|
The Guides Newsletter – Important Clinical Concepts
from Past Issues
How to Measure Lower Extremity
Atrophyby Craig M. Uejo MD, MPH
This is the eighth in a series of articles
written to assist evaluators in their use and interpretation
of The AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition (Cocchiarella L, Anderson G, AMA
Guides to the Evaluation of Permanent Impairment, Fifth
Edition, AMA Press, 2001). It will be used to help summarize
key points of clarification documented in past issues of The
Guides Newsletter. References to specific issues will
be provided to allow anyone the opportunity to review the
entire issue/ article for assistance in understanding and
accuracy of reporting.
This particular article will discuss the
issues of rating muscle atrophy in the lower extremities. This
issue was discussed in the Sept/Oct 2002 edition of The
Guides /i>Newsletter.
Unilateral Leg Muscle
AtrophyUnilateral leg atrophy (Thigh and Calf) is
a ratable condition if it meets the criteria established in
section 17.2d, Muscle Atrophy (Unilateral) on pages 530-531 of
the AMA Guides, 5th ed. The criteria are clear and
precise regarding the specific measurements needed to rate
impairment. The Guides recommend no impairment for
conditions involving less than 1.0 cm of atrophy or difference
in circumferential measurements between an injured and an
uninjured leg. Table 17-6 outlines the impairment ratings that
coincide with the respective atrophy measurements.
The errors or problems seen regarding the
rating of leg atrophy involve the specific area or location an
evaluator should use to measure the leg circumferences. As
noted in the Guides Newsletter authored by Dr. Charles Brooks
and Dr. James Talmage, Chapter 17 section 17.d Muscle Atrophy
was written in a way that has caused errors due to “semantic
imprecision.” Namely, inconsistent statements that outline the
locations in which the measurements of the Thigh and Leg
(Calf) are to be measured have lead to imprecise and varied
locations of measurements by evaluators.
The Guides describe in one location
performing the measurements “at equal distances from either
the joint line or another palpable anatomic structure.” (page
530, 5th ed.) Table 17-6 on page 530 (5th ed.) recommends
measurements made 10 cm above the patella. The Guides also
describe later that the Calf should be measured at the maximum
circumference.
Which location is best for measurements of
the atrophy in the leg?As discussed by Drs. Brooks and
Talmage in their Guides Newsletter article, the best
location to measure thigh and calf circumference has posed an
area of inconsistency amongst evaluators. Certain evaluators
may choose to measure from the superior pole of the patella
(most common), while others may measure from the middle
portion of the patella. Patellar location differences between
legs can cause such measurements to be inaccurate.
For consistency Dr. Brooks and Talmage
recommended the following in their article:
- Table 17-6, Impairment Due to Unilateral Leg Muscle
Atrophy (5th ed, 530), states, “The [thigh] circumference is
measured 10 cm above the patella with the knee fully
extended and the muscles relaxed.” Presumably this means the
base (superior end) of the patella, but given the lack of
specificity an examiner might measure from its midpoint,
apex (inferior end), or some other portion. Regardless,
unilateral patella alta or baja would result in measurement
at different thigh heights were the latter instruction
followed. Because 15 cm superior to medial joint line
approximately equals 10 cm above the base of patella and the
joint line height is less variable, evaluating physicians
should follow the initial text instructions rather than
those in the table when measuring thigh circumferences.
- Since the maximum leg circumference may lie at different
heights on left and right sides and due to the inherently
greater subjectivity in selecting the maximum circumference
as opposed to a bony landmark such as medial joint line,
examiners may also wish to follow the initial instructions
when measuring leg circumferences. The 15 cm inferior to
medial joint line of the knee usually lies at or about
maximum leg circumference in adults.
- What to do? The answer is to replace all the sometimes
vague and inconsistent measurement instructions with a
simple unambiguous one: Thigh and leg circumferences are
measured 15 cm superior and inferior to medial joint line of
the knee, respectively.
In summary: Thigh and Leg (calf)
atrophy requires precision in the location of its measurements
to insure accuracy of impairment rating. The most ideal
location is to measure Thigh and Leg atrophy 15cm superior
(thigh) and inferior (calf) to the medial joint line of the
knee. Both legs should be measured in the same locations and
compared. Table 17-6 on page 530 of the Guides(5th ed.)
should be used for the specific calculation.
