AMA Guides® Newsletter - Issue Archive

Articles

1. Evaluating Shoulder Impairment

   Richard T. Katz, Sankar Perraraju

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.1998.SepOct01

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, offers several categories to describe impairment in the shoulder, including shoulder amputation, abnormal shoulder motion, peripheral nerve disorders, subluxation/dislocation, and joint arthroplasty. This article clarifies appropriate methods for rating shoulder impairment in a specific patient, particularly with reference to the AMA Guides, Section 3.1j, Shoulder, Section 3.1k, Impairment of the Upper Extremity Due to Peripheral Nerve Disorders, and Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. A table shows shoulder motions and associated degrees of motion and can be used in assessing abnormal range of motion. Assessments of shoulder impairment due to peripheral nerve lesion also requires assessment of sensory loss (or presence of nerve pain) or motor deficits, and these may be categorized to the level of the spinal nerves (C5 to T1). Table 23 is useful regarding impairment from persistent joint subluxation or dislocation, and Table 27 can be helpful in assessing impairment of the upper extremity after arthroplasty of specific bones of joints. Although inter-rater reliability has been reasonably good, the validity of the upper extremity impairment rating has been questioned, and further research in industrial medicine and physical disability is required.
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2. Clinical Update: Measuring Shoulder Joint Motion

   Christopher R. Brigham

   Pages 4–5

   DOI: 10.1001/amaguidesnewsletters.1998.SepOct02

   Abstract

   Accurate measurement of shoulder motion is critical in assessing impairment following shoulder disorders. To this end, measuring and recording joint motion are important steps in diagnosing, determining the severity and progression of a disorder, assessing the results of treatment, and evaluating impairment. Shoulder movement usually is composite rather than in a single plane, so isolating single movements is challenging. Universal goniometers with long arms are used to measure shoulder motion, and testing must be performed and recorded consistently. Passive motion may be carried out cautiously by the examiner; two measurements of the same patient by the same examiner should lie within 10° of each other. Shoulder extension and flexion are illustrated. Maximal flexion of the shoulder also includes slight external rotation and abduction, and controlling or eliminating these components during evaluation is challenging. Abduction and adduction are illustrated. Deficits in external rotation may occur in patients who have undergone reconstructive procedures with an anterior approach; deficits in internal rotation may result from issues with shoulder instability. The authors recommend recording the shoulder's range of motion measurements according to the Upper Extremity Impairment Evaluation Record in the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition.
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3. Impairment Tutorial: Dermatological Impairment Assessment

   Laura Welch

   Pages 6–7

   DOI: 10.1001/amaguidesnewsletters.1998.SepOct03

   Abstract

   The main function of the skin is to protect the body that it encloses. Anatomically and physiologically, the skin's regions differ to the extent that skin is not one organ but a combination of multiple systems. The skin has a limited range of reaction patterns, but these may express a wide range of clinical syndromes. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) states that the morphology of the lesion and the pattern of distribution suggest the differential diagnosis. Skin lesions can be characterized as macule, papule, change in pigmentation, plaque, erythema, or eczema. The evaluating physician should consider relevant characteristics, including: Is the condition localized or generalized? Does in involve the face or spare it? Does the condition involve or spare the palms and soles? Approximately 95% of occupational skin disease involves contact dermatitis from irritation, contact allergy, or both. The remaining instances usually arise from biological, physical, mechanical, or other miscellaneous causes. The AMA Guides directs the evaluating physician to complete a detailed work description and conduct a physical examination with biopsy or patch testing as needed. Because most cases of occupational contact dermatitis involve irritants, a systematic approach to examination of the skin and use of good dermatology tests can pinpoint the diagnosis in the majority of cases.
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4. Questions and Answers

   James B. Talmage

   Pages 7–7

   DOI: 10.1001/amaguidesnewsletters.1998.SepOct04

   Abstract

   The authors respond to the two-part article by Ensalada in the November/December 1997 and January/February 1998 issues of The Guides Newsletter. Disability determination in the AMA Guides to the Evaluation of Permanent Impairment often is based on formulations that use a scaled ranking of the impaired function(s) that approximates the impact on the individual's ability to perform specific tasks. The method, although imperfect, generates a percentage impairment score for rating the disability. This method breaks down when applied to disorders with far-reaching effects, such as reflex sympathetic dystrophy (RSD), because it tends to focus only on the affected extremity. The AMA Guides also identifies five factors can affect disability in individuals with RSD: First, RSD spreads in an unpredictable temporal manner. Second, RSD is associated with global effects on cognitive processes (eg, constant pain leads to impairment of sleep, decreased alertness, and altered attention). Third, depression often is a reactive consequence to impaired function. Fourth, RSD may change over time yet may remain quite disabling. Fifth, RSD can significantly affect remote systems (eg, bladder disturbance). For these reasons, during the evaluation of people affected by RSD, physicians should be aware of additional issues besides the percentage loss of function of the affected injured extremity.
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5. Letter to the Editor: The Continuing Challenge of Evaluating RSD Impairment and Disability

   Robert L. Knobler, Charles N. Brooks, Leon H. Ensalada, James B. Talmage, Christopher R. Brigham

   Pages 8–10

   DOI: 10.1001/amaguidesnewsletters.1998.SepOct05

   Abstract

   The author of the two-part article about evaluating reflex sympathetic dystrophy (RSD) responds to criticisms that a percentage impairment score may not adequately reflect the disability of an individual with RSD. The author highlights the importance of recognizing the difference between impairment and disability in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): impairment is the loss, loss of use, or derangement of any body part, system, or function; disability is a decrease in or the loss or absence of the capacity to meet personal, social, or occupational demands or to meet statutory or regulatory requirements because of an impairment. The disparity between impairment and disability can be encountered in diverse clinical scenarios. For example, a person's ability to resume occupational activities following a major cardiac event depends on medical, social, and psychological factors, but nonmedical factors appear to present the greatest impediment and many persons do not resume work despite significant improvements in functional capacity. A key requirement according to the AMA Guides is objective documentation, and the author agrees that when physicians consider the disability evaluation of people, more issues than those relating to the percentage loss of function should be considered. More study of the relationships among impairment, disability, and quality of life in patients with RSD are required.
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6. Tools and Resources

   Pages 10–10

   DOI: 10.1001/amaguidesnewsletters.1998.SepOct06

   Abstract

   The editor and associate editor of The Guides Newsletter respond to and comment on a letter by Knobler and Mandel and the response by Ensalada in this issue. Knobler and Mandel raise interesting issues, including the importance of a thorough medical evaluation and analysis in which the physician must differentiate, on the one hand, symptoms associated with a physical disease process and, on the other hand, illness behavior (symptom magnification) and somatization. Probable relationships must be differentiated from those that are only possible. For example Knobler and Mandel note that RSD can change, but permanent impairment is rated as the individual is, not as he or she will be in the future. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) states that the degree of disability in the social and vocational contexts is not necessarily the same as the degree of impairment, and loss of function may be greater or less than the impairment might imply. Further, many factors can confound the relationships between impairment and disability, including motivation and illness behavior. The AMA Guides also states that the complexities of secondary gain and motivation complicate the assessment process. Finally, the AMA Guides is used to assess impairment; it was not designed to define disability.
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7. Literature Review

   William S. Shaw

   Pages 11–11

   DOI: 10.1001/amaguidesnewsletters.1998.SepOct07