Developing and Authoring an IME Report

Abstract

The most important part of the IME process is the creation of a credible and defensible report. The written report reflects the expertise and comprehensiveness of the process. In addition, it markets the IME physician’s performance. The key components of a quality IME report include an introduction, results of the clinical evaluation, clinical impressions, assessment of current health status, medical management plan, synthesis of information, recommendations, and conclusions.

Physicians as authors should pay particular attention to formatting and stylistic issues. Writing for the reader’s convenience and in a manner that is relaxed but at the same time will move the reader forward should be the goal.

Appendices

Appendix 1: Three Sample Disclaimers

These are three sample disclaimers which I find useful for incorporation in the medical report

• The opinions rendered in this case are the opinions of this evaluator. This evaluation has been conducted on the basis of the medical examination and documentation as provided, with the assumption that the material is true and correct. If more information becomes available at a later date, an additional service/report/reconsideration may be requested. Such information may or may not change the opinions rendered in this evaluation. This opinion is based on a clinical assessment, examination, and documentation. This opinion does not constitute per se a recommendation for specific claims or administrative functions to be made or enforced.

• This Independent Medical Evaluation is based upon the subjective complaints, history given by the patient, the objective medical records and tests provided to me, and the physical findings of the patient. Impairment ratings are given according to the Guides to the Evaluation of Permanent Impairment, Fourth Edition, American Medical Association. Recommendations regarding work and impairment ratings are given totally independently of the requesting agents. The opinions are based upon reasonable medical probability. Medicine is both an art and a science and although a patient may appear to be fit for return to duty there is no guarantee that the patient will not be reinjured or suffer additional injury once he returns. If further information is required please contact the undersigned.

• The opinions rendered in this case are the opinions of the reviewer. The review has been conducted without a medical examination of the individual reviewed. The review is based on documents provided with the assumption that the material is true and correct. If more information becomes available at a later date, an additional service/report/reconsideration may be requested. Such information may or may not change the opinions rendered in this report. This report is a clinical assessment of documentation and the opinions are based on the information available. This opinion does not constitute per se a recommendation for specific claims or administrative functions to be made or enforced.

Freeman G. Tips for writing reports. Conference proceedings of the AADEP Comprehensive Training Course. 31 March 1998. Chicago. Chicago: American Academy of Disability Evaluating Physicians

Appendix 2: Example IME Reports

January 8, 2008

RITA SMITH, RN

MEDICAL CASE MANAGEMENT NURSE

BASS & HALIBUT COMPANIES

P.O. BOX 2201

OCEAN CITY, IA 51104

RE: Processor Watson

SS#: xxx-xx-9170

DOB: 12/18/1982

Dear Ms. Smith:

Please be advised that I had the opportunity to evaluate the above named individual at my office at 4230 War Eagle Drive in Sioux City, Iowa for purposes of an Independent Medical Examination on January 8, 2008.

Please be advised the examinee read, understood and signed the notice of informed consent for Independent Medical Evaluation and this was placed in her chart.

Please also be advised that I had an opportunity to review pertinent past medical records surrounding her claim of injury to her low back. The following constitutes a medical record source list:

• 1. Medical records from Richard J. Klein, D.O. of the St. Luke’s Center for Occupational Health Excellence

• 2. Medical records from Leonel Hightower, M.D., neurologist affiliated with the Tri-State Orthopedic group

• 3. Medical records from Steven J. Shocker, M.D. of the Center for Awesomeness.

• 4. Physical therapy records from Physical Therapy Guys, P.C.

• 5. Physical therapy records from Sioux City Physical Therapy

• 6. Physical therapy records from the Center for Neurosciences, Orthopaedics and Spine, P.C.

• 7. Medical records from Eric Heiden, D.O., Radiology Department, St. Luke’s Regional Medical Center

• 8. Functional Capacity Examination Report from Marcus Witbier of Witbier Workforce Assessment, L.L.C.

• 9. Procedure note from Paul Burke, D.O., from the Pierce Street Same Day Surgery Center, L.C.

There are additional records surrounding her care which are not available, but are known to exist, which include those from the following source:

• 1. Chiropractic records from Fluent Chiropractic Center

History of Present Illness

Ms. Processor Watson is a 25-year-old white female who presents herself today at the request of Rita J. Smith, RN, nurse case management nurse affiliated with Bass & Halibut, at the behest of CCMSI Insurance Company, for purposes of an Independent Medical Evaluation surrounding complaints of back pain stemming from a work related incident that occurred on February 1, 2007.

She explains that she was working for Sunrise Retirement Center and was helping to lift a resident from a wheelchair to a bed, with the assistance of another Certified Nursing Assistant. Both coworkers attempted to lift the resident underneath each opposing arm, but when Ms. Watson attempted to do this, she strained her back experiencing not pain right away, but approximately 5 to 10 minutes after the incident. She described the initial pain as sharp and stabbing, and on the left side of the low back.

She presented to Dr. Richard Klein of the St. Luke’s Center for Occupational Health Excellence for treatment on February 8, 2007 initially with a diagnosis of lumbar strain. She was treated with conservative measures, including Tylenol, Flexeril and physical therapy. She was placed on restricted duty.

The lady was followed up on February 19, 2007 and, again on March 5, 2007 and March 19, 2007 with continuation of conservative based care and the same medications.

When she returned for a follow up visit on April 2, 2007, she was referred to Neurology for further evaluation and treatment, as she continued to have complaints of lower back discomfort.

She was seen by Dr. Leonel Hightower, who suggested MRI scanning, as well as an epidural corticosteroid injection and other medications, including Amitriptyline, Mobic and Ultram. The MRI scan showed degenerative disk changes at the L5-S1 level, but no impact upon the exiting nerve roots or impact upon the spinal cord.

It is a little bit unclear as to the events, with respect to her injections, in that the documentation indicates a June 8, 2007 leftward sacroiliac joint injection performed by Dr. Luebbert, as opposed to an epidural injection. Ms. Watson indicates that she received approximately 1 week’s worth of improvement of her symptoms after that injection, only to have this return to baseline.

Dr. Hightower did not have any other recommendations, other than continuing with conservative based measures. The lady was then, apparently, evaluated by Dr. Fluent of Fluent Chiropractic and had a treatment attempt at chiropractic measures. I do not have any chiropractic notes to know specifically the content or the duration of the chiropractic intervention, but apparently this did not alleviate any of her symptoms either.

She was eventually forwarded by Dr. Fluent on to Dr. Steven Shocker, who saw her and also felt that she did not have a surgical lesion. He suggested continued conservative measures.

She had an epidural corticosteroid injection performed by Dr. Paul Burke in November of 2007. She indicates that gave no relief whatsoever, even for a short duration of time.

It is my understanding that Dr. Shocker did not have any other recommendations for treatment. Dr. Klein also got back into the evaluation process in late November and early December of 2007 suggesting a Functional Capacity Examination and Independent Medical Examination.

A Functional Capacity Examination performed by Marcus Witbier of Witbier Workforce Assessment dated December 13, 2007 indicates an invalid Functional Capacity Examination with passage of only 39 percent of the validity criteria.

In speaking with Ms. Watson today, she continues to complain of low back pain, left side of mid line and the lower portion of her lumbar spine. She denies any current radiation of pain into the legs, nor does she complain of any numbness or tingling into the legs.

She does not complain of any type of bowel or bladder function abnormalities.

She notes that she occasionally will have difficulties with her sleep quality, but not consistently so.

As far as her work activities are concerned, she has been on a transitional duty situation where she basically is only doing portions of her job, including dining activities.

Review of Systems

Her Review of Systems is positive for having a history of hospitalization for pyelonephritis in December of 2006 and January of 2007.

The remainder of the Review of Systems is negative except for that described above.

Past Medical History

Current Medications: Include Mobic 7.5 mg. q. day; Tramadol 50 mg. q. 4 to 6 hours p.r.n; Extra Strength Tylenol, 1 q. 4 to 6 hours p.r.n; Amitriptyline 10 mg., 2 tablets q. h.s.

Allergies: To sulfa and morphine sulfate

Family History : Positive for hypertension.

Social History : Reveals that this lady smokes approximately 1/2-pack of cigarettes daily. She denies alcohol or illicit drug use.

Occupational History : Reveals that she has worked as a Certified Nursing Assistant for 6 years. She has been at Sunrise Retirement Center for 5 years and prior to that, at Indian Hills Nursing and Rehab Center for 1-1/2 years.

Surgical History : Positive for a laparoscopic appendectomy.

Radiographs Available for My Review

I have no radiographs that have been made available for my review, other than the plain film x-rays that were taken by Dr. Klein. I find no specific or concerning abnormalities on those films.

She, apparently, has had a bone scan in addition to the lumbosacral spine MRI scan. I only have those Radiology reports. The Radiology reports would suggest that the MRI scan showed degenerative disk desiccation at L5-S1 with degenerative protrusions with no evidence of herniation or impact upon the exiting nerve roots or spinal cord. There, apparently, was some question on the bone scan of a vertebral body abnormality, but this is relatively unremarkable and not correlated on the MRI scan imaging.

Physical Examination

The lady was pleasant and cooperative during the course of the history taking and physical examination. She was able to get on and off the examination table in no acute distress.

In the seated position, her straight leg and crossed straight leg raise tests were negative.

Her lower extremity strength revealed 5/5 strength using manual muscle testing protocols of the dorsiflexors and plantar flexors of the feet, as well as the quadriceps and the hamstrings.

There was no muscular tone loss, atrophic change or spasm of the lower extremity musculature.

Calf circumferences measured 10 centimeters below the tibial tubercle were equal bilaterally at 36 centimeters.

Light touch and two-point discrimination testing of the lower extremities were well within normal limits.

There is no evidence of any clubbing, cyanosis or edema. Peripheral pulses were normal.

Lumbosacral spine inclinometry was performed. The following measured values were obtained:

• Lumbar flexion 45 degrees

• Lumbar extension 20 degrees

• Right lateral flexion 20 degrees

• Left lateral flexion 25 degrees

Her supine straight leg raise test on the left was 70 degrees and on the right was 75 degrees.

Waddell’s testing was performed which revealed no representation of pain with simulated rotation or axial compression. There were no nonanatomic descriptors of pain. There was no hypersensitivity noted. There were no significant differences between supine versus seated straight leg raise tests.

Palpably, she did complain of tenderness upon palpation over the left parasacral area. There is no sacroiliac joint or sciatic notch tenderness appreciated. The Faber’s testing was negative.

Her gait pattern reveals retained capabilities with heel-toe and tandem gait. There is no antalgic posturing noted.

Assessment

• (1) Mechanical low back pain

Prognosis

This lady’s prognosis is good.

Recommendations

The evidence based medical recommendations, at this point, for this lady’s complaints of back pain would be to continue with a home based exercise program concentrating on flexibility, strengthening and aerobic-type of activity.

Concerning medication treatment, the evidence based medical protocols and literature would strongly suggest management of her back pain, at this point, with over-the-counter analgesic medications, either in the form of Acetaminophen or Ibuprofen, or a combination of those two. Long term utilization of muscle relaxant medications and pain medications are not supported by the literature.

She does not need any further diagnostic testing.

She is not a surgical candidate.

There is no indication, at this point, for additional injection therapy, such as epidural corticosteroid injection, sacroiliac joint injection, or facet injection.

The evidence based medical literature would strongly support resumption of normal activity.

Causation

Causation, in this case, is based upon the medical evidence as presented in the record, as well as interview with the examinee. Her current back pain situation does have direct causal correlation to the work related lifting incident that occurred on February 1, 2007.

Impairment

Impairment rating, in this case, is based upon the principles of the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition.

This lady’s impairment rating would be based upon the Spinal Chapter, which is Chapter 17 of the AMA Guides, Sixth Edition.

Concerning the lumbar spine, one would specifically review the spine regional grid system, which is contained within Table 17-4 on page 570. This lady would meet the Class 1 descriptor under Nonspecific Chronic or Chronic Recurrent Low Back Pain. The default value for the CDX designation within this Class is 2 percent.

The adjustment score for the functional history is taken from Table 17-6 and is consistent with a Grade 3 modifier of pain and symptoms with less than normal activity. Her Grade modifier for physical examination, taken from Table 17-7 on page 576 is a Grade 0. Her Grade Modifier for Clinical Studies, taken from Table 17-9 on page 581 is somewhat difficult to interpret. There is no possibility for the physician to use a Grade Modifier 1; however, when presented with this dilemma, one needs to pick a side, so to speak, with respect to either utilization of Grade 0 or Grade 2. I am arguing for utilizing Grade 2 modifier because of the MRI findings of the L5-S1 degenerative condition not being clinically insignificant and certainly not being consistent with this individual’s age. Therefore, I think a Grade 2 modifier is appropriate.

In calculating the Net Adjustment Score utilizing the instructions on page 582, this would yield a -1 Net Adjustment, which would place this lady within a Grade B designation of Class 1.

Turning back to Table 17-4 on page 570, this would, therefore, yield a 1 percent whole person permanent partial impairment rating.

This lady has reached a degree of maximum medical improvement.

Return to Work Issues

The current evidence based medical literature on this lady’s clinical condition strongly suggests return to normal activities.

We have a Functional Capacity Examination which has been performed, which is invalid. The examinee was willing to show us only a sedentary light physical demand level and the physical therapist administering this test felt that she should be able to work at least at a light medium physical demand level with the recommendation that her true functional capabilities must be left to professional conjecture.

I would indicate that professional conjecture, although typically somewhat argumentative and difficult to understand previously, has now become more clear-cut with advanced scientific studies on chronic low back pain, which clearly show that an individual does better with long term outcomes if they are told to resume normal activities. Therefore, I do not believe that this lady should be placed on any permanent physical restrictions and should be encouraged to return to her normal activities.

Conclusion

The above statements have been made with a reasonable degree of medical certainty/probability.

The opinions rendered in this case are the opinion of this evaluator. This evaluation has been conducted on the basis of medical examination and documentation as provided, with the expectation this material is true and correct. If more information becomes available at a later date, an additional service/report/reconsideration may be requested. Such information may or may not change the opinions rendered in this evaluation. This opinion is based on clinical assessment, examination and documentation. This opinion does not constitute, per se, recommendations for specific claims or administrative functions to be made or enforced.

If you have any questions with respect to this evaluation, please contact me personally through the office.

Sincerely,

Douglas W. Martin, MD, FACOEM, FAADEP, FAAFP, CIME, CEDIR

Fellow, American College of Occupational & Environmental Medicine

Fellow, American Academy of Disability Evaluating Physicians

Fellow, American Academy of Family Physicians

Certified Independent Medical Examiner (ABIME)

Certified Evaluator of Disability & Impairment Rating (AADEP)

DWM/lap

XXX

March 21, 2011

CHRIS J. ATTORNEY

ATTORNEY WORLD P.C.

225 SECOND STREET, SE, SUITE 200

P.O. BOX 36

CEDAR CREEK, NE 68037

RE: Valorie Grant

SS#: XXX-XX-1052

DOB: 11/07/1953

Dear Mr. Attorney:

Please be advised that I had the opportunity to evaluate the above named individual at my office at 4230 War Eagle Drive in Sioux City, Iowa for purposes of an Independent Medical Examination on March 21, 2011.

Please be advised that the examinee read, understood and signed the notice of informed consent for Independent Medical Evaluation and this was placed in her chart.

Thank you for your letter dated March 16, 2011 that summarizes this lady’s claim history and includes questions that you need to have addressed. Accompanying this letter are pertinent past medical records and other information sources what I have reviewed in preparation of this report. Please see Appendix A for a listing of these pieces of correspondence.

History of Present Illness

Ms. Valorie Grant is a 57-year-old white female who presents herself today for an Independent Medical Examination, at the request of Chris J. Attorney, attorney-at-law, surrounding claims of injury to her right shoulder. The letter that I have received from Mr. Attorney would also seem to imply that she is claiming a back injury. However, when I reviewed this with the claimant today, she seemed extremely surprised about any spinal problems and stated that it was her understanding that the issue was simply with respect to her right shoulder.

This lady reports that she believes that she began to experience problems with respect to right shoulder pain several years ago (she is unable to give me a specific date) where she was carrying a tray of food into a freezer at her work place, known as Timmy’s Catering, when she had a slip injury and fell with her right arm into a rack. She, apparently, did not go all the way to the ground. The medical record would suggest that this incident was taken care of by Dr. Strittholt in 2005, wherein his record would indicate an evaluation on October 24, 2005, which resulted in treatment with a shoulder injection.

The lady reports that she did have good improvement with respect to the injection, at that point. The medical record would also suggest that the lady underwent advanced diagnostic imaging of her right shoulder with an MRI scan on November 15, 2005 showing mild acromioclavicular joint hypertrophy and degenerative changes with tendinosis.

Over the course of the next several years, the lady then states that she had on and off exacerbations of right shoulder pain. The medical record would suggest that yearly thereafter she presented back to Dr Strittholt for right shoulder pain which was basically treated with repeat injections. This was done in 2006 and then also again in 2007. In early 2008, she had another reported problem of exacerbation which was treated with injection and then the lady had another problem of reexacerbation in October of 2008 which led to yet another injection. However, apparently, that did not necessarily improve her symptoms, as it had prior. In April of 2009 she had more problems and a repeat MRI scan was done. Partial thickness tearing of the rotator cuff appeared to be present with, again, the acromioclavicular joint hypertrophy, which was noted on the prior MRI scan. An extensive tendinitis signal was noted.

After this point in time, there was some discussion about options for care. But, eventually, on July 21, 2009, the lady underwent a shoulder arthroscopic procedure. A subacromial decompression with rotator cuff repair was performed.

The lady, apparently, did reasonably well with surgery, but in discussion with her today, she reports that it took longer than what she had hoped. She states that she had some postoperative physical therapy that was helpful.

She reports that she continues to have some degree of issues concerning her right shoulder. She reports that it is better with the surgery than what it was. The main issue that she seems to have is with respect to overhead type of activity with her right arm. She states that she is unable to lift as much as she used to be able to lift with her right arm. She reports difficulty with household chores, such as vacuuming. She has had significant improvement in problems with nighttime wakening, and that is not really a substantial issue for her presently. She does state that she awakens sometimes with stiffness in the right shoulder.

She denies any substantial numbness or tingling that follows a dermatomal distribution. She does not report any crepitus into the shoulder joint currently. She denies any type of headache symptomatology.

Upon questioning, she specifically denies any current neck, thoracic or lumbar pain.

Review of Systems

This lady’s Review of Systems reveals that she has no reported active medical problems.

Past Medical History

Current Medications: Include a calcium supplement, a multivitamin and Effexor (unknown dose q. day).

Allergies: None

Family History : Positive for cancer and diabetes mellitus.

Occupational History : Reveals that this lady worked for Timmy’s Catering for a period of 20 years with the last date of employment being July 21, 2009.

She began working for Floyd Valley Hospital as a cook in December of 2009, where she continues to work today.

Social History : Reveals that this lady smokes 2-packs of cigarettes weekly. She denies alcohol or illicit drug use.

Surgical History : Positive for 2 C-Sections and a cystoscopy.

Prior Medical Intervention : The medical record presented suggests that this lady has had back and neck problems that have been evaluated by chiropractic. She has also had prior low back pain evaluated by primary care physicians at Medical Associates in 2002. There is a listing in September of 2003 from Krull Chiropractic of pain in the trapezius and the posterior right shoulder.

Radiographs Available for My Review

None.

Physical Examination

The lady was pleasant and cooperative during the course of the history taking and physical examination. She was able to get in and out of the chair, off and on the examination table, and move about the room with no difficulty.

Examination of her right shoulder reveals that there is a 7 centimeter scar which is located in somewhat of a curvilinear, horizontal location in the anterior aspect of her upper right arm. I am assuming that this is from the previous surgical intervention.

Palpably, she complains of no tenderness over the collar bone, over the acromioclavicular joint, over the biceps tendon, or of the subacromial bursa. She has mild tenderness upon palpation over the medial superior scapular border at the insertion of the levator scapular muscle. There is no scapular winging, however. There is no tenderness over the rhomboid, nor over the trapezius or the cervical structures.

The reflexes of the biceps, brachioradialis and triceps are 2+ and symmetric. Light touch and two-point discrimination testing are well within normal limits.

Confrontation strength testing reveals 5/5 strength concerning dorsal interosseous, grip strength and wrist deviator strength bilaterally. There is, likewise, 5/5 strength concerning bilateral biceps and triceps strength.

There is 5/5 strength bilaterally in the shoulder with flexion, extension, internal and external rotation and adduction. The right shoulder does show, however, 4+/5 strength with lateral abduction, whereas, on the left, this is 5/5.

There is no evidence of any muscle tone loss, atrophic change or spasm of the upper extremity musculature. There is no muscle tone loss, atrophic change or spasm of the posterior shoulder girdle or over the paracervical musculature.

Range of motion examination of the shoulders was then performed utilizing the goniometric protocols described in the Fifth Edition of the AMA Guides to the Evaluation of Permanent Impairment. The range of motion values are as follows:

Right

• Flexion      130 degrees

• Extension     50 degrees

• Internal rotation  60 degrees

• External rotation 75 degrees

• Abduction    120 degrees

• Adduction    60 degrees

Left

• Flexion     140 degrees

• Extension    75 degrees

• Internal rotation  70 degrees

• External rotation 90 degrees

• Abduction    140 degrees

• Adduction    60 degrees

No other abnormalities are noted.

Assessment

• 1. History of right shoulder impingement syndrome

• 2. Status post multiple injections and eventually decompression operation for #1 above.

Prognosis

This lady’s prognosis is good.

Recommendations

I have no additional medical care recommendations for Ms. Grant.

I do not believe that she requires additional diagnostic testing, medication prescriptions, injections or surgical intervention concerning her right shoulder.

Causation

Causation, in this case, is based upon a review of the medical documentation as presented, as well as interview with the examinee.

This has been applied to current evidence based medicine in the form of medical literature published concerning the issue of causation analysis for shoulder impingement problems.

It is recognized by this examiner that there is some degree of differences of opinion within Dr. Strittholt’s notes of whether or not he either feels or does not feel that her right shoulder issues have some contribution of work relatedness. Early on, it appears as though his opinion is more on the line that this was a degenerative process; but then, towards the end of the treatment protocol, he seems to change his opinion a bit, thinking that this is either an aggravation or exacerbation. I admit that it is somewhat difficult to follow his thought processes as they change throughout the years.

It is also recognized that Dr. Brian Johnson, who is an Orthopedic Surgeon affiliated with the Center for Neurosciences, Orthopedics and Spine, P.C. was apparently asked to do an Independent File Review by a claims manager concerning this, and has given the opinion that he feels it is not work related and only a degenerative process.

I do not have a formal job description that has been presented to me for this lady’s work activities at Timmy’s Catering. Given her description to me today of what this company does, which is primarily provide catering for a variety of different social functions in the LeMars and surrounding area, including things such as graduations, weddings, class reunions, business trips, etc., she reports that primarily her job was food preparation and transport. From her deposition transcript, it appears that the main issues that she was having at the work place was pain concerning stirring of pots and also chopping vegetables and fruits.

Applying the evidence based medicine causation analysis, as well as the principles of the Bradford-Hill causation analysis protocol indicates that the medical literature suggests that individuals have to have a combination of risk factors for rotator cuff tendinitis or impingement syndrome to have a relationship to work activities. The combination of risk factors can be repetitive, from the standpoint of overhead activities, as well as with awkward postures, or with respect to vibratory insult with overhead reaching, etc.

Concerning the issue of upper arm positioning, the medical literature would suggest that individuals need to have repetitive lateral abduction-type of postures greater than 70 degrees in order for work to be assigned a causal contribution.

