Ask the Rating Experts
iRatings, LLC, has launched a new monthly information series entitled “Ask the Rating Experts”. In this periodical, we will answer your questions on the rating issues of the day. Topics can range from the proper application of the AMA Guides all the way to common errors we see, even the assessment of impairment under Almaraz/Guzman in California.
We invite you to submit your questions online, or via email.
Our first question comes from California, where the physician used grip loss in place of motion for a wrist injury.
Use of Grip Loss
Q: I have a case where the injured worker sustained a fracture to the right wrist. There is some motion loss on exam that the doctor rated to 4% upper extremity. Instead of rating this, however, the physician used loss of grip strength on the right and gave a rating of 20% upper extremity. The injured worker also had significant complaints of pain. Am I correct that grip loss cannot be used in this case? How do I dispute this?
A: Yes, you are correct that the Guides strictly forbid the use of grip loss in this case. In Section 16.8, the Guides state that loss of strength cannot be rated in the presence of pain or motion loss, as these “prevent effective application of maximal force.” (p. 508) The Guides do state that strength loss can be used “in a rare case,” such as a “severe muscle tear,” but the examiner would still need to adequately explain why this is this case. In your example, however, it does not appear as though the Guides would support the rare case exception.
While we know that the Guides do not allow grip loss for most conditions, this sometimes is not enough to dispute the rating. We encourage you to look at the physical examination and ensure that the procedures outlined in Section 16.8b were followed. Ask the following questions:
1. Was grip strength measured in all five positions on the Jamar Dynomometer?
2. Is there a bell-shaped curve for these measurements?
3. Was rapid grip exchange performed?
4. Was grip measured at different times throughout the examination?
In our experience, most examiners measure grip only once in the examination and at one position of the Jamar Dynomometer. In these cases, it is not possible to accurately rate for grip, as the findings have not been tested for consistency and reliability. Given the lack of reliability, we note that even in the unlikely event that grip loss could be used to rate impairment, there are insufficient physical examