How To

  • Getting Range of Motions Correct

    18 March 2013 / How To, Impairment Physical Exam, Uncategorized / Comments Off on Getting Range of Motions Correct

    The AMA Guides use Range of Motion rating to calculate impairment in joints
    which move. For example, shoulders, knees, wrists, elbows.

    There are a few simple steps to ensure that a Range of Motion rating is
    correct. Sadly, many doctors are not familiar with these 5 simple steps.

    The steps are based on the fundamental principle in the Guides that
    measurements should be reproducible because we are measuring permanent
    impairment. This means that the measurements should be CONSISTENT between
    examiners and also when done by one examiner on several occasions. Why?
    Because the impairment is PERMANENT and should not change.

    Let me give you an example. If half of your arm were cut off, would the
    length cut off change from examination to examination? No, because the
    finding is permanent. Each doctor who measured your amputated arm should
    get the same result.

    Joints (like the shoulders, elbows, knees) with permanent impairment are
    the same way. They should produce the same measurements each time a doctor
    examiners them, if the doctor does the examination correctly.

    So, here are the 5 simple steps to ensure that a Range of Motion rating of
    a joint is correct:

    1. The doctor should use a goniometer to measure the angles of motion of
    the joint. A goiniometer is like a giant protractor (which you had in
    junior high school) which measures angles. The doctor should use this
    device to get an exact measurement of the angle of motion (for example,
    flexion or extension in the shoulder). In the shoulder, the reference that
    a goniometer should be used is found at p. 475-478 of the Guides where the
    instructions for rating are given. The instructions tell the physician to
    record the actual goniometer readings. (I can always tell when a doctor
    has not used a goniometer because all of the measurements end in 0, for
    example, 40 degrees, 50 degrees, 60 degrees--this means, usually, that the
    physician is simply eye balling it and not using a goniometer.)

    2. The physician should measure active motion of the joint. That means
    the patient moves the joint under his own power. (See pp. 475-478 for the
    shoulder.)

    3. The physician should do the measurements a minimum of 2 times in the
    upper extremities (p. 20 of the Guides) and a minimum of 3 times in the
    lower extremities (p. 533, Section 17.2f Range of Motion in the Lower
    Extremities). Yes, these numbers are inconsistent. That is because the
    physicians writing the principles of the Guides and the physicians writing
    the lower extremity chapter did not talk to each other. The physician is
    to record the actual measurements (see p. 475-479). That means they have
    to be written down in the medical report or in the physician's notes (which
    he must keep).

    But here is what is most important. Why do we have the patient do at least
    two motions and measure them? To ensure that the measurements are
    reliable, consistent, and reproducible. That means that they are
    permanent, do not change, and show up from one evaluation to another. This
    principle is stated at p. 20 of the Guides:

    "As with any biological measurements, some variability and normal
    fluctuations are inherent in permanent impairment
    ratings. Two measurements made by the same examiner using the Guides
    that involve an individual or an individual's
    functions would be consistent if they fall within 10% of each other.
    Measurements should also be consistent between two
    trained observers or by one observer on two separate occasions,
    assuming the individual's condition is stable. "

    So, a minimum of two measurements must be done in the upper extremities,
    and three measurements in the lower extremities. The measurements must
    fall within 10% of each other to be reliable.

    Why is this? Because people with PERMANENT impairment can only move the
    joint to the same position each time. By ensuring that a minimum of 2
    measurements are done which fall within 10% of each other, we weed out
    results which are not permanent.

    Example: A patient demonstrates flexion in the right shoulder of 180
    degrees and 0 degrees. Is this consistent? No. What does it tell us?
    That the measurements are not reliable.

    When a patient's measurements are not reliable, they cannot be used as a
    basis for impairment rating. The resulting rating for that motion is 0%
    WPI. (P. 20.)

    4. The motions done (all of them) must fall within 10% of each other to be
    deemed reliable. (p. 20)

    5. Finally, if the right shoulder is injured, then the left uninjured
    shoulder should also be measured. If that shoulder demonstrates impairment
    (and has never been injured before), then that impairment is subtracted out
    from the impaired shoulder per p. 453 of the Guides. The Guides use fancy
    medical terminology for this: "If a contralateral 'normal' joint has a
    less than average mobility, the impairment value(s) corresponding to the
    uninvolved joint can serve as a baseline and are subtracted from the
    calculated impairment for the involved joint. The rationale for this
    decision should be explained in the report."