Given my knowledge of what this lady is describing to me, with respect to her catering job, and also based upon her deposition transcript, as well as upon a review of the medical documentation, it is my opinion that her work activities are insufficient to be able to assign a contribution cause to the issue of shoulder impingement.

As is more typically true than not, individuals who have shoulder impingement follow a continuum of problems over years. With respect to her diagnostic imaging, which shows acromioclavicular joint hypertrophy with a small inferior spur and the original MRI scan of 2005, which shows not much space in the subacromial bursa, typically, the tendon first is impinged by the bony structures and then subsequently, just as a rope has a nick put on it and continues to fray over time, it becomes thin to the point where a partial tear develops and then, in some individuals, a full thickness tear. This continuum, however, is a natural part of the aging process and only in a situation where there is a clear or traumatic event or substantial combination of risk factors, as is described above, can a work causation contribution be assigned to the problem.

I, therefore, have a tendency to agree with Dr. Johnson’s Independent File Review concerning the causation analysis.

Furthermore, I would note that, on physical examination today, this lady does have some limitation of range of motion and does not have “normal” range of motion concerning the unaffected left shoulder. This is further evidence that the degenerative process has a more stronger association with these types of issues.

Impairment

Impairment rating, in this case, is based upon the principles of the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, as well as the principles and practices and utilization of those Guides, as taught by the American Academy of Disability Evaluating Physicians and as tested by that organization, as well as that by the American Board of Independent Medical Examiners.

It is unclear to me the basis for the previous impairment rating of Dr. Strittholt, which apparently is 12 percent of the upper extremity.

Proper application of the AMA Guides, Fifth Edition is to calculate this lady’s impairment rating based upon the range of motion figures, which appear on page 476, 477 and 479, respectively.

It is incorrect to assign any additional impairment above and beyond this for any type of strength loss, as the AMA Guides, Fifth Edition strength section clearly indicates, on page 508, that decreased strength can not be rated in the presence of decreased motion, painful conditions, deformities, or absence of parts that prevent effective application of maximal force in the region being evaluated.

There is also a fundamental in the Fifth Edition of the AMA Guides, as well as all other Editions of the AMA Guides that are currently in use that one is to compare the unaffected joint when providing range of motion evaluations to establish a baseline and then rate the evaluated joint appropriately.

Concerning this, this lady would, therefore, have a 10 degree decrease from the contralateral side concerning flexion, a 25 degree decrease in extension, a 10 degree decrease in internal rotation, a 15 degree decrease in external rotation, a 20 degree decrease in abduction and no degree of decrease in adduction.

Applying the appropriate values from Figures 16-40, 16-43 and 16-46 would then assign the following upper extremity percentage impairments to the right shoulder:

• Flexion 1 percent

• Extension 0 percent

• Abduction 1 percent

• Adduction 0 percent

• Internal rotation 0 percent

• External rotation 1 percent

According to the instructions in the Guides, these values are added together, as they are within the same joint, which would yield a 3 percent upper extremity impairment to the right shoulder. If administrative purposes dictate, this can be expressed as a 2 percent whole person impairment from Table 16-3 on page 439.

It is my opinion that this lady has reached a degree of maximum medical improvement for her right shoulder impingement syndrome condition.

Return to Work Issues

Concerning the issue of permanent recommendations for activity prescription concerning the right upper extremity, I would limit this lady’s above shoulder-type of activities to only occasional. I would have no limitations concerning her left arm.

She would have no limitations as long as the work activities can be confined to an area from the belt line to the chest line. I believe it is inappropriate to assign any type of weight restriction concerning the right arm activities above shoulder use, but simply only limit the activity to an occasional basis.

Specific Questions

I have been asked several questions in a letter by Mr. Scheldrup dated March 16, 2011, which I respond to as follows:

• 1. “Do you believe the claimant’s right shoulder condition and need for surgery are causally related to her work activity at Timmy’s Catering or do you believe that it is more likely than not that claimant’s right degenerative right condition and need for surgery are due to preexisting and/or nonindustrial medical condition and that her work at Timmy’s Catering, while it may be one of the many factors, was not a substantial factor in bringing about her right shoulder condition and need for surgery?”

Answer: This is a very complex and compound sentence; however, I will answer it in its parts. First of all, based upon the evidence based medical literature that has been published on the subject of causation analysis for rotator cuff tendinitis and impingement syndrome, I am unable to identify the work activity at Timmy’s Catering that would meet the threshold for that to be considered having causation, from the standpoint of the work activities.

The evidence based literature, on the other hand, would suggest that genetics and age play a larger role in the development of these problems.

It certainly would appear, based primarily on her diagnostic imaging, that this lady’s shoulder impingement has developed, as it typically does in individuals over a number of years and on a continuum that has more to do with degeneration.

• 2. “If you believe claimant sustained a right shoulder injury as a result of her work activity at Timmy’s Catering, do you believe that claimant sustained a permanent injury to her right shoulder as a result of his work activity at Timmy’s Catering, or do you believe that claimant sustained, at most, a temporary exacerbation of a preexisting medical condition that returned to baseline?”

Answer: The answer is ‘not applicable’ as I do not believe that this right shoulder problem is a result of her work activity.

• 3. “Regardless of the causal mechanism of the same, when do you believe that claimant reached maximum medical improvement with regards to right shoulder injury?”

Answer: This would have occurred at some time after her surgical intervention. Typically after a decompression operation, this occurs somewhere between 8 and 12 weeks. It is somewhat difficult for me to pick a specific date, based upon the medical records that have been presented. I would simply give you that time reference framework as a reasoned, educated estimate.

• 4. “Regardless of the causal mechanism of the same, what permanent impairment, if any, would you assign for claimant’s alleged right shoulder injury?”

Answer: The impairment rating for the right shoulder impingement syndrome condition is 3 percent of the upper extremity. Please see the Impairment section of the report above for a detailed description of the calculation of this, based upon the AMA Guides, Fifth Edition rules and protocols.

• 5. “Regardless of the causal mechanism of the same, what permanent restrictions, if any, would you assign the claimant’s alleged right shoulder injury?”

Answer: I would limit her overhead activities with the right arm to only on an occasional basis.

• 6. “Regardless of the causal mechanism of the same, what future treatment, if any, would you recommend for claimant’s shoulder ankle?”

Answer: I am unaware of any ankle condition, but I would not suggest that any additional treatment is required for her right shoulder condition.

Conclusion

The above statements have been made with a reasonable degree of medical certainty/probability.

The opinions rendered in this case are the opinion of this evaluator. This evaluation has been conducted on the basis of medical examination and documentation as provided, with the expectation this material is true and correct. If more information becomes available at a later date, an additional service/report/reconsideration may be requested. Such information may or may not change the opinions rendered in this evaluation. This opinion is based on clinical assessment, examination and documentation. This opinion does not constitute, per se, recommendations for specific claims or administrative functions to be made or enforced.

If you have any questions with respect to this evaluation, please contact me personally through the office.

Sincerely,

Douglas W. Martin, MD, FACOEM, FAADEP, FAAFP, CIME, CEDIR

Fellow, American College of Occupational & Environmental Medicine

Fellow, American Academy of Disability Evaluating Physicians

Fellow, American Academy of Family Physicians

Certified Independent Medical Examiner (ABIME)

Certified Evaluator of Disability & Impairment Rating (AADEP)

DWM/lap

Appendix A

Medical Records Reviewed Valorie Grant

• 1. Medical records summary provided by Scheldrup Blades

• 2. Records from Krull Chiropractic Center

• 3. Medical records from Tri-State Orthopedics of Sioux City, Iowa

• 4. Records from Medical Associates Family Medicine Clinic of LeMars, Iowa

• 5. Medical records from Floyd Valley Hospital of LeMars, Iowa

• 6. Medical records from Siouxland Orthopedics and Sports Medicine Clinic, Sioux City, Iowa

• 7. Correspondence from Brian Johnson, M.D., Center for Neurosciences, Orthopedics and Spine, P.C.

• 8. Medical records from Northwest Surgery Associates

• 9. Additional medical records from Floyd Valley Hospital

• 10. Deposition transcript of Valorie Grant

• 11. Photograph of a motorcycle said to be claimant’s husband’s

November 7, 2016

TELMA LOUISE

PROGRAM SPECIALIST

NORTH NEBRASKA WORKFORCE SAFETY & INSURANCE

P.O. BOX 5585

LINCOLN, NE 66666

RE: Lawrence Jughead

CLAIM#: 4569-878811

SS#: XXX-XX-1045

DOB: 10/27/1947

DOI: 11/06/12

Dear Ms. Louise:

Please be advised that I had the opportunity to evaluate the above named individual at my office at 4230 War Eagle Drive in Sioux City, Iowa for purposes of an Independent Medical Examination for impairment rating derivation purposes on October 21, 2016.

Please be advised that the examinee read, understood and signed the notice of informed consent for Independent Medical Evaluation and this was placed in his chart. He was accompanied the entire time during the course of his history and physical examination by his wife.

Previously, he was earlier in the day seen by Steve Ferguson, O.D. for purposes of documenting visual field and visual acuity, as well as other visual issues which will be used for purposes of impairment derivation and will be included in this report.

Thank you for your introductory letter dated July 13, 2016. You have sent to me a CD of this gentleman’s past medical records, which encompass 1,706 pages. For a list of the records reviewed by source, please see Appendix A attached to this report.

History of Present Illness

Mr. Lawrence Jughead is a 68-year-old white male who presents himself today for an Independent Medical Examination, at the request of North Nebraska Workforce Safety and Insurance Program Specialist, Telma Louise, to determine impairment rating with regards to conditions of left eye, cervical spine, and left hip abnormalities.

This gentleman states that he was involved in a commercial truck accident on November 6, 2012 in Arkansas. He, apparently, was drinking coffee and choked on it, which led him to veer off of the road, where he had a substantial impact trauma to the cab. Emergency medical personnel were dispatched to the scene and it took several hours for him to be extricated from the vehicle. He was subsequently taken to the Baptist Health Medical Center in Little Rock, Arkansas, where he was evaluated by trauma services. He had diagnostic testing that showed a left pedicle and pars fracture at the C6 level, as well as a nondisplaced linear fracture involving the left paramedian aspect of the anterior arch of C1. He was also noted to have multilevel degenerative conditions of his cervical spine. He had a subdural hemorrhage that was not thought to need to have any type of immediate surgical attention. He had a left displaced orbital floor fracture with intrusion of the intraorbital fat and there was some degree of intraorbital hemorrhage that occurred. He also was noted to have an ocular laceration.

He was kept in the hospital for several days and eventually was discharged to home. There was definite identification of need to have surgical intervention regarding his ocular laceration. However, the physicians did not feel his orbital floor fracture was something that required immediate attention. After he got back to his home in Cherokee, Iowa, he saw his primary care physician, Dr. Veit and then subsequently other specialty physicians at the University of Iowa. He was treated in a collar for his cervical spine fractures and it was determined that he did not need to have any additional intervention for that. In discussion with him, he does not give any symptoms consistent with a radicular issue or problem.

He had some comorbid issues that he had to take care of regarding an abdominal aortic aneurysm and subsequently had to have a surgery for that, which was complicated by a Methicillin-resistant Staphylococcus aureus infection that required some additional surgical intervention. As he also carried a diagnosis of chronic obstructive pulmonary disease, coronary artery disease (which required previous stents) and Wolff-Parkinson-White arrhythmia, they were very careful to monitor him during this process. His orbital floor fracture was eventually operated on, but, unfortunately, he was left with issues regarding blurry vision and double vision, and those continue to be an issue for him today. He had previously been seen by Dr. Ferguson, who is an Optometrist affiliated in the Dakota Dunes area, for a variety of different strategies to try to help with this, including prism-type glasses.

He was under the care of Dr. Blow in Sioux Falls, South Dakota for rehabilitation needs and was sent to physical therapy to work on a variety of conditions, including neck pain and shoulder pain. After he had his physical therapy, he, unfortunately, continued to complain of neck pain and now also is complaining of lower back pain. The medical records would reflect that he also started to have issues with his left hip, which were evaluated by Orthopedic Surgeon, Dr. Hermanson in Sioux Falls, South Dakota. An MRI scan imaging study showed that there may have been a degree of labral abnormality, but it was felt that this was not necessarily due to trauma and Dr. Hermanson did not believe that there would necessarily be any help, from a surgical standpoint.

He has had multiple injections done by the Dakota Dunes Pain Clinic regarding back, hip and actually shoulder concerns.

More recently, he has been followed by Dr. Adams, who is a physician from Norfolk who comes up and does a clinic in South Sioux City. They have seen him on multiple different occasions and he has had multiple different recommendations—some of which happened and others which have not. The wife expresses concern about intravenous treatments that he gets and is referring to Decadron and Toradol, and openly questions whether or not those treatments are reasonable and necessary.

In discussion with Mr. Jughead today, he states that his visual problems are the most paramount things that he has to deal with. He complains of neck stiffness, which, would not necessarily be surprising. But, again, he does not complain of any radiation in the arms that could be construed to have a dermatomal distribution. He does have some left shoulder discomfort which seems to be related to some degenerative issues there.

Regarding his left hip, he does have some come-and-go type of discomfort in that area, but he actually is complaining more of back pain to me today than anything. There does not appear to be any radicular phenomenon to his problem, but he does state that the problems seem to interfere with his walking activities, and he has a single cane that he uses in his right hand. Given the way that he walked around in the examination room, and the fact that he was also complaining to me of some balance issues, which probably are related to some of his vision trouble, I did ask if he had contemplated a walker, and they told me that he had a 4-pronged walker on order which has a seat, which I think would be an excellent alternative for him.

Review of Systems

His Review of Systems is positive for coronary artery disease, abdominal aortic aneurysm, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and extremity edema.

Past Medical History

Current Medications: Include Tramadol 50 mg. q.i.d; Gabapentin 300 mg. that he takes anywhere from 4 to 8 times a day; Isosorbide Extended Release 30 mg. daily; Spironolactone 25 mg. daily; Atorvastatin 20 mg. daily; Furosemide 40 mg. daily; Pantoprazole 20 mg. daily; Trazodone 50 mg. daily; Venlafaxine 75 mg. daily; Montelukast 10 mg. q. day; Co-Q supplements; Vitamin D3 supplement; aspirin 81 mg. daily; Glucosamine Chondroitin supplement; Bupropion 150 mg. q. day; Hydrocodone/acetaminophen 7.5 mg./325, 1 q.i.d.

Allergies: He Has No Known Medical Allergies

Family History : Positive for cancer and coronary artery disease.

Occupational History : Reveals that he drove a commercial truck for greater than 30 years.

Social History : Reveals that he currently smokes 5 cigarettes daily, down from a maximum of 2 packs a day in the past. He denies alcohol or illicit drug use.

Surgical History : Positive for his left eye surgery, left shoulder rotator cuff surgery, a cholecystectomy, heart stent and abdominal stent placement that required a redo operation due to Methicillin-resistant Staphylococcus aureus infection development.

Physical Examination

The gentleman was pleasant and cooperative during the course of the history taking and physical examination. He walked into the examination room with utilization of a single cane that he used into his right hand, and it was noted that his gait pattern was antalgic. He was able to get in and out of the chair, and off and on the examination table with no assistance, but it took him extra time in order to accomplish that.

His visual appearance of his facial structures reveals that there is a visible abnormality and anophthalmos-type situation with regards to his left eye, no doubt from his orbital floor fracture. He has a tendency to not want to open his left eye because of issues that he is experiencing with respect to diplopia. His funduscopic examination and extraocular movement, as well as other visual function tests will be reported out by Dr. Ferguson in his notes. Otherwise, his cranial nerve examination is unremarkable.

The ear, nose and throat examination is unremarkable as well.

NECK : Supple. There is no lymphadenopathy or mass.

HEART: Regular rate and rhythm without murmur.

LUNGS: Reveal coarse breath sounds bilaterally.

Specific examination to his cervical spine shows that there is diffuse tenderness upon palpation of the paracervical structures. There is no evidence of any paravertebral muscle tone loss, atrophic change or spasm. His range of motion is grossly symmetrical. He is able to flex to 40 degrees, extend to 40 degrees, right and left laterally flex to 35 degrees, and right and left rotate to 60 degrees. Spurling’s maneuver for radiculopathy is not revealing. There is some crepitus with both active and passive motion of the cervical spine, consistent with some degenerative conditions. I do not see any evidence of occipital nerve abnormalities. Tinel’s testing over both the greater and lesser occipital nerves are negative.

Examination of his left hip showed that he had diffuse complaints with range of motion. Palpably, there does not appear to be any substantial pain into the hip proper. However, there is discomfort upon palpation over the left lower paralumbar segments. No kyphosis or scoliosis are identified. He had some degree of discomfort also over the left sacroiliac joint. There is no paravertebral muscle tone loss, atrophic change or spasm of the lumbar spine identified.

His lower extremity reflexes of the patellae and Achilles are 2+ and symmetric. Light touch and two-point discrimination testing show a minor stocking glove distribution abnormality probably more consistent with peripheral vascular disease than anything. Indeed, after we removed his shoes and socks, there is a significant degree of ruddy cyanotic appearance to his feet and toes. I can not feel a dorsalis pedis or posterior tibial pulse. The strength of dorsiflexion, plantar flexion, quadriceps and hamstring strength are 5/5 and symmetric. I do not measure any degree of muscle tone loss or atrophy in either the quadriceps or the calf areas.

He certainly does have some end range of motion discomfort with regards to the left hip. But, there is also some of that in the right hip - although it is not as significant. The range of motion of the left hip shows that he is able to flex to 90 degrees, extend to 10 degrees, internally rotate to 20 degrees, externally rotate to 40 degrees, laterally abduct to 40 degrees and adduct to 20 degrees. This is largely symmetrical with the unaffected right hip area.

Finally, as we stated, his gait pattern was assessed. He has an antalgic gait pattern favoring his left leg. He utilizes a single cane in his right hand, which does help his ambulatory status, both from a speed and stability standpoint. We did not have him perform heel-toe or tandem gait secondary to these issues, nor did we have him attempt any squatting.

Assessment

• 1. History of traumatic brain injury with subdural hematoma; managed conservatively

• 2. Left orbital floor fracture; managed conservatively

• 3. Left eye abnormality secondary to #2 above with diplopia and visual difficulties

• 4. Cervical spine fracture of the pars and the facet at C6 and the arch at C1, nondisplaced; managed conservatively

• 5. Left hip injury, difficult to characterize; probably a sprain or a strain; I doubt, and would be in agreement with the Orthopedic Surgeon that the labral abnormality would not be necessarily traumatic in its origin

• 6. Degenerative disease of the lumbar spine

• 7. Degenerative disease of the cervical spine

• 8. History of chronic obstructive pulmonary disease

• 9. History of coronary artery disease

• 10. History of aneurysm, status post repair with infection complications

• 11. History of hypercholesterolemia

• 12. Peripheral vascular disease

• 13. Gastroesophageal reflux disease

Prognosis

This gentleman’s prognosis is fair.

Recommendations

I have no additional medical care recommendations for Mr. Jughead regarding the injuries sustained as a result of his commercial motor vehicle accident.

Causation

Causation, in this case, is based upon review of the medical documentation as presented, as well as interview with the examinee. I do not think there is any question that this gentleman’s motor vehicle accident created the 2 areas of the cervical spine fracture, as well as the left orbital floor fracture and residual visual problems that he has with his left eye thereafter.

Less clear is the situation with regards to his left hip. It is probably true that some degree of injury occurred. Whether this was a strain, a sprain, a bad contusion, some other soft tissue issue or what have you, is probably a more likely explanation as to what has occurred there. I would agree with the Orthopedic Surgeon that his labral abnormality would not necessarily be trauma related and probably is better explained by degenerative processes.

He has some degenerative issues with regards to his lumbar spine which seem to be fairly significant for him. However, I do not think that those things are trauma related.

He is not the most healthy person in the world, having had issues with chronic obstructive pulmonary disease, coronary artery disease, peripheral vascular disease and so forth. I think these comorbidities likely play a role with respect to perhaps slow or incomplete healing, with regards to some of his other trauma related issues.

Impairment

Impairment rating, in this case, is based upon the principles of the American Medical Association Guides to the Evaluation of Permanent Impairment, Sixth Edition, as well as the principles and practices and utilization of those Guides, as taught by the International Academy of Independent Medical Evaluators (previously known as the American Academy of Disability Evaluating Physicians) and as tested by that organization, as well as that by the American Board of Independent Medical Examiners.

This gentleman’s left eye impairment rating, with regards to his impairment of visual field and visual acuity, is based upon the information obtained from Dr. Ferguson’s office.

The results of visual acuity and visual field testing were obtained from Dr. Steven Ferguson’s office on November 7, 2016.

The gentleman’s visual acuity assessment was actually equal in both the left and the right eye with distance visual acuity of 20/25 OD and 20/25 OS.

Visual field score information was reviewed and the visual field test actually indicated that the gentleman had more of a visual field deficit in the right eye than he necessarily had in the left. There could be a variety of reasons for this, but probably is representative of other chronic medical condition issues. The point of this is that it does not appear that the trauma has affected the visual field independently any greater with regards to the left than what is included in the right eye.

In looking at this information and applying it to the Visual System, Chapter 12, in the AMA Guides, Sixth Edition, I do not think that one can necessarily apply an impairment rating due to the trauma, therefore, with regards to any type of visual field issue, per se, with the left eye.

Regarding the visual acuity situation, given the fact that the right and the left eye are equal at 20/25, I also do not think that one could assign an impairment rating to the injury with the left eye specifically.

I do believe, however, that the issue with regards to the gentleman’s diplopia from his visual system would be appropriately identified. Diplopia is an adjustment to the visual impairment rating system evaluation, which is discussed within Section 12.4.b. beginning on page 305. Essentially, with regards to the instructions on page 306 in the first column, point #4, the issue here is with respect to assessing any interference with activities of daily living with regards to whatever extent suppression may reduce the awareness of double vision.

As indicated in the report above, Mr. Jughead has a tendency to keep his left eye closed to avoid any type of diplopia situation. I am not sure that I necessarily can state that it is so severe that it warrants continuous occlusion, as discussed in the AMA Guides, Sixth Edition. In that type of a situation, the impairment is suggested to be a 20 point loss. I think that it is probably more than just 1 quadrant. As is typically the case with regards to these orbital-type of blowout fractures, either the superior or inferior 2 quadrants are affected. Thus, I think that one-half of this value is probably the more appropriate way of looking at the true impact on activities of daily living.

As such, I would assign a 10 percent visual system impairment rating to the situation, with regards to the diplopia problems with respect to the left eye.

The visual system impairment of 10 percent equals a 10 percent whole person impairment.

The other issue dealing with his left eye problem is the fact of the visual abnormality with respect to the orbital floor fracture, which is visible on examination. One would need to take into consideration Chapter 11 of the Ear, Nose, Throat and Related Structures in order to determine any impairment from that. Appropriate application of Table 11-5 dealing with facial disorders/disfigurement would seem appropriate, especially given the criteria under Section 11.3 of the face, which begins on page 260.

In my opinion, this gentleman would best be categorized as a Class 2 level of impairment because the physical examination does show a loss of some of the supporting structures of the orbital floor and would include depressed appearance, with regards to his lower orbital areas. He does have x-ray studies that are consistent with this. Although he does not have any obstruction of the nasal passages and his shortness of breath probably is best described by his chronic obstructive pulmonary disease issues, I think that there is a strong argument that this Class is more appropriate than Class 1.

