ama guides definitions and philosophy american …：ama指南定义和哲学美国…

1

AMAGuides6thEditionAADEP

Bloomington,ILApril28-29,2012

JamesB.TalmageMDAMAGuides,6thEditionLOWERLIMBIMPAIRMENTS222Questions?JamesB.TalmageMD,OccupationalHealthCenter,315N.WashingtonAve,Suite165Cookeville,TN38501Phone931-526-1604(Fax526-7378)olddrt@

olddrt@occhealth.md

33ICFModelofImpairmentPathologyImpairmentDISABILITYHANDICAPKeytotheAMAGuides6thEdition4AMAGuides,6thEditionCHAPTER16TheLowerExtremities5Chapter16:LowerExtremities16.1PrinciplesofAssessmentpg49416.2Diagnosis-BasedImpairmentpg49716.3AdjustmentGridandGradeModifiers –Non-KeyFactorspg51516.4PeripheralNerveImpairmentpg53116.5ComplexRegionalPainSyndromeImpairmentpg53816.6AmputationImpairmentpg54216.7Range-of-MotionImpairmentpg54316.8Summarypg55216.9Appendix16-ALowerLimbQuestionnairepg555UsedMOSToften6LowerExtremitySimilarinPhilosophyandMethodologytotheUpperExtremityandSpine.MostconditionswillberatedbyDiagnosisfromtheDiagnosisBasedGrids.Many“rules”copiedandpastedfromtheUpperExtremitychapter.7AssigningImpairmentp500“Rangeofmotionwill,insomecases,serveasanalternativeapproachtoratingimpairment.ItisNOTcombined

withthediagnosis-basedimpairment,andstandsalone

asanimpairmentrating.”ComparedtoUpperExtremity,ROMwillbeusedverylittle.8AssessingLowerLimbMusculoskeletalImpairment6thEditionemphasizestheimpactoftheimpairmentonADLsatMMI.ThemostaccurateDIAGNOSISisthefoundationoftheimpairmentDiagnosis-BasedImpairment(DBI). -p495 “Theauthorsofthischapterrecognizethattheprocessdescribedisstillfarfromperfect

withrespecttodefiningimpairment…however,theauthor’sintentionistosimplifytheratingprocess,toimproveinterraterreliability,andtoprovideasolidbasisforfutureeditionsoftheGuides.”–p494

9LowerExtremity:

Dividedinto3RegionsFootandAnkleMidshafttibiatotipsoftoes.KneeMidshaftfemurtomidshafttibiaHipFromarticularcartilageoftheacetabulumtomidshaftofthefemur.Note1:

PelvisratingsarefoundinChapter

17.4,p.592-97(SPINEChapter)Note2:

VascularDiseasesaffectingtheLowerExtremitiesfoundinChapter4.8Note3:LE%=0.4%WPI101153112Page499StepsinDeterminingImpairment.13LowerExtremity:DBI(p495)

STEP

ONE

(DIAGNOSIS)ChoosethemostaccurateRegional

DIAGNOSIS Impairmentclassisdeterminedbythediagnosisandspecificcriteria,consideredtheKEYFACTOR,andthenadjustedbyGRADEMODIFIERSornon-keyfactors.Listalldiagnosesforeachregion.IntheeventaspecificdiagnosisisnotintheDiagnosis-BasedGrid,usetheclosest

similar

conditionlistedasaguidetodeterminingtheDiagnosisportionoftheImpairment,andexplainyourrationale.“RIGHTTABLE,RIGHTROW”14THREEREGIONALGRIDS,listsallpossiblediagnoseswithineachLEregion(foot/ankle,knee,andhip).LEAlgorithmtoFinalDBI%-STEPONE(DIAGNOSIS)Table16-2;p501-8Table16-3;p509-11Table16-4;p512-1515StepOne:DiagnosticCriteria GridOneFOOT/ANKLEREGION

(Table16.2,p501-8)SoftTissue:

Typicallyassignedthelowest

impairmentsNailabnormalitiessecondarytotraumaCallus/recurrenthealedplantarulcerationunderposttraumaticbonyprominence;contusion/crushinjury;plantarfasciitis;plantarfibromatosis;symptomaticsofttissuemass(ganglion,etc);retrocalcanealbursitis.LEAlgorithmtoFinalDBI%16StepOne:DiagnosticCriteria

