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Rating Impairments of the Spine

# Rating Impairments of the Spine

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## Rating Impairments of the Spine

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1. Rating Impairments of the Spine March 2006 Presenters: Craig Barry, Annalisa Faina, Barry Knight, Blair Megowan, Tess Snaer DWC Statewide Training March 2006

2. Overview • Principles of Combining • Methods of Rating Spinal Impairment • Sample Cases DWC Statewide Training March 2006

3. What is Combining? • Estimate of cumulative effect of multiple impairments or disabilities • Example: • Lumbar spine = 25% PD • Shoulder = 20% PD 25 C 20 = 40 Final PD DWC Statewide Training March 2006

4. Combining v. Adding • Most impairments are combined • Two notable exceptions use addition • Motion values of the same joint, e.g. the six motion values of the shoulder • Finger impairments Example: 20 Hd for the thumb + 10 Hd for the index finger 30 Hd for the hand DWC Statewide Training March 2006

5. Calculating a Combined Value • Formula • A + B(1-A) where A and B are expressed as percentages or decimals • Combined Values Chart • Use the table in the PDRS (AMA Guides contain five errors) DWC Statewide Training March 2006

6. General Combining Principles • For three or more values, combine from largest to smallest • Round the result to the nearest whole number (percentage) after each combination DWC Statewide Training March 2006

7. Sequencing Matters • Combine 48 PD, 20 PD and 27 PD DWC Statewide Training March 2006

8. Order of Combining • Combine by body part within extremities • Convert to whole person (WP) scale • Adjust for FEC, occupation and age • Combine by extremity • Combine all remaining values DWC Statewide Training March 2006

9. Combining Example • Cervical DRE = 5 WP • Lumbar DRE = 25 WP • L Shoulder ROM = 6 UE • L Shoulder instability = 10 UE • L Wrist ROM = 4 UE DWC Statewide Training March 2006

10. 1. Consolidate by Body Part Cervical DRE = 5 WP 5 WP Lumbar DRE = 25 WP 25 WP L Shoulder ROM = 6 UE 17 UE L Shoulder instability = 12 UE L Wrist ROM = 4 UE 4 UE DWC Statewide Training March 2006

11. 2. Convert to Whole Person Cervical DRE = 5 WP Lumbar DRE = 25 WP L Shoulder = 17 UE x .6 = 10 WP L Wrist = 4 UE x .6 = 2 WP DWC Statewide Training March 2006

12. 3. Adjust for FEC, etc. Cervical DRE: 15.01.01.00 – 5 – [5]6 – 320F – 6 – 6 PD Lumbar DRE: 15.03.01.00 – 25 – [5]32 – 320F – 32 – 32 PD L Shoulder: 16.02.02.00 – 10 – [7]14 – 320H – 18 – 18 PD L Wrist: 16.04.01.00 – 2 – [4]2 – 320I – 4 – 4 PD DWC Statewide Training March 2006

13. 4. Combine by Extremity Cervical DRE: 6 PD 6 PD Lumbar DRE: 32 PD 32 PD L Shoulder: 18 PD 21 PD L Wrist: 4 PD DWC Statewide Training March 2006

14. 5. Combine Remaining Values Cervical DRE: 6 PD Lumbar DRE: 32 PD L Extremity: 21 PD 32 PD C 21 PD = 46 PD 46 PD C 6 PD = 49 Final PD DWC Statewide Training March 2006

15. Spine • Consists of 5 regions: • Cervical • Thoracic • Lumbar • Sacral • Coccygeal DWC Statewide Training March 2006

16. Spine • Three Primary Regions • Cervical • Thoracic • Lumbar These are rated similarly. DWC Statewide Training March 2006

17. Spine • Two Methods for Rating the Spine • Diagnostic Related Estimate (DRE) • Range of Motion (ROM) DWC Statewide Training March 2006

18. When to Use DRE Method • Injury (as opposed to illness) • Single level within a spinal region, e.g. L4-5 • First injury or repeat injury to a different region • Corticospinal damage DWC Statewide Training March 2006

19. When to Use ROM Method • Impairment caused by illness, not specific injury • Multilevel involvement (fractures, herniations or stenosis) with radiculopathy in same region • Bilateral radiculopathy • Recurrent radiculopathy in same region See AMA Guides, pg. 380 for flowchart to determine which method to use DWC Statewide Training March 2006

20. Spine Example Roofer fell off ladder, herniated disk at L4-5, had laminectomy Which method? DWC Statewide Training March 2006

21. Spine Example Carpenter re-injured neck at C5-6 level with recurrent radiating pain in right arm Which method? DWC Statewide Training March 2006

22. Spine Example Farm laborer run over by tractor, fractured lumbar spine at L3, herniated disk at C3-4 Which method? DWC Statewide Training March 2006

23. Spine Example Roofer fell off roof, fusion at T3-T5 Which method? DWC Statewide Training March 2006

24. Terms Radiculopathy is the significant alteration of function of a nerve root. • pain, numbness or paresthesia in a dermatomal pattern. • confirmed by positive nerve tension sign and imaging study DWC Statewide Training March 2006

25. Terms Motion Segment Integrity is the normal degree of motion at two adjacent vertebrae. • loss of motion segment integrity can either be a decrease or increase of motion between two adjacent vertebrae • easiest to detect with flexion and extension x-rays DWC Statewide Training March 2006

26. DRE Method (Page 384) DRE Method - Lumbar Spine • DRE Category • Corticospinal damage, if applicable DWC Statewide Training March 2006