An 8 percent impairment of the whole person is afforded as a baseline for that particular Class. The determination with regards to varying from that Class is given within the instructions on page 261. Since the key factor is the History, the Physical Examination would also be a Class 2 level of descriptor. The diagnostic tests also would be a Class 2 level of descriptor. I think that the gentleman would, therefore, stay within the 8 percent whole person impairment rating for that particular condition.

Regarding his cervical spine fractures at the C1 arch and C6 pars and facets, this is assessed according to the Spine and Pelvis Chapter, with correspondence to the Cervical Spine Regional Grid.

This gentleman would be rated under Fractures/Dislocations of the Spine, as discussed within Table 17-2 and as described on page 565.

The determination of Class, in this particular situation, would seemingly be a decision between Class 0 and Class 1, as discussed within that Table. Class 0 is reserved for single or multiple fractures with minimal compression, which is appropriate in this situation, that have been healed with no residual signs or symptoms. Class 1 is reserved for single or multiple fractures that are healed with or without surgery, and an individual may have documented resolved radiculopathy or nonverifiable radicular complaints at clinically appropriate levels.

There has always been somewhat of an argument here as to whether or not that term “may” is a requirement or a necessity for the Class. But, in reality, it is not necessarily intended to be that. Thus, since the gentleman does have some degree of residual difficulty with respect to his neck, it would seemingly be most appropriate, I think, to place him in Class 1 simply from the standpoint that he has had fractures in 2 cervical levels - 1 at the C1 and 1 at the C6 level. Thus, I would choose Class 1 as his descriptor. Of course, the Grade C value with regards to that would be a 4 percent whole person impairment.

According to the Sixth Edition, adjustment factors need to be applied.

We had the gentleman complete the Pain Disability Questionnaire today, which is the identified methodology to determine the Grade Modifier for Functional History. This was scored at a 99.

According to Table 17-6 on page 575, this would yield a Grade Modifier 2 for Functional History.

Regarding the Physical Examination Grade Modifier, this is taken from Table 17-7 on page 576. This would be a Grade Modifier of 0.

The Grade Modifier for Clinical Studies is not applied, in this situation, because the diagnostic test of a CT scan documented the diagnosis. In that case, when a test is used to confirm or make the diagnosis, it is not applied as a Grade Modifier.

There is also another instruction in the AMA Guides here with regards to Grade Modifiers that is appropriate to be used, in that the Grade Modifier for Functional History is disregarded if it lies 2 or more levels different than either the Grade Modifiers for Physical Examination or Clinical Studies.

Thus, this gentleman’s only Grade Modifier that is taken into consideration is for the Physical Examination, which I have said is 0. This would allow a Net Adjustment of −1, which would drop his impairment rating to the Grade B level within the Table that was previously identified. Thus, his impairment rating for his cervical spine problem would be 2 percent of the whole person.

Regarding his left hip issue, this would be assessed utilizing the Lower Extremity Chapter, which is Chapter 16. Again, one would turn to the Diagnosis Regional Grid for the hip, which is within Table 16-4 beginning on page 512. I think that there could be an argument here to use an “other soft tissue lesion” as opposed to “strain.” One could also look at the “acetabular or labral tear” on page 513. However, as we have previously indicated, we do not necessarily agree that the acetabular tear has any relationship to the trauma. Thus, one is challenged with using either the strain under the muscle tendon diagnosis, or the other soft tissue lesion area under the soft tissue diagnosis.

In actuality, it does not make any difference because one would pick the lower description value within each diagnosis. The gentleman does not have any motion deficits in his left hip that can be identified to be any different above and beyond the right hip, as we have indicated. Therefore, the palpatory and/or radiographic findings appear to be most appropriate to use here. That Default Grade C value is 1 percent of the lower extremity.

We do go through the process, again, of assigning the Grade Modifiers. In this case, for the Grade Modifier for Functional History, we had the gentleman complete the AAOS Lower Limb Questionnaire. Scoring this indicates that his standardized mean score is 47. His normative score is 18. This is indicative of a moderate problem, which would be assigned a Grade Modifier of 2.

Regarding his Physical Examination Adjustment from Table 16-7, he is probably best assigned to a Grade Modifier 1 for his minimal palpatory findings.

The Clinical Studies Adjustment from Table 16-8 is best termed as a Grade Modifier 0 because there are no relevant abnormalities that are found on the exam specific to the injury at hand.

Therefore, using the Net Adjustment Formula, one, again, is faced with having to disregard the Functional History Grade Modifier because it lies 2 or more values from the Grade Modifier for either the Physical Examination or the Clinical Studies. If one were to then use the Net Adjustment Formula, you would find that this would be a −1, which would, again, drop this down to a Grade B level of impairment and, going back into the Regional Grid for the hip, regarding the strain or the other soft tissue lesion area, this would still be at a 1 percent lower extremity impairment.

The 1 percent lower extremity impairment would need to be converted to a whole person impairment. This would also be a 1 percent whole person impairment (the conversion factor is 40 percent, but impairment ratings that are greater than absolute 0, but less than 0.5, are not rounded to 0, but, instead, are rounded up to 1).

Thus, this gentleman’s final impairment rating would be a combination of the 8 percent whole person impairment from the facial disfigurement coupled with the 1 percent whole person impairment from the left hip injury, combined with the 10 percent impairment of the whole person to the visual system.

When one performs this function utilizing the Combined Values Table, this yields an 18 percent whole person permanent partial impairment rating.

The gentleman has reached a degree of maximum medical improvement.

Conclusion

The above statements have been made with a reasonable degree of medical certainty/probability.

The opinions rendered in this case are the opinion of this evaluator. This evaluation has been conducted on the basis of a medical examination and documentation as provided, with the expectation this material is true and correct. If more information becomes available at a later date, an additional service/report/reconsideration may be requested. Such information may or may not change the opinions rendered in this evaluation. This opinion is based on a clinical assessment, examination and documentation. This opinion does not constitute, per se, recommendations for specific claims or administrative functions to be made or enforced.

If you have any questions with respect to this evaluation, please contact me personally through the office.

Sincerely,

Douglas W. Martin, MD, FACOEM, FAADEP, FAAFP, CIME, CEDIR

Fellow, American College of Occupational & Environmental Medicine

Fellow, American Academy of Disability Evaluating Physicians

Fellow, American Academy of Family Physicians

Certified Independent Medical Examiner (ABIME)

Certified Evaluator of Disability & Impairment Rating (AADEP)

DWM/lap

TIME SPENT ON CONDUCTING HISTORY AND PHYSICAL EXAMINATION = 1-1/2 HOURS

TIME SPENT ON REVIEW OF MEDICAL RECORD DOCUMENTATION = 4 HOURS

TIME SPENT ON REPORT GENERATION, INCLUDING INCORPORATION

OF DR. FERGUSON’S INFORMATION, REVIEW AND EDITING = 1 HOUR

Appendix A

Records Reviewed Lawrence Jughead

• 1. Medical records from the Baptist Health Medical Center of Little Rock, Arkansas

• 2. Various different care plan and correspondence issues surrounding that hospitalization

• 3. Medical records from Stephen Veit, M.D., Cherokee, Iowa

• 4. Sanford Health Clinic records, Sioux Falls, South Dakota, multiple providers

• 5. GENEX case management nursing correspondence from Mary Griffith, RN, BSN

• 6. Medical records from the University Hospital and Clinics, Oculoplastic Service

• 7. Other correspondence from the University Hospital and Clinics

• 8. Medical record information from the Cherokee Regional Medical Center of Cherokee, Iowa

• 9. Medical records from Jerry Blow, M.D., Sioux Falls Rehabilitation Specialists

• 10. Physical therapy notes from the Cherokee Regional Medical Center of Cherokee, Iowa

• 11. Medical records from Eli Chesen, M.D., Psychiatric Services of Lincoln

• 12. Medical records from Avera McKennan Hospital, Sioux Falls, South Dakota

• 13. Medical records from the Orthopedic Institute, Sioux Falls, South Dakota Evan Hermanson, M.D.

• 14. Medical records from Jeffrey Sykes, M.D., Cardiovascular Associates of Sioux City, Iowa

• 15. Medical records from the University of Iowa Hospital and Clinics, Neuro-Ophthalmological Service

• 16. Medical records from Siouxland Surgery Center Pain Clinic, Dakota Dunes, South Dakota

• 17. Medical records from Steve Ferguson, O.D., Dunes Eye Care

• 18. Neuropsychological evaluation, Neuropsychology Consultants, L.L.C., Michael McGraff, PhD, Sioux Falls, South Dakota

• 19. Functional Capacity Examination Report, Human Performance Testing’s, Terry Nelson, P.T.

• 20. Report of Integrity Physical Therapy, Storm Lake, Iowa

• 21. Medical records from C. Robert Adams, M.D., Norfolk, Nebraska

SSDI IME Reports

ST. LUKE’S OCCUPATIONAL MEDICAL CLINIC

224 NORTH DERBY LANE

NORTH SIOUX CITY, SD 57049

NAME: Steven Certain

SS#: 615-46-4419

DATE: 1/02/07

DOB: 5/13/1991

STATE OF IOWA DISABILITY DETERMINATION SERVICES BUREAU

COMPREHENSIVE EXAMINATION REPORT

CHIEF COMPLAINT: Behavioral disorder, and right arm problems.

HISTORY OF PRESENT ILLNESS: This is a 15-year-old male who presents himself today at the request of the State of Iowa Disability Determination Services Bureau for comprehensive examination and report.

He is the product of an extremely difficult family situation. The gentleman has been a resident of a boy’s ranch for trouble youth for a number of years. Apparently, his parents are basically out of the scene. He is currently being cared for by his uncle, who accompanies him in the examination room today.

The main problem that the gentleman has is with respect to behavioral disorders. He has been given the diagnosis of Attention Deficit Hyperactivity Disorder and his uncle relates that he has also been given the diagnosis of depression and schizophrenia in the past. He has difficulty with school work, concentration and other behavioral issues. There is a strong history of child abuse by the parents in the past. He has had multiple attempts of trying to attend regular school, but that has failed and he now goes to the Boys and Girls Home for individualized schooling.

He is on a number of psychiatric medications which the uncle tells me are going to need to be adjusted. He tells me that they have an appointment with a psychiatrist later today, as he is having difficulty maintaining behavioral control with the medications that he currently is taking.

From a medical standpoint, the gentleman had a forearm fracture approximately 1-1/2 years ago that was pinned and plated. He indicates that will occasionally give him some discomfort with activity, but he tells me that he is involved in training for ultimate fighting type of matches. This tells me that he actually is quite functional with it.

In addition, the gentleman states that he has a problem with asthma, which has been present for a number of years. He discusses difficulty with dyspnea on exertion and shortness of breath with extreme activity, but, again, as he is in the middle of training for these ultimate fighting type of activities, I would find it difficult to believe that it is significantly limiting to him.

REVIEW OF SYSTEMS: Except for that described above, is negative.

SURGICAL HISTORY: Positive for the right forearm open reduction and internal fixation.

CURRENT MEDICATIONS: Include DDAVP .2 mg., 2 q. h.s; Zyprexa inhaler q. 6 hours p.r.n; Risperdal 2 mg. q. h.s; Mirtazapine 15 mg. q. h.s; Zoloft 100 mg., 2 q. h.s; Hydroxyzine 25 mg. q. h.s; Singulair 10 mg. q. h.s; Concerta 36 mg., 2 q. a.m.

Allergies: He Has No Known Medical Allergies

FAMILY HISTORY: Positive for cancer, coronary artery disease, diabetes mellitus.

SOCIAL HISTORY: Reveals that he is the product of significant problems with family violence and a distorted family situation in the past. He denies smoking, alcohol or illicit drug use.

OCCUPATIONAL/SCHOOL HISTORY: Reveals that he currently attends the Boys and Girls Home for high school.

PHYSICAL EXAMINATION: Height without shoes is 70.5″; weight is 261 pounds; blood pressure is 118/92; temperature is 98F; pulse is 80; respiratory rate is 18.

VISUAL ACUITY: Snellen equivalence at 20′ with corrective lenses, OD 20/30, OS 20/25; OU 20/25.

GENERAL APPEARANCE: Reveals a teenage boy who appears his stated age. He has a mohawk haircut. He sits on the examination table in an extremely forward, slouched type of posture.

HEENT: Reveals the head to be normocephalic. Eyes: Pupils equal, round, react to light and accommodation. Extraocular movements are intact. Normal funduscopic and normal conjunctival examination. The ear, nose and throat examination is positive for ceruminosis in the canals bilaterally, but otherwise benign.

NECK: Supple. There is no lymphadenopathy or mass.

HEART: Regular rate and rhythm without murmur.

LUNGS: Clear to auscultation and percussion.

ABDOMEN: Benign.

EXTREMITIES: Extremity examination reveals that the range of motion of the spine and extremities are as included in the enclosed range of motion form.

The right upper extremity reveals that there is an approximately 15 centimeter scar located over the volar surface of the mid portion of the right forearm, presumably in the area of the prior internal fixation. It is mildly tender upon palpation, but does not appear to negatively inhibit the wrist or elbow capabilities.

The strength of the bilateral rotator cuff musculature, biceps, triceps, wrist deviators and grip strength are 5/5 and symmetric. There is no muscular tone loss, atrophic change or spasm identified. Light touch and two-point discrimination testing are well within normal limits.

Examination of the cervical, thoracic and lumbar spines are without abnormality.

Lower extremity examination reveals normality with respect to the hips, knees, ankles and muscular tone loss is not appreciated. His strength is 5/5 throughout. Neurosensory examination is normal. Reflexes of the biceps, brachioradialis, triceps, patellae and Achilles are 1+ and symmetric.

Further neurologic examination reveals cranial nerves II-XII to be grossly intact. Rapid alternating movements are well within normal limits. He is able to perform heel-toe and tandem gait without difficulty. He is able to squat without difficulty.

Assessment

• 1. Various psychological and psychiatric disorders including Attention Deficit Hyperactivity Disorder, history of depression, schizophrenia, behavioral and conduct disorders

• 2. History of right forearm fracture requiring open reduction and internal fixation

• 3. Asthma

Recommendations

With respect to this gentleman’s remaining functional capacities, by far the issues with his psychological and psychiatric issues outweigh any problems from a physical nature. I do not think there are any limitations that I would place on him, from the standpoint of his right forearm or from his asthma. They appear to be under reasonably good control. With his activity level that he describes, I can not envision that his asthma would be limiting.

Therefore, I would have no concerns with respect to lifting, carrying, standing, moving about, walking, or sitting; nor would I have concerns with stooping, climbing, kneeling or crawling activities. I would have no issues with handling objects, seeing, hearing, speaking, traveling, or with issues concerning exposures to the work environment such as to dust, fumes, temperatures or hazards.

Obviously, I will let other professionals better able to comment on the psychiatric component of his claim for disability to comment upon such. Please find enclosed, for your review, the range of motion form. If you have any concerns or questions with respect to this examination, please do not hesitate to contact me.

Sincerely,

Douglas W. Martin, MD, FAADEP, FACOEM, FAAFP, CIME, CEDIR

Fellow, American Academy of Disability Evaluating Physicians

Fellow, American College of Occupational and Environmental Medicine

Fellow, American Academy of Family Physicians

Certified Independent Medical Examiner by the American Board of Independent Medical Examiners

Certified Evaluator of Disability and Impairment Rating

Medical License Number: 28886 (IA) Exp. 03/01/07

3939 (SD) Exp. 02/28/07

18932 (NE) Exp. 10/01/08

DWM/lap

Enclosure

ST. LUKE’S OCCUPATIONAL MEDICAL CLINIC

224 NORTH DERBY LANE

NORTH SIOUX CITY, SD 57049

NAME: Carley Snowball

SS#: 320-52-4353

DATE: 1/04/07

DOB: 12/25/1953

STATE OF NEBRASKA DISABILITY DETERMINATION SERVICES BUREAU

COMPREHENSIVE EXAMINATION REPORT

CHIEF COMPLAINT: Sleep apnea problems, kidney trouble, and obesity.

HISTORY OF PRESENT ILLNESS: This is a 53-year-old Native American female who presents herself today at the request of the State of Nebraska Disability Determination Services Bureau for comprehensive examination and report.

This lady has been given a diagnosis of interstitial cystitis. She states that she has frequent bladder spasms and painful urination with frequent urinary tract infections. She, apparently, has been seen by renal specialists.

In addition to this, she has trouble with sleep apnea. She currently has a CPAP mask, which she is working with.

She complains of day time fatigue. Apparently, someone has discussed with her the possibility of fibromyalgia as a diagnosis; but, of course, this is difficult to assess, given her sleep apnea history. She does complain of neck and back pain, and difficulty going up and down stairs.

REVIEW OF SYSTEMS: Also positive for asthma and being deaf in the left ear (She states that this occurred as a result of childhood injury at age 10.). She also has a history of depression.

CURRENT MEDICATIONS: Include Cymbalta 30 mg. q. day; aspirin q. day; Elavil 10 mg. q. h.s; Albuterol inhaler 2 times a day; Allegra q. day; Singulair daily.

Allergies: She Has Stated Allergies To Penicillin And Latex

SURGICAL HISTORY: Positive for a right knee anterior cruciate ligament repair, cholecystectomy, tubal ligation, ganglion cyst removal of the right wrist, and right sided bunionectomy.

FAMILY HISTORY: Positive for cerebrovascular accident and diabetes mellitus.

SOCIAL HISTORY: Reveals that she does not smoke, abuse alcohol or use illicit drugs.

OCCUPATIONAL HISTORY: Reveals that she last worked as a social service worker.

PHYSICAL EXAMINATION: Height without shoes is 65-1/4″; weight is 277.6 pounds; blood pressure is 142/92; temperature is 98.4F; pulse is 84; respiratory rate is 18.

VISUAL ACUITY: Snellen equivalence at 20′ with contact lenses, OD 20/20, OS 20/25; OU 20/20.

HEENT: Reveals the head to be normocephalic. Eyes: Pupils equal, round, react to light and accommodation. Extraocular muscles are intact. Normal funduscopic and normal conjunctival examination. The ear, nose and throat examination is unremarkable.

NECK: Supple. There is no lymphadenopathy or mass.

HEART: Regular rate and rhythm without murmur.

LUNGS: Clear to auscultation and percussion.

ABDOMEN: Reveals diffuse tenderness over the superpubic area, but no rebound, guarding or masses appreciated. Bowel sounds are positive x 4 quadrants.

EXTREMITIES: The upper extremity examination reveals that the reflexes of the upper and lower extremities are 2+ and symmetric. The strength of major muscle group testing of both the upper and lower extremities are 5/5 throughout. There is no muscular tone loss, atrophic change or spasm identified.

Neurologic examination reveals that light touch and two-point discrimination testing are well within normal limits. I do not appreciate any significant limitations of any of the joints.

I did perform a tender point examination, per the American College of Rheumatology criteria. She had no positive tender points today in any of the 18 areas.

Further neurologic examination reveals cranial nerves II-XII to be grossly intact. Rapid alternating movements are well within normal limits. She is able to perform heel-toe and tandem gait and able to squat with some complaints of right knee pain.

Assessment

• 1. Obesity

• 2. Sleep apnea

• 3. History of asthma

• 4. Interstitial cystitis

• 5. Day time fatigue; etiology unclear

• 6. Deafness in the left ear from childhood injury

• 7. Mild residual knee pain from anterior cruciate ligament repair

Recommendations

With respect to this lady’s remaining functional capabilities, I would first state that she had no difficulty understanding my speech at a normal volume, and I had no difficulty understanding her speech.

With respect to her orthopedic issues, she has some mild residual trouble from her right knee from an anterior cruciate ligament repair.

She is dealing with obesity and depression.

From the standpoint of impact on lifting and carrying, I would expect her to be able to perform between 25 and 30 pounds occasionally, 15 to 20 pounds frequently, and 5 to 10 pounds constantly.

With respect to standing, moving about, walking or sitting, I would have no particular concerns.

Stooping, climbing, kneeling and crawling activities would best be limited to about half of what would be considered normal.

With respect to handling objects, seeing, hearing, speaking, or traveling, I would have no particular concerns.

With respect to exposures in the work environment such as to dust, fumes, temperatures or hazards, I would have no particular issues.

As always, I will leave her remaining functional capacities to your current guidelines. If you have any concerns or questions with respect to this examination, please do not hesitate to contact me.

Sincerely,

Douglas W. Martin, MD, FAADEP, FACOEM, FAAFP, CIME, CEDIR

Fellow, American Academy of Disability Evaluating Physicians

Fellow, American College of Occupational and Environmental Medicine

Fellow, American Academy of Family Physicians

Certified Independent Medical Examiner by the American Board of Independent Medical Examiners

Certified Evaluator of Disability and Impairment Rating

Medical License Number: 28886 (IA) Exp. 03/01/07

3939 (SD) Exp. 02/28/07

18932 (NE) Exp. 10/01/08

DWM/lap

Appendix 3: Exercise—Before and After Report Example

Before Example

Date

Managed Care Organization

Attn: Case Manager

Address

City, State Zip Code

Claimant: Ms. XXXX

BWC Number:

Date of Injury:

Social Security Number:

Employer: THE COMPANY

Allowed Conditions: Right Lateral Epicondylitis

Dear Case Manager:

At your request, I performed an independent medical examination on Ms. XXXX on November 15, 2XXX. It was explained to Ms. XXXX that the purpose of this examination was for evaluation purposes only and that no treatment would be undertaken. It was further explained to her that the client requesting and paying for the assessment would receive a report. Lastly, it was explained to Ms. XXXX that no medical relationship would be formed; thus no physician-patient relationship would be established during the course of this assessment.

A request is being made for an additional allowance of right carpal tunnel syndrome

CHIEF COMPLAINT: Hand pain and numbness.

HISTORY OF PRESENT ILLNESS: The following narrative was told to the examiner by Ms. XXXX and was dictated in her presence.

Ms. XXXX denied having an prior history of neck, upper back, shoulder, or upper extremity problems before 19XX. MS. XXXX worked intermittently for THE COMPANY since approximately 19XX. In 19XX she was rehired and worked at THE COMPANY continuously until 19XX. THE COMPANY is now known as THE COMPANY. MS. XXXX worked as an equipment technician, where she ran a bender and/or saws. She stated that the bender machine did not run properly. She said when operating the bender, she would slide parts for framing windows. In the spring of 19XX the machine jerked and caused her to jerk her right arm. She stated that she quickly had right lateral elbow swelling and pain, but that her entire arm also hurt. She was initially diagnosed as having tennis elbow. X-rays were performed. She was told to use a forearm or (tennis elbow) band. She had injections over a period of several visits. At this point in time she was seeing her family doctor, but continued to work, usually seven days a week.

Ms. XXXX indicated that her elbow and arm continued to bother her, especially her shoulder. She complained of having shoulder pain at night, which would wake her. She stated that placing her shoulder and arm in a sling type position seemed to help decrease the discomfort. Once every other week, the pain in her right shoulder would become excruciating, at which time the pain would radiate into the right arm to the elbow. Using ice seemed to help, sometimes. The pain in the shoulder was so severe at times that she was unable to go to work.

One morning some time in mid to late October 19XX, she could not use her shoulder because of severe pain and swelling. She thought that the last day she worked was October 13, 19XX. She followed up with Dr. K at her family physician’s office, who referred her to an orthopedic surgeon, Dr. D. An arthrogram was subsequently performed and a tear in the right rotator cuff was found. She had surgery to repair the right rotator cuff in December 19XX (surgery had been delayed secondary to problems with her asthma and chronic bronchitis).