FOOT/ANKLEREGIONMuscle/Tendon:Strain;tendonitis;orherniatedorrupturedtendon,specificallyinvolvingposteriortibial,anteriortibial,Achilles,orperonealtendon(allothertendonsbelow)Strain;tendonitis;orherniatedorrupturedtendonAllothertendonsLEAlgorithmtoFinalDBI%17

StepOne:DiagnosticCriteria

FOOT/ANKLEREGIONLigament:(Ligament/Bone/Jointgivenhighestimpairment%)Jointinstability/ligamentouslaxity-traumaticAnkle(includingsyndesmosis)[referencetable16-8]Jointinstability/ligamentouslaxity-traumatic;metatarsal-phalangeal[MTP].LEAlgorithmtoFinalDBI%18StepOne:DiagnosticCriteria

FOOT/ANKLEREGIONFracture/Dislocation:Tibia(extra-articular);tibia(intra-articular–pilon/plafond);Ankle(malleolar,bimalleolar,trimalleolar);Talus;Calcaneus;Navicular/cuboid(transtarsal)/charcot;Metatarsal-tarsalfracture/dislocation;metatarsal(s);sesamoid;phalanx.LEAlgorithmtoFinalDBI%19StepOne:DiagnosticCriteria

FOOT/ANKLEREGIONDeformity:Midfoot-cavus;midfoot-”rockerbottom”Arthritis:Degenerativecondition:unrelatedandsymmetric;pan-talar(tibial-talar,talar-calcaneal,talar-navicular)Ankle;Subtalar;talonavicular;calcaneocuboid;firstmetatarsophalangealjoint;othermetatarsophalangealjoint;interphalangealjointsLEAlgorithmtoFinalDBI%20StepOne:DiagnosticCriteria FOOT/ANKLEREGIONAthrodesis(JointAnkylosis,fusion):Pan-talar;tibialtocalcanealfusion;ankle;subtalar;doubleortriplearthrodesis;toes;totalanklereplacementLEAlgorithmtoFinalDBI%FootandAnkle8PagesofDiagnoses2122StepOne:DiagnosticBasedCriteria

GridTwoKNEEREGION

(Table16-3,p509-11)SoftTissue:Bursitis,plica,h/ocontusion,orothersofttissuelesionMuscle/Tendon:Strain;tendonitis;orrupturedtendonMyositisossificans(hypertrophicossification)LEAlgorithmtoFinalDBI%23StepOne:DiagnosticCriteria

KNEEREGIONLigament/Bone/Joint:Meniscalinjury;cruciateorcollateralligamentinjury–surgerynotratingfactor;cruciateandcollateralligamentinjury–surgerynotratingfactor.PatellarLesion:PatellarsubluxationordislocationPatellectomyLEAlgorithmtoFinalDBI%24StepOne:DiagnosticCriteria

KNEEREGIONFracture:Femoralshaftfracture;supracondylarorintercondylarfracture;patellarfracture;tibialplateaufracture;proximaltibialshaftfractureArthritis:Primarykneejointarthritis;patellofemoralarthritisArthrodesis:Arthrodesis(jointankylosis,fusion)Osteotomy/KneeReplacement:s/ptibialosteotomy;totalkneereplacementLEAlgorithmtoFinalDBI%25Knee3Pages2627KneeFootandAnkleGrids:8pages (501-508)KneeGrids: Only3pages (509-511)HipGrids: 3½pages (512-515)28StepOne:DiagnosticCriteria

GridThreeHIPREGION

Table16-4,p512-515SoftTissue:Bursitis,h/ocontusion,orothersofttissuelesionMuscle/Tendon:Strain;tendonitis;orh/orupturedtendonMyositisossificans(hypertrophicossification)LEAlgorithmtoFinalDBI%29StepOne:DiagnosticCriteria

HIPREGIONLigament/Bone/Joint:Hipdislocation;avascularnecrosis;acetabularlabraltearFracture:Osteochondralfracture;osteochondritisdissecans;fracturesaboutthehipjoint(acetabulumandproximalfemur)Arthritis:Degenerativeconditions;hiparthritis(arthosis)LEAlgorithmtoFinalDBI%30StepOne:DiagnosticCriteriaHIPREGION Arthrodesis:Hipjointarthrodesis(ankylosis,fusion)Osteotomy/JointReplacement:s/pFemoralosteotomy;totalhipreplacementLEAlgorithmtoFinalDBI%31STEPTWO