    Essentially, the Guides use the uninjured joint as a baseline against which
    to measure the injured joint.

    So, in summary, for a perfect Range of Motion rating in a joint:

    a. Find the joint you are dealing with.

    b. Go to the section of the Guides where range of motion of that joint is
    discussed. The section will tell you what motions need to be measured
    (for example, flexion in the shoulder).

    c. Use a goniometer to do the measurements. (p. 475-479 for the shoulder)

    d. Have the patient do active motion of the joint (that means he moves the
    joint under his own power). Measure the motion 2 times in the upper
    extremities and 3 times in the lower extremities. (pp. 475 and 20 for the
    shoulder)

    e. Make sure the measurements fall within 10% of each other. If they do,
    then you can use them for calculating impairment. If they do not, then
    they cannot be used for calculating impairment for that motion, and the
    corresponding rating is 0% WPI for that motion. (p. 20)

    f. Measure any impairment in the uninvolved joint and subtract it from the
    impairment in the involved joint. (p. 453)

    g. Convert your final impairment to whole person impairment using the
    conversion charts at p. 439 for the upper extremity and p. 525 for the
    lower extremities.

    And with that, you will have a perfect Joint Range of Motion rating every
    time!

    Phil Walker, Esq.
    Legal Director Impairment Rating Specialist

    Phil Walker
    Phil Neal Walker Law Corporation
    "Workers' Compensation for the World"
    250 King Street, Suite 414
    San Francisco, California 94107
    phone me at either:
    +1 415.295.4447
    cell: +1 415.816.3527
    fax: 888.563.9444
    Phil@askphilwalker.com
    www.askPhilWalker.com

  • My Employer Doesn't Have Light Duty

    21 February 2013 / How To, Uncategorized / Comments Off on My Employer Doesn't Have Light Duty

    “My employer doesn't have light duty. You need to take me off work.”

    In this situation I first inform the patient that the determination for available of modified work is not mine, but the employer’s.

    I am happy to add on the return to work note that “If no light duty is available please send the worker home”.

    This usually settles the situation, and clarifies for both the patient and the supervisor that the decision to cease working is now removed from the clinic, but rather based on modified work availability.

    Writing return to work instructions may be challenging, but need not be confrontational, or prevent the worker from remaining at work.

    Make every effort to define common goals with the patient, employer and yourself. Reinforce the critical need for the employer and employee to make every effort to remain at work, as it will impact their ability to recover and remain with gainful employment.

    Take a careful look at your clinic’s return to work instructions, and make every effort to use time weighted descriptions whenever possible. Make sure all providers in the clinic are using the same return to work policy so there is no inconsistency in the product and expectations of the patients and clients.

    Using these techniques, you will find writing return to work prescriptions less intimidating and more satisfying for your practice of occupational medicine.

  • It Hurts Too Much for Me to Work

    07 February 2013 / California Workers Compensation, How To, Impairment Physical Exam, Medical History / Comments Off on It Hurts Too Much for Me to Work

    “It hurts too much for me to work” is a common complaint in the clinic.

    In this situation be sure you have clearly reviewed the physical exam findings, objective imaging (x-ray, MRI, consultant opinions, etc.). Inform the patient that the pain is not dangerous, but does require activity modification during the healing process.

    Movement is essential for soft tissue recovery, as is strengthening and following conservative treatment measures. If the worker is still having difficulty tolerating work one of two things can be additionally done.

    The first is to shorten the work day.

    I reserve this for situations where there has been a reasonable change in condition, and the subjective findings are at least in part supported by objective findings i.e. increased muscle tension, guarding with distraction on exam, and good compliance with therapy attendance etc. I will often shorten the shift by a maximum of 1-3 hours.

    “Still hurts too much”.

    At this point I will revisit my work restrictions and see if they can be further limited with regards to weight bearing, bending, and lifting. In general I do not place anyone on a work shift less than 4 hours, and preclude lifting less than 10 pounds, or bending less than 10 x per hour.

