Arthritis and the Impairment Physical Exam

13 March 2012 / Impairment Physical Exam / 0 Comment

Arthritis:

Arthritis is a term used to describe many forms of inflammation and degeneration of a joint and its components. The joint, made of bone and covered with cartilage, is constructed to allow smooth movement and minimal friction with motion.

Arthritis has been found to have a genetic component, particularly in the spine.

Individuals suffering from arthritis may have enlargement and swelling of the joint.

The most common form, osteoarthritis, can result from trauma or fracture of the joint or simply the aging process. Septic arthritis is caused by joint infections from bacteria. Rheumatoid arthritis is linked to autoimmune conditions. Crystal disease such as gout or pseudogout may cause and/or aggravate arthritis.

Treatment for arthritis ranges from conservative methods such as ice, anti-inflammatory medications, cortisone injections, or manufactured joint fluid supplements such as Synvisc. More aggressive treatments can include surgical intervention or total joint replacement.

X-ray’s and CT scans are used in diagnoses. One should be aware that medical imaging does not always accurately indicate the severity of the symptoms.

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Review:

*Some causes of arthritis are: normal aging process, underlying autoimmune conditions, metabolic conditions, or trauma.

*Treatment for arthritis may include anti-inflammatory medications, injections, and possible surgical intervention for advanced conditions.

*Medical imaging such as an X-ray and CT scan may aid in diagnosis.

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Rating Comment:

The AMA Guides Fifth Edition provides rating for arthritis, particularly in the lower extremities, based on X-ray cartilage intervals. Rating for arthritis in the lower extremities should be obtained based on bilateral X-rays and weight bearing. When assessing arthritis of the kneecap and joint for impairment rating, it is best to obtain a Merchant's view with the knee flexed 45°.

Independent Medical Exam Results for Impairment Ratings

08 March 2012 / Impairment Physical Exam, Impairment Rating Specialists / 0 Comment

A treating physician who is not familiar with The AMA Guides can refer impairment evaluations to Impairment Rating Specialists. Our goal is to assign cases the correct and independent rating.

 

Physicians: send us a case referral with our online form for treating doctors. Our staff will obtain authorization and schedule the patient.

Primary Treating Physicians Have an Option

06 March 2012 / Impairment Physical Exam / 0 Comment

Our cases are ideally referred by the primary treating doctors who understand the value of the quality of our impairment reports. They also do not want to turn in an incorrect report or a report that can result in getting a letter-after-letter from the insurance carrier.

 

Physicians: send us a case referral with our online form for treating doctors. Our staff will obtain authorization and schedule the patient.

What Is The Difference Between Exacerbation and Aggravation?

01 March 2012 / Impairment Physical Exam, Medical History / 0 Comment

A CASE STUDY FOR LEARNING.

A 28 year old man injured his low back at work while doing repeated bending and lifting. He had a well documented pre-existing low back pain history with lumbar spine imaging that showed moderate to severe degenerative changes.

His base line back pain was 2/10 and occasional. His work injury increased his symptoms to 8/10 and constant. The claim was accepted.

Treatment consisted of anti-inflammatory medication and therapy. Repeat imaging confirmed his degenerative pre-existing low back pain condition.

He was found to be a non surgical candidate. He was referred for impairment rating with the claim being nearly three years old at referral. He remained on light duty these entire three years.

At impairment rating, he was obese, and his lumbar spine exam demonstrated no ratable findings (i.e. WPI =0%). It was discussed and agreed upon that the employee would perform a trial of full duty, although his pain was still above his pre-injury baseline.

The employee was opined to be at maximal medical improvement (MMI). He was provided a provisional opinion that his pre-existing low back condition had been “aggravated” on an industrial basis. Future care was outlined, and it was asked he follow up in three months for an update on his clinical status.

At four months, the carrier provided additional prior chart documentation for review, which contained no new contributory information.

A symptom review update was carried out the employee, and it was learned that he was tolerating work at full duty without problems, and his back pain had entirely returned to his pre-injury baseline without the need of increased supportive treatment (i.e. more pain medications or an “increased burden of treatment”).

A summary supplemental report was issued which documented the return of the employee to his pre-injury baseline. The opinion of causation was revised based on new and additional information which found the employee’s back pain to now be best described as an “exacerbation”.

No further future care was indicated, the impairment rating remained WPI =0%, and no further treatment on an industrial basis was recommended. The employee was discharged as cured.

 

Discussion:

There is often confusion about the terms “exacerbation” and “aggravation”. This case nicely demonstrates these “words of art” and how they apply to clinical situations.

