with the California Permanent Disability RatingSchedule and prior use of the Multiple Disabilities Table the California Disability Evaluation Unit (DEU) isadvising to combine the two largest values first.Adding and CombiningMost of the times values are combined, however range of motion (ROM) deficits within a joint and multiple digitalimpairments (when converted to hand) are added. In general, impairment ratings within the same region arecombined and adjusted before combining the regional impairment rating with that from another region in the sameextremity. The extremity impairment then is combined with an impairment from another extremity/region or bodysystem (unless criteria for the second impairments are included in the primary impairment) to determine final overallWPI. In California, with the Permanent Disability Rating Schedule, individual regional impairments once convertedto whole person are adjusted and combined. When to add as opposed to combine impairments is discussed inSections 16.1c, Combining impairment ratings (5th ed., 438), and 16.1d, Principles for Adding Impairment Values(5th ed., 440), and noted in Figure 16-1. It is fairly important to read these sections. 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides8Upper Extremity I mpairment Evaluation RecordThe AMA Guides suggests that one method for recording results from a systematic examination is the use of theUpper Extremity Impairment Evaluation Record (Figure 16-1a (5th ed., 436), and Figure 16-1b (5th ed., 437). Theimpairment evaluation record form is designed for use with unilateral upper extremity impairments. Cases ofbilateral involvement require completion of a separate record form for each upper extremity. Completion of thisbilaterally will also assist in documenting what is normal for that individualPart 1 (Figure 16-1a (5th ed., 436) of the evaluation record addresses the hand region and lists impairments due toabnormal motion or ankylosis, amputation, and sensory loss resulting from digital nerve lesions and to otherdisorders.Part 2 (Figure 16-1b (5th ed., 437) is designed to assist impairment evaluation of the wrist, elbow, and shoulder dueto abnormal motion or ankylosis, amputation, and “other” disorders, as well as those related to the peripheral nervesystem, peripheral vascular system, and other disorders not included in regional impairments (e.g., grip strength).Table 16-1 (5th ed., 438), gives conversions from digit to hand impairment, and Table 16-2 (5th ed., 439), givesthose from hand to upper extremity impairment.Regional impairments resulting from the hand, wrist, elbow, and shoulder regions are combined to provide the upperextremity impairment (Use of the Combined Values (5th ed., 604). The upper extremity impairment is thenconverted to a whole person impairment by means of Table 16-3 (5th ed., 439). If both upper extremities areinvolved, the values derived for each are then combined using the Combined Values Chart (*604) to derive the totalwhole person impairment.If the total combined whole person impairment does not seem to adequately reflect the actual extent of alteration inthe individual’s ability to perform activities of daily living, this should be noted.; however, this does not alter theimpairment rating itself.AmputationsSection 16.2 (5th ed., 441) provides the methodology to rate amputation impairment. Table 16-4 ImpairmentEstimates for Upper Limb Amputation at Various Levels (5th ed., 440) and Figure 16-2 Impairment Estimates forUpper Extremity Amputation at Various Levels (5th ed., 441), along with Figure 16-3 Impairments of the Digits(values outside digits) (5th ed., 442) and the Hand (values inside digits) for Amputations at Various Levels, providesthe basis for calculating the amputation impairment rating value.From distally to proximally, each anatomic unit is given a relative value to the next larger unit and, eventually, thewhole person. By multiplying the appropriate percent, impairment of each unit can be converted sequentially tohand, upper extremity, and whole person impairment.As needed, you would then go from distally to proximally to obtain the Upper Extremity Impairment using thefollowing Tables. Table 16-1 Conversion of Impairment of the Digits to Impairment of the Hand (5th ed., 438)Table 16-2 Conversion of Impairment of the Hand to Impairment of the Upper Extremity (5th ed., 439)Table 16-3 Conversion of Impairment of the Upper Extremity to Impairment of the Whole Person (5th ed.,439)Evaluation of the residual stump must assess the status of soft tissue coverage, of the peripheral nerve and vascularsystems, and of the bone itself. See Conditions Associated With Amputation 16.2d (5th ed., 444) for a furtherdiscussion of this topic. 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides9Sensory Impairment Due to Digital Nerve LesionsSection 16.3 (5th ed., 445) is used to rate digital nerve lesions. It is not used to rate more proximal peripheral nerves.It does provide direction on the evaluation of sensibility.Only unequivocal and permanent sensory deficits are given permanent impairment ratings. Sensory impairment israted according to the sensory quality and the distribution of the sensory loss.The sensory quality is based on the results of the two-point discrimination test carried out over the distal palmar areaof the digit, or on the most distal part of the stump in the presence of a partial amputation.Sensibility defects on the dorsal surfaces of the digits are not considered impairing. The sensory quality impairmentis classified according to Table 16-5 (5th ed., 447).In total sensory losses ( 15 mm), the response to touch, pinprick, pressure, and vibratory stimuli is absent. In partialsensory losses (7-15 mm), there