    The reality is that these are the basic minimal required functions for activity of daily living i.e. dressing, shopping, preparing food and self hygiene etc. I also point this out to the patient.

  • Discuss Your Clinic's Work Note with the Employer

    09 January 2013 / Chart Reviews, How To / Comments Off on Discuss Your Clinic's Work Note with the Employer

    Take a close and critical look at the format of your clinic’s work note. You will find that some employers have their own form for administrative reasons. This is sometimes an unavoidable situation.

    You may find a maze of confusing options, or options that very slightly with poorly defined terms and time frames. In a poorly designed employer work status note, I will often look for the comment sections, and write in common sense limitations as outlined above. I may also reference my clinic check out functional instructions.

    The most important issue, however, to have a clear discussion in advance with the employer so they understand your philosophy of return to work policy, and become familiar with the practice’s policies.

    Educate the employer on why “time weighted” instructions are used and their practical application.

    Communicate the common goal of returning the injured worker to the workplace under any reasonable circumstances.

  • Driving To and From Work Is the Responsibility of the Employee

    12 December 2012 / California Workers Compensation, How To / Comments Off on Driving To and From Work Is the Responsibility of the Employee

    What about driving to and from work? This is a very, very commonly asked question.

    Primarily in the setting of spine strain conditions where the employee claims they are incapable of sitting in a car for the necessary period of time to get to and from work. In situations like this, I simply clarify for the employee that if the employer does not require the driving as part of the actual work day activity, work limitations outlined by the clinic do not apply to how they choose to get to and from work.

    This is the responsibility of the employee, not the employer. Just as the employer cannot choose where the employee lives, the work limitations only apply once the worker is at the job.

    I advise these workers to consider taking the bus where they can sit and stand in transit, simply plan to take longer driving to work and take driving breaks, or perhaps ride share etc. I do not excuse workers from work because of “rush hour traffic” nor do I excuse them from a certain work time or shift because the “traffic is less”.

    Again, I reference it is their responsibility to coordinate their transport to and from work. Often this works well, and if done with proper tact and detailed with reason, it need only to be discussed once.

  • The Process of Chart Review

    28 November 2012 / Chart Reviews, How To / Comments Off on The Process of Chart Review

    Very little is formally written about the process of chart review. The style varies greatly between medical providers, and we had a very hard time finding anything describing this important event in the medical legal report.

    Chart review for the most part is regarded with dread and dislike. We want the chart because it is important to see what has or has not been documented in the case. We want to know the work up, the interpretation of the work up, and an inside look at the case. On the other hand, we fear the chart. How much will there be? Who actually has the chart?

    When performing the actual medical legal visit, often only a part or a small part of the chart is available.

    The Fed Ex pouch that mocks us silently in the mail room. Menacing really.

    I think we all have this experience in common. The first encounter is always visual. How big is that box? Is it a bluff and only one half full? And what kind of creative packaging are we dealing with today?

    I truly believe that the packaging of the medical record chart gives special insight into the personality of the sender. Examples? I have received medical records in recycled grocery bags with duct tapes, Nike shoe boxes, once in a cereal box, and my favorite…a Jack Daniels carton. Fascinating! Unfortunately I am not creative enough to make this stuff up.

    Grasping the chart has a certain sense of intimacy. It is like grappling with the opponent up close. Even like a hand shake. It is here that consideration of the medical records becomes more personal. The weight. The weight quickly gives a sense of the gravity of the situation. "Hey, this is a lot heavier than it looks!" or "How could they possible pack this much mass into such a small space?"

    Personally, I am one of those that have to know right away. I am actually a bit unsettled until I look inside quickly. I would be unable to focus, or sleep, or eat with satisfaction unless I can see what the contents of the box contain. I always am therefore always compelled to open the box immediate. After all, this may represent four to seven hours of my life flashing in front of my eyes.

  • Clarifying Return to Work Instructions for the Injured Worker

    13 November 2012 / California Workers Compensation, How To / Comments Off on Clarifying Return to Work Instructions for the Injured Worker

    As doctors, we have all gotten the phone call from the either the employee or the employer asking for clarification on what the employee can and cannot do.