(placethediagnosisinaCLASS)THREEREGIONALGRIDS,listallpossiblediagnoseswithineachLEregionFoot/ankleKneeHip32Table16-1DefinitionofImpairmentClasses(pg.495)ClassProblemLowerExtremity(LEI)WholePerson(WPI)0Noobjectivefindings0%0%1Mild1%-13%LEI1%-5%WPI2Moderate14%-25%LEI6%-10%WPI3Severe26%-49%LEI11%-19%WPI4VerySevere50%-100%LEI20%-40%WPILEAlgorithmtoFinalDBI%-STEPTWO

(CLASS)33Example:TotalHip3possibleclassesforTHR2setsofnumbersinClass42123252525Errata

34REPEATprocessforEACHseparateDIAGNOSISineachlimbinvolved.Inmostcasesonly

ONE

DIAGNOSISwillbeappropriate.(1pergrid)MAYratebothanankleandahipfracture.Ifapatienthas2significantdiagnoses(i.e.ankleinstabilityandposteriortibialtendonitis)usethe(one)

diagnosiswiththehighest

impairment

ratingfortheimpairmentcalculation.-p497LEAlgorithmtoFinalDBI%-STEPTWO

(CLASS)

CONTRADICTION

35REPEATprocessforEACHseparateDIAGNOSISineachlimbinvolved.Inmostcasesonly

ONE

DIAGNOSISwillbeappropriate.“Ifmorethan1diagnosiscanbeused,the1thatprovidesthemostCLINICALLYACCURATEimpairmentratingshouldbeused;thiswillgenerallybethemorespecificdiagnosis.Typically1diagnosiswillcharacterizetheimpairmentanditsimpactonADLs.”-p499LEAlgorithmtoFinalDBI%-STEPTWO

(CLASS)

CONTRADICTION

36ERRATA37Example16-9p526Subject:52yearoldmanHistory:Twistinginjurys/pACLreconstructionandmedialmeniscalrepair38Example16-9p52639Example16-9p526"Themethodologyrequirestheexaminertopickonediagnosisfortheregion.Theanteriorinstabilitydiagnosiswaschosen,andtheeffectofthemeniscaltearisreflectedintheadjustments."INCREASEtheClinicalStudiesGradeModifiertoreflecttheADDITIONALPATHOLOGYpresent40Example16-9p526ClinicalStudies:Currentweight-bearingXraysshowbioabsorbablefixationoftheACLingoodpositionwithanormal5mmjointspaceinall3compartments.41Example16-9"Diagnosis:"cruciateorcollateralligamentinjury"withmildinstabilityassignedtoclass1withadefaultvalueof10%LEI.FunctionalHistoryjudgedunreliableinthepresenceofonlymildinstabilityandnoatrophy,andthusnotusedinrating.Physicalexam

instability

not

usedasagrademodifiersincestabilitywasusedinclassassignment.Noatrophywouldbegrade0,but5°flexioncontracturewouldberatedat10%LEIbytable16-23,andtable16-25indicatesa10%LEIratingwouldbeamilddegreeofproblem,oragrade1modifierfromtable16-7.42Example16-9ClinicalStudies:Theanteriorcruciatereconstructioningoodpositionwithoutjointspacenarrowingoncurrentweightbearingx-raysbyitselfwouldbeagrade1,mildpathologyadjustment.Thepresenceofthemeniscaltearandsubsequentrepair(documentedintheoperationreport)wouldjustifymovingupagradetograde2

forthefinalclinicalstudiesadjustment.Thenetadjustmentis+1,soclass1,gradeD,or12%LEIisthefinalrating."43Example16-9p526Diagnosis:ACL“mildlaxity”Class1Diagnosis:MeniscalinjuryClass1FH=grade4,butnotutilized