Ms. XXXX stated that she has had significant pain since before and after having surgery to her right shoulder. She stated the pain has not improved since surgery, but does wax and wane in severity. She attended six weeks of physical therapy at HHHH HOSPITAL and then eight additional weeks performing work hardening at CCCC CENTERr. She underwent several nerve blocks, which relieved the pain only briefly. She also spent six weeks in the pain program at THE CENTER in Columbus, Ohio. She finished that program in September 19XX. She stated that the program did not help relieve her pain.

She has pain when lying on her shoulder, at night the pain wakes her up. She has severe pain approximately once a month. She had no improvement in shoulder movement after surgery. The severity of the shoulder pain varies significantly. She can be moderately pain free at rest. Using ice does help. Reaching forward is less bothersome than reaching laterally. Reaching behind her is especially bothersome. She occasionally gets neck and right upper back pain and spasms. Pain worsens with lifting, such that she can no longer lift a one gallon jug of milk. She has difficulty getting groceries out of her car. She has markedly decreased activities of daily living such as house cleaning, because of the shoulder pain and right upper extremity weakness. She now has to get help performing her normal housekeeping chores. She had decreased sleep secondary to her shoulder problem, but it has worsened because of her recent hand difficulties.

She stated that she has been on Social Security Disability since 19XX. She is unable to lift like she used to. She is also unable to perform repetitive activities using her shoulders. Her right shoulder strength is markedly decreased. She stated that her right elbow has not been treated or evaluated since 19XX. The right elbow pain is not as severe as it was initially after the accident. The right elbow can be pain free for several days in a row. The right elbow can be exacerbated with lifting type activities and can be painful for several days in a row. She believes her right elbow has some swelling in it on a fairly persistent basis. She wears a forearm band which does seem to help when she has to lift.

She has had some right hand or other upper extremity difficulties for the past 9–12 months. Her right hand, including all digits and the thumb, can go numb. This can occur during the day, but especially happens at night. It can wake her several times a night and the numbness can be present when she wakes up in the morning. She also noted that she has recurrent right hand swelling. She noted that this numbness can last for a while. She said because of her right upper extremity difficulties she has been using her left hand more (especially since the shoulder injury). She denied having any left handed numbness, but she has had pain at the ulnar side of the left wrist and hand for several months.

Dr. D has been evaluating her for her upper extremity difficulties and had wanted to do electrodiagnostic testing of the right upper extremity. This was not completed until May 2XXX, when testing by Dr. H demonstrated right carpal tunnel syndrome. Dr. D advised her to undergo carpal tunnel release, but she is not certain if she wants this performed. She has been dropping objects with both hands. She has recurrent hand swelling, the right usually worse than the left. The left has been bothering her more recently. She uses a wrist splint on the right side at night which helps decrease her symptoms. She also uses a left wrist band, which helps support her left wrist.

She recently lifted a jewelry box, maybe 5 pounds in weight, with her left hand. She ended up dropping the box. It twisted her left wrist, which increased her left wrist pain. She specifically denied ever having any injuries to her upper extremities since 1996. As part of this claim, she stated that she has been seen for both depression and anxiety. She has been treated by a psychologist for this condition.

She denied having any testing for thyroid, arthritis, or diabetes. She stated that she has had a 20-30 pound weight loss over the past year. She complained of having decreased weight, decreased sleep, decreased appetite, but denied having any fevers. She stated that she has nocturia, which has increased recently, although she indicated that she has also increased her fluid intake recently.

During the discussion with Ms. XXXX regarding the development of her symptoms, she persistently reiterated that she had no problems with her hands until after she had injured her right upper extremity. She noted that she has had a gradual onset of bilateral hand and wrist symptoms over the past several years. She specifically denied any new incident or injury to her upper extremities during this time frame. Over the past year, she has been less able to extend her fingers. This has worsened to the point where she is no longer able to fully extend certain fingers of both hands. Her hands are very stiff in the morning. This can last easily for half an hour or longer. She stated that some mornings she has to pry her fingers open. She complained of having ongoing finger pain and stiffness, as well as wrist pain and stiffness. She has recurrent swelling in her distal upper extremities, primarily involving the hands and fingers. She reiterated that her right hand is worse than her left, but that the left has very similar if not identical symptoms to the right, except for the lack of tingling and numbness.

PAST MEDICAL HISTORY: Ms. XXXX has undergone the following surgeries: surgical repair of her right earlobe, 19XX; hysterectomy, bilateral salpingo-oophorectomy, and appendectomy, 19XX; low back surgery (L3-4, L4-5) with residual left leg symptoms from nerve damage, 19XX; and right rotator cuff repair, 19XX. She has been hospitalized for hemoptysis, 19XX and for hypertension, 19XX. Other past medical problems have included a history of sinus and allergy problems since 19XX; diagnosis of irritable bowel syndrome in 19XX; history of recurrent bladder infections; a history of gastric ulcers times two, 19XX or 19XX, also associated with gastritis and accompanying esophageal stricture, status post dilation. She also was diagnosed with hypertension, 19XX; diagnosed with asthma, 19XX; diagnosed with coronary artery disease with a 50% posterior coronary block, 19XX; and diagnosed with depression and anxiety, 19XX. Past musculoskeletal problems include a removal of a ganglionic cyst from her right hand in the 19XXs, the low back injury with resultant surgery in 19XX, diagnosis of left knee bursitis requiring drainage in 19XX, the diagnosis of tennis elbow in 19XX, the right rotator cuff tear and rotator cuff repair in 19XX, diagnosis of right shoulder tendonitis, 19XX; diagnosis of right forearm tendonitis, 2XXX and diagnosis of carpal tunnel syndrome, 2XXX. Medications include Prilosec, Ultram, Soma compound, Elavil, Allegra, Tenormin, Albuterol, Singulair, Flovent, Seravent, Estratab, and an aspirin a day. She denied having any allergies to medications.

FAMILY HISTORY: There is a family history of high blood pressure, heart attack, stroke, bleeding problems, ulcers, obesity, birth defects, diabetes, cerebral palsy, asbestosis and cancer. Her father is deceased at the age of __ years from asbestos disease and cancer. Her mother is alive and well at the age of __ years. She has ____ brothers, ages ______ who are all alive and well, except that the oldest and youngest both have diabetes. She has ____ living children, ages_______. A sixth child was born with cerebral palsy and died in 19XX. She is currently divorced from her only marriage.

SOCIAL HISTORY: She has not smoked in 5–6 years, but does have a 15–20 pack year smoking history. She does not consume alcohol and denied recreational drug use. She does enjoy reading, primarily the bible. She occasionally plays card games or checkers with her grandchildren. She denied performing any repetitive hand activities as far as hobbies. She denied performing any regular exercise, although she does try to walk once a week. She has no pets at home. She wears glasses.

OCCUPATIONAL HISTORY: Ms. XXXX worked at ANOTHER COMPANY in SOMEPLACE, Ohio from 19XX – 19XX doing spot welding on an automatic sealer. After that she worked at ANOTHER PLACE cleaning offices from 19XX – 19XX. She also worked at A NURSING HOME as a nursing assistant from 19XX – 19XX. She worked continuously at THE COMPANY (formerly THE COMPANY) from 19XX – 19XX, and also worked there previously on an intermittent basis and during lay-offs she worked at nursing homes.

She has had past occupational exposures to grinding dust, metal dust, other dust, engine exhaust, smoke, other fumes mists or vapors, ammonia, welding fumes, acids and/or caustics, oils, metal coolants, viruses, noise, cold, heavy lifting, change in shift work, repetitive mechanical work and poor lighting.

REVIEW OF SYSTEMS: She is a gravida X, para X, with X living children. She has a history of bleeding problems. There is a history of hemophilia in the family. She has trouble sleeping. She has intermittently blurry vision. She has persistent ringing in her ears since 19XX. She has a history of sinus problems. She has a history of cough, some shortness of breath at rest, recurrent wheezing and congestion. She has coughed up blood in the past, including while at work in 19XX-19XX. She has a history of chest pain, but this has been less since resuming female replacement hormones. She also has a history of heart flutter and a history of high blood pressure. She complains of having a change of appetite and of having heart burn. She does get up a lot at night to urinate. She has complaints of anxiety, depression, confusion, and memory problems. She has a history of pain, swelling, or stiffness in her joints, arthritis, pain or numbness in her extremities, of having muscle cramps, of having low back pain or stiffness, of having neck pain or stiffness, of having swelling in her ankles, and of having some joint deformities and decreased function.

PAIN ASSESSMENT: On the Borg’s pain scale, she rated her current pain as a 5. On the Borg’s pain scale, 0 is no pain at all and 10 is a very very strong pain. She indicated that over the past 30 days her best level of pain was a level 5 and at it’s worst it was a level 8. She stated that she is more limited by her hand movements than the pain. With further questioning, she noted that she did not get pain in the tip of her tailbone, that her whole leg does not become painful, nor does it go numb, nor does it give away. She did indicate that she has not had any spells with very little pain during the past year. These answers were not the same as those when she initially answered the questionnaire. On the Visual Analogue Pain Scale, she marked near the 50% mark, which correlates with her responses on the Borg’s Analogue Pain Scale. Her responses on the McGill Pain Questionnaire totaled 33, which demonstrates a tendency to abnormal psychodynamics. Her responses on the Ransford Pain Drawing are consistent with the stated complaints. Ms. XXXX’s responses using the pain assessment tools do not indicate significant pain symptom magnification, but are not entirely normal.

PHYSICAL EXAMINATION: This was a well-developed, well-nourished right hand dominant over weight 54 year old black female with short black hair and glasses. Her vital signs were all normal except for mildly elevated blood pressure at 152/96. Her height was 5′ 6½″ tall. Her weight was 217 pounds. Although she was pleasant and cooperative throughout the interview process and during the examination, her responses seemed somewhat delayed. Her affect appeared flat. In general, she appeared to be somewhat depressed.

She ambulated somewhat slowly with a wide based gait and a slight limp. Neck range of motion was mildly decreased, especially left lateral bending. No guarding was observed during active neck range of motion. There was no pain elicited with gentle cervical compression. No masses were palpated in the neck. There was posterior cervical paraspinal muscle tenderness palpated especially at both occiputs, as well as point tenderness of the central right cervical paraspinal muscles. There was tenderness to palpation of the right rhomboid, right trapezius, and right infraspinatus muscles. There was no tenderness to palpation of the cervical or thoracic spine. Back range of motion was fair with some decreased anterior flexion and lateral bending. No scapular winging was appreciated. A well healed lower mid-line surgical back scar was visualized.

Multiple tender points were palpated including over the left greater trochanter, left buttock, both trapezius muscles, at the occiputs bilaterally, both rhomboids, at the right anterior chest, right deltoid, and right dorsal forearm. A well-healed surgical scar was visualized over the anterior portion of the right shoulder. Active shoulder range of motion revealed the following: right shoulder abduction was 80° while left shoulder abduction was 120° (normal being 170°+). Right shoulder adduction was 10° while left shoulder adduction was 30° (normal being 50°). Right shoulder flexion was 90° while left shoulder flexion was 135° (normal being 180°). At 90° of abduction (somewhat less on the right), left external and internal rotation reached 45°, (normal internal rotation being 80° or greater, and external rotation being 60° or greater). Right internal shoulder rotation at approximately 80° of shoulder abduction, reached 35° with the above normals previously being described. No right shoulder external rotation was elicited. No shoulder laxity was elicited. There was tenderness to palpation of the right anterior chest, throughout the right glenohumeral joint, the right acromioclavicular joint and right deltoid. The anterior chest and deltoid tenderness was limited to point tenderness. There was no right arm or clavicle tenderness to palpation. No obvious swelling, deformity, or atrophy was appreciated, except at the hands. There was marked decreased strength of the right shoulder and was associated with give way weakness.

A well healed scar was visualized on the left dorsal radial wrist. There was tenderness to palpation of the left wrist, at the anatomic stuff box, and of the left hand, especially at the metacarpal phalangeal joints, and over the second through fifth proximal interphalangeal (PIP) finger joints. This tenderness was slightly less over the third PIP. There was also slight discomfort to palpation at the left distal interphalangeal finger joints. There was some slight swelling throughout the hands and wrists primarily over the metacarpal phalangeal joints and fingers. No thenar atrophy was appreciated. There was also tenderness to palpation over the right wrist, right anatomic stuff box, and over the right metacarpal phalangeal finger joints and second and third proximal interphalangeal finger joints. The right hand swelling was similar to that of the left. She complained of mildly decreased sensation throughout the fingers and thumb of the right hand, especially over the thumb, third and second digits. She had markedly decreased grip strength bilaterally. She also had markedly decreased opposition of her thumb with the fourth and fifth fingers, especially on the right. No crepitus was appreciated of either upper extremity. There was decreased supination bilaterally and decreased wrist flexion and extension, especially on the left. Finklestein’s maneuver elicited no symptoms bilaterally. Elbow flexion appeared to be mildly decreased but was symmetrical, with decreased elbow extension, the right reaching 160° while the left reaching 170° (normal being 180°). There was tenderness to palpation of the right lateral epicondyle and into the adjacent dorsal forearm, but not at the olecranon or antecubital fossa. Pulses were normal and symmetrical at the radial arteries. Reflexes were normal and symmetrical at the biceps, triceps, and brachioradialus tendons. Finger movements were markedly slow. She was unable to fully extend all of her fingers (digits). Flexion deformities at the PIPs existed, especially at the right third and fourth PIP joints, as well as the left third PIP joint. Sensory examination of the digits was grossly intact to light touch, pressure, as well as to pin prick, but with complaints of decreased sensation on the right side. Two point discrimination testing was diminished on the right, but somewhat inconsistent varying between 5–10 millimeters two point perception, especially decreased at the right thumb and index finger of the right hand. Capillary refill was brisk in all digits. No gross bony deformities were present at the wrists or hands. Upper extremity strength was generally decreased at the elbows, wrists, and forearms. This was more so on the right, but was also associated with give way weakness.

Hand strength grip testing was evaluated using a Jamar dynamometer. In the number 3 position while rapidly alternating strength testing between the right and left hands through a total of at least five cycles, the right hand strength varied between 10–19 pounds per square inch and the left hand grip strength varied between 12–34 pounds per square inch. Grip strength testing using the Jamar dynamometer throughout all positions did not yield the normally expected bell-shaped curve for either hand with the right hand strength varying between 9 and 14 pounds per square inch and left hand strength varying between 8 and 18 pounds per square inch. The results of grip strength testing using the Jamar dynamometer were not consistent with good examinee effort. It should be noted that according to the AMA’s Guides to the Evaluation of Permanent Impairment, Fourth Edition, that the average grip strength for a 50–59 year old female should be approximately 49 pounds per square inch in the dominant hand and 40 pounds per square inch in the non-dominant hand. It is also noted that tests that are repeated at intervals are considered to be more reliable if there is less than 20% variation readings and that if there is more than a 20% variation, one may assume the patient is not exerting full effort. It should be noted that the variation in strength of Ms. XXXX’s right hand was almost 100% when rapidly alternating the grip strength testing and more than 100% variation in her left hand. Thus, these results are not consistent with good examinee effort.

REVIEW OF MEDICAL RECORDS: One hundred and nine pages of medical records were reviewed.

• 1. Seventy-four pages of Ohio Bureau of Worker’s Compensation C-141 forms were evaluated. These are wage loss statements for job search.

• 2. Seventeen pages of office notes, correspondence, as well as prescriptions from the ORTHOPEDIC PLACE were reviewed. These included at least 25 different office entries and were dated from October 30, 19XX through August 10, 2XXX. There were entries for every year. It should be noted that no mention of involvement concerning her hands was noted until July 8, 19XX when her pain was noted to extend from the base of her neck down into the arm and including the fingers and hands. It was also noted at that time that she had numbness and tingling in the hand. It was at this point in time that Dr. D desired obtaining electrodiagnostic studies of the right upper extremity and in his words, “To evaluate possible cervical radiculitis.”

• 3. Nine pages of Ohio Bureau of Worker’s Compensation forms were reviewed. These included C-84’s, C-94A’s, C-86’s, C-9’s, all signed by MS. XXXX or Dr. D. These forms dated between January 11, 19XX and August 15, 2XXX. The final work capacity form signed by Dr. D. Specifically the C-86 dated March 26, 19XX requested payments for loss wage benefits and requested additional allowances for major depressive disorder and generalized anxiety disorder as well as for authorization for outpatient psychotherapy treatment. The C-9 dated August 15, 2XXX requested allowance for carpal tunnel syndrome of the right upper extremity.

• 4. The job description and physical requirements of the position held by MS. XXXX at THE COMPANY completed by MS. XXXX from I M GROSS ATTORNEYS, LPA, dated January 21, 19XX was reviewed.

• 5. A psychological evaluation report dated January 11, 19XX completed by J M PING Conclusions was reviewed. Impressions were that MS. XXXX suffered from a major depressive disorder and general anxiety disorder which, based on his opinion, were disorders developed as a result of the injury of June 7, 19XX, and that MS. XXXX would require ongoing treatment and evaluation.

• 6. Correspondence from RISK E EVALUATORS’ C. M. WORK, dated April 3, 2XXX, noting that the employer will approve the EMG and nerve conduction study for diagnostic purposes only.

• 7. Electrodiagnostic studies performed by Dr. H. dated May 26, 2XXX on the right upper extremity indicated that there was electrophysiologic evidence of moderate right carpal tunnel syndrome. These studies demonstrated no electrophysiologic evidence of cervical radiculopathy, brachioplexopathy, other entrapment neuropathy, polyneuropathy, or myopathy involving the right arm.

Diagnosis

1. Right lateral epicondylitis, 19XX.

2. Status post right rotator cuff tear and subsequent repair, 19XX.

3. Diagnosed with right shoulder tendonitis, 19XX.

4. Tendonitis of the right flexor carpiradialis, 2XXX.

5. Diagnosis of right carpal tunnel syndrome, 2XXX.

6. Obesity.

7. Diagnosed with depression and anxiety, 19XX.

8. Inflammation bilaterally of the hands and wrists, unknown etiology.

SUMMARY: The following conclusions are based on the available medical records, the history as supplied by Ms. XXXX, and the physical examination that I performed on November 15, 2XXX. It should be noted that the only allowed condition of this claim, of which I am aware, is for a right lateral epicondylitis. This was after contacting MANAGED CARE ORGANIZATION and speaking with the CASE MANAGER.

It is apparent by the information available that Ms. XXXX has had ongoing right elbow and right shoulder problem since 19XX. The right rotator cuff tear and subsequent repair has left Ms. XXXX with ongoing persistent pain problems in her right shoulder. It was apparent by the available medical records that Ms. XXXX had no complaints consistent with upper extremity neurological involvement until such was documented in October 19XX, when it was suggested that she may have a cervical radiculopathy. This was the first documented evidence of any possible neurological problems affecting Ms. XXXX or her right upper extremity. This leaves a gap of more than two years, from the time of the injury to the development of her hand symptoms. While it is true that some conditions develop because of a pre-existing condition, the belief that carpal tunnel is work related is primarily based on the concept of overuse, where occupational behaviors including heavy manual labor, repetitive stress or other injury are thought to be the predisposing (or definitive) cause of the development of an entrapment neuropathy, such as carpal tunnel syndrome.

The Medical Disability Advisor, Third Edition, warns that the diagnosis of carpal tunnel is controversial. The Medical Disability Advisor adds that causes may include highly repetitive wrist motion or sustained posturing of the wrist in awkward positions, but that the actual cause of carpal tunnel syndrome is swelling and inflammation about the nerve which may be caused by fluid retention, which itself can be related to late stages of pregnancy, menopause, use of birth control pills, hypothyroidism, fracture of the wrist or chronic inflammatory conditions such as rheumatoid arthritis among others. Additionally, diabetes is thought to be an additional risk factor for development of carpal tunnel syndrome. Obesity is also often believed to be a risk factor for the development of the condition.

In July 1997, the National Institute for Occupational Safety and Health made an attempt to review the literature regarding carpal tunnel syndrome (and other conditions). In their publication, Musculoskeletal Disorders and Workplace Factors, a Critical Review, of all the articles available for carpal tunnel syndrome at that time, six articles met their criteria for evaluation. The conclusions among the different articles varied between that there was no difference between low and high risk exposures, that there was some degree of risk associated with repetitiveness, that risk was associated with age rather than activity, to no association between either repetition or posture being a cause or effect of carpal tunnel syndrome. The conclusion’s of this review is that there is weak, but not absent, evidence found for an association between occupation and the disease. Also absent in the review was a dose/effect relationship between the development of carpal tunnel syndrome and work, yet the evidence regarding specific occupational risk factors, such as force, repetition or posture were not consistently present with regard to the development of carpal tunnel syndrome. The concept that carpal tunnel syndrome should be considered a work related condition, although commonly accepted, is not 100%, as in fact more than half of all cases of carpal tunnel syndrome diagnosed are not considered to be work related.

In addition to this, Ms. XXXX has not worked for four years. By her own admission, she has been doing markedly less activity over the past several years, especially the past one to two years, than she did previously. She’s been having pain as her primary complaint in both hands and wrists, with the numbness and tingling affecting her right upper extremity in a more pronounced manner in the past six months. According to an article in the Journal of the Southwest Orthopedic Association, by Robert R. Slater, Jr., M.D., titled “Carpal Tunnel Syndrome: Concepts,” he too notes that occupation or job related hand or wrist overuse as risk factors for developing carpal tunnel is highly controversial. Dr. Slater noted that the most common symptom is paresthesias in the distribution of the median nerve. Although pain can be present, the presence of pain without paresthesias is much less common than the presence of paresthesias without pain. This means, at least by the statements that Ms. XXXX made, that she was having pain and discomfort in her upper extremities for a year or better before developing the numbness in her right hand.

Thus, I have several significant qualms with the idea that the development of Ms. XXXX’s carpal tunnel syndrome would be directly or causally related to a specific incident that occurred more than four years previously. The June 7, 19XX work incident affected her right elbow and (apparently) also her right shoulder. She has multiple risk factors for the development of carpal tunnel syndrome including obesity, as well as an ongoing inflammatory process affecting her hands and wrists, which has not been evaluated to date or diagnosed. She also has a history of marked polyuria and nocturia, which although she stated that she does drink a lot of fluids, may be a sign of her having diabetes. She also has not been evaluated for the presence or absence of thyroid disease. Additionally, Ms. XXXX had no complaints of hand or wrist pain or paresthesias (numbness and tingling) for more than two years after the work related incident affected a distinctly separate anatomic area, her right elbow (and possibly also her right shoulder). Therefore, it is my medical opinion that within a reasonable degree of certainty there has been shown no direct and causal relationship between the specific work related incident in 19XX and resultant injuries to her right elbow (and shoulder) and the development of carpal tunnel syndrome XX years later.

I had informed Ms. XXXX that there would be no physician-patient relationship established during the course of this assessment, but I also told her that if I found anything of significance affecting her health, I would inform her of such information. Thus, as it is apparent that Ms. XXXX is suffering from an ongoing and markedly debilitating active inflammatory process affecting her wrists and hands, she was strongly advised to follow up with a rheumatologist at her earliest convenience.

I hope the above information has been helpful. If any additional information does become available, its review may or may not alter my conclusions contained within this report. If you have further questions related to this report, please feel free to contact me at your convenience.

