AMA Guides® Newsletter - Issue Archive

Articles

1. Upper Extremity Impairment Scenarios–Challenges in Rating

   Frank Jones, James B. Talmage

   Pages 1–4

   DOI: 10.1001/amaguidesnewsletters.1999.MayJun01

   Abstract

   This article discusses situations in which an evaluating physician may find rating according the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) cumbersome, including fingertip injuries, transection of flexor digitorum sublimis tendon, medial and lateral epicondylitis, upper extremity amputations, and recurrent shoulder dislocation. On finding decreased motion at a finger distal interphalangeal joint (DIP) or thumb interphalangeal (IP) joint, the examiner should carefully assess the functional consequences and ensure the rating adequately addresses the impairment but does not rate the same problem twice. Laceration of the distal palm or proximal phalanx of a finger resulting in isolated transection of the flexor digitorum sublimis tendon (flexor digitorum profundus tendon remains intact) is a challenging scenario. Medial and lateral epicondylitis are not mentioned in the AMA Guides because usually they resolve with time. Grip strength loss usually is not an appropriate way to rate epicondylitis because pain limits grasp in this condition. Impairment ratings for upper extremity amputations may not be consistent in terms of the location where the procedure is used. Recurrent shoulder dislocation may complicate an initial traumatic dislocation, particularly in younger patients and must be medically documented rather than anecdotally reported. When faced with a situation that is not covered in the AMA Guides, the rating physician should consider analogous situations, consult other manuals or guidelines, or discuss the case with other experienced evaluators.
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2. Letter to the Editor

   Kathryn Mueller

   Pages 4–4

   DOI: 10.1001/amaguidesnewsletters.1999.MayJun02

   Abstract

   This letter responds to “Evaluating impairment from allergic disorders” in the March/April 1999 issue of The Guides Newsletter. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not provide clear direction about whether allergies themselves constitute impairment. Consider a worker whose symptoms of asthma subsequent to workplace exposure to toluene diioscyanate resolve when he or she is removed from the job and is no longer exposed to the chemical. Because everyday exposure to diisocyanates is not common and the patient no longer requires medication, one could conclude the patient has no impairment. In contrast, consider a patient who has developed latex allergies as a result of being a health care worker and has experienced two anaphylactic reactions at work after entering rooms where powdered latex gloves had been used and must travel with an epinephrine pen. This person would have a minimum of a Class I impairment because of the few limitations of this person's activities of daily living (ADLs) and the condition requires no or intermittent treatment. Both patients might feel they had permanent changes in their body functions that required permanent changes in their ADLs. Clinicians who make evaluations should be aware of patients’ need for medications or monitoring, the severity of the patient's reactions, and limitations on social activities (eg, need for medications and need to avoid seasonal pollens).
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3. Quick Reference: Measuring Impairment Due to Other Disorders of the Upper Extremity

   Pages 5–6

   DOI: 10.1001/amaguidesnewsletters.1999.MayJun03

   Abstract

   When performed according to criteria in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, upper extremity impairment assessment requires a thorough physical examination of the involved (and contralateral) upper limb. Observation and palpitation require no instrumentation, and much of the equipment necessary for the remainder of the examination may be present in the physician's office. According to the AMA Guides, sensory testing, particularly in the hand and digits, requires equipment and considers all sensory modalities, including perception of pain, heat, cold, and touch. For example, the two-point discrimination test of sensory quality can be performed using a paper clip or commercially available test disks. Traditionally, light touch is assessed using a cotton tipped swab, and sharp-dull discrimination can be assessed using a safety pin or needle (discard after use). Pressure and vibration sensibility can be assessed using the end of an initially still, then vibrating 128-Hz tuning fork. Deep tendon reflexes are tested with a reflex hammer; goniometers of various sizes are used for range-of-motion tests; and grip strength is assessed using a hand dynamometer. Other instruments are available to assess hand and upper extremity sensibility, coordination, strength, and motion but are not used by the AMA Guides for estimating impairment.
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4. Tools and Resources: Instrumentation for Upper Extremity Impairment Assessment

   James B. Talmage

   Pages 7–8

   DOI: 10.1001/amaguidesnewsletters.1999.MayJun04

   Abstract

   The primary methods of evaluating impairment in the upper extremity are range of motion testing and neurological examination. For certain conditions that do not cause motion or neurological deficits yet leave the extremity significantly impaired, the editors of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, provided Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. The AMA Guides emphasizes that the criteria described in these “other disorders” should be applied only when the other criteria have not adequately encompassed the extent of the impairments. The evaluator must carefully read the criteria for rating each derangement to ensure the rating is correct and not duplicative. Table 26, Upper Extremity Impairment Due to Carpal Instability Patterns, includes values based on radiographic findings, and Table 27, Impairment of the Upper Extremity after Arthroplasty of Specific Bones or Joints, features ratings for resection arthroplasty and implant arthroplasty. Tables 28, 29, and 30 for musculotendinous impairments require that the percent of digit impairment be multiplied by the relative value of the digit according to Table 18. The AMA Guides does not assign a large role to functional measurements such as pinch and grip strength tests because they are influenced by subjective factors that are difficult to control.
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5. Impairment Tutorial: Evaluating Impairment Due to Other Disorders of the Upper Extremity

   Robert Haralson, Christopher R. Brigham

   Pages 8–9

   DOI: 10.1001/amaguidesnewsletters.1999.MayJun05

   Abstract

   Because grip and pinch strength are highly correlated and most literature deals with the former, this article focuses on grip strength, which is controversial because, as a functional test, it can be influenced by subjective factors that are difficult to control and include effort, pain, time of day, and fatigue. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) identifies additional factors that influence grip and include sex, age, sensation, comorbidities, age, nutritional status, and, perhaps, handedness. Although grip strength is considered a measure of hand function, its correlation with activities of daily living is poor. Grip strength measurements must be performed in a standard manner because altering wrist, forearm, or elbow position can change the results. Impaired hand strength is compared to that of the opposite extremity, which usually is normal; if both extremities are involved, the strength measurements are compared to the average normal strengths. The AMA Guides specifies that grip measurements are regarded as reliable if there is less than 20% variation in the readings, but subjective factors may result in higher-than-normal variance between measurements of grip. Because pain interferes with maximal effort and, if present, may invalidate grip strength measurement, the latter generally is inappropriate to rate tendonitis or other painful conditions. Generally, grip strength is not used to rate neurological deficits.
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6. Clinical Update: Strength Testing–Grip and Pinch

   Margit L. Bleeker, Sania Amr

   Pages 9–10

   DOI: 10.1001/amaguidesnewsletters.1999.MayJun06

7. Impairment Questions and Answers

   Pages 11–12

   DOI: 10.1001/amaguidesnewsletters.1999.MayJun07