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AMA Guides Resources
Training on the Guides is Key May 16, 2007

In this issue

How to Test Muscle Strength for Carpal Tunnel Syndrome Impairment

Summer AMA Guides Seminar Series

Ask An Expert at 1-888-GUIDES-5

AMA Guides: State of the States

Tip of the Day: Extension Lag vs. Passive Flexion Contracture


 

How to Test Muscle Strength for Carpal Tunnel Syndrome Impairment
carpal tunnel

The Guides Newsletter - Important Clinical Concepts from Past Issues
by Kenneth Subin, MD, MPH, CIME

This is the tenth 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 article will focus on the proper method to assess muscle strength in the hand when rating impairment in individuals with Carpal Tunnel Syndrome or median nerve entrapment neuropathy at the wrist. This issue was discussed in the January/February 2006 edition of The Guides Newsletter - Clinical Assessment subheading. The article was authored by James B. Talmage, MD, Christopher R. Brigham, MD, and Charles N. Brooks, MD. Muscle strength testing is discussed in the Guides 5th Ed. in Chapter 16, section 16.5b Impairment Evaluation Methods, Grading Motor Deficits and Loss of Power (page 483 - 486). The Guides state:

  • Clinical examination of the upper extremity demands precise anatomic knowledge to properly select the muscle tests that correlate to the specific nerve structure(s) involved.

Table 16-12b describes the motor innervation to the thenar muscles from the median nerve. The Guides Newsletter article provides insight on the appropriate method to isolate the opponens pollicis muscle for strength testing in carpal tunnel syndrome.

  • Strength testing should include the opponens pollicis. This muscle is assessed by having the examinee adduct the thumb metacarpal and oppose the volar pulp of the distal phalanges of thumb and little finger. The evaluator then applies force in an attempt to return the thumb to its anatomic position. Many examiners assess thumb abduction strength, thinking they are testing the abductor pollicis brevis muscle. However, thumb abduction is produced by two muscles-the relatively small and weak abductor pollicis brevis, innervated by the median nerve distal to the carpal tunnel and thus affected by severe CTS, and the larger and stronger abductor pollicis longus, innervated by radial nerve and unaffected by CTS. Therefore, neurologic weakness can be missed by examining only thumb abduction strength. Another common error is to misattribute to CTS thenar (opposition) weakness caused by painful thumb carpometacarpal joint osteoarthritis or, less commonly, a C8 or T1 radiculopathy.

In summary:

An accurate assessment of muscle strength when rating for carpal tunnel syndrome requires isolation of the opponens pollicis muscle since this reflects the function of the medical nerve at the level of the wrist. Abduction of the thumb is provided by both the abductor pollicis brevis and abductor pollicis longus. Since the longus is not innervated by the median nerve, abduction strength testing will not precisely measure median nerve function.

  • 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.



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In this ezine you will find details to our upcoming seminars and useful information pertinent to our industry and the use of the AMA Guides.


  • Summer AMA Guides Seminar Series
    • san diego night time

    Our Summer Seminar series for Guides training will be held on August 17th and August 18th in our new training facility in San Diego. We do hope you will join us for this special event!

    Friday, August 17, 2007

    Practical Application of the AMA Guides, 5th Edition

    This course is back by popular demand. Attendees will be reviewing medical reports to determine accuracy of impairment. A step-by-step approach will be taught for assessing and calculating impairment based on report review. Specific strategies will be taught for reviewing medical reports and how to handle erroneous impairment ratings.

    This seminar is oriented to claims managers, adjusters, case managers, defense attorneys, applicant attorneys, raters, judges and physicians who have had prior training on the Guides, 5th Edition.

    Saturday, August 18, 2007

    Clinical Assessment of Impairment

    We have had many requests for this course which will focus on specific exam techniques as outlined in the Guides, 5th Edition. This will be a hands-on approach to learning with live demonstrations of physical examination.

    The data acquired during the assessment will then be reviewed and applied to the criterion in the Guides. Attendees will work through several musculoskeletal cases using this didactic model.

    This one day course is oriented to physicians (orthopedic surgery, neurosurgery, neurology, occupational medicine, physical medicine and rehabilitation, and pain medicine, chiropractors and other health professionals who have had prior training on the AMA Guides, 5th Edition).