Respectfully submitted,

Grumpy Oldie, M.D., FAADEP

Certified Independent Medical Examiner, ABIME

After Example - Using Color, Alternate Formatting, and Diagrams

Report Table of Contents

CHIEF COMPLAINT:3

HISTORY OF PRESENT ILLNESS:3

Past Medical History6

FAMILY HISTORY:7

SOCIAL HISTORY:7

OCCUPATIONAL HISTORY:7

REVIEW OF SYSTEMS:7

PAIN ASSESSMENT:8

Physical Examination8

Review of Medical Records11

Diagnosis12

Summary12

Medical Analysis Conclusion14

The Medical Disability Advisor17

Date:

Managed Care Organization

Attn: Case Manager

Address

City, State Zip Code

Claimant: Ms. XXXX

BWC Number:

Date of Injury :

Social Security Number:

Employer : THE COMPANY

Allowed Conditions: Right Lateral Epicondylitis

Dear Case Manager:

At your request, I performed an independent medical examination on Ms. XXXX on November 15, 2XXX. It was explained to Ms. XXXX that the purpose of this examination was for evaluation purposes only and that no treatment would be undertaken. It was further explained to her that the client requesting and paying for the assessment would receive a report. Lastly, it was explained to Ms. XXXX that no medical relationship would be formed; thus no physician-patient relationship would be established during the course of this assessment.

A request is being made for an additional allowance of right carpal tunnel syndrome

CHIEF COMPLAINT: Hand pain and numbness .

HISTORY OF PRESENT ILLNESS: The following narrative was told to the examiner by Ms. XXXX and was dictated in her presence.

Ms. XXXX denied having an prior history of neck , upper back , shoulder , or upper extremity problems before 19XX. MS. XXXX worked intermittently for THE COMPANY since approximately 19XX. In 19XX she was rehired and worked at THE COMPANY continuously until 19XX.

THE COMPANY is now known as THE COMPANY. MS. XXXX worked as an equipment technician, where she ran a bender and/or saws. She stated that the bender machine did not run properly. She said when operating the bender, she would slide parts for framing windows. In the spring of 19XX the machine jerked and caused her to jerk her right arm .

She stated that she quickly had right lateral elbow swelling and pain , but that her entire arm also hurt. She was initially diagnosed as having tennis elbow. X-rays were performed. She was told to use a forearm or (tennis elbow) band. She had injections over a period of several visits.

At this point in time she was seeing her family doctor, but continued to work , usually seven days a week.

Ms. XXXX indicated that her elbow and arm continued to bother her, especially her shoulder . She complained of having shoulder pain at night, which would wake her. She stated that placing her shoulder and arm in a sling type position seemed to help decrease the discomfort . Once every other week, the pain in her right shoulder would become excruciating, at which time the pain would radiate into the right arm to the elbow. Using ice seemed to help, sometimes. The pain in the shoulder was so severe at times that she was unable to go to work .

One morning sometime in mid to late October 19XX, she could not use her shoulder because of severe pain and swelling. She thought that the last day she worked was October 13, 19XX. She followed up with Dr. K at her family physician’s office, who referred her to an orthopedic surgeon, Dr. D. An arthrogram was subsequently performed and a tear in the right rotator cuff was found. She had surgery to repair the right rotator cuff in December 19XX (surgery had been delayed secondary to problems with her asthma and chronic bronchitis).

Ms. XXXX stated that she has had significant pain since before and after having surgery to her right shoulder . She stated the pain has not improved since surgery, but does wax and wane in severity. She attended six weeks of physical therapy at HHHH HOSPITAL and then eight additional weeks performing work hardening at CCCC CENTER. She underwent several nerve blocks, which relieved the pain only briefly. She also spent six weeks in the pain program at THE CENTER in Columbus, Ohio. She finished that program in September 19XX. She stated that the program did not help relieve her pain.

She has pain when lying on her shoulder , at night the pain wakes her up. She has severe pain approximately once a month. She had no improvement in shoulder movement after surgery . The severity of the shoulder pain varies significantly. She can be moderately pain free at rest. Using ice does help. Reaching forward is less bothersome than reaching laterally. Reaching behind her is especially bothersome.

She occasionally gets neck and right upper back pain and spasms. Pain worsens with lifting, such that she can no longer lift a one gallon jug of milk.

She has difficulty getting groceries out of her car. She has markedly decreased activities of daily living such as house cleaning, because of the shoulder pain and right upper extremity weakness .

She now has to get help performing her normal housekeeping chores. She had decreased sleep secondary to her shoulder problem, but it has worsened because of her recent hand difficulties.

Currently on Social Security Disability

She stated that she has been on Social Security Disability since 19XX. She is unable to lift like she used to. She is also unable to perform repetitive activities using her shoulders. Her right shoulder strength is markedly decreased. She stated that her right elbow has not been treated or evaluated since 19XX. The right elbow pain is not as severe as it was initially after the accident . The right elbow can be pain free for several days in a row.

The right elbow can be exacerbated with lifting type activities and can be painful for several days in a row.

She believes her right elbow has some swelling in it on a fairly persistent basis. She wears a forearm band which does seem to help when she has to lift.

She has had some right hand or other upper extremity difficulties for the past 9–12 months. Her right hand , including all digits and the thumb , can go numb . This can occur during the day, but especially happens at night. It can wake her several times a night and the numbness can be present when she wakes up in the morning.

She also noted that she has recurrent right hand swelling. She noted that this numbness can last for a while. She said because of her right upper extremity difficulties she has been using her left hand more (especially since the shoulder injury ). She denied having any left handed numbness, but she has had pain at the ulnar side of the left wrist and hand for several months.

Diagnosis of Carpal Tunnel Syndrome ~ Surgery Recommended

Dr. D has been evaluating her for her upper extremity difficulties and had wanted to do electrodiagnostic testing of the right upper extremity. This was not completed until May 2XXX, when testing by Dr. H demonstrated right carpal tunnel syndrome . Dr. D advised her to undergo carpal tunnel release, but she is not certain if she wants this performed. She has been dropping objects with both hands. She has recurrent hand swelling, the right usually worse than the left . The left has been bothering her more recently. She uses a wrist splint on the right side at night which helps decrease her symptoms. She also uses a left wrist band, which helps support her left wrist.

She recently lifted a jewelry box, maybe 5 pounds in weight , with her left hand . She ended up dropping the box. It twisted her left wrist , which increased her left wrist pain . She specifically denied ever having any injuries to her upper extremities since 1996.

As part of this claim , she stated that she has been seen for both depression and anxiety . She has been treated by a psychologist for this condition.

She denied having any testing for thyroid , arthritis , or diabetes . She stated that she has had a 20–30 pound weight loss over the past year. She complained of having decreased weight, decreased sleep , decreased appetite, but denied having any fevers.

She stated that she has nocturia, which has increased recently, although she indicated that she has also increased her fluid intake recently.

During the discussion with Ms. XXXX regarding the development of her symptoms, she persistently reiterated that she had no problems with her hands until after she had injured her right upper extremity. She noted that she has had a gradual onset of bilateral hand and wrist symptoms over the past several years.

No New Incident Reported During Time Frame of Interest

She specifically denied any new incident or injury to her upper extremities during this time frame. Over the past year, she has been less able to extend her fingers . This has worsened to the point where she is no longer able to fully extend certain fingers of both hands. Her hands are very stiff in the morning. This can last easily for half an hour or longer. She stated that some mornings she has to pry her fingers open. She complained of having ongoing finger pain and stiffness, as well as wrist pain and stiffness.

She has recurrent swelling in her distal upper extremities, primarily involving the hands and fingers . She reiterated that her right hand is worse than her left , but that the left has very similar if not identical symptoms to the right, except for the lack of tingling and numbness .

Past Medical History

Ms. XXXX has undergone the following surgeries:

• 1. surgical repair of her right earlobe,

• 2. 19XX; hysterectomy, bilateral salpingo-oophorectomy,

• 3. and appendectomy, 19XX;

• 4. low back surgery (L3 -4 , L4 -5 ) with residual left leg symptoms from nerve damage, 19XX;

  Right rotator cuff repair, 19XX.

Ms. XXXX Has the Following Medical Conditions

• 1. She has been hospitalized for hemoptysis,

• 2. 19XX and for hypertension, 19XX.

• 3. Other past medical problems have included a history of sinus and allergy problems since 19XX;

• 4. diagnosis of irritable bowel syndrome in 19XX;

• 5. history of recurrent bladder infections;

• 6. a history of gastric ulcers times two, 19XX or 19XX, also associated with gastritis and accompanying esophageal stricture, status post dilation.

• 7. She also was diagnosed with hypertension,

• 8. 19XX; diagnosed with asthma, 19XX;

• 9. diagnosed with coronary artery disease with a 50% posterior coronary block,

• 10. 19XX; and diagnosed with depression and anxiety , 19XX.

• 11. Past musculoskeletal problems include a removal of a ganglionic cyst from her right hand in the 19XXs,

• 12. the low back injury with resultant surgery in 19XX,

• 13. diagnosis of left knee bursitis requiring drainage in 19XX,

• 14. the diagnosis of tennis elbow in 19XX,

• 15. the right rotator cuff tear and rotator cuff repair in 19XX,

• 16. diagnosis of right shoulder tendonitis ,

• 17. 19XX; diagnosis of right forearm tendonitis,

• 18. 2XXX and diagnosis of carpal tunnel syndrome ,

• 19. 2XXX. Medications include Prilosec, Ultram, Soma compound, Elavil, Allegra, Tenormin, Albuterol, Singulair, Flovent, Seravent, Estratab, and an aspirin a day.

• 20. She denied having any allergies to medications.

FAMILY HISTORY: There is a family history of high blood pressure , heart attack, stroke, bleeding problems, ulcers, obesity , birth defects, diabetes , cerebral palsy, asbestosis and cancer. Her father is deceased at the age of __ years from asbestos disease and cancer. Her mother is alive and well at the age of __ years. She has ____ brothers, ages ______ who are all alive and well, except that the oldest and youngest both have diabetes. She has ____ living children, ages_______. A sixth child was born with cerebral palsy and died in 19XX. She is currently divorced from her only marriage.

SOCIAL HISTORY: She has not smoked in 5–6 years, but does have a 15–20 pack year smoking history. She does not consume alcohol and denied recreational drug use. She does enjoy reading, primarily the bible. She occasionally plays card games or checkers with her grandchildren. She denied performing any repetitive hand activities as far as hobbies. She denied performing any regular exercise, although she does try to walk once a week. She has no pets at home. She wears glasses.

OCCUPATIONAL HISTORY: Ms. XXXX worked at ANOTHER COMPANY in SOMEPLACE, Ohio from 19XX – 19XX doing spot welding on an automatic sealer. After that she worked at ANOTHER PLACE cleaning offices from 19XX – 19XX. She also worked at A NURSING HOME as a nursing assistant from 19XX – 19XX.

She worked continuously at THE COMPANY (formerly THE COMPANY) from 19XX – 19XX, and also worked there previously on an intermittent basis and during lay-offs she worked at nursing homes.

She has had past occupational exposures to grinding dust, metal dust, other dust, engine exhaust, smoke, other fumes mists or vapors, ammonia, welding fumes, acids and/or caustics, oils, metal coolants, viruses, noise, cold, heavy lifting, change in shift work , repetitive mechanical work and poor lighting.

REVIEW OF SYSTEMS: She is a gravida X, para X, with X living children. She has a history of bleeding problems. There is a history of hemophilia in the family. She has trouble sleeping. She has intermittently blurry vision. She has persistent ringing in her ears since 19XX. She has a history of sinus problems.

She has a history of cough, some shortness of breath at rest, recurrent wheezing and congestion. She has coughed up blood in the past, including while at work in 19XX-19XX. She has a history of chest pain , but this has been less since resuming female replacement hormones. She also has a history of heart flutter and a history of high blood pressure . She complains of having a change of appetite and of having heart burn.

She does get up a lot at night to urinate. She has complaints of anxiety , depression , confusion, and memory problems. She has a history of pain , swelling, or stiffness in her joints, arthritis , pain or numbness in her extremities, of having muscle cramps, of having low back pain or stiffness, of having neck pain or stiffness, of having swelling in her ankles, and of having some joint deformities and decreased function .

PAIN ASSESSMENT: On the Borg’s pain scale, she rated her current pain as a 5. On the Borg’s pain scale, 0 is no pain at all and 10 is a very very strong pain. She indicated that over the past 30 days her best level of pain was a level 5 and at it’s worst it was a level 8. She stated that she is more limited by her hand movements than the pain. With further questioning, she noted that she did not get pain in the tip of her tailbone, that her whole leg does not become painful, nor does it go numb , nor does it give away.

She did indicate that she has not had any spells with very little pain during the past year. These answers were not the same as those when she initially answered the questionnaire. On the Visual Analogue Pain Scale, she marked near the 50% mark, which correlates with her responses on the Borg’s Analogue Pain Scale. Her responses on the McGill Pain Questionnaire totaled 33, which demonstrates a tendency to abnormal psychodynamics. Her responses on the Ransford Pain Drawing are consistent with the stated complaints. Ms. XXXX’s responses using the pain assessment tools do not indicate significant pain symptom magnification, but are not entirely normal.

Physical Examination

General

This was a well-developed, well-nourished right hand dominant over weight 54 year old black female with short black hair and glasses. Her vital signs were all normal except for mildly elevated blood pressure at 152/96. Her height was 5′ 6 ½″ tall. Her weight was 217 pounds. Although she was pleasant and cooperative throughout the interview process and during the examination, her responses seemed somewhat delayed. Her affect appeared flat. In general, she appeared to be somewhat depressed .

Gait and Motion

She ambulated somewhat slowly with a wide based gait and a slight limp. Neck range of motion was mildly decreased, especially left lateral bending.

No guarding was observed during active neck range of motion. There was no pain elicited with gentle cervical compression. No masses were palpated in the neck.

Spinal Examination

There was posterior cervical paraspinal muscle tenderness palpated especially at both occiputs, as well as point tenderness of the central right cervical paraspinal muscles. There was tenderness to palpation of the right rhomboid, right trapezius, and right infraspinatus muscles. There was no tenderness to palpation of the cervical or thoracic spine. Back range of motion was fair with some decreased anterior flexion and lateral bending. No scapular winging was appreciated. A well healed lower mid-line surgical back scar was visualized.

Multiple Tender Points Reported

Multiple tender points were palpated including over the left greater trochanter, left buttock, both trapezius muscles, at the occiput bilaterally, both rhomboids, at the right anterior chest, right deltoid, and right dorsal forearm. A well-healed surgical scar was visualized over the anterior portion of the right shoulder .

Active Shoulder Range of Motion: revealed the following:

• (a) Right shoulder abduction was 80°

• (b) Left shoulder abduction was 120° (normal being 170°+).

• (c) Right shoulder adduction was 10°

• (d) Left shoulder adduction was 30° (normal being 50°).

• (e) Right shoulder flexion was 90°

• (f) Left shoulder flexion was 135° (normal being 180°)

• (g) At 90° of abduction (somewhat less on the right),

• (h) Left external and internal rotation reached 45°, (normal internal rotation being 80° or greater,

• (i) External rotation being 60° or greater).

• (j) Right internal shoulder rotation at approximately 80° of shoulder abduction, reached 35° with the above normals previously being described.

• (k) No right shoulder external rotation was elicited.

• (l) No shoulder laxity was elicited.

• (m) There was tenderness to palpation of the right anterior chest, throughout the right glenohumeral joint , the right acromioclavicular joint and right deltoid.

The anterior chest and deltoid tenderness was limited to point tenderness. There was no right arm or clavicle tenderness to palpation. No obvious swelling, deformity, or atrophy was appreciated, except at the hands. There was marked decreased strength of the right shoulder and was associated with give way weakness.

A well healed scar was visualized on the left dorsal radial wrist .

Upper Extremity Examination

There was tenderness to palpation of the left wrist , at the anatomic stuff box, and of the left hand , especially at the metacarpal phalangeal joints, and over the second through fifth proximal interphalangeal (PIP) finger joints.

This tenderness was slightly less over the third PIP. There was also slight discomfort to palpation at the left distal interphalangeal finger joints. There was some slight swelling throughout the hands and wrists primarily over the metacarpal phalangeal joints and fingers. No thenar atrophy was appreciated.

There was also tenderness to palpation over the right wrist , right anatomic stuff box, and over the right metacarpal phalangeal finger joints and second and third proximal interphalangeal finger joints. The right hand swelling was similar to that of the left . She complained of mildly decreased sensation throughout the fingers and thumb of the right hand , especially over the thumb, third and second digits. She had markedly decreased grip strength bilaterally. She also had markedly decreased opposition of her thumb with the fourth and fifth fingers, especially on the right.

No crepitus was appreciated of either upper extremity. There was decreased supination bilaterally and decreased wrist flexion and extension, especially on the left . Finklestein’s maneuver elicited no symptoms bilaterally. Elbow flexion appeared to be mildly decreased but was symmetrical, with decreased elbow extension, the right reaching 160° while the left reaching 170° (normal being 180°). There was tenderness to palpation of the right lateral epicondyle and into the adjacent dorsal forearm, but not at the olecranon or antecubital fossa. Pulses were normal and symmetrical at the radial arteries.

Tendon Reflexes

Reflexes were normal and symmetrical at the biceps, triceps, and brachioradialus tendons.

Finger movements were markedly slow. She was unable to fully extend all of her fingers (digits). Flexion deformities at the PIPs existed, especially at the right third and fourth PIP joints, as well as the left third PIP joint . Sensory examination of the digits was grossly intact to light touch, pressure, as well as to pin prick, but with complaints of decreased sensation on the right side.

Sensation and Strength

Two point discrimination testing was diminished on the right , but somewhat inconsistent varying between 5–10 millimeters two point perception, especially decreased at the right thumb and index finger of the right hand . Capillary refill was brisk in all digits. No gross bony deformities were present at the wrists or hands. Upper extremity strength was generally decreased at the elbows, wrists, and forearms. This was more so on the right, but was also associated with give way weakness.

Hand strength grip testing was evaluated using a Jamar dynamometer. In the number 3 position while rapidly alternating strength testing between the right and left hand s through a total of at least five cycles, the right hand strength varied between 10–19 pounds per square inch and the left hand grip strength varied between 12–34 pounds per square inch. Grip strength testing using the Jamar dynamometer throughout all positions did not yield the normally expected bell-shaped curve for either hand with the right hand strength varying between 9 and 14 pounds per square inch and left hand strength varying between 8 and 18 pounds per square inch.

The results of grip strength testing using the Jamar dynamometer were not consistent with good examinee effort.

AMA Guides Grip Strength Data

It should be noted that according to the AMA ’s Guides to the Evaluation of Permanent Impairment , Fourth Edition, that the average grip strength for a 50–59 year old female should be approximately 49 pounds per square inch in the dominant hand and 40 pounds per square inch in the non-dominant hand. It is also noted that tests that are repeated at intervals are considered to be more reliable if there is less than 20% variation readings and that if there is more than a 20% variation, one may assume the patient is not exerting full effort. It should be noted that the variation in strength of Ms. XXXX’s right hand was almost 100% when rapidly alternating the grip strength testing and more than 100% variation in her left hand . Thus, these results are not consistent with good examinee effort.

Review of Medical Records

One hundred and nine pages of medical records were reviewed.

• 1. Seventy-four pages of Ohio Bureau of Worker’s Compensation C-141 forms were evaluated. These are wage loss statements for job search.

• 2. Seventeen pages of office notes, correspondence, as well as prescriptions from the ORTHOPEDIC PLACE were reviewed. These included at least 25 different office entries and were dated from October 30, 19XX through August 10, 2XXX. There were entries for every year. It should be noted that no mention of involvement concerning her hands was noted until July 8, 19XX when her pain was noted to extend from the base of her neck down into the arm and including the fingers and hands. It was also noted at that time that she had numbness and tingling in the hand . It was at this point in time that Dr. D desired obtaining electrodiagnostic studies of the right upper extremity and in his words, “To evaluate possible cervical radiculitis .”

• 3. Nine pages of Ohio Bureau of Worker’s Compensation forms were reviewed. These included C-84’s, C-94A’s, C-86’s, C-9’s, all signed by MS. XXXX or Dr. D. These forms dated between January 11, 19XX and August 15, 2XXX. The final work capacity form signed by Dr. D. Specifically the C-86 dated March 26, 19XX requested payments for loss wage benefits and requested additional allowances for major depressive disorder and generalized anxiety disorder as well as for authorization for outpatient psychotherapy treatment . The C-9 dated August 15, 2XXX requested allowance for carpal tunnel syndrome of the right upper extremity.

• 4. The job description and physical requirements of the position held by MS. XXXX at THE COMPANY completed by MS. XXXX from I M GROSS ATTORNEYS, LPA, dated January 21, 19XX was reviewed.

• 5. A psychological evaluation report dated January 11, 19XX completed by J M PING Conclusions was reviewed.

  Impressions were that MS. XXXX suffered from a major depressive disorder and general anxiety disorder which, based on his opinion, were disorders developed as a result of the injury of June 7, 19XX, and that MS. XXXX would require ongoing treatment and evaluation .

• 6. Correspondence from RISK E EVALUATORS’ C. M. WORK, dated April 3, 2XXX, noting that the employer will approve the EMG and nerve conduction study for diagnostic purposes only.

• 7. Electrodiagnostic studies performed by Dr. H. dated May 26, 2XXX on the right upper extremity indicated that there was electrophysiologic evidence of moderate right carpal tunnel syndrome .

These studies demonstrated no electrophysiologic evidence of cervical radiculopathy , brachioplexopathy, other entrapment neuropathy, polyneuropathy, or myopathy involving the right arm .

Diagnosis

• 1. Right lateral epicondylitis , 19XX.

• 2. Status post right rotator cuff tear and subsequent repair, 19XX.

• 3. Diagnosed with right shoulder tendonitis , 19XX.

• 4. Tendonitis of the right flexor carpiradialis, 2XXX.

• 5. Diagnosis of right carpal tunnel syndrome , 2XXX.

• 6. Obesity .

• 7. Diagnosed with depression and anxiety , 19XX.

• 8. Inflammation bilaterally of the hands and wrists, unknown etiology.

Summary

The following conclusions are based on the available medical records , the history as supplied by Ms. XXXX, and the physical examination that I performed on November 15, 2XXX. It should be noted that the only allowed condition of this claim , of which I am aware, is for a right lateral epicondylitis . This was after contacting MANAGED CARE ORGANIZATION and speaking with the CASE MANAGER.

It is apparent by the information available that Ms. XXXX has had ongoing right elbow and right shoulder problem since 19XX. The right rotator cuff tear and subsequent repair has left Ms. XXXX with ongoing persistent pain problems in her right shoulder .

It was apparent by the available medical records that Ms. XXXX had no complaints consistent with upper extremity neurological involvement until such was documented in October 19XX, when it was suggested that she may have a cervical radiculopathy .

This was the first documented evidence of any possible neurological problems affecting Ms. XXXX or her right upper extremity. This leaves a gap of more than two years, from the time of the injury to the development of her hand symptoms. While it is true that some conditions develop because of a pre-existing condition, the belief that carpal tunnel is work related is primarily based on the concept of overuse, where occupational behaviors including heavy manual labor , repetitive stress or other injury are thought to be the predisposing (or definitive) cause of the development of an entrapment neuropathy, such as carpal tunnel syndrome .

The Medical Disability Advisor, Third Edition, warns that the diagnosis of carpal tunnel is controversial. The Medical Disability Advisor adds that causes may include highly repetitive wrist motion or sustained posturing of the wrist in awkward positions, but that the actual cause of carpal tunnel syndrome is swelling and inflammation about the nerve which may be caused by fluid retention, which itself can be related to late stages of pregnancy, menopause , use of birth control pills, hypothyroidism, fracture of the wrist or chronic inflammatory conditions such as rheumatoid arthritis among others. Additionally, diabetes is thought to be an additional risk factor for development of carpal tunnel syndrome. Obesity is also often believed to be a risk factor for the development of the condition.

