Impairment Physical Exam

  • Elementary, my dear Watson!

    25 July 2013 / California Workers Compensation, Chart Reviews, Cloud Based Computing, Impairment Physical Exam, Impairment Rating Specialists, Medical History, Medical Technology / Comments Off on Elementary, my dear Watson!

    There’s a new cloud-based computer service that takes in patient information and then spits out useful results in record time. And no, I’m actually not talking about RateFast. Did you catch the 2011 Jeopardy special where Watson (IBM’s language savvy super-computer) competed against two former Jeopardy champions? The AI system out-answered—or rather, out-asked—both of its human opponents, and won $1 million in prize cash.

    But Watson’s verbal talent is now taking on questions that are tougher than those Alex Trebek would ask: the computer system is diagnosing and generating treatment plans for cancer patients. An agreement between IBM, healthcare company Wellpoint, and Memorial Sloan-Kettering Cancer Center is going to make Watson’s thinking power available to hospitals and clinics around the nation.

    Here’s how it works: you’re a doctor, and you need to write a treatment plan for your patient, but you’re stretched for time, knowledge, resources—or maybe you just want a second opinion. So you log into Watson using an app on your tablet or computer, and you enter your patient’s medical situation. Within minutes—usually within seconds—Watson gives you a series of treatment plans based on the latest medical research, and each plan is ranked by its expected effectiveness and cost.

    Over the past few years, Watson has become an expert oncologist. According to an article at Wired Magazine, Watson needs only a few seconds to search through “600,000 pieces of medical evidence, more than two million pages from medical journals” and 1.5 million patient records. Wellpoint clams that Watson can correctly diagnose lung cancer 90% of the time, as opposed to the relatively paltry 50% correct-diagnosis rate of a human doctor.

    For now, Watson’s expertise is restricted to lung, prostate, and breast cancer, but the computer never stops learning. It’s difficult for doctors to stay abreast of the current medical research in their field, but Watson can “read” the results of new studies as they’re published, and instantly apply the information.

    The Memorial Sloan-Kettering Cancer Center in New York says that it would take 160 hours of reading a week for a doctor to stay current on all new medical knowledge as its published—and that doesn’t even account for applying that knowledge (or taking care of tedious clerical work like filling out PR-4 reports). Obviously, no human medical worker can do what it takes to know everything about their work. But Watson and computer systems like it are unencumbered by the human weakness of, you know, having a life.

    The goal is to have computers crunch numbers and negotiate the rules of today’s labyrinthine healthcare system, while medical professionals can leave work on time. Watson could be a major wave in medical technology’s recent move toward cloud-based apps that aim to streamline productivity around hospitals and clinics.

  • 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

  • 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.

  • Tendons and Impairment Ratings

    20 September 2012 / Impairment Physical Exam / Comments Off on Tendons and Impairment Ratings

    The tendon is a tough, fibrous tissue structure that connects muscle to bone. A tendon differs from a ligament, which connects bone to bone.

    Injury occurs when a tendon becomes stretched, partially torn, or completely disrupted. Disastrous results can occur when a tendon is completely torn in the knee, heel cord (Achilles tendon), distal bicep, and rotator cuff. Tendon injuries may be diagnosed through a palpable (visible) defect and/or MRI.

    Timely diagnosis is essential to prevent shortening of the muscle and optimize surgical outcome. Significant disability and impairment can result if diagnosis is delayed. Concern over a complete tendon rupture should prompt urgent consultation with an orthopedist.

     

    • Tendon injuries may range from minor strains to complete disruption.
    • Delay in diagnosis may result in significant disability and impairment, especially in the knee, heel, spinal cord, distal bicep, or rotator cuff.
    • Prompt referral for imaging and consultation with an orthopedist is necessary to determine extent of injury and to prevent further damage.

    Rating Comment: The AMA Guides to the Evaluation of Permanent Impairment Fifth Edition provides impairment rating for tendon injuries with regards to weakness and range of motion impairment. AMA Guides do not allow impairment rating for weakness in the presence of a painful condition.

    The AMA Guides 5th Edition instruct on page 531 section 17.2e, “Individuals whose performance is inhibited by pain or fear of pain are not good candidates for manual muscle testing, and other evaluation methods should be considered for them.”

  • Fit for Duty vs. Return to Work

    17 August 2012 / California Workers Compensation, Impairment Physical Exam / Comments Off on Fit for Duty vs. Return to Work

    Fit for duty is an exam when the employer has a suspicion that the employee may be exhibiting abnormal behavior such as under the influence of a substance, or injured (non industrially) in a way that may impair their ability to perform the job safely. Examples may include slurring speech, balance difficulty or limping. Are they "fit" for work?

    Return to work implies the employee has been absent from the workplace on a non-industrial basis and now need an evaluation to see if they can be safely re-integrated into the workplace. Examples include having missed work with an excused physician note due to an auto accident, an elective surgery, or an orthopedic fracture. Are they able to "Return to work"?

    It is critical that the employer has a very clear and consistent policy about how each exam is referred to the clinic, and it is always my recommendation that consultation is carried out with an attorney well-studied in the applicable labor codes and laws when considering a policy to exercise.

    These exams are in place to prevent further injury to employees and protect co-workers. The exams need to detailed, and multiple consents for exam and information must be obtained prior to the examination which explains the scope and extent of the information requested, and to whom it will be disclosed. 