[INVALID]PE=grade1FlexioncontractureCS=grade1

2[Moveupbecauseofmeniscaltear/repair]NetAdjustment=+1,andgradeDisusedforACL.Class1,GradeD=12%LEIExample16-9FinalratingforACLreconstructionANDmedialmeniscaltearwithrepairisfromCLASSOne,GradeD4445“Subjectivecomplaints

withoutobjectivephysicalfindingsorsignificantPEabnormalitiesaretypicallyassignedclass0

withnoratableimpairment.”-p497“Objectivefindingsarealwaysgiventhegreaterweightofevidenceoversubjectivecomplaints”–p495“Ifanexaminerisroutinelyusingmultiplediagnoseswithoutobjectivesupportingdata,thevalidityandreliabilityoftheevaluationmaybequestioned.”-p497LEAlgorithmtoFinalDBI%-STEPTWO

(CLASS)

PicktheCLASSSomeDiagnoseshavemorethanoneClass,andthewords(text)withinthetabledirectyoutothePROPERCLASS4647DBIisdefinedbyCLASS&GRADE.OncetheImpairment(severity)Class(IC)andtheGRADE(0-4)isdetermined,aGRADEMODIFIER(A,B,C,D,E)isinitiallyassignedtheDEFAULTVALUE=C.LEAlgorithmtoFinalDBI%-STEPTHREE

(GRADE)

48

STEPTHREE(GRADE)Thefinalimpairmentgrade,withintheclassiscalculatedusingGrademodifiers,ornon-keyfactors(Section16.3) -p497Non-keyGrademodifiersaredeterminedfrom:

FunctionalHistory(FH)PhysicalExamination(PE)ClinicalStudies(CS)NON-keyGrademodifiersareconsidered

onlyiftheyarereliableandassociated

withtheDIAGNOSIS.–p495NON-key“Grademodifiersallowmovementwithinaclass,butDONOTALLOWMOVEMENTINTOADIFFERENTCLASS.”-p497491-2=minus11-2=minus11-2=minus15050NetAdjustmentFormulaAdjustment-2-1012GradeABCDEModifierspermitmovingUporDownwithinaClasstoadifferentseverityGrade.ModifiersdoNOTpermitchangingtoadifferentClass.51FunctionalHistoryp496“Functional(History)assessmentisonlyconsidered

forthelimbimpairmentwiththehighestrating,sinceitisexpectedthatthiswillencompassthefunctionallimitationsrelatedtootherimpairmentsinthesamelimb.”Alsoonpage51652FunctionalHistory:Page516WatchingalimpIspartofthePhysicalExam,NOTpartoftheHistory.53FunctionalHistory(FH):-p496Grademodifier

0:nodemonstrableinterferencewithfunctionGrademodifier

1:interferencewiththevigorousorextremeuseofthelimbonly."Grademodifier

2:antalgiclimpthatlimitsambulationdistance;regularlyusesorthoticdevice(atleastankle-footorthosis)Grademodifier

3:antalgiclimp;routineuseof2canes,or2crutches,orknee-ankle-footorthosisGrademodifier

4:

non-ambulatoryLEAlgorithmtoFinalDBI%-STEPTHREE(GRADE)Non-KeyGradeModifiers54FunctionalHistoryp496“Afunctionalassessmenttool

MAYbeused…tofurtherevaluatethisparameter.Thephysicianisexpectedtoweighthepatient’ssubjectivecomplaintsandSCOREonthe…tool,relativetotheexpectedseverityforagivencondition.ThegradeMODIFIERthatreflectsthisanalysisMAYbeacceptedORNOT

asavariableintheimpairmentcalculation.”55FunctionalHistoryp516“IfthegradeforFunctionalHistorydiffersby2ormoregrades

fromthatdefinedbyphysicalexamination

or

clinicalstudies,theFunctionalHistorySHOULDbeassumedtobeunreliable.If…unreliableorinconsistentwiththeotherdocumentation,itisEXCLUDEDfromthegradingprocess.”Note:“or”,DoesnotsayfromthehigherofeitherthePEortheCS5656FunctionAdjustment:LowerLimbNOnumbersinthistabletodefinewhatascoremeans.Note:Watchingapatient’sgaitispartofthePhysicalExam,NOTpartoftheHistory.5757FunctionalHistory