In July 1997, the National Institute for Occupational Safety and Health made an attempt to review the literature regarding carpal tunnel syndrome (and other conditions). In their publication, Musculoskeletal Disorders and Workplace Factors, a Critical Review, of all the articles available for carpal tunnel syndrome at that time, six articles met their criteria for evaluation .

The conclusions among the different articles varied between that there was no difference between low and high risk exposures, that there was some degree of risk associated with repetitiveness, that risk was associated with age rather than activity, to no association between either repetition or posture being a cause or effect of carpal tunnel syndrome . The conclusion’s of this review is that there is weak , but not absent, evidence found for an association between occupation and the disease.

Also absent in the review was a dose /effect relationship between the development of carpal tunnel syndrome and work , yet the evidence regarding specific occupational risk factors, such as force, repetition or posture were not consistently present with regard to the development of carpal tunnel syndrome. The concept that carpal tunnel syndrome should be considered a work related condition, although commonly accepted, is not 100%, as in fact more than half of all cases of carpal tunnel syndrome diagnosed are not considered to be work related.

In addition to this, Ms. XXXX has not worked for four years. By her own admission, she has been doing markedly less activity over the past several years, especially the past one to two years, than she did previously.

She’s been having pain as her primary complaint in both hands and wrists, with the numbness and tingling affecting her right upper extremity in a more pronounced manner in the past six months. According to an article in the Journal of the Southwest Orthopedic Association, by Robert R. Slater, Jr., M.D., titled “Carpal Tunnel Syndrome : Concepts,” he too notes that occupation or job related hand or wrist overuse as risk factors for developing carpal tunnel is highly controversial.

Dr. Slater noted that the most common symptom is paresthesias in the distribution of the median nerve. Although pain can be present, the presence of pain without paresthesias is much less common than the presence of parasthesias without pain. This means, at least by the statements that Ms. XXXX made, that she was having pain and discomfort in her upper extremities for a year or better before developing the numbness in her right hand .

Thus, I have several significant qualms with the idea that the development of Ms. XXXX’s carpal tunnel syndrome would be directly or causally related to a specific incident that occurred more than four years previously. The June 7, 19XX work incident affected her right elbow and (apparently) also her right shoulder .

She has multiple risk factors for the development of carpal tunnel syndrome including obesity , as well as an ongoing inflammatory process affecting her hands and wrists, which has not been evaluated to date or diagnosed. She also has a history of marked polyuria and nocturia, which although she stated that she does drink a lot of fluids, may be a sign of her having diabetes . She also has not been evaluated for the presence or absence of thyroid disease. Additionally, Ms. XXXX had no complaints of hand or wrist pain or paresthesias (numbness and tingling) for more than two years after the work related incident affected a distinctly separate anatomic area, her right elbow (and possibly also her right shoulder ).

Medical Analysis Conclusion

Therefore, it is my medical opinion that within a reasonable degree of certainty there has been shown no direct and causal relationship between the specific work related incident in 19XX and resultant injuries to her right elbow (and shoulder ) and the development of carpal tunnel syndrome XX years later.

I had informed Ms. XXXX that there would be no physician-patient relationship established during the course of this assessment, but I also told her that if I found anything of significance affecting her health , I would inform her of such information. Thus, as it is apparent that Ms. XXXX is suffering from an ongoing and markedly debilitating active inflammatory process affecting her wrists and hands, she was strongly advised to follow up with a rheumatologist at her earliest convenience.

I hope the above information has been helpful. If any additional information does become available, its review may or may not alter my conclusions contained within this report. If you have further questions related to this report, please feel free to contact me at your convenience.

Respectfully submitted,

Grumpy Oldie, M.D., FAADEP

Certified Independent Medical Examiner, ABIME

Report Word Index

A

Abdominal, 44

Abuse, 44

Alcohol, 7, 44

AMA, 11

Arthritis, 6, 8, 14, 18, 26, 36

Osteoarthritis, 18, 26

Rheumatoid, 14, 18, 26, 36

Asbestos, 7

Atrophy, 10, 26, 36

B

Benefit, 12

Bladder, 7

Bowel, 7

Bursitis, 7, 26, 36

C

Calcification, 18, 26

Causation, 13, 14, 15, 18, 26, 36, 44

Injured, 6

Preexisting, 13, 26

Previous, 26, 36, 44

Prior, 3, 44

Recurrence, 18, 44

Remission, 44

Cerebral, 7

Chronic fatigue, 44

Chronic Fatigue Syndrome, 44

Claim, 5, 13

Cognitive, 44

Compensation, 12

Compliance, 18

Contusion, 36

D

Degenerative, 36

Depressive, 12, 44

Deterioration, 36

Diagnostic, 12, 26, 44

Electrodiagnostic, 5, 12

Disability, 5, 13, 18, 26, 36, 44

Disorder, 12, 44

Dysfunction, 44

E

Ecchymosis, 36

Electrophysiologic, 12

Employer, 3, 12, 18, 26

Endocrine

Menopausal, 13

Endocrine Disease

Diabetes, 6, 7, 14, 15, 26, 36, 44

Thyroid, 6, 15

Entrapment, 12, 13, 18, 26

Carpal Tunnel, 3, 5, 7, 12, 13, 14, 15

Cubital Tunnel, 18

Ulnar Neuropathy, 18

Epicondylitis, 3, 13, 18

Evaluation, 3, 11, 12, 14, 18, 26, 44

F

Fatigue, 44

Finding

Guarding, 9

Function, 8, 18, 26, 36, 44

H

Head, 26

Headache, 44

Health, 14, 15, 18, 26, 44

Hearing, 36, 44

High blood pressure, 7, 8

I

IME, 15

Impairment, 11, 26

Inconsistent, 11

Independent, 3, 15

Independent Medical Evaluation, 15

Infection, 18, 36

Injury, 3, 5, 6, 7, 12, 13, 26, 36, 44

Accident, 5

J

Joint, 8, 10, 11, 18, 26, 36

L

Labor, 13, 36

Lateral, 3, 4, 9, 10, 13, 18

Lower, 9, 26

Lower Extremity

Ankle, 36

Calf, 36

Foot, 36

Knee, 36

Left knee, 7

Leg, 6, 8

Lumbar

L3, 6

L3-4, 6

L4, 6

L4-5, 6

M

Medial, 18

Medical records, 11, 13

Medication, 18, 36, 44

Menopause, 13

Mental, 44

Migraine, 44

Mood, 44

Motion, 9, 13, 18, 26, 36

Motor vehicle, 44

MRI, 18, 26, 36

Musculoskeletal, 7, 14

Muscle, 8, 9, 18, 26, 36

Strain, 36

N

Neurologic

Radiculitis, 12, 36

Neurological, 13, 44

Brain, 44

Motor, 4, 5, 10, 11, 14, 18, 26, 36, 44

Paresthesias, 14, 15

Radiculopathy, 12, 13, 18, 36

Rating, 44

Sensory, 3, 5, 6, 8, 11, 12, 14, 15

Neurovascular, 36

O

Obesity, 7, 13, 14, 15

Occupation, 14, 18, 26, 36, 44

Occupational, 8, 13, 14, 18, 26, 36

P

Pain, 3, 4, 5, 6, 8, 9, 12, 13, 14, 15, 18, 26, 36, 44

Discomfort, 4, 10, 14

Passive modalities

Massage, 18

Posture, 14

Prognosis, 18, 26, 36, 44

Psychological, 44

Anxiety, 5, 7, 8, 12, 13, 44

Depression, 5, 7, 8, 9, 13, 44

Mania, 44

MMPI, 44

Motivation, 44

Personality, 44

Psychotherapy, 12, 44

R

Repetitive, 5, 7, 8, 13, 18, 26, 36

Restrictions, 18, 26, 36, 44

S

Sexual, 44

Side

Left, 5, 6, 7, 9, 10, 11, 13

Right, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 44

Sign, 15

Sleep, 5, 6, 26

Spine

Cervical, 3, 4, 8, 9, 12, 13, 18, 26

Lumbar, 3, 4, 6, 7, 8, 9, 44

Thoracic, 9

Status

Better, 14, 18, 26, 36, 44

Worst, 8

Studies

Bone scan, 36

MRI, 18, 26, 36

X-Ray, 4, 18, 26, 36

Suffering, 15, 44

Surgery

Arthroscopy, 26, 36

Symptom, 8, 14

Syndrome, 3, 5, 7, 12, 13, 14, 15, 18, 26, 36

T

Tendonitis, 7, 13, 26, 36

Therapeutic, 44

Timeframe

Acute, 18, 26, 36, 44

Chronic, 4, 14, 18, 26, 36, 44

Treatment, 3, 12, 18, 26, 36, 44

Chiropractor, 44

Massage, 18

Operation, 4, 6, 7, 18, 26, 36

Physical Therapy, 4, 18, 26, 36

U

Upper, 3, 4, 5, 6, 10, 11, 12, 13, 14, 18, 26

Upper Extremity

Arm, 4, 10, 12, 18, 26

Elbow, 4, 5, 7, 10, 18, 26

Finger, 6, 10, 11, 12, 18, 36

Hand, 3, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 18, 26, 36

Left hand, 5, 10, 11

Left shoulder, 9

Left wrist, 5, 10

Right elbow, 5, 13, 15

Right hand, 5, 6, 7, 9, 10, 11, 14

Right shoulder, 4, 5, 7, 9, 10, 13, 15

Right wrist, 10

Rotator Cuff, 4, 6, 7, 13, 26, 36

Shoulder, 3, 4, 5, 9, 13, 15, 18, 26, 36

Thumb, 5, 10, 11, 36

Wrist, 5, 6, 10, 13, 14, 15, 18, 36

V

Vascular

Artery, 7, 44

W

Weight, 5, 6, 9, 18, 44

Work, 4, 8, 12, 13, 14, 15, 18, 26, 36, 44

The Medical Disability Advisor

Epicondylitis, Medial and Lateral

Related Terms: Golfer’s Elbow , Tennis Elbow

• Definition

Epicondylitis occurs when tendons in the elbow develop inflammation, and ultimately microscopic tears and degeneration.

Many of the muscles and tendons responsible for wrist and finger movements attach in the elbow region to the upper arm bone (humerus). The areas of attachment are the bony prominences just above the elbow joint (epicondyles). The tendons develop inflammation and sometimes microscopic tears. This process is known as epicondylitis. It can occur on either on the outside (lateral ) or inside (medial ) face of the elbow. It is more commonly known as “tennis elbow” when on the lateral side and “golfer’s elbow” when on the medial side. Medial epicondylitis accounts for only about 10% to 20% of all epicondylitis (Young).

Although the cause is unknown, epicondylitis may be a result of overuse or overexertion of the forearm and wrist muscles. Up to half of all tennis players may experience epicondylitis (Disabella).

Risk: Risk increases with occupations and sports that require a repetitive or stressful movement of the forearm. Epicondylitis typically afflicts individuals between the ages of 20 and 40. Although men are twice as likely to develop medial epicondylitis as women, lateral epicondylitis affects men and women equally (Mercier).

Incidence and Prevalence: Lateral is 5 times more common than medial epicondylitis (Mercier). The exact incidence is difficult to determine, although it is estimated that lateral epicondylitis occurs in about 6 per 1,000 industrial workers (Disabella).

• Diagnosis

History: Individuals commonly report elbow pain with forceful gripping, swelling, and decreased ability to use the wrist of one arm (frequently the dominant arm). The symptoms may appear suddenly, but more often the onset is gradual and progressive. Pain is localized to the elbow region initially, but may progress to involve the muscle mass of the forearm. Individuals may relate a change in activity or increase in size and weight of tools used immediately preceding the pain. Most cases, however, occur without an obvious cause . History of neck and shoulder injuries should be noted.

Physical exam: On physical examination, pain may be localized over either epicondyle and may increase with resisted wrist motion . Bending the wrist forward against resistance (flexion) causes pain for individuals with medial epicondylitis and bending the wrist backward against resistance (extension) causes pain for those with lateral epicondylitis. Passive stretch of the involved muscle /tendon units also causes pain. As the condition becomes more chronic , pain and weakness may involve the forearm as well, especially with resisted wrist and finger motion.

Tests: An injection test, in which a local anesthetic is injected into the most tender point of the elbow , may suggest the diagnosis if the elbow pain is relieved by the injection. When the diagnosis is in doubt or if an individual fails to respond to treatment, x-rays are done to rule out bony abnormalities about the joint. MRI may show abnormal signals in the medial or lateral epicondyle but is usually unnecessary.

• Treatment

Initial conservative treatment consists of rest from the precipitating or exacerbating activity, generally anti-inflammatory medication for pain and inflammation, and a band around the proximal forearm (forearm strap or counter-force brace). The forearm strap spreads the force of the muscle contraction over a greater area, and diminishes tensile stresses on the common extensor tendon (lateral epicondylitis ) or common flexor tendon (medial epicondylitis). A wrist extension (cock-up) splint may be helpful in more severe cases. Ice often relieves pain after activity, with or without swelling. Massage may be beneficial. Stretching can be started immediately and strengthening exercises as the pain subsides.

Local anesthetic-corticosteroid injection may be used in individuals who do not improve after a few weeks of treatment. The injection may not be fully effective for 5 to 7 days and can be repeated. Splints provide restriction of both the wrist and elbow and can be used in individuals not responding to other methods of treatment.

Surgery is rarely necessary, but may be performed on individuals with pain lasting longer than 6 months despite appropriate nonoperative treatment. Surgery usually involves open release of the tendon’s origin, excision of degenerated tendon and/or inflammatory tissue, and repair of any tendon gaps or tears. Any abnormalities in the elbow joint may be addressed concurrently.

• Prognosis

Although recovery may be slow and tedious, most individuals have relief of all symptoms 1 year from onset. Conservative measures (i.e., nonsurgical) can relieve symptoms in more than 90% of the cases. Surgery relieves symptoms for more than 80% of individuals (Young), although some individuals experience pain during aggressive activities. Ulnar nerve involvement is associated with a poor prognosis. Recurrence of epicondylitis later in life is common.

• Utilization Management Knowledgebase

• ELB501 Epicondylitis , Medial

• ELB517 Epicondylitis, Lateral

• Differential Diagnoses

• Calcium deposits (calcification )

• Cervical radiculopathy

• Compartment syndrome

• Fracture

• Infection

• Inflammatory disease (rheumatoid arthritis , etc.)

• Intra-articular elbow pathology (osteoarthritis , osteochondritis dissecans)

• Irritation of the radial or ulnar nerve around the elbow (e.g., nerve entrapment )

• Ligament injuries

• Loose bodies

• Medial collateral ligament instability

• Pain traveling from another site (referred pain)

• Radial nerve compression

• Ulnar neuropathy

• Specialists

Hand Surgeon Occupational Therapist Orthopedic (Orthopaedic) Surgeon Physiatrist

Physical Therapist Rheumatologist Sports Medicine Internist

• Rehabilitation

Note on research and authorship

The primary focus of rehabilitation for medial and lateral epicondylitis is to control pain and restore function . Modalities such as cold packs may be helpful in controlling painful symptoms. Loss of motion is usually not a problem with epicondylitis. However, individuals may avoid full range of motion as a result of excessive pain. During the initial period of acute symptomatology, advise individuals to avoid any movements that exacerbate pain. Occasionally, a resting splint may be recommended. Stretching and strengthening exercises of the wrist and extrinsic hand muscles may be beneficial and, when performed in conjunction with modalities, may provide relief. Home exercises should be taught as well as pain control measure (heat and cold).

There is some evidence to support the use of topical non-steroidal anti-inflammatory agents for epicondylitis (Green), and further evidence to support treatment with iontophoresis (Nirschl) or ultrasound (Smidt, “Effectiveness of Physiotherapy”) for relief of symptoms. Local corticosteroid injections can provide short term relief (Hart). However, physical therapy may be more successful in the long term outcome of epicondylitis (Hart; Smidt, “Corticosteroid Injections”).

It is advisable to consider work and leisure activities that may have contributed to the condition and attempt to reduce the risk factors associated with epicondylitis (Haahr). An ergonomic evaluation may be beneficial if work tasks are suspected as a cause (Lewis).

FREQUENCY OF REHABILITATION VISITS

Nonsurgical
Specialist	Epicondylitis, Medial and Lateral
Physical or Occupational Therapist	Up to 8 visits within 4 weeks

The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

• Comorbid Conditions

• Arthritis

• Carpal tunnel syndrome

• Cervical spine disease

• Other injuries to the arm and shoulder.

• Complications

Radial neuropathy occurs in less than a small percentage of the cases of lateral epicondylitis. Ulnar neuropathy (cubital tunnel syndrome) is some what more likely to occur in of the cases of medial epicondylitis. After local injections, there may be a 1 or 2 day increase in pain called postinjection flare.

• Factors Influencing Duration

Duration of disability depends on job requirements (use of wrist , forearm), dominant versus nondominant arm work requirements, conservative versus surgical treatment, and compliance to rehabilitation program. Disability may be longer for individuals with job duties that require intensive use of both arms or repetitive actions.

• Length of Disability

Supportive treatment, medial and lateral epicondylitis

DURATION IN DAYS

Job Classification	Minimum	Optimum	Maximum
Sedentary	0	7	28
Light	1	10	28
Medium	7	21	56
Heavy	14	28	56
Very Heavy	14	28	56

• Duration Trend from Reference Data

DURATION TRENDS

ICD-9-CM: 726.31, 726.32
Cases	Mean	Min	Max	No Lost Time	Over 6 Months
1373	60	0	272	0.2%	5.8%

Percentile:	5th	25th	Median	75th	95th
Days:	7	20	42	78	182

Differences may exist between the duration tables and the reference graphs. Duration tables provide expected recovery periods based on the type of work performed by the individual. The reference graphs reflect the actual experience of many individuals across the spectrum of physical conditions, in a variety of industries, and with varying levels of case management. Selected graphs combine multiple codes based on similar means and medians.

• Return to Work ( Restrictions / Accommodations)

An ergonomic evaluation of the workplace may be necessary. The precipitating or exacerbating activity needs to be avoided until symptoms are relieved. Change in job duties, sharing or alternating tasks, and limiting time and frequency of repetitive activities are important accommodations. Use of vibrating tools such as impact wrenches or jackhammers should be minimized. Increasing or decreasing the size of tool grips so the wrist can be held in the “ideal” position is also helpful. Use of splints, straps, and casts affect dexterity and the individual may be temporarily unable to lift and carry heavy or bulky objects, operate equipment, or perform other tasks requiring the use of both hands. If the dominant arm was affected, the individual may be unable to write legibly, type well, or perform activities that require fine motor skills such as those in a laboratory or assembly line. Prescribed medications for pain and inflammation require evaluation of safety issues and drug policies.

• Failure to Recover

If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual’s medical case.

Regarding diagnosis:

• Does individual’s occupation or hobby involve repetitive and/or stressful use of the forearm?

• Does individual report elbow pain , swelling, and the inability to use the wrist and arm ?

• Has pain spread to the forearm?

• Is the affected elbow on the dominant or nondominant side?

• Does individual have a history of neck or shoulder injuries?

• On physical examination, is the pain localized over either epicondyle?

• Does pain increase with resisted wrist motion ?

• Is there weakness noted in the forearm?

• Did individual have an injection test done? X-ray ? MRI ?

• Have conditions with similar symptoms been ruled out?

Regarding treatment :

• Has individual responded favorably to treatment consisting of rest from the aggravating activity, ice packs, NSAIDs, and a splint?

• Has individual received a corticosteroid injection?

• Was surgery necessary?

Regarding prognosis :

• Is individual active in physical therapy ? Does individual have a home exercise program?

• Is individual’s employer able to accommodate any necessary restrictions ?

• Has individual had an ergonomic evaluation of their work area?

• Does individual have any conditions that may affect the ability to recover?

• Does individual have any complications such as radial or ulnar neuropathy ?

• Did individual have a postinjection flare?

• Medical Codes

ICD-9-CM:	726.31, 726.32
ICD-10:	M77, M77.1

• Cited References

Disabella, Vincent N. “Lateral Epicondylitis .” eMedicine.com. Eds. A. D. Perron, et al. 26 Oct. 2004.eMedicine.com, Inc. 8 Feb. 2005 <http://www.emedicine.com/sports/topic59.htm>.

Green, S., et al. “Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for Treating Lateral Elbow Pain in Adults.” Cochrane Database System Review 2 (2002): CD003686. National Center for Biotechnology Information.National Library of Medicine. 17 Nov. 2004 <PMID: 12076503>.

Haahr, J. P., and J. H. Andersen. “Prognostic Factors in Lateral Epicondylitis : A Randomized Trial with One-Year Follow-Up in 266 New Cases Treated with minimal Occupational Intervention or the Usual Approach in General Practice.” Rheumatology 42 10 (2003): 1216–1225. National Center for Biotechnology Information.National Library of Medicine. 17 Nov. 2004 <PMID: 12810936>.

Hart, L. E. “Corticosteroid Injections, Physiotherapy, or a Wait-and-See Policy for Lateral Epicondylitis ?” Clinical Journal of Sports Medicine 12 6 (2002): 403–404. National Center for Biotechnology Information.National Library of Medicine. 17 Nov. 2004 <PMID: 12650155>.

Lewis, M., et al. “Effects of Manual Work on Recovery from Lateral Epicondylitis .” Scandinavian Journal of Work, Environment and Health 28 2 (2002): 109–116. National Center for Biotechnology Information.National Library of Medicine. 17 Nov. 2004 <PMID: 12019587>.

Mercier, L. R. “Epicondylitis .” Ferri’s Clinical Advisor: Instant Diagnosis and Treatment . Ed. Fred Ferri. St. Louis: Mosby-Year Book, Inc., 2000. 384. MD Consult.Elsevier, Inc. 5 Oct. 2004 <http://home.mdconsult.com>.

Nirschl, R. P., et al. “Iontophoretic Administration of Dexamethasone Sodium Phosphate for Acute Epicondylitis . A Randomized, Double-Blinded, Placebo-Controlled Study.” American Journal of Sports Medicine 31 2 (2003): 189–195. National Center for Biotechnology Information.National Library of Medicine. 17 Nov. 2004 <PMID: 12642251>.

Smidt, N., et al. “Corticosteroid Injections, Physiotherapy, or a Wait-and-See Policy for Lateral Epicondylitis : A Randomised Controlled Trial.” Lancet 359 9307 (2002): 657–662. National Center for Biotechnology Information.National Library of Medicine. 17 Nov. 2004 <PMID: 11879861>.

Smidt, N., et al. “Effectiveness of Physiotherapy for Lateral Epicondylitis : A Systematic Review.” Annals of Medicine 35 1 (2003): 51–62. National Center for Biotechnology Information.National Library of Medicine. 17 Nov. 2004 <PMID: 12693613>.

Young, Craig C. “Medial Epicondylitis. ” eMedicine.com. Eds. Anthony J. Saglimbeni, et al. 26 Oct. 2004.eMedicine.com, Inc. 8 Feb. 2005 <http://www.emedicine.com/sports/topic74.htm>.

Copyright © 2005–2007 Reed Group, Ltd.

Rotator Cuff Tear

Related Terms: Tear of the Rotator Cuff Definition

Rotator cuff tear occurs when the tendons that form the rotator cuff weaken and tear.