    Location: Rio Vista Building (Conference Facility) 8885 Rio San Diego Drive, San Diego, CA 92108

    Fees: (Educational Investment)

    • Practical Application of the AMA Guides, 5th Edition
      Friday
      (includes continental breakfast and lunch)

      In Advance: $397.00,
      At Door      : $425.00

    • Clinical Assessment of Impairment
      Saturday
      (includes continental breakfast and lunch)

      In Advance: $397.00,
      At Door      : $425.00

    • Both Seminars
      Friday & Saturday

      In Advance: $747.00,
      At Door      : $797.00

    • CME/WCCP credits: 7 hours/seminar.

    Registration fees include syllabus, breaks, and food- and, most importantly the best training on the Guides.

    Both seminars are participatory, focusing on case studies reflective of the most common and challenging situations encountered in California workers' compensation.

    They also include practical demonstrations of physical examination techniques (including inclinometry), insights to Apportionment, and ample opportunity to have your specific questions addressed.

    In advance, you will be able to present to us with questions that will be answered at these seminars.

  • Ask An Expert at 1-888-GUIDES-5
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    Have a "Quick Question" regarding impairment on a case? We are happy to assist! We are pleased to announce our new service "Ask An Expert". Our seasoned AMA Guides experts are ready to take your call. Perhaps you are an evaluator and you are stumped on an issue which impedes you from completing your evaluation. Or, you are an attorney or adjuster who needs a quick answer so you can move forward on your file. "Ask An Expert" is your unique solution. Gain from our experience reviewing thousands of impairment evaluations and being recognized leaders in this field.

    • Give us a call at 888-GUIDES-5 (888-484-3375)
    • The fee for this service is $65 per 15 minutes of consultation and payment may be made with credit card over the phone

    We look forward to answering your "Quick Questions" to get you back on track with your case quickly and efficiently.

  • AMA Guides: State of the States
    • map of US

    Universally we all encounter challenges in assessing impairment; the majority of impairment ratings are erroneous. In the workers' compensation arena, states vary in how they make use of the Guides. Join us in an exciting new series of state specific teleseminars, each one hour in duration.

    The goal is to provide you with a better understanding of the AMA Guides to the Evaluation of Permanent Impairment, the problems with associated erroneous impairment ratings, and how to manage the rating process.

    Dr. Brigham, a nationally recognized expert on the Guides and Editor of the Guides Newsletter, will summarize the findings based on review of thousands of ratings, identify critical errors, and provide suggestions for managing ratings. A panel of leading claims, legal and medical experts from each state will participate in lively discussion about use of the Guides and their insights.

    This event is appropriate for all professionals involved with impairment ratings, including claims professionals, attorneys, fact finders (judges, commissioners, and hearing officers), physicians, and other health care providers. Advance registration is required, attendance is limited, and this program is complimentary. As a result of applying the strategies discussed, attendees and ultimately the state will have more reliable ratings.

    The first of this series will be for the State of Vermont on May 23rd.

    • All seminars are held on Wednesdays at 2 pm Eastern (1 pm Central, noon Mountain, 11 am Pacific)
    • If you are interested in participating as an expert in your state, please contact:
      Leslie Dilbeck      .

  • Tip of the Day: Extension Lag vs. Passive Flexion Contracture
    • knee image

    The Difference between Active Extension Lag and Passive Flexion Contracture After Total Knee Replacement
    by Craig Uejo MD, MPH, QME, CIME, CIR Medical Director, Brigham and Associates Inc.

    When rating Impairment of the lower extremity after Total Knee Replacement, an examiner must know to examine and document both passive and active motion in the knee so as insure measurement of Extension Lag and Flexion Contracture, if present. These terms are not interchangeable.

    Extension Lag is defined as the maximum extension measurement when performing active motion testing. Flexion Contracture is the maximum extension measurement when performing passive motion testing.

    These values can be the same but can also be different. An example being if an examinee has -10 degrees of active extension lag but only -5 degrees of passive flexion contracture. Under Table 17-35 (5th Ed., p 549), these values would have separate deduction values since they are not identical in measurement.

    A circumstance discussed in The Guides Casebook on page 309 documents another situation when active extension lag and passive flexion contracture are identical in measurement. In this case, no points would be deducted for extension lag as the flexion contracture deduction would adequately consider the loss of full extension.

    For weekly tips click here or visit our website at www.impairment.com.

    619-299-7377