page516AAOSLowerLimbInstrument“…maybeused…““…onlytoassist…”“…doesnotserveasabasisfordefiningfurtherimpairment…”“…assessthereliabilityofthefunctionalreportsrecognizingthepotentialinfluenceofbehavioralandpsychologicalfactors.”Ifthegradeforfunctionalhistory

differsby2ormoregradesfromthatdefinedbyphysicalexamination

or

clinicalstudiesthefunctionalhistoryshouldbeassumedtobeunreliable.”5858AAOS

Outcome

Instrument5959Questionsre-writtenforlegibility

AAOSLowerLimbOutcomeScoreDuringthepastweek,howstiffwasyourlowerlimb?Duringthepastweek,howswollenwasyourlowerlimb?Duringthepastweek,howpainfulwasyourlowerlimbduring:Walkingonflatsurfaces?Goingupordownstairs?Lyinginbedatnight?6060Questionsre-writtenforlegibility

AAOSLowerLimbOutcomeScoreWhichofthefollowingstatementsbestdescribesyourabilitytogetaroundmostofthetimeduringthepastweek?Howdifficultwasitforyoutoputonortakeoffyoursocks/shoesduringthepastweek?6161:///research/outcomes/Lower_LimbScoring.xlsCalculationofStandardized&NormativeScores:TheStandardizedandNormativeScoreswillonlybecalculatedforthefirst500records.Theyareonthethirdtabofthisworksheet.

MissingItems:Ifanitemcontainedwithinascaleisnotanswered,thatitemisnotcomputedintothemeanusedforthatscale.

StandardizedscoresandNormativeScoresshouldberoundedtothenearestwholenumber.

Standardizedscoresarecalculatedsothata"0"representsapooroutcome/worsehealthwhile"100"isthebestpossibleoutcome/besthealth.

Normativescoresarecalculatedsothatahigherscoresindicatebetterfunctioning.Allscoresarereferencedtothegeneral/healthypopulationNormativemeanscoreof50.FormoreinformationonNormativeScores,pleaseseethe"Outcomes-UnderstandingScoring,NormativeStudy,Reliability&Validity"webpage.Answersof'cannotdoactivityduetootherreason'forQuestions3through5:achoiceof"7"ontheseitemsisconsideredtobemissingandrecodedautomaticallyintheworksheet.

StandardizedMeanandNormativeScoresshouldonlybegeneratedifarespondentansweredatleast4items.Notethatthisruleincludesitemswhichareconsideredmissingduetorecodingof'cannotdoactivityduetootherreason'(asnotedabove).NOTE:Thereare2differentmethodsthatcouldbeusedtoscorethis.Standardizedscore:0-100NormalizedscoreMINUS16TOPLUS576262:///research/outcomes/Lower_LimbScoring.xlsThealgorithmforthelowerlimbcorescaleisasfollows:componentvalueResulta=(Q1-1)*5/4Valueranging0to5b=(Q2-1)*5/4Valueranging0to5c=(Q3-1)ifrated1-6;aratingof7(couldnotdoforotherreason)isconsideredmissingValueranging0to5d=(Q4-1)ifrated1-6;aratingof7(couldnotdoforotherreason)isconsideredmissingValueranging0to5e=(Q5-1)ifrated1-6;aratingof7(couldnotdoforotherreason)isconsideredmissingValueranging0to5f=(Q6-1)*5/6Valueranging0to5g=(Q7-1)Valueranging0to5OutputonStandardized&NormativeScoreWorksheetResultRawscore:(sumofallcomponentsathroughg)Valueranging0to35MeanofItems:(sumofallcomponentsathroughg)/(numberofnon-missingitems)Valueranging0to5StandardizedMean*:100-100x(meanofitems)/5Valueranging0to100NormativeScore:10*[(Standardizedmeanscore-Generalpopulationscore)/Generalpopulationstandarddeviation]+50.Valueranging-16to57

*Forall0-100scales,a"0"representsapooroutcomeanda"100"representsthebestpossibleoutcome.

Unhiderows2-3andallcolumnsonthe"Standardized&NormativeScores"Worksheetformoreinformationonrecodingprocedures.