is poor localization and abnormal response to the sensory stimuli. Anything lessthan 7 mm is considered normal.The next step is to determine the distribution, or area, of sensory loss by the level of involvement (percentage ofdigit length affected) of either both digital nerves (transverse sensory loss) or one digital nerve on either the radial orulnar side of the digit (longitudinal sensory loss). The percentage of digit length involved is derived from the topscale of Figure 16-6 (5th ed., 447) for the thumb and of Figure 16-7 (5th ed., 447) for the fingers.A total transverse sensory loss represents 100% sensory loss ( 15 mm) involving both digital nerves and receives50% of the digit amputation impairment value for the corresponding level (Figures 16-6 (5th ed., 447) and 16-7 (5thed., 447) bottom scale, and Table 16-6 (5th ed., 448) and Table 16-7 (5th ed., 448).A partial transverse sensory loss represents 50% sensory loss (7-15 mm) involving both digital nerves and receives25% of the digit amputation impairment value for the corresponding digit length percentage (Tables 16-6 (5th ed.,448) and 16-7 (5th ed., 448).Longitudinal sensory loss impairments are based on the relative importance of the side of the digit for sensoryfunction as follows: thumb and little finger, radial side 40% and ulnar side 60%; index, middle, and ring fingers,radial side 60% and ulnar side 40%. The surfaces used for opposition in various pinch functions and the ulnar aspectof the border finger are rated more highly. If the little finger has been amputated, the relative value of the ulnar sideof the ring finger becomes 60% and that of the radial side, 40%. The digit impairment values are calculated similarlyas above based on the sensory quality and distribution of the sensory loss.Section 16.3 (5th ed., 445) is used to rate digital nerve lesions. It is not used to rate more proximal peripheral nerves.It does provide direction on the evaluation of sensibility. It should be noted sensory loss must be permanent andunequivocal. Dorsal surfaces with sensibility defects are not considered impairing.Sensory Loss using the two-point discriminator over the distal palmar area of the digit or on the distal part of thestump in amputations. The following definitions of sensory loss are noted as referenced in Table 16-5 (5th ed, 447):oooNone 7 mmPartial 7-15 mmTotal 15 mmIt is important to know if there is transverse loss (both digital nerves involved) or longitudinal (either the radial orulnar digital nerve involved).For ease of determination, digit impairment values for total transverse and longitudinal and partial transverse andlongitudinal sensory losses were calculated according to the percentage of digit length involved and are presented intable form. Consult Table 16-6 (5th ed., 448, for the thumb and little finger and Table 16-7 (5th ed., 448), for the 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides10index, middle, and ring fingers. Corresponding hand impairment values can be derived from Table 16-1 (5th ed.,438), as shown in Figure 16-8 (5th ed., 449), for total sensory losses involving 100% of the digit length.16.3d Digital Nerve Sensory Impairment Determination Method – 16.3d (5th ed., 449)1.2.3.4.5.6.Use the two-point discrimination test to identify the sensory quality, or type of sensory loss, as total ( 15mm) or partial (7 through 15 mm) (Table 16-5 (5th ed., 447).Determine the distribution of sensory loss involvement or whether one (longitudinal sensory loss) or both(transverse sensory loss) digital nerves are involved.Identify the level of involvement, or percentage of digit length involved, using the top scale of Figure 16-6(5th ed., 447, for the thumb and of Figure 16-7 (5th ed., 447, for the fingers.Consult Table 16-6 (5th ed., 448, for the thumb and little finger and Table 16-7 (5th ed., 448, for the index,middle, and ring fingers to determine the digit impairment for either total or partial, transverse orlongitudinal (ulnar or radial) sensory loss according to the percentage of digit length involved.If both digital nerves are involved in the same digit, the sensory impairments relating to the ulnar or radialpalmar nerves are added.Convert the digit impairment to hand, upper extremity, and whole person impairment by using Tables 16-1(page 438), 16-2 (page 439), and 16-3 (page 439). When a digit has more than one impairment, obtain thetotal digit impairment value by combining its various impairments before converting the digit values to ahand value.Evaluating Abnormal MotionSection 16.4 (5th ed., 450-480) provides specific directives in rating motion impairment. It is imperative that motiondeficits are reliable, i.e. values should fall within 10% of each other. If the opposite extremity is uninjured, it mayserve as a baseline for what is normal for that individual. For hand ratings it is highly recommend that you completeFigure 16-1a (5th ed., 436) to assure a reliable rating, with appropriate, adding, combining and versions. It is easy tomisread a pie chart, therefore make sure you are reading the correct arc, i.e. V the measured angle, I F % theimpairment due to flexion, I E % the impairment due to extension, I A % the impairment due to ankylosis.Impairments of motion at the same joint are added.The reader is referred to this section in the book as the complexity of this section does not lend itself to a summaryexplanation.Impairment of the Upper Extremities Due to Peripheral NerveDisordersSection 16.5 (5th ed., 480) presents a method of evaluating upper extremity impairments related to disorders of thespinal nerves (C5 to C8 and T1), the brachial plexus, and major peripheral nerves of the upper extremities. It alsoaddresses the evaluation of specific