27. DRE Category I0 WP Impairment • Subjective findings only • No significant clinical findings • An example is a back strain with no radiculopathy DWC Statewide Training March 2006

28. DRE Category II5-8 WP Impairment • Significant muscle guarding or asymmetric ROM • Non-verifiable radicular pain • History of verifiable radiculopathy no longer present • Fracture < 25% compression one vertebrae DWC Statewide Training March 2006

29. Category III10-13 WP Impairment • Verifiable radiculopathy • Surgery (diskectomy) • Fracture 25-50% compression of one vertebrae /posterior element fracture with displacement and disruption of spinal canal DWC Statewide Training March 2006

30. Category IV20-23 WP Impairment • Loss of motion segment integrity • Increased – spondylolisthesis • Decreased – fusion (most common) • Fracture of > 50% compression of one vertebrae DWC Statewide Training March 2006

31. Category V25-28 WP Impairment • Loss of motion segment integrity with radiculopathy • Fracture > 50% compression with neurologic compromise DWC Statewide Training March 2006

32. Spine Problem #1 Roofer, 39 years old, fell off ladder, herniated disk at L3-4 with pain radiating into left leg. After diskectomy pain was no longer present. No difficulty with ADL. DRE Category: Standard: Formula: DWC Statewide Training March 2006

33. Spine Problem #2 Custodian, 24 years old, herniated disk at L4-5. Following fusion she still has pain radiating down thigh into foot. She has difficulty with standing, walking and sitting. DRE Category: Standard: Formula: DWC Statewide Training March 2006

34. Spine Problem #3 Farm laborer, 46 years old, strained low back. Still has pain in low back, but no radicular symptoms. DRE Category: Standard: Can there be an add-on for pain? DWC Statewide Training March 2006

35. DRE Method Corticospinal Damage (pgs. 396-97) • Arm impairment • Gait impairment • Bladder and bowel impairment • Sexual impairment • Respiratory impairment DWC Statewide Training March 2006

36. Spine Example Painter fell from scaffold resulting in 50% compression fracture of L2. L2 nerve root damaged with weakness in both legs. Walks with crutches and has intermittent incontinence of bladder. DWC Statewide Training March 2006

37. Spine Example • Fracture is DRE Category III - 13 WP (Page 384) • Crutches are class III gait impairment - 39 WP (Pg 396) • Intermittent incontinence is a class I bladder impairment - 9 WP (Page 397) DWC Statewide Training March 2006

38. Spine Example Formulas: 15.03.01.00 – 13 – [5]17 – 380H – 21 – 17 PD (A) 15.04.03.00 – 39 – [5]50 – 380I – 59 – 52 PD (A) 15.04.04.00 – 9 – [2]10 – 380H – 13 – 10 PD (A) • 52 C 17 C 10 = 64 Final PD DWC Statewide Training March 2006

39. ROM Method ROM Method – Lumbar Spine • Diagnosis (pg. 404) • ROM (pgs. 407 and 409) • Neurologic Deficit ( pg. 424) DWC Statewide Training March 2006

40. Spine Problem #4 Farm laborer, 25 years old, sustained a re-injury of his low back while lifting. He sustained herniated disk at L3-4 which was operated on, however he continues to have pain radiating into left leg. Testing revealed a class 4 (25%) sensory and motor deficit in the L3 nerve root. ROM of lumbar spine shows forward flexion of 45 degrees (sacral flexion 50 degrees), extension of 10 degrees, right and left lateral bending of 15 degrees each. DWC Statewide Training March 2006

41. Spine Problem #4 Diagnosis (pg. 404) What is the value of a surgically treated disk with residual? Look under disk or soft tissue lesion Category E DWC Statewide Training March 2006

42. Spine Problem #4 ROM (pg. 407 and 409) Forward flexion 45 = Extension 10 = Lt lateral bending 15 = Rt lateral bending 15 = Total ROM = DWC Statewide Training March 2006

43. Spine Problem #4 Combine the Diagnosis and ROM impairments DWC Statewide Training March 2006

44. Spine Problem #4 Nerve Root Deficit (pg. 424) Maximum sensory deficit L3 nerve 5% x 25% (class 4) = 1% 1% x .4 = 0 WP Maximum motor deficit L3 nerve 20% x 25% (class 4) = 5% 5% x .4 = 2 WP DWC Statewide Training March 2006

45. Spine Problem #4 Final formula looks like this: 15.03.02.02 – 20 – [5]25 – 491H – 30 – 25 PD (A) 15.03.02.06 – 2 – [5]3 - 491H – 5 – 4 PD (A) (A) 25 C 4 = ? DWC Statewide Training March 2006

46. Spine Problem #5 Truck driver, 56 years old, injured in a motor vehicle accident, sustained a 65% compression fracture at T-1. No previous injury. He is able to drive again and do usual ADL. Which method? DWC Statewide Training March 2006

47. Spine Problem #5 Truck driver, 56 years old, injured in a motor vehicle accident, sustained a 65% compression fracture at T-1. No previous injury. He is able to drive again and do usual ADL. Which method? DWC Statewide Training March 2006

48. Spine Method Each region of the spine is evaluated as a separate body part DWC Statewide Training March 2006

49. Spine Problem #6 Farm laborer, 28 years old, was run over by a tractor sustaining a fracture at L3 with a 25 percent compression of the vertebrae. He also sustained a herniated disk at C5-6, resulting in a fusion surgery. He still has radiculopathy into the right arm causing some difficulty with activities of daily living. DWC Statewide Training March 2006

50. Spine Problem #6 Cervical spine (pg. 392) What method? Which DRE Category? Whole Person Impairment? DWC Statewide Training March 2006