The claim had been appropriately managed with conservative care, and the employee was a non surgical candidate. He had become MMI. He had not, however, been returned to a trial of full duty.

If this were the end of the story, his condition would be considered an industrial “aggravation” of his pre-existing low back pain.

The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”. More specifically, in clinical terms, a permanent “aggravation”.

There was a clinical opportunity here, however, because the employee was very motivated to return to work. He was assured that after a thorough examination and review of his imaging studies, his pain was “not dangerous” and he should consider a trial of regular work, given that his current restrictions were based only on tolerance of symptoms, and not risk or capacity loss.

He was furthermore reassured that if his symptoms worsened, he would simply return to clinic for replacement of his tolerance limitations. He agreed.

The story ends happily, as the employee not only successfully returned to his usual and customary work, but the pain also returned to pre-injury baseline.

An adequate trial of full duty for four months had been performed without “recurrence” of his low back symptoms. At this time, the opinion was revised to describe his condition as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by an exposure/injury”.

 

Keys of Review:
• The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”.

• This condition is best defined as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by a exposure/injury”.

• If the employee is motivated, and present restrictions are based only on tolerance, and not risk or capacity loss, consider a trial of full duty. Fear on behalf of the employee can be managed with adequate review of the physical exam findings and imaging if clinically appropriate. Agree on a clinical follow up plan to decide if future care management is still indicated in the claim, and further support your recommendations. This approach may minimize industrial morbidity and allow the employee to play a decisive role in the ultimate outcome of their injury.

Ligaments and The Impairment Physical Exam

23 February 2012 / Impairment Physical Exam / 0 Comment

Ligament:

A ligament is a soft, fibrous tissue structure that connects bone to bone to form a joint. A ligament differs from a tendon, which connects muscle to bone. Injury can occur when a ligament becomes stretched, partially torn, or completely disrupted. The injury can range from a minor strain to complete disruption of all fibrous tissue. Serious cases of injury may result in instability of the joint, significant bleeding, chronic pain, and swelling.

 

Most ligament injuries can be diagnosed by an X-ray or MRI scan and treated with conservative measures such as ice, rest, compression, and limited bracing. When a ligament overlies a joint, it may become difficult to determine if pain and symptoms are due to a ligament injury or an underlying joint injury. In certain instances such as a knee injury, the tendon and joint cartilage may be injured at the same time. Injuries that do not respond to conservative care may require additional imaging by an MRI and/or referral to an orthopedic specialist.

 

*A ligament connects bone to bone.
*Treatment is usually conservative. If the condition fails to improve, additional imaging by an orthopedic specialist may be indicated.

 

Review:
* Caution must be taken when diagnosing an injury that involves a ligament overlying a joint. Consideration must be given for a possible deep joint or cartilage structure injury.

 

Rating Comment: The AMA Guides Fifth Edition provides impairment rating for ligament instability in the wrist, chapter 16: Upper Extremities and in the knee, chapter 17: Lower Extremities. Additional impairment rating may also be assigned in some circumstances for ligament injuries that impair range of motion.

Bursa/Bursitis in Impairment Physical Exams

21 February 2012 / Impairment Physical Exam / 0 Comment

Bursa/Bursitis:

A bursa is a fluid-filled sac made of soft tissue that acts as a cushion to reduce friction between tendons and bones. Bursitis (inflammation of a bursa) occurs when the bursa becomes irritated from overuse or direct trauma. Symptoms include: pain, swelling, and even redness if infected. Shoulders, elbows, and knees are common areas prone to bursitis.

 

This condition is often seen in trades where the employee is frequently on his/her knees such as carpet and floor industries. Treatment consists of ice, rest, physical therapy, and cortisone injections. Surgery, excision, and drainage are rarely recommended as treatment methods. Difficult cases should be referred to an orthopedist for further evaluation.

Review:
*Common locations: shoulder, elbow, and knees.
*Common causes: repetitive use or trauma.
*Bursitis usually responds well to conservative treatments such as cortisone injections. Orthopedic evaluation may be needed for difficult cases.

Rating Comment: Per the AMA Guides Fifth Edition, bursitis alone is a non-ratable condition. Bursitis may qualify for rating if it interferes with range of motion of a joint.

Are Your IME Workers Comp Claims Managed Correctly?

16 February 2012 / Impairment Rating Specialists / 0 Comment

Phil Walker, Esq with Impairment Rating Specialists goals include people getting well, going back to work, permanent impairments measured accurately, and getting paid promptly.

Phil Walker, Esquire & Impairment Rating Specialists

14 February 2012 / Impairment Rating Specialists / 0 Comment

Phil Walker, Esq. has over 25 years experience in representing California’s largest airlines, shipyards, steel companies, retailers, universities and insurers. He also specializes in Longshore claims and is a member of the bars of California, New York and the District of Columbia.

Phil Walker, Esq. is an educator, professional speaker, author and AMA Guides expert well recognized in California. Phil Walker, Esq., owns Walker Companies, a California Law Corporation that offers AMA report review services to California’s largest businesses (Macy’s, UC California, Wal-Mart). Report review services insure physician rating reports are legally compliant with the AMA Guides. Mr. Walker is an expert in California employment and Worker's Compensation law. Walker Companies perform comprehensive legal services and consulting for employers, physician practices, and insurance carriers who want to improve their standards of care, and place high value on returning injured workers to their jobs. He is the author of The AMA Guides Made Simple and is a noted public speaker.

Phil Walker is proud to be partnering with Dr. John Alchemy and Impairment Ratings Specialists to provide correct AMA reports and results for injured workers and the California Workers’ Compensation industry.

Walker Companies and Impairment Ratings Specialists are innovators in the industry working tirelessly to meet this goal. The goal is simple: “Make California’s Workers’ Comp Work”.

A Different Workers' Comp Attorney -- Phil Walker, Esquire

07 February 2012 / Impairment Rating Specialists / 0 Comment

How Dr. Alchemy, MD first met Phil Walker, Esq, a Different Workers' Comp Attorney.

Legal Question on Chapter 18 Pain (AMA Guides to the Evaluation of Permanent Impairment 5th Edition)

30 January 2012 / Impairment Physical Exam / 0 Comment

Pain Chapter 18 Question Sent in by a Guest:

Dear Phil Walker, Esq: My employee has bilateral knee injury from patellofemoral industrial condition-lifted a box. It results in functional limitations. No knee problems prior. On exam she has 12 degrees of ratable valgus deformity 5% WPI (each knee). The valgus deformity is entirely genetic in it's design and has now resulted in a painful patellofemoral syndrome (old term would have been "lit up"). There are no ratable knee findings other than the non industrial condition. So could chapter 18 Pain add on be considered in this situation? Can the add on be given when there is only non industrial impairment?

Sincerely, Confused in Chapter 18 Pain (AMA Guides to the Evaluation of Permanent Impairment 5th Edition).

**

Dear Confused in Chapter 18 Pain (AMA Guides to the Evaluation of Permanent Impairment 5th Edition),

Here is what you need to know:

1.  There cannot be an add-on when the underlying rating for the industrial condition is 0% WPI.

2.  The add-on for pain is given in less than 1% of all cases, nationally.  That is because the AMA Guides indicate that all normal pain is included in the underlying ratings.  Chapter 18 indicates that an add-on for pain is ONLY to be given when the pain is greater than expected, that the Applicant is credible, and that the pain significantly impacts the Activities of Daily Living.  Because of those restrictions in the Guides, doctors nationally give the Add-on for pain in less than 1% of all cases.

3.  However, we are different in California.  No surprise there!

a.  Interestingly, when the Applicant attorneys first learned that the Guides permit an add-on of 3% for pain, they requested that the DEU simply increase all ratings by 3%.  Amazing.

b.  The DEU declined.

c.  While the AMA Guides, as applied by doctors nationally, make the add-on for pain very limited; California doctors and the DEU have taken a different approach.  The DEU takes the position that there can be an add-on for pain of up to 3% WPI anytime that there is a minimal rating of 1% WPI or greater for the industrial condition.

d.  The DEU also takes the position that there can be no add-on for pain if the underlying rating for the industrial condition is 0% WPI.

The position taken by the DEU to permit an add-on for pain anytime there is an industrial rating of 1% or greater is not consistent with the position of the AMA Guides that all normal pain is included in the underlying rating.  The AMA Guides were made the law of California by our Labor Code.  

The DEU's position raises the question of whether or not the DEU has the power to make law versus the Legislature.  None of the members of the DEU are elected, as the Legislature is.  

I am not aware of the issue's having been addressed legally, and I anticipate that that is because of the cost of a legal challenge versus the value of 3% WPI.

So, from an economic standpoint, I recommend that people accept the add-on of up to 3% WPI if there is an underlying rating of 1% WPI or greater.  When people get angry over that, I remind them of how, under the Old System, pain add-ons were 20% PD, 30% PD, or higher, and a very large number of our workers' compensation cases were "subjective only, i.e., pain, with no objective findings."

Hope that will help.

Phil Walker, Esquire
Legal Director, Impairment Rating Specialists

Phil Neal Walker Law Corporation
"Workers' Compensation for the World"
250 King Street, Suite 414
San Francisco, California 94107