conditions, including entrapment/compression neuropathy and complex regionalpain syndromes (CRPS), which include CRPS I/reflex sympathetic dystrophy (RSD) and CRPS II/causalgia. Onlyobjective neurological deficits with reliable findings are rated.The upper extremity impairment is calculated by multiplying the grade of severity of the sensory deficit (Table 1610a (5th ed., 482) and/or of the motor deficit (Table 16-11a (5th ed., 484) by the respective maximum upperextremity impairment value resulting from sensory and/or motor deficits of each nerve structure involved, as listedin Section 16.5c Regional Impairment Determination ((5th ed., 488-491): spinal nerves, Table 16-13 (5th ed., 489);brachial plexus, Table 16-14 (5th ed., 490); and major peripheral nerves, Table 16-15 (5th ed., 492). When bothsensory and motor functions are involved, the impairment values derived for each are combined (Combined ValuesChart, p. 604). 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides11The steps of the impairment determination method are detailed on page 481, Impairment Determination Method, andare copied below:1.If sensory deficits or pain is present, localize the distribution and relate it to the nerve structure involved(Table 16-12 and Figures 16-48, 16-49, and 16-50).2. If motor deficits or loss of power is present, identify the key muscles involved and relate the motor deficitto the nerve structure(s) involved (Table 16-12 and Figures 16-47 and 16-50).3. Grade the severity of sensory deficits or pain according to Table 16-10a and/or that of the motor deficitsaccording to Table 16-11a.4. Find the values for maximum impairment of the upper extremity due to sensory and/or motor deficits of thenerve structure involved: individual spinal nerve (Table 16-13), brachial plexus (Table16-14), and majorperipheral nerves (Table 16-15).5. For each nerve structure involved, multiply the grade of severity of the sensory and/or motor deficits (seestep 3 above) by the appropriate maximum upper extremity impairment value (see step 4 above) todetermine the upper extremity impairment percent for each function.6. For a structure with mixed motor and sensory fibers, determine the upper extremity impairment for eachfunction (steps 1 through 5), then combine the sensory and motor impairment percents (Combined ValuesChart, p. 604) to obtain the total upper extremity impairment value.7. When more than one nerve structure is involved, combine their respective upper extremity impairmentvalues (steps 1 through 5) to obtain the total upper extremity impairment resulting from peripheral nervedisorders (Combined Values Chart).8. When multiple impairments of the extremity are present because of amputation, loss of motion that is notstrictly attributed to a peripheral nerve lesion, or peripheral vascular disorders, combine the peripheralnerve upper extremity impairment value with the other upper extremity impairment values (CombinedValues Chart) to obtain the total upper extremity impairment.9. The total upper extremity impairment is converted to a whole person impairment by means of Table 16-3.10. If there is bilateral upper extremity involvement, determine separately the impairment values for each side,and convert them to whole person impairment. Combine the whole person impairment values for each side(Combined Values Chart) to obtain the total whole person impairment. Consult page 435 for furthercomments on bilateral upper extremity involvement.I mpairment rating of Entrapment/ Compression NeuropathiesOnly individuals with an objectively verifiable diagnosis should qualify for a permanent impairment rating, asexplained on page 493. The diagnosis is made not only on believable symptoms but, more important, on thepresence of positive clinical findings and loss of function.The sensory deficits or pain, and/or the motor deficits and loss of power, are evaluated according to the impairmentdetermination method described in Section 16.5b (see earlier in this article, Impairment of the Upper ExtremitiesDue to Peripheral Nerve Disorders – 16.5 (5th ed., 480). Sensory impairments strictly due to lesions of digital nervesare evaluated according to Section 16.3.In compression neuropathies, additional impairment values are not given for decreased grip strength. 2014 – 2019 Steven D. Feinberg, MD and Christopher R. Brigham, MD. All rights reserved. No part of this publication may be reproduced ortransmitted by any means without written permission. Permission granted for use by WorkCompCentral.
Guides to the Guides: Evaluator’s Resource Algorithm to the AMA Guides12Carpal Tunnel SyndromeThe AMA Guides provide on page 495 three scenarios forimpairment rating following surgical decompression when theindividual continues to complain of pain, paresthesias, and/ordifficulties in performing certain activities.1.2.3.Positive clinical findings of median nervedysfunction and electrical conduction delay(s):the impairment due to residual CTS is ratedaccording to the sensory and/or motor deficitsas described above.Normal sensibility and opposition strengthwith abnormal sensory and/or motor latenciesor abnormal EMG testing of the thenarmuscles: a residual CTS is still present, and animpairment rating not to exceed 5% of theupper extremity may be justified.Normal sensibility (two-point discriminationand Semmes-Weinstein monofilament testing),opposition strength, and nerve conductionstudies: there is no objective basi
This resource is designed to simplify use of the AMA Guides to the Evaluation of Permanent Impairment and improve the accuracy of ratings. The reality is that there is no easy way to learn the AMA Guides but this is an approach at perhaps making it a little simpler. It is critical that you keep the AMA