6363NoMethodtoconvertscore(number)toWords(like“moderate”)Chapter16has19examples:NONEevenmentiontheAAOSLowerLimbInstrumentERRATAPROVIDESNOGUIDANCE64LEAlgorithmtoFinalDBI%-STEPTHREE(GRADE)PhysicalExamination(PE):Page496DocumentLEobjectivefindings:gait,limblengthdiscrepancy,deformity,MMT,atrophy,instability,ROMdeficitsandneurofindings(sensory/motor/DTRdeficits).Removebraces,orthotics,etc.,ifappropriateDocumentquantitativePOSITIVE,NEGATIVE,&nonphysiologicalfindingsbilaterally.UseoppositeextremityifuninvolvedTODEFINENORMAL.Usequantitativefindings-Avoidgeneraldescriptions.6566PhysicalExamination“Examinationfindingsthatdiffersignificantlyfrompreviouslyrecordedobservations

AFTERtheprobabledateofMMIshouldbereported,withcommentsnotingthediscrepancy;thesefindings

MAYBEEXCLUDED

fromtheimpairmentcalculation.”–p49667PhysicalExamination“IfphysicalexaminationfindingsaredeterminedtobeUNRELIABLE

or

INCONSISTENT,ortheyareforconditionsunrelatedtotheconditionbeingrated,theyareEXCLUDEDfromthegradingprocess.Thephysicianmustexplain,inthereport,therationaleforthechoiceofgrade.”-p51768PhysicalExam“Iftheneurologicexampointstoanunderlyingspinedisorder,thelowerextremity(impairment)would,inmostcases,beaccountedforinthespineimpairmentrating,assumingtherearenootherprimarylowerextremitydiagnosesrequiringaconcomitantrating.”-p49669PhysicalExam:RangeofMotion“RangeofmotionisgradedaccordingtotheprocessandthecriteriaspecifiedinSection16.7.”“Ifitiscleartotheevaluatorthatarestrictedrangeofmotionhasanorganicbasis,3measurementsshouldbeobtainedandtheGREATESTrangemeasuredshouldbeused…”–p51770PhysicalExam:RangeofMotion“Ifmultiplepreviousevaluationshavebeendocumented,andthereisinconsistencyinaratingclass[asinONECLASS]

betweenthefindingsof2observers,orinthefindingsonseparateoccasionsbythesameobserver,theresultsareconsideredINVALID.”-p51871PhysicalExam:RangeofMotion“Rangeofmotionrestrictionsinmultipledirections

DOINCREASEtheimpairment.”ADDimpairmentsforall6directionsofhipmovement.“Rangeofmotionimpairmentis NOTcombinedwiththe diagnosis-basedimpairment.”-p51872PhysicalExam:ATROPHY“Formuscleatrophy,thelimbcircumferenceshouldbemeasuredandcomparedtotheOPPOSITElimbatequaldistancesfromeitherthejointlineoranotherpalpableanatomicstructure.Forexample,thighcircumferencemaybemeasured10cmabovethepatellaandcompared(to)asimilarmeasureontheotherleg.”[thigh]-p51873PhysicalExam:ATROPHY“Calfcircumferenceiscomparedatthelevelofmaximalcircumstancebilaterally.Neitherlimbshouldhaveswellingorvaricositiesthatwouldinvalidatethemeasurements.”-p51874PhysicalExam:p518

LimbLengthDiscrepancyMeasurewithatapemeasureASIStomedialmalleolusbilaterally.Measure3timesandaverage“…toreducemeasurementerror.”“Skeletal…teleroentgenographyisrecommended.”757677ClinicalStudies(CS):p496“WhileimagingandotherstudiesmayassistphysiciansinmakingaDiagnosis,theyareNOTthesoledeterminantsofaDiagnosis.“Clinicaltestresultsthatdonotcorrelatewiththepatient’ssymptomsorsupportthediagnosisshouldnotbementioned.”[consideredinthefinalDBI=0%]LEAlgorithmtoFinalDBI%-STEPTHREE(GRADE)Non-KeyGradeModifiers78ClinicalStudies“Insomecases,theclasswillbedefinedbyphysicalexaminationfindingsor

clinicalstudiesresults.Whenthisisthecase,thosefindingsMAYNOTBEUSEDtodeterminethegradeinthecorrelatingadjustmentsgrid.”-p500“Ifphysical