Look for additional articles in this series,
The Guides Newsletter – Important Clinical Concepts
from Past Issues, coming in upcoming issues of this Brigham
and Associates Ezine.
|
|
|
Happy New Year!
We have many new tools and resources for you in the month's
eZine. Please let us know if you have questions or comments.
We wish you a healthy & prosperous new year!
|
|
|
|
|
New! Weekly Wednesday Tips & Impairment Conversion
Tools! |
|
You may have noticed our newest complimentary training
tidbits with Dr. Smart on Wednesdays - our new series of
"Weekly Tips". Each Wednesday you will be receiving an email
with highlighting a particular tip on using the Guides.
We have already received many thankful emails regarding
this service. We are pleased you find it so helpful and
stimulating! If you did not receive them, or if you ever want
to go back to review these Weekly Tips, go to www.impairment.com/tips.
- Rating Sleep Disturbance
- Rating Spinal Degenerative Disk Disease
- Rating Patellofemoral Arthritis
We also enjoy
receiving your suggestions on which chapters or topics you'd
like a Weekly Tip on. We'd love to hear your feedback on Dr.
Smart as well!
We also have new conversion tools! These tools were
designed to assist you in the performance and review
impairment ratings. Feel free to bookmark this page and share
this free resource with others. http://www.impairment.com/tools
|
|
Click Here For Conversion Tools! |
|
|
Physical
Examination Essentials DVD - Sale Price until
1/31/07 |
|
Due to such an enormous response to the release of this
superb DVD, we have decided to extend the special price of
$147 until January 31, 2007. Don't miss this $50 savings!
Do you know how to perform the examinations exactly as
specified in the AMA Guides? Most physicians do not.
These skills are absolutely essential. As a physician - are
you certain that you are performing the evaluation as
required? As an attorney or claims manager - do you know what
is required for a correct examination and how to challenge an
incorrect one?
In this new DVD learn from the experts
how to perform a required impairment evaluation physical exam.
All physicians and reviewers of reports must be knowledgeable
of this content which is superbly demonstrated by experienced
clinicians, step-by- step. Principles are explained and the
required examinations are demonstrated.
As a result of viewing this program you will be able to
perform:
- spinal inclinometry
- extremity evaluation
- assessment of each joint and special required testing
- accurate neurological evaluation - including two-point
discrimination, monofilament testing & strength
evaluation) & Much More!
This is a necessity for anyone involved in performing
physical exams or reviewing impairment reports. Call or Click
below and use Coupon Code 288010 to Save $50 off this
exceptional DVD!
Don't miss this special price -
only available until January 31, 2007. Do not wait.
|
|
Purchase now for $147 - $50 Savings with Coupon
Code 288010 |
|
|
GuidesIQ -
One Month Trial for just $1! |
|
This on demand AMA Guides training contains over 60 modules
of training on the Guides! View a complimentary video of how
to assess impairment of Carpal Tunnel Syndrome at
www.guidesiq.com
- Easy to Use Video Demonstrations
- Available 24 Hours a Day
- Necessity for all Physicians, Claims Professionals &
Attorneys reviewing or performing impairment reports
- Daily, weekly, monthly & yearly subscriptions
- Monthly conference calls for all subscribers with Dr.
Brigham
- Subscribe now and have unlimited access to Guides
training whenever you need it!
- Subscribe NOW & Save!
The following is an
unsolicited testimonial from one of our subscribers, Max
Moses, MD, an orthopedic surgeon from California.
“I
have attended many seminars, in the past two years, on the
Guides 5th edition. I must say that the Guides IQ is the most
complete and most enjoyable. It has been said that if you want
to go to sleep, open and read the 5th edition. If you want to
learn in an easy and relaxing manner, listen to Guides IQ. It
is made for beginner and veteran alike. It is the best program
I have ever used.”
If you have questions on GuidesIQ,
please contact webmaster@guidesiq.com or call
866.848.9205.
GuidesIQ is the equivalent of 3 to 4 days of seminars. You
can access the resources whenever necessary – to build
knowledge and to manage a specific case. The resource is
available on a membership model: members pay a modest annual
subscription – a fraction of the true cost associated with
attending a meeting.
What does it contain?
- Video presentations on the AMA Guides – 5th and 4th
editions – demonstration of proper examination techniques
- Online self-assessment
- Digital publications
- Members only forum and monthly teleconference calls, and
much more!