The rotator cuff comprises four muscles and their tendon attachments that wrap over the upper arm (humeral head ) in the shoulder . These tendons come under stress from repeated activities that require lifting and rotating the arm. Any abnormalities of the shoulder joint can aggravate the stress, especially looseness (laxity); narrowing of the impingement interval, which is the space between the shoulder blade and the collarbone (impingement syndrome ); and bursitis . As the tendons become irritated, they become inflamed and eventually weaken and may tear.

Tears are described as either partial thickness tears or complete rupture, depending on the amount of tissue damage. Partial tears do not go all the way through the cuff, although there may be a fairly large surface area involved. Complete tears create a hole in the cuff with partial or total loss of tendon function . The size of tear ranges from small to massive, depending on the size of the hole created and how much of the humeral head is exposed.

Tears are classified as acute or chronic , depending on onset. Acute tears are the result of forceful injury to the shoulder and straining the tendon beyond its limits, which causes a tear. Chronic tears come from repetitive wear and tear to the cuff mechanism. Conditions that may lead to rotator cuff tear include impingement syndrome (see rotator cuff syndrome), instability of the glenohumeral joint, or inborn (congenital) abnormalities of the shoulder.

Risk: Although rotator cuff tears can affect young adults, typically as the result of a trauma, they are most often found in individuals over 40 years of age (Roy). Individuals at a higher risk of sustaining a rotator cuff tear include those who perform overhead work (e.g., warehouse workers, laborers, carpenters, construction workers) and certain athletes (e.g., swimmers, tennis players, baseball players). Men are twice as likely as women to sustain rotator cuff tears (Tuite).

Incidence and Prevalence: Rotator cuff tears may affect from 5% to 40% of the population (Malanga). In general, tears are more common in older age groups than younger ones. Cadaver studies showed that 39% of individuals over the age of 60 have full-thickness tears (Malanga), although tears may produce no symptoms, making frequency estimates difficult to verify.

• Diagnosis

History: Most individuals with acute tears will describe a fall or attempt to break a fall by grabbing a rail, or an athletic injury . Those with a chronic tear will describe increasing pain and difficulty using the shoulder . Individuals will complain of increasing shoulder pain with activity and pain at night with inability to sleep on the affected shoulder. They may complain of shoulder weakness and the inability or limited ability to raise (abduct) their arm . The individual may report that he or she has impingement syndrome .

Physical exam: Range of shoulder motion is tested by asking individuals to raise their arm away from their side toward the ear (abduction). A tear is indicated when an individual cannot perform this maneuver or, when the arm is raised by someone else, cannot hold the position. Touching (palpation) over the top of the shoulder into the deltoid will produce pain . There may be wasting (atrophy ) of the cuff muscles with fairly good range of motion (ROM) by substitution of other shoulder muscles. There are numerous other active and passive shoulder physical examination tests. Each is specific for different muscle groups and function of the shoulder. The nonaffected shoulder is examined first to establish a normal baseline.

Tests: Plain x-rays are not diagnostic for rotator cuff tears but will show abnormalities in the bone, shoulder structure, and inflammation and calcification of the shoulder bursa (calcific tendinitis ). Arthrography, MRI , or CT scan, often with contrast media (CT-arthrography), are the tests used most often to define a tear. Ultrasonography is used in many facilities, although differentiating a partial and full thickness tear may not be as accurate as with the other tests. Diagnostic arthroscopy is occasionally done to evaluate the rotator cuff and shoulder mechanics, especially on acute tears in athletes.

• Treatment

The goals of treatment are pain relief and improved shoulder function . Partial tears that do not cause dramatic or progressive shoulder weakness are treated conservatively with rest, ice, NSAIDs, and, possibly local anesthetic or corticosteroid injection into the subacromial space. Physical therapy will help increase cuff strength, stabilize the shoulder blade (scapula), increase motion , and decrease pain and inflammation. Use of heat on an inflamed or torn tendon may increase pain and worsen the situation. Although nonoperative treatment will not repair the tear, it often achieves the goals of pain relief and partial restoration of function.

Complete tears and any tears that cause marked pain or weakness and interfere with daily activities in younger adults are treated with surgical repair, either arthroscopically or with open surgery (open rotator cuff repair). Partial tears are sometimes cleaned (débrided) arthroscopically to remove the inflamed tissue and ragged edges of the tear. Rotator cuff surgery may be performed under regional or general anesthesia. Treatment in older individuals is based on overall health , weakness of the shoulder joint , pain, and the ability to function. Surgery is done to repair the tear when there are marked changes in these parameters. Otherwise, a complete tear in an elderly individual is treated conservatively, or with simpler procedures such as arthroscopic débridement and subacromial decompression. Massive tears may be inoperable and would also be treated nonoperatively.

• Prognosis

Conservative treatment of small rotator cuff tears has a good outcome (a return to normal functioning) for 40% to 90% of individuals (Felsenstein) but may take 6 months or longer. Younger individuals are more likely to have a good outcome than older individuals. However, athletes have a poorer outcome in terms of returning to previous levels of competition, especially after a full-thickness rotator cuff tear. Conservative treatment of chronic , larger tears, especially in the dominant shoulder , has a poor outcome. Surgical repair of a rotator cuff tear has a good outcome in about 90% of cases (Felsenstein), provided the tear is small, there are no complications, and the individual’s general health is good. Surgical repair in elderly individuals has a poor outcome, due to pre-existing rotator cuff degeneration. Massive tears have a poorer prognosis and are associated with a high degree of disability. Some individuals never regain full motion or strength in the affected shoulder.

• Utilization Management Knowledgebase

• SH501 Rotator Cuff Tear

• SH515 Labral Tear

• Differential Diagnoses

• Cervical nerve root injury

• Impingement syndrome

• Painful arc syndrome

• Rotator cuff tendinitis

• Subacromial bursitis

• Subscapular nerve entrapment

• Specialists

Occupational Therapist	Physical Therapist
Orthopedic (Orthopaedic) Surgeon	Rheumatologist
Physiatrist	Sports Medicine Internist

• Rehabilitation

Note on research and authorship

Acute Phase: The early goals of rehabilitation in the acute phase of a rotator cuff tear are to decrease pain and inflammation, to reduce the stress on the torn tendon(s), and to prevent the development of joint stiffness, which can severely complicate recovery (Kelley).

In conjunction with pharmacological management, the individual will be instructed in the use of cold treatments to the shoulder to decrease inflammation. Reduction of stress to the healing tendon(s) is often achieved through education, ergonomic adjustments, and/or work modifications aimed at reducing painful activities (Breazeale; Mantone). Such activities often include positions in which the elbow is raised above the level of the shoulder, and should be avoided. Stiffness may be prevented by passive range of motion exercises conducted during supervised rehabilitation and a home exercise program (Mantone).

Healing Phase: As the pain and inflammation ease, treatment aims at improving strength and flexibility to the shoulder without irritating the healing tendon(s) (Breazeale). The strengthening exercises begin with scapular muscles. These are important muscles for normal shoulder function , and the exercises can usually be performed without excessively stressing the healing tendon(s). Gentle stretching exercises may be initiated, avoiding stress on the healing tendon(s). As the tendon heals, strengthening exercises are added, as indicated (Mantone).

Chronic Phase: The goal of rehabilitation in this phase is to restore pain-free function (Mantone). Strengthening exercises emphasize all muscles of the shoulder area. Flexibility exercises and manual therapy are incorporated within the available range of motion. Individuals who are not able to regain function or control pain may be evaluated for surgery.

If managed operatively, see Rotator Cuff Repair.

FREQUENCY OF REHABILITATION VISITS

Nonsurgical (Acute Phase)
Specialist	Rotator Cuff Tear
Physical or Occupational Therapist	Up to 16 visits within 8 weeks
Surgical (Acute Phase)
Specialist	Rotator Cuff Tear
Physical or Occupational Therapist	Up to 24 visits within 12 weeks

The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

• Comorbid Conditions

• Diabetes mellitus

• Osteoarthritis

• Osteoporosis

• Rheumatoid arthritis

• Shoulder trauma

• Tendinitis

• Complications

Post-traumatic arthritis of the shoulder, impingement syndrome, osteoporosis of the humeral head, chronic inflammation of the subacromial bursa, nerve injury, frozen shoulder (adhesive capsulitis), and poor shoulder motion are possible complications.

• Factors Influencing Duration

The size of the tear; the individual’s age, occupation , and overall health ; dominant side involvement, the need for surgery , and the effectiveness of rehabilitation may affect the length of disability. There may be permanent disability regarding certain activities. The larger the tear, the more likely that permanent weakness will result. Therefore, heavy or very heavy work may no longer be possible.

• Length of Disability

Disability may be permanent for individuals who do heavy work or repetitive overhead work.

Medical treatment, rotator cuff tear

DURATION IN DAYS

Job Classification	Minimum	Optimum	Maximum
Sedentary	1	3	4
Light	1	3	7
Medium	14	21	42
Heavy	28	42	84
Very Heavy	28	42	84

Surgical treatment, arthroscopic rotator cuff repair

DURATION IN DAYS

Job Classification	Minimum	Optimum	Maximum
Sedentary	7	10	21
Light	7	14	21
Medium	28	42	56
Heavy	56	70	112
Very Heavy	56	70	112

Surgical treatment, open rotator cuff repair

DURATION IN DAYS

Job Classification	Minimum	Optimum	Maximum
Sedentary	28	42	70
Light	28	56	84
Medium	42	84	140
Heavy	70	84	140
Very Heavy	70	84	140

• Duration Trend from Reference Data

DURATION TRENDS

ICD-9-CM: 840.4
Cases	Mean	Min	Max	No Lost Time	Over 6 Months
3982	68	1	329	<0.1%	7.3%

Percentile:	5th	25th	Median	75th	95th
Days:	7	21	49	96	189

DURATION TRENDS

ICD-9-CM: 727.61
Cases	Mean	Min	Max	No Lost Time	Over 6 Months
1667	90	0	372	0.1%	10.3%

Percentile:	5th	25th	Median	75th	95th
Days:	14	42	76	123	217

Differences may exist between the duration tables and the reference graphs. Duration tables provide expected recovery periods based on the type of work performed by the individual. The reference graphs reflect the actual experience of many individuals across the spectrum of physical conditions, in a variety of industries, and with varying levels of case management. Selected graphs combine multiple codes based on similar means and medians.

• Return to Work ( Restrictions / Accommodations)

Limiting use of the affected shoulder or avoiding any use at all may be necessary. Arm use above shoulder level should be avoided. The arm and hand can be used at the individual’s side for activities that do not require lifting, pushing, or carrying. These restrictions may become permanent. An ergonomic evaluation of the workplace may be necessary. Changing job duties, sharing or alternating tasks, working at a reduced rate, taking more frequent rest breaks, and limiting the time and frequency of repetitive activities are important accommodations. Work site modifications can include forearm rests for individuals who use computer keyboards frequently, headsets for those who answer telephones, and alterations such that repetitive activities are performed with the arms in a lower level of elevation.

Recovery from surgical repair is the most restrictive, with no use of the arm and shoulder for 2 months and only a gradual increase in allowed activities. The use of a sling will affect manual dexterity. Some individuals will never regain full range of motion or strength in the affected arm. Depending on job duties, individuals may require permanent reassignment, which may necessitate retraining. Use of analgesics and other medications can affect dexterity and alertness. Use of these medications may require review of drug policies.

• Failure to Recover

If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual’s medical case.

Regarding diagnosis:

• Does individual have any risk factors for a rotator cuff tear (those who perform overhead work , certain athletes, those who have impingement syndrome , instability of the glenohumeral joint , or congenital abnormalities of the shoulder )?

• Did individual fall?

• Did individual experience associated shoulder weakness or inability to raise his or her arm ?

• Did individual have any positive findings on exam, such as pain in the deltoid, muscle atrophy , or impairment of range of motion ?

• Has individual received adequate testing to establish the diagnosis (i.e., MRI , CT scan, arthroscopy )?

• If diagnosis was uncertain, were other conditions with similar symptoms been ruled out (i.e., painful arc syndrome , impingement syndrome, rotator cuff tendinitis , biceps tendinitis, and subacromial bursitis )?

Regarding treatment :

• Has individual responded favorably to conservative treatment of rest, ice, NSAIDs, and physical therapy ? If not, have steroid injections been tried?

• Did it become necessary to repair the tear surgically?

Regarding prognosis :

• Is individual active in physical therapy ? Does the individual have a home exercise program?

• Is individual’s employer able to accommodate necessary restrictions ?

• Is affected shoulder on the dominant or nondominant side?

• Does individual have any other conditions, such as shoulder dislocation or other shoulder injuries, osteoarthritis , rheumatoid arthritis , diabetes , gout, or osteoporosis, that could affect recovery?

• Has individual experienced any complications that could affect recovery and prognosis?

• Medical Codes

ICD-9-CM:	718.01, 727.61, 840.4
ICD-10:	S43.4, S43.7

• Cited References

Breazeale, N. M., and E. V. Craig. “Partial-Thickness Rotator Cuff Tears. Pathogenesis and Treatment .” Orthopedic Clinics of North America 28 2 (1997): 145–155. National Center for Biotechnology Information.National Library of Medicine. 14 Dec. 2004 <PMID: 9113711>.

Felsenstein, Chad H., and Robert M. McNamara. “Rotator Cuff Injury .” eMedicine Consumer Health . Eds. Scott H. Plantz, et al. 7 Sep. 2004.eMedicine.com, Inc. 29 Oct. 2004 <http://www.emedicinehealth.com/articles/5582-1.asp>.

Kelley, M. J., and William A. Clark, eds. Orthopedic Therapy of the Shoulder . Philadelphia : J.B. Lippincott Company, 1995.

Malanga, Gerard A. “Rotator Cuff Injury .” eMedicine.com. Eds. Andrew L. Sherman, et al. 17 Dec. 2004.eMedicine.com, Inc. 29 Oct. 2004 <http://www.emedicine.com/sports/topic115.htm>.

Mantone, J. K., W. Z. Burkhead, and J. Noonan. “Nonoperative Treatment of Rotator Cuff Tears.” Orthopedic Clinics of North America 31 2 (2000): 295–311. National Center for Biotechnology Information.National Library of Medicine. 14 Dec. 2004 <PMID: 10736398>.

Roy, Andre. “Rotator Cuff Disease.” eMedicine.com. Eds. Robert E. Windsor, et al. 12 Jan. 2005.eMedicine.com, Inc. 29 Oct. 2004 <http://www.emedicine.com/pmr/topic125.htm>.

Tuite, Michael. “Shoulder, Rotator Cuff Injury (MRI ) .” eMedicine.com. Eds. David S. Levey, et al. 7 Jul. 2004.eMedicine.com, Inc. 29 Oct. 2004 <http://www.emedicine.com/radio/topic894.htm>.

Copyright © 2005–2007 Reed Group, Ltd.

Tendinitis

Related Terms: Tendonitis

• Definition

Tendinitis is inflammation of a tendon, the fibrous tissue that connects a muscle to bone. Some tendons are rope-like and others are similar to thick sheets. The inflammation is often accompanied by degeneration of the collagen fibers comprising the tendon.

Tendinitis occurs only when there is direct injury to the tendon itself along with partial tearing of the fibers. Tendinitis is a very common condition, prevalent in individuals engaged in sporting events and/or heavy labor . Tendinitis can be caused from an infection , acute trauma, poor technique with activity, lack of strength and flexibility, age-related deterioration , or overload or overuse of the affected tendon. The condition can also be caused by inflammatory diseases such as rheumatoid arthritis , systemic sclerosis, gout, Reiter’s syndrome , and diabetes mellitus.

Inflamed tendons are frequently found in the hand . Other common sites for tendinitis are in the shoulder and knee (rotator cuff tendinitis, patellar tendinitis, and iliotibial band tendinitis). Tendinitis that affects the site of tendon insertion into the bone (insertional tendinopathy) is the most common. Since tendons fail to regenerate quickly because of lack of a rich blood supply, aging may also cause gradual deterioration (tendinosis). The term “tendinosis” is used to describe the chronically painful degenerative tendon. In this condition there are no inflammatory cells present, unlike acute tendinitis.

Calcific tendinitis occurs when calcium deposits form in the tendons, usually at the rotator cuff. This type of tendinitis will frequently resolve spontaneously in 1 to 4 weeks (Cluett).

Ongoing (chronic ) conditions result from microtrauma or “overuse” of the tendon, with symptoms developing over time. The overuse can be caused from excessive pressure or workload. Tendon failure occurs from stretching of collagen fibers within the tendon. Up to 4% of tendon elongation is tolerated well; however, from 4% to 8% of tendon elongation causes microtrauma, and greater than 8% of tendon elongation causes macrotrauma with rupture of the tendon fibers (Rettig). Repetitive tasks and excessive exercise also may cause tendinitis. Shearing stress on the tendon may occur where tendons pass in close proximity to the bone. Sudden onset (acute) or traumatic tendinitis may be caused by a bruise with bleeding into the tissue (contusion ) or muscle-tendon strain .

Risk: Tendinitis is generally most common in males, and Achilles tendon tears occur 4 to 7 times more frequently in males than females (Maffulli). Individuals who are middle-aged are more likely to develop tendinitis (Steele).

Calcific tendinitis usually occurs in individuals between the ages of 30 to 40, and is more frequent in those who are diabetic (Cluett).

Incidence and Prevalence: Incidence of tendinitis as an occupational injury is 11 per 100,000 individuals who work full-time (“Incidence Rates”).

Overuse tendinitis is most common in the wrist and hand , and comprises between 25% to 50% of all sports injuries (Rettig).

• Diagnosis

History: Individuals with tendinitis caused by trauma may have heard or felt a “pop” as the tendon fibers tore. There may be increasing pain . Most individuals, however, report symptoms that begin gradually. Ongoing (chronic ) tendinitis creates symptoms including pain during or after activity. Other symptoms may include swelling, stiffness and a sensation of creaking or squeaking with motion .

Individuals with tendinitis of the hand caused by infection may report pain and swelling over the top (dorsum) of the hand. There may be history of a recent bacterial infection, an open wound, or tuberculosis. Individuals may also report previous injuries that may not have been successfully diagnosed and rehabilitated.

Physical exam: Swelling, warmth and tenderness may be evident. A stethoscopic exam may reveal creaking or popping (crepitus) noises along the course of the tendon. Pain accompanying movement may be detected. There may be a visible deformity, such as a torn biceps tendon curling and making a ball under the skin. A neurovascular exam may be necessary to rule out compartment syndrome and nerve injury .

Tests: An x-ray may reveal calcium deposits along the tendon and sheath. MRI may be needed to identify tendon tears. Laboratory studies, x-ray, bone scans , and compartment pressure measurements may be used to rule out complications or underlying conditions.

• Treatment

Tendinitis caused by trauma, especially if it occurs suddenly (acute ), is generally treated with rest, ice (cold therapy), compressive dressing and elevation to control swelling (RICE). Heat rather than cold therapy might be used for acute forms of the condition, depending on patient response. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for pain and swelling. Muscle -tendon length should be maintained with gentle stretching. When the onset (acute) episode has passed, rehabilitation for strengthening may be needed to prevent re-injury .

Ongoing (chronic ) tendinitis is treated by stopping the aggravating activity, RICE, NSAIDs and physical therapy to control pain and swelling. With the chronic form, heat may be more effective than cold in therapy. Muscle strengthening may be recommended to restore normal function .

Corticosteroids and/or anesthetics may be injected into the tendon sheath to relieve pain and swelling. In extreme cases, surgery (excision, tenosynovectomy) may be needed to remove inflamed tissue or calcium deposits. Ruptured tendons may require repair through suturing (ruptured tendon repair).

• Prognosis

Full recovery is likely to occur in ongoing (chronic ) cases. In severe cases, traumatic tendinitis with rupture may require surgery (ruptured tendon repair) and take longer to heal. Tendinitis in the hand caused by infection (infective tendinitis) can lead to loss of tendon structure. Repair of the tendon, excision, or tenosynovectomy will likely have a good outcome if damage to the tendon is not extensive. Cases requiring surgery are rare, but individuals with significant tendon damage may experience at least partial loss of function. The recovery period also is likely to be painful.

• Utilization Management Knowledgebase

• ANF501 Ankle or Foot Tendinitis

• ELB509 Tendonitis

• KN512 Patellar Tendinitis

• Differential Diagnoses

• Bursitis

• Carpal tunnel syndrome

• Chronic compartment syndrome

• Distal nerve compression injury

• Myositis ossificans

• Radiculitis

• Rheumatoid arthritis

• Stress fracture

• Vascular disorders

• Specialists

Internal Medicine Physician Orthopedic (Orthopaedic) Surgeon Physiatrist

Rheumatologist Sports Medicine Internist

• Rehabilitation

Note on research and authorship

The initial goals of rehabilitation for tendinitis are controlling pain and swelling, followed by regaining motion , flexibility, strength , and endurance of the tendon, muscle , and involved joint structures. An effort should be made to identify the underlying cause of the current symptoms, after which, when possible, modifications should be made to reduce the risk factors associated with the condition.

Modalities such as heat and cold may be used throughout rehabilitation to control pain and swelling (Braddom). If pain significantly limits motion, then splinting the involved part may be necessary. When indicated, therapy should begin with range of motion exercises, progress to strengthening exercises as indicated, and continue by instructing individuals in a home exercise program to complement supervised rehabilitation (Biundo; Mafi).

The final goal is returning the individual to full function for work and recreational activities with minimal risk of re-injury . If work tasks expose the individual to risk factors for tendinitis, an ergonomic assessment may be indicated. If leisure activities are suspect, the individual should be educated in ways to modify the activity and decrease the likelihood of developing symptoms.

Additional information may provide insight into the rehabilitation needs of these individuals (Huang).

FREQUENCY OF REHABILITATION VISITS

Nonsurgical
Specialist	Tendinitis
Physical, Occupational or Hand Therapist	Up to 16 visits within 8 weeks

The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

• Comorbid Conditions

• Diabetes mellitus

• Rheumatoid arthritis

• Complications

Compartment syndrome and nerve injury may be caused by tissue swelling associated with tendinitis . Inflammation of the lining of the tendon sheath (tenosynovitis) often accompanies tendinitis, and may occur with infection by gonococcal bacteria that is transmitted sexually (gonorrhea). When tendinitis is treated with corticosteroid injections, cell death and tendon atrophy may result. Tendon rupture may occur. When tendon fibers are torn away from the bone, usually from excessive pulling forces, the result is a condition called enthesopathy. Inflammation in tendons of the hand may cause the thumb to extend (de Quervain’s disease). Fingers and/or the thumb may be hampered in movement by swelling of the tendons, which creates a sensation of popping or catching (trigger finger).

• Factors Influencing Duration

Location of the tendinitis, severity, ability to control aggravating activities, treatment required, and complications might affect the disability period.

• Length of Disability

Medical and/or supportive treatment, tendinitis.

DURATION IN DAYS

Job Classification	Minimum	Optimum	Maximum
Sedentary	1	3	7
Light	1	7	14
Medium	3	14	56
Heavy	3	21	56
Very Heavy	3	28	56

• Duration Trend from Reference Data

DURATION TRENDS

ICD-9-CM: 726.9, 726.90
Cases	Mean	Min	Max	No Lost Time	Over 6 Months
1256	41	0	204	0.4%	2.6%

Percentile:	5th	25th	Median	75th	95th
Days:	4	12	26	54	134

Differences may exist between the duration tables and the reference graphs. Duration tables provide expected recovery periods based on the type of work performed by the individual. The reference graphs reflect the actual experience of many individuals across the spectrum of physical conditions, in a variety of industries, and with varying levels of case management. Selected graphs combine multiple codes based on similar means and medians.