findingshavebeenusedtodetermineclassplacement,theyshouldNOTbeconsideredagain,forexample,rangeofmotioninmanylowerextremitydiagnoses.”-p51779ClinicalStudies"Foradjustmentpurposesfindingsatmaximalmedicalimprovementareused."I.E.DONOTusex-rayondayoninjury,ratherusethefinalx-rayforrating.80ClinicalStudies:ImagingNodefinitionsfor“mild”,“moderate”,“severe”,&“verysevere”.NOdefinitionfor“CONFIRMPATHOLOGY”.P519-52081ClinicalStudiesp518ArthritisisgradedbycartilageintervalonSTANDING(Weightbearing)x-rays.Idealcamera-to-filmdistanceis90cm(36inches).Ankle:mortiseviewKnee:standingA-PviewFlexioncontractureprecludesevaluationPatellofemoraljoint:“sunrise”viewHip:standingA-Pview82P519-52083BILATERAL?NoGuidancePerhaps5thEdT17-31,p54484ERRATA85NOTE:5THEd.Ifalternatemethodneeded.Grade1Grade2Grade3Grade486ClinicalStudiespage520NODefinitionsinEITHERbookorErrataConsult

EMGTextorMDdoingtheEMG87Class4EXCEPTIONP521-522“Ifthekeyfactorisclass4,andbothnon-keyfactorsweregrademodifier4,thedifferencewouldsummatetozero,andplacementinagradeabovethedefaultvalueCinclass4wouldnotbepossible.Inordertocorrectthisdeficiency,ifthekeyfactorisclass4,automaticallyadd+1tothevalueofeachnon-keyfactor.”88Class4EXCEPTIONP521-522“Forexample,ifthekeyfactorisclass4,andthefirstnon-keyfactorwasgrade3,thesecondwasgrade4,thedifferencesare-1andzero,or-1.

Adding+1toeachoftheseyieldszeroand+1;thissummatesto+1.

Consequently,thefinalclass(is)4andthefinalimpairmentisclass4gradeD.”8916.4PeripheralNerveImpairmentPeripheralnerveimpairmentmaybecombinedwithDBI’s,iftheDBIdoesNOT

alreadyincludethenerveimpairment.–p531Impairmentduetochronicpain

isdiscussedinChapter3,Pain.-p531MotivationandbehavioralconcernsareconsideredinChapter14,MentalandBehavioralDisorders.-p531ThissectionisNOTusedfornerveentrapments,sincenerveentrapmentsarenotisolatedtraumaticevents.”-p533HOWEVER,ThereisNOsectionforNerveEntrapmentintheLowerLimbChapter90PeripheralNerveImpairment“Characteristicdeformitiesandmanifestationsresultingfromperipheralnervelesions,suchasrestrictedmotion,atrophy,andvasomotor,trophic,andreflexchanges,have[already]beentakenintoconsiderationintheimpairmentvaluesshowninthissection.”–p531“Therefore,whenimpairmentresultsstrictlyfromaperipheralnerveinjury,nootherratingmethodisappliedtothissectiontoavoidduplicationorunwarrantedincreaseintheimpairment.”–p53191P53792P53793Page532:SensoryExam"Theexaminer'sfingertip,oracottontippedapplicatorcanbeusedtoassesslighttouch.Sharpdullrecognitionandprotectivesensationcanbeassessedusingadisposablepin.Thesensoryexamresultsshouldconformtothecutaneousdistributionofaperipheralnerve,orabranchofaperipheralnerve.”94"Thesensoryexamshouldbeclassifiedintooneoffivecategories.Severitygrade0isNormalsensibilityandsensation.Severitygrade1issubjectivelyalteredsensoryperceptionbutretainedlighttouchandsharpdullrecognition.Inthisgradetheexamineecorrectlyreportseachtimehe/sheistouched,butstimuliareperceivedassubjectivelyabnormal(paresthesia-like),butinonlythedistributionofaparticularcutaneousnerve.Severitygrade2isimpairedlighttouch,butretainedsharpdullrecognition.Thismeansseveralofthelighttouchstimuliarenotfeltbytheexaminee,butsharpanddullstimuliareconsistentlyrecognizedcorrectly.Severitygrade3isimpairedsharpdullrecognition,butretainedprotectivesensibility.Inthisgradelighttouchrecogn