Register Now!
- Price: $897.00 for an annual subscription - however you
get a One Month Trial for just $1
- Register: www.guidesiq.com
- Your satisfaction is fully guaranteed!
- Multiple-User Discounts Available
|
|
Register for GuidesIQ today - you need this
resource |
|
|
Free Webinar
- February 15 |
|
Did you miss one of our recent webinars? Or did you enjoy
the last one you attended? If the answer is yes to either one
of these questions you will not want to miss our next webinar
“Impairment Ratings from a Claims Perspective” on
February 15th from 12pm - 1 pm PST. Leslie Dilbeck, WCCP,
CIR will be presenting practical application of the Guides
from a claims perspective. She will cover common pitfalls in
the musculoskeletal chapters, novel approaches in calculating
erroneous impairment ratings, how to evaluate the impairment
rating and what strategies to consider for handling erroneous
ratings. This event will provide you the opportunity to ask
questions on the Guides and have them answered in this forum.
Within the next week we will email you registration
information. Save the date!
Click here to listen to past Webinar sessions...
|
|
|
|
|
Chapter
Highlights of the AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition |
|
Chapter Five: The Respiratory System By Aimee Lazell, CIR,
WCCP
This article is the fifth in a series intended to point out
a few of the highlights from each chapter of the AMA Guides to
the Evaluation of Permanent Impairment, Fifth Edition
(Cocchiarella L, Andersson G, AMA Guides to the Evaluation of
Permanent Impairment, Fifth Edition, AMA Press, 2001).
This article will discuss important points of reference for
Chapter Five of the AMA Guides, which addresses the
respiratory system. The conditions addressed in this chapter
include respiratory diseases like asthma, sleep apnea and lung
cancer.
Similar to the discussion in the cardiovascular discussion
this chapter requires specialized testing which should be
performed by an expert in respiratory disorders to ensure
proper testing is completed and interpreted.
Section 5.2 (5th ed., pgs. 89-90) discusses the symptoms
associated with respiratory disease. They include dyspnea,
cough, sputum production and hemoptysis, wheezing and thoracic
case abnormalities.
In order for an accurate rating to be performed for
patients with these conditions, the patient should undergo
examinations and testing performed by an expert in this
specific field. This should include the following:
- Physical examination - it is pertinent the evaluation
should include the patient’s respiratory rate, use of
accessory muscles, and body habitus.
- Chest Roentgenograms – this is to look for chest
abnormalities. Findings would not correlate with respiratory
diseases such as asthma or emphysema.
- Computed Tomography (CT) - A CT scan is good for
evaluation nodules with high radiographic attenuation. It is
more sensitive in evaluation of certain pulmonary diseases
such as asbestosis.
- Forced Expiratory Maneuvers - measurements include
forced vital capacity (FVC, forced expiratory volume the
first second (FVC1), and the ration of these measurements
(FEV1/FVC). The results of these tests are used in
correlation with Tables 5-2a through 5-5b
Asthma is discussed in section 5.5 (5th ed., 102- 104).
Table 5-9 Impairment Classification for Asthma Severity is
used to score the severity of a patient’s asthma. Table 5-10
Impairment Rating for Asthma is then used to determine the
total asthma score and determine the level of impairment. Each
class of impairment has a range of impairment values. The
examiner should use clinical judgment in evaluating how the
patient’s condition impacts his/her ADLs to determine where in
the range the patient’s impairment will fall.
Watch for the next article in the series, which will
highlight sections of Chapter 6 The Digestive System.
|
|
|
|
|
Kaiser
Permanente National Occupation Medicine
Conference |
|
This will be an excellent event and it is located in
Hawaii. Our president, Dr. Brigham, is one of the featured
speakers.
Sessions include: Emerging Topics in OEM
Disaster Preparedness and Response (Gary Greenberg & Lee
Jacobs) Common Reproductive Toxicology Risks Disability Issues
Related to the Working Woman Functional Restoration and
Delayed Recovery (Michael Sullivan & Tim Gilmore) AMA
Guides: Common Pitfalls and Pearls (Chris Brigham & Steven
Feinberg)
- April 9 – 13, 2007
- Hilton Waikoloa Village, Kohala Coast
- Big Island of Hawaii
|
|
Register & Learn More Here |
| |