  • Neurological Focused Exams

    10 May 2012 / Impairment Physical Exam / Comments Off on Neurological Focused Exams

    Neurological Focused Exams should include documentation of cranial nerves 2-12, and vision screening corrected with lenses or pin hole if appropriate.

    Comment on:

    • facial symmetry,
    • light and sharp touch,
    • cold and warm perception,
    • motor grade testing (0-5 Grade Testing, page 484, Table 16-11, Chapter 16 Upper Extremity, AMA Guides 5th Edition, AMA Press, 2004),
    • deep tendon reflexes, long tract findings (clonus and plantar reflexes),
    • in addition to coordination (finger to nose, heel to shin motions), and
    • testing for ataxia (tandem gait testing and Romberg testing).
  • The Neurological Sensory Exam

    01 May 2012 / Impairment Physical Exam / Comments Off on The Neurological Sensory Exam

    Light touch sensory documentation is adequate if there are no sensory complaints, however, if “numbness” or “tingling” is noted in the history, it is advised to objectively document sensory complaint levels by using the Seims-Weinstein monofilament sets.

     

    I begin with the lightest weight in my set which is 0.07gm. Be certain the employee understands what the testing is looking for and how a positive sensation is registered.

     

    I do this by showing the employee the set, letting them apply the monofilament themselves (which has been mis understood as a needle by many an employee) and confirming they can relay a positive pre-examination test before closing their eyes and having the testing performed, right vs. left sides.

     

    A Seims-Weinstein filament weight is exercised properly when the filament is applied perpendicular and the body of the filament is bent. Do not drag or tickle the filament across the skin area being tested. Also, on hands and feet where there may be callus, apply the filament testing on the flexor creases for best testing results.

  • What Is Included in the Impairment Physical Exam

    26 April 2012 / Impairment Physical Exam / Comments Off on What Is Included in the Impairment Physical Exam

    In general, each orthopedic body location is examined in the same sequence order to include the following:

     

    Inspection: scars, atrophy, right left asymmetry, deformity, joint contractures, asymmetric gross motion, joint misalignment and muscle fasciculation.

     

    Palpation: tenderness, spasm, crepitus, masses, guarding.

     

    Range of motion: Use the goiniometer for measurements. “Measurments of active motion take precedence in the Guides. The actual measured goiniometer readings or linear measurements are recorded”. (page 451, Chapter 16, The Upper Extremities, AMA Guides 5th Edition, AMA Press, 2004)Active motion is the motion the employee can do on his/her own.

     

    The most common convention is to list right over left side in reporting the measurements, and a minimum of two measurements must be obtained to verify accuracy and reproducibility for rating purposes. The AMA Guides state, "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." (page 20, Chapter 2, Practical Application of the Guides, AMA Guides 5th Edition, AMA Press, 2004).

     

    I list the measurement set as “Valid” or “Invalid” based on the 10% reproducibility requirement. This practice helps assists the reader in identifying ratable vs. unratable findings early on in the report.

  • Spine Examination in an Impairment Rating Exam

    24 April 2012 / Impairment Physical Exam / Comments Off on Spine Examination in an Impairment Rating Exam

    Doing the exam, I prefer to work from the top of the body down, the same format that is followed in the report dictation. This serves two purposes, it allows the examiner to again have a predictable format to minimize the chance of missed examination data, and, it helps the reader move logically through the findings.

     

    Spine Examination

    I use a bubble inclinometer for all measurements on the spine regardless of the DRE or Range of Motion Method being used. This is also helpful to insure accurate measurements, and validate asymmetric motion rating on Box 15-1 (page 382, Chapter 15, The Spine, AMA Guides 5th Edition, AMA Press, 2004). Become familiar with bony land marks to use the bubble inclinometer correctly. Use Chapter 15 Spine, AMA Guides 5th Edition, AMA Press, 2004 for full instructional details.

     

    Examine both right and left sides on all extremity exams, as this is critical for subtracting the employee’s normal (if any) impairment baseline findings from the injured side when arcs are separated and subtracted in the rating calculations. "If a contra-lateral "normal" joint has 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". (page 453, Chapter 16, The Upper Extremities, AMA Guides 5th Edition, AMA Press, 2004).

  • Measuring Atrophy in The Impairment Physical Exam

    10 April 2012 / Impairment Physical Exam / Comments Off on Measuring Atrophy in The Impairment Physical Exam

    “Atrophy is measured with a tape measure at identical levels on both limbs. For reasons of reproducibility, the difference in circumference should be 2 cm or greater in the thigh and 1 cm or greater in the arm, forearm or leg.” (page 382, Box 15-1, Chapter 15, The Spine, AMA Guides 5th Edition, AMA Press, 2004)

     

    For neck and upper extremity injuries measure right and left side circumferences for comparison. For the upper extremities measure mid bicep, mid forearm and wrists. If rating specifically elbows, also include the elbow measurements here.

     

    Likewise, for lower extremity cases, measure mid thigh, calf and ankle. The thigh is measured 10 cm above the patella, and the calf is measured at the maximum level bilaterally (page 530, Chapter 17, The Lower Extremities, AMA Guides 5th Edition, AMA Press, 2004).If rating the knee, also include the knee measurements.

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