    Often the indications for the recommended work functions are unclear, poorly described, or simply left up to the employee and the employer to figure out how to best "get along".

    The problem with this any of these options is that they leave the interpretation and necessity for work functional limitations up to interpretation.

    Employees and employers frequently look to us to guide the rehabilitation process, and clearly outlining the employees duty is central to that service.

    The employer wants a safe return to work environment, and needs specifics to determine if return to work accommodations can indeed be made. The employee is concerned about worsening of symptoms or anticipated worsening of symptoms.

    A review of "Definitions for Work Load Classifications in a Return to Work Note," may aid the medical provider in clarifying the intent and medical necessity of outlining return to work instructions for the injured worker.

  • Definitions for Work Load Classifications in a Return to Work Note

    31 October 2012 / California Workers Compensation, How To / Comments Off on Definitions for Work Load Classifications in a Return to Work Note

    The definitions below are classifications of work load that are used administratively to communicate the terms of “sedentary”, “light”, “medium” and “heavy” and “very heavy” work.

    These terms in and by themselves are not to be used to as standalone work functional instructions, but rather to provide a common reference when reading the literature, or communicating what is accepted as industry standards of the terminology.

    Sedentary Work:

    Occasional (0%-33% of the Work Day) 10 lbs. Exerting up to 10 lb. of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

     

    Light Work:

    Occasional (0%-33% of the Work Day) 20 lbs. Frequent (34%-66% of the Work Day) 10 lbs and/or walk/stand, push/pull, or arm/leg controls. Constant (67%-100% of the Work Day) Push/pull or arm/leg controls while seated. Exerting up to 20 lbs of force occasionally, and/or up to 10 lbs of force frequently, and/or a negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for sedentary work.

    Even though the weight lifted may be only negligible, a job should be rated light work: (1) when it requires walking or standing to a significant degree, or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible.

    NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, is physically exhausting.

     

    Medium Work:

    Occasional (0%-33% of the Work Day) 50 lbs. Frequent (34%-66% of the Work Day) 20 lbs. Constant (67%-100% of the Work Day) 10 lbs. Exerting 20-50# of force occasionally, and/or 10 to 25 lbs of force frequently, and/or greater than negligible up to 10 lbs of force constantly to move objects. Physical demand requirements are in excess of those for light work.

     

    Heavy Work:

    Occasional (0%-33% of the Work Day) 100 lbs. Frequent (34%-66% of the Work Day) 50 lbs. Constant (67%-100% of the Work Day) 20 lbs. Exerting 50 to 100 lbs of force occasionally, and/or 25 to 50 lb of force frequently, and/or 10 to 20 lb of force constantly to move objects. Physical demand requirements are in excess of those for medium work.

     

    Very Heavy Work:

    Occasional (0%-33% of the Work Day) over 100 lbs. Frequent (34%-66% of the Work Day) over 50 lbs. Constant (67%-100% of the Work Day) over 20 lbs. Exerting in excess of 100 lbs of force occasionally, and/or in excess of 50 lb of force frequently, and/or in excess of 20 lb of force constantly to move objects. Physical demand requirements are in excess of those for heavy work.

  • Recommendations for Chart Reviews

    19 October 2012 / Chart Reviews, How To / Comments Off on Recommendations for Chart Reviews

    • Purchase Writing and Defending Your IME Report, The Comprehensive Guide by Steven Babitsky, Esq, James J. Mangraviti, Jr., Esq, and J. Mark Melhorn, MD. SEAK, Inc.
    • Become an Adobe “Jedi Knight Master” if you work with electronic medical records.
    • Look for themes and trends in specific notes. Are they consistent?
    • What is missing in the chart if you were managing the case?
    • What is or is not present to confirm the working diagnosis of the report?
    • Be judicious with what you present in your chart review. Be easy on the reader’s eyes, and obvious with what is valuable.

    Fear no chart!

  • A Witnessed Injury and Taking the Medical Impairment History

    15 October 2012 / How To, Medical History / Comments Off on A Witnessed Injury and Taking the Medical Impairment History

    Was this a witnessed injury?

    • Who was at the injury?
    • What was their name and job title?
    • What was the interaction with this person?
    • Did this person help them initially at the injury?
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