• Return to Work ( Restrictions / Accommodations)

Restrictions include removing aggravating activities, depending on the tendon involved. This may include avoidance of lifting, carrying, twisting movements of the wrist or forearm, repetitive and overhead work . Use of protective or assistive devices such as splints, crutches, or slings may affect dexterity. Safety issues may need to be evaluated. Prescribed medication for control of symptoms may require review of drug policies.

Return to work requiring physical activity may need monitoring, as many individuals attempt to resume “normal” activity too soon. This often leads to a cycle of re-injuries.

• Failure to Recover

If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual’s medical case.

Regarding diagnosis:

• Does individual have a history of injury , overload, or overuse of the tendon?

• Does individual have a history of rheumatoid arthritis , systemic sclerosis, gout, Reiter’s syndrome , or diabetes mellitus?

• Does individual’s work or play involve repetitive tasks or excessive exercise?

• Which tendon is involved?

• Does individual report hearing a pop with injury ?

• Does individual report a gradual onset of pain during or after activity, swelling, stiffness and a sensation of creaking or squeaking with motion ?

• On exam, was swelling, warmth, tenderness, or crepitus evident?

• Is pain with movement detected? Is there visible deformity?

• Has individual had an x-ray , MRI , bone scan or compartment pressure measurements?

• Was neurovascular exam necessary?

• Have conditions with similar symptoms been ruled out?

Regarding treatment :

• Is individual with an acute injury being treated with rest, ice, compression and elevation (RICE)? Is heat, depending on patient response, being used rather than ice?

• Is individual being treated with NSAIDs?

• Has physical therapy been prescribed?

• Has individual stopped aggravating activity?

• Has individual received an injection of corticosteroids and/or anesthetics?

• Did tenosynovectomy become necessary?

• Was ruptured tendon repaired surgically?

Regarding prognosis :

• Is individual active in physical therapy ?

• Does individual have a home exercise program?

• Does individual have any conditions that may affect ability to recover?

• Does individual have any complications such as compartment syndrome, nerve injury tenosynovitis, tendon rupture, enthesopathy, de Quervain’s disease or a trigger finger?

• Medical Codes

ICD-9-CM:	726.10, 726.11, 726.61, 726.64, 726.71, 726.72, 726.79, 726.9, 726.90
ICD-10:	M25.7, M65.8, M71.5, M77.9, M89.9

• Cited References

Biundo, J. J., R. W. Irwin, and E. Umpierre. “Sports and Other Soft Tissue Injuries Tendinitis , Bursitis , and Occupation -related Syndromes.” Current Opinion in Rheumatology 13 2 (2001): 146–149. National Center for Biotechnology Information.National Library of Medicine. 1 Dec. 2004 <PMID: 11224739>.

Braddom, Randolph L. Physical Medicine and Rehabilitation. 2^nd ed. Philadelphia: W.B. Saunders, 2000.

Cluett, Jonathan. “Calcific Tendonitis .” About.com. 21 Jan. 2004 <http://www.about.com>.

Huang, H. H., A. A. Qureshi, and J. J. Biundo. “Sports and Other Soft Tissue Injuries, Tendinitis , Bursitis , and Occupation -Related Syndromes.” Current Opinion in Rheumatology 12 2 (2000): 150–154. National Center for Biotechnology Information.National Library of Medicine. 1 Dec. 2004 <PMID: 10751018>.

“Incidence Rates for Nonfatal Occupational Injuries and Illnesses Involving Days Away from Work per 10,000 Full-time Workers for Selected Characteristics and Industry Division, United States, 2002.” U.S. Department of Labor .U.S. Department of Labor. 27 Oct. 2004 <http://www.bls.gov/opub/cwc/sh20040414tb06.htm>.

Maffulli, N., J. Wong, and L. C. Almekinders. “Types and Epidemiology of Tendinopathy.” Clinics in Sports Medicine 22 4 (2003): 675–692. MD Consult.Elsevier, Inc. 27 Oct. 2004 <http://home.mdconsult.com>.

Mafi, N., R. Lorentzon, and H. Alfredson. “Superior Short-term Results with Eccentric Calf Muscle Training Compared to Concentric Training in a Randomized Prospective Multicenter Study on Patients with Chronic Achilles Tendinosis.” Knee Surgery , Sports Traumatology, Arthroscopy 9 1 (2001): 42–47. National Center for Biotechnology Information.National Library of Medicine. 1 Dec. 2004 <PMID: 11269583>.

Rettig, A. C. “Wrist and Hand Overuse Syndromes.” Clinics in Sports Medicine 20 3 (2001): 591–611. MD Consult.Elsevier, Inc. 27 Oct. 2004 <http://home.mdconsult.com>.

Steele, Mark. “Tendonitis. ” eMedicine.com. Eds. Richard S. Krause, et al. 11 Nov. 2004.eMedicine.com, Inc. 27 Oct. 2004 <http://www.emedicine.com/emerg/topic570.htm>.

Copyright © 2005–2007 Reed Group, Ltd.

Depression, Major

Related Terms: Depressive Psychosis, Major Depressive Disorder , Psychotic Depression , Unipolar Depression

• Definition

Major depression is a serious psychiatric illness that negatively affects how an individual feels, thinks, and acts. Everyone experiences depressed moods as a result of a change, either in the form of a setback or a loss, or as Freud said, “everyday misery.” The sadness and depressed feelings that accompany the changes and losses of life are usually appropriate, necessary, transitory, and can present an opportunity for personal growth. However, depression that persists and results in serious dysfunction in daily life could be an indication of a depressive disorder that may need to be treated as a medical problem. Severity, duration, and presence of other symptoms are factors that distinguish normal sadness from a depressive disorder.

Major depression, called major depressive disorder in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition, Text Revision), is a mood disorder distinguished by the occurrence of one or more major depressive episodes. A major depressive episode is diagnosed when an individual experiences persistent feelings of sadness or anxiety , with loss of interest or pleasure in usual activities (anhedonia). In addition, five or more of the following symptoms must be present for at least two consecutive weeks: changes in appetite that result in weight losses or gains not related to dieting; insomnia or oversleeping; loss of energy or increased fatigue ; restlessness or irritability; feelings of worthlessness or inappropriate guilt; difficulty thinking, concentrating, or making decisions; and thoughts of death or suicide, or attempts at suicide.

A depressive episode is diagnosed only if the above symptoms are not due to any other psychiatric conditions (such as bipolar disorder) or medical conditions (such as neurological or hormonal problems, cancer, or heart attack). Symptoms must not be due to unexpected side effects of medications or substance abuse .

The DSM-IV-TR divides major depressive disorder into two subtypes based on whether or not the individual has experienced a single depressive episode or recurrent depressive episodes. The DSM-IV-TR also adds specifiers to a diagnosis, rating severity along a continuum of mild, moderate, severe, and severe with psychotic features. The latter is sometimes known as depressive psychosis. Partial and full remissions are additional specifiers.

Major depression can afflict anyone, regardless of age, race, class, or sex. Only a third of depressed individuals receive proper treatment . Recently, a study showed that of bereaved spouses who meet major depression criteria, 83% received no antidepressant medication . One explanation for the low percentage of treatment of depressed individuals is that society has stigmatized mental illness for so long that people with depression, and sometimes their families, feel too ashamed to acknowledge the disease and to seek treatment.

It is estimated that up to 25% of individuals experiencing severe medical conditions will experience a concurrent major depressive disorder (DSM-IV-TR 372-73).

Risk: Major risk factors are female sex, age, family history, bereavement, and brain injury . Women suffer from the disorder at least twice as often as men in societies around the world. The peak age at onset is between 20 and 25 years, and 40 and 45 years. Although older individuals frequently seek treatment , there is no evidence that major depression is more common in older than in younger adults. Individuals who have parents or siblings with major depression have a 1.5 to 3 times greater risk of developing this disorder. Grief is a risk factor because it may turn into major depression, especially in bereaved spouses, who often meet the criteria for major depression.

Incidence and Prevalence: In the US, lifetime risk is 10% to 25% for women, and 5% to 12% for men. An international study (17 researchers, 38,000 individuals from 10 countries) reported that the lifetime risk of depression ranged from 1.5% in Taiwan to 19% in Lebanon. Risks in other countries, in ascending order, were 2.9% in Korea, 4.3% in Puerto Rico, 5.2% in the US, 9.2% in Germany, 9.6% in Canada, 11.6% in New Zealand, and 16.4% in France.

• Diagnosis

History: A thorough history includes taking an account of current and previous symptoms, questions about mood , memory, and changes in relationships, and corroborative history from friends, family members, or employers. It is important to determine whether there is a family history of depression or of suicides. A careful, non-judgmental inventory of substance abuse should be made in every case, as this requires specific treatment measures of its own. A general history of psychological problems could predispose an individual to depression. Because physical conditions have been associated with depression, a thorough history should include an account of diseases such as neurologic disorders (stroke, Parkinson’s, and Alzheimer’s disease, multiple sclerosis, epilepsy, encephalitis, brain tumors); endocrine disorders (diabetes mellitus, hypothyroidism, and hyperparathyroidism); and other disorders (coronary artery disease, cancer, and chronic fatigue syndrome ). Conversely, individuals with major depression may see a medical doctor for physical complaints of headache , abdominal pain , body aches, low energy, feeling poorly, or problems with sexual function .

It is also important to obtain a complete drug history because major depression has been shown to be a side effect of some medications, especially antihypertensive agents (such as calcium channel and beta blockers), analgesics, and certain migraine medicines.

Physical exam: Complete physical examination and medical workup are indicated to rule out medical causes. Illnesses that frequently cause depression include hyperthyroidism and other glandular disturbances, cancer, stroke, and heart attack. As these illnesses are usually associated with dramatic symptoms, individuals are likely to have already sought medical attention. When the disease process is less acute and without many outward signs, however, depression may be the only complaint.

Tests: Besides routine laboratory tests, more specialized endocrine tests may be helpful in establishing the diagnosis. A CT may also be requested to test for relatively rare causes such as brain tumor or a clinically silent stroke. Psychological tests such as the Minnesota Multiphasic Personality Inventory - 2 (MMPI- 2) and the Beck Depression Inventory (BDI) may be useful in establishing a baseline of reported symptoms and monitoring response to treatment.

• Treatment

Treatment choice depends on the outcome of the evaluation (history, physical exam, and tests). Treatment usually consists of psychotherapy , medications, or both. Today, there are a number of effective antidepressant medications that work by correcting imbalances in the levels of brain chemicals (neurotransmitters). About two-thirds of individuals treated will respond to one or more medications. Generally, these medications take full effect 3 to 6 weeks after treatment has begun. Psychiatrists usually recommend that individuals continue to take the medication for five or more months after symptoms have improved.

Treatment of depression consists of three phases. Acute treatment, lasting 6 to 12 weeks, is aimed at remission of symptoms. Continuation treatment, lasting 4 to 9 months, is aimed at preventing relapse. During this phase, medication should be continued at full dosage. Psychotherapy may also be helpful. Maintenance treatment is aimed at preventing new episodes (recurrence ) in individuals with prior episodes. Both maintenance medication and maintenance psychotherapy can prevent relapse or delay the next episode. Individuals and their families should be educated before treatment about the diagnosis, likely outcome, treatment options, costs, and side effects.

Psychotherapy or talk therapy may be used alone for treatment of mild depression. Antidepressant medications in combination with psychotherapy are used for moderate to major depression. Different types of psychotherapy include cognitive -behavioral therapy, psychodynamic psychotherapy, interpersonal therapy, and supportive psychotherapy. In a major analysis of four randomized comparative studies, cognitive-behavioral therapy was shown to be as effective as antidepressants in treating severe or major depression, but not dysthymia. Much of the success of psychologic therapy, in any case, depends on the skill of the therapist.

Research indicates that using a combination of antidepressants and therapy is more effective than either treatment alone for most individuals, possibly because most individuals are more likely to take their medication regularly when they are also undergoing therapy.

For those for whom neither medications nor psychotherapy are effective, other techniques, such as electroconvulsive therapy (ECT), are safe and effective. Although ECT has received bad press since it was introduced in the 1930s, it has been refined over the years, and is now successful in treating more than 90% of individuals suffering from mood disorders.

Psychiatric hospitalization is warranted in instances when there is indication of personal neglect or high-risk of self-harm.

• Prognosis

Most individuals with a major depressive episode will get better . As the number of available antidepressant medications continues to grow, most individuals will respond to at least one of these. Individual may also benefit from psychotherapy . With time, recovery is usually complete, though risk of relapse increases with each episode. More than half of all individuals with one episode of major depression will have another, while those individuals with a history of three previous episodes have a 90% likelihood of having a fourth. Because of this high relapse rate, it is now recommended that individuals with a history of multiple depressive episodes receive medication for the rest of their lives.

Spontaneous recovery may take months. During that time the individual is at such a great risk of complications that it would be unthinkable not to intervene. Risk of recurrence is about 70% at 5 years, and at least 80% at 8 years. For individuals with severe major depression, 76% on antidepressants recover, whereas only 18% on sugar pills (placebo) or on psychotherapy without medication recover.

Poor outcome is associated with inadequate treatment , severe initial symptoms (including psychosis), early age of onset, greater number of previous episodes, only partial recovery after 1 year, having another severe mental or medical disorder, and family dysfunction.

Major depression causes more physical and social dysfunction than many chronic medical conditions.

• Differential Diagnoses

• Adjustment disorder with depressed mood

• Bipolar disorder

• Dementia

• Dysthymic disorder

• Mood disorder due to general condition

• Schizoaffective disorder

• Substance-induced mood disorder

• Specialists

Clinical Psychologist

Psychiatrist

• Comorbid Conditions

• Alcohol /substance abuse

• Anxiety disorders

• Cardiac conditions

• Other general medical conditions

• Personality disorders

• Complications

Substance abuse , especially alcohol , frequently complicates a diagnosis for depression , although in some cases it may be difficult to determine which problem is primary. About 80% to 90% of individuals with major depression also have anxiety symptoms, such as anxiety, obsessive preoccupation, panic attacks, phobias, and excessive health concerns, and about one-third also have a full-blown anxiety disorder —usually panic disorder, obsessive-compulsive disorder, or social phobia. Anxiety symptoms may require special treatment , but frequently respond to antidepressant medications, reinforcing the view that the two disorders share common brain chemistry imbalances. Approximately 1 in 10 individuals who has experienced a major depressive episode will subsequently be diagnosed as having bipolar mood disorder, a chronic condition with episodes of both depression and mania , that may only partly respond to treatment. In some cases, an episode of bipolar mood disorder may emerge as the result of antidepressant medication use.

In extremely severe cases of major depression, psychotic symptoms may be present, such as hearing voices (auditory hallucinations) or having false beliefs (delusions).

Up to 15% of individuals with severe major depression die by suicide. Death rate is 4 times higher over age 55. Suicide attempt may paradoxically occur as the individual begins to respond to therapy because the extreme apathy sometimes seen in major depression before treatment may actually prevent them from committing suicide due to lack of motivation or energy.

• Factors Influencing Duration

Length of disability might be influenced by the severity of the illness, the presence of complicating factors such as substance abuse or suicide attempts, response to therapy, and the occupation requirements. Only in the most severe and unusual cases should this result in permanent disability.

Substance abuse will complicate treatment and may significantly delay returning to work. Suicide attempts that lead to hospitalization will also be associated with longer periods of disability.

• Length of Disability

Psychotherapy and/or pharmacotherapy, major depressive disorder (single episode).

DURATION IN DAYS

Job Classification	Minimum	Optimum	Maximum
Any Work	14	28	56

Psychotherapy and/or pharmacotherapy, major depressive disorder (recurrent episode).

DURATION IN DAYS

Job Classification	Minimum	Optimum	Maximum
Any Work	14	28	70

• Duration Trend from Reference Data

DURATION TRENDS

ICD-9-CM: 296.2
Cases	Mean	Min	Max	No Lost Time	Over 6 Months
6347	52	0	266	2.5%	4.1%

Percentile:	5th	25th	Median	75th	95th
Days:	4	17	35	71	167

DURATION TRENDS

ICD-9-CM: 296.3, 296.32, 296.33
Cases	Mean	Min	Max	No Lost Time	Over 6 Months
3693	74	0	360	0.1%	9.2%

Percentile:	5th	25th	Median	75th	95th
Days:	12	30	55	97	189

DURATION TRENDS

ICD-9-CM: 311
Cases	Mean	Min	Max	No Lost Time	Over 6 Months
9185	68	0	315	< 0.1%	8.6%

Percentile:	5th	25th	Median	75th	95th
Days:	11	26	47	90	196

Differences may exist between the duration tables and the reference graphs. Duration tables provide expected recovery periods based on the type of work performed by the individual. The reference graphs reflect the actual experience of many individuals across the spectrum of physical conditions, in a variety of industries, and with varying levels of case management. Selected graphs combine multiple codes based on similar means and medians.

• Return to Work ( Restrictions / Accommodations)

Temporary work accommodations may include the avoidance of stressful situations and may include reducing or eliminating activities where the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicle s, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during employee’s personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote timely and safe transition back to full work productivity. Daytime work hours may be necessary for a period of time.

• Failure to Recover

If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual’s medical case.

Regarding diagnosis:

• Was a thorough history obtained? Does family have history of depression or of suicides?

• Was substance abuse identified or ruled out?

• Does individual have history of psychological problems? Does individual have any physical conditions such as neurologic disorders (stroke, Parkinson’s, epilepsy), endocrine disorders (diabetes mellitus, hypothyroidism, or hyperparathyroidism), or other disorders (cancer, coronary artery disease)?

• Were endocrine tests done?

• Is the physician an expert in diagnosis and psychopharmacology?

• Was diagnosis confirmed?

• Is it possible that individual was misdiagnosed?

• Would individual benefit from a second opinion?

Regarding treatment :

• Since major depression is the result of biochemical imbalances in the brain , is the physician adequately trained in psychopharmacology?

• Even though the right medication is prescribed, does the dosage need to be increased in order to achieve an adequate level of therapeutic benefit?

• Is individual beginning to feel any positive response from current medication (s)? Because responses differ and several trials of medicine may be needed before an effective treatment is found, is change of medication warranted at this time?

• If individual is experiencing side effects from current medication , is individual comfortable with and diligent in reporting side effects to doctor? If not, does individual trust family member or caregiver to share this information with physician?

• Is psychotherapy being used as part of individual’s treatment regimen?

• Is individual learning to recognize and change behaviors, thoughts, or relationships that cause or maintain depression ? Is therapy helping individual to develop more healthful and rewarding habits?

• Are underlying medical conditions that may complicate treatment or impact recovery being effectively addressed?

• If individual’s depression is incapacitating, severe and life-threatening, or if he or she cannot take or does not respond to antidepressant medications, is electroconvulsive therapy (ECT) being considered at this time?

• Is individual seriously contemplating suicide or previously attempted it? Does the threat of self-harm or personal neglect put individual at risk?

• Is individual frail because of weight loss or at risk for heart problems because of severe agitation?

• Would individual benefit from hospitalization until self-care is possible?

Regarding prognosis :

• Assuming diagnosis and treatment are accurate, can individual comprehend and follow medication treatment regimen including proper dose to be taking, what time of day to take medication, and how to increase dosage when ordered? If individual is not capable, is another responsible individual available to oversee treatment? If not, would individual benefit from hospitalization until self-care is possible?

• Was individual made aware of possible side effects and what to do if a side effect is experienced?

• Does individual have a good working rapport with his or her physician?

• Does individual know how often to see physician and is transportation available? Is individual diligent about keeping appointments?

• Has the physician informed individual as to what to do to improve response to treatment and which activities to avoid to increase the likelihood of improvement? Is individual engaged in psychotherapy ?

• What other support is available to individual? Family? Friends? Church? Support group?

• Medical Codes

ICD-9-CM:	296.2, 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.3, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 296.5, 311
ICD-10:	F31.3, F31.4, F31.5, F32.0, F32.1, F32.2, F32.8, F32.9, F33, F33.0, F33.1, F33.2, F33.3, F33.4, F33.8, F33.9

• Cited References

Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4^th ed. Washington, DC: American Psychiatric Association, 2000.

Copyright © 2005–2007 Reed Group, Ltd.

Appendix 4: AADEP Fellowship Gradation Scheme

AADEP Fellowship Revised Case Report Reviewer’s Analysis

Case Report #
Reviewer:	Date:	Deadline:
If Category does not apply, a minimum of two (2) points should be assigned.
Content Item		Points Assigned
I. Overall Length, Structure and Readability of Report (20 points)
A. Length - adequate description overall (0–4)
B. Structure (6 points)
1. Report divided into labeled sections (0–2)
2. Identifying information [biographical, referral source, purpose] (0–1)
3. Short paragraphs - one topic per paragraph (0–1)
4. Answers to critical questions clearly identifiable (0–2)
C Well written / discussion clear to non-physician reader (choose one – 0–10)
1. Well written / no confusion (10) or
2. Some difficulty in following text (5) or
3. Poor or confusing (0)
II. Medical content - History and Physical Examination (34 points)
A. Purpose of exam, with disclaimer (0–1)
B. Date of Injury and Jurisdiction [P.I., W.C., etc.] (0–1)
C. Examinee’s employer/job description provided (if relevant) (0–1)
D. Chief complaint stated clearly (0–1)
E. History of injury/event elicited from Examinee (0–2)
F. Past medical and surgical history elicited (0–4)
G. Discussion of prior claims (if applicable) (0–2)
H. Review of systems (0–2)
I. Medications described (including if taken day of examination) (0–2)
J. Social history, INCLUDING activities of daily living, hobbies, etc, both prior to and after claim, elicited and described in depth (0–4)
K. Physical exam thorough/consistent with the Guide’s Recommendations:
1. Examinee’s age, height, weight, sex, hand dominance included (0–2)
2. Examination thorough and focused on area of chief complaint (0–6)
3. Relevant ancillary areas also evaluated (0–2)
4. Subjective versus objective “findings” differentiated (0–2)
5. Use of distraction testing/Waddell’s (if appropriate) (0–2)
Case Report #
III. Medical content - Diagnostic Testing and Record Review (12 points)
A. Diagnostic tests ordered by Examiner stated, with interpretations (0–2)
B. Diagnostic tests reviewed by Examiner listed and described (0–2)
C. Medical records reviewed are listed and discussed
1. Medical records listed (0–2)
2. Content of records specifically described, separate from history (0–4)
3. Potentially useful but unavailable records described and requested (0–2)
IV. Impressions/Conclusions (34 points)
A. Content
1. Diagnosis specifically stated (0–2)
2. Symptom magnification or not (0–2)
3. Causation of diagnoses discussed in context of claim (0–4)
4. Apportionment to old injuries discussed (0–2)
5. Is Examinee at MMI or not? (0–2)
6a. If at MMI, Impairment rating (if applicable) or prognosis given
OR         [0–2 for (a) OR (b)]
6b. If not at MMI, need for further testing or procedures defined?
7. Impairment rating (if applicable) performed correctly (0–4)
8. Work ability/restrictions defined as permanent or temporary? (0–2)
9. Physical capacities described [based upon objective findings] (0–4)
B. Conclusions fit with history, exam, testing, records (choose one - 10 points)
1. Conclusions fit (10) or
2. Questionable fit (5) or
3. Conclusions not justified/no fit (0)
Total Points Awarded		0
Percentage of Total Points Possible                  (N/100) =		0.00%
Fellow Criteria Points            (Percentage × 40) =		0
Reviewer’s Comments: PLEASE PUT CONSTRUCTIVE, CONCISE, CRITICISM THAT THE EXAMINEE CAN UTILIZE EASILY
Signature of Reviewer:                   MD or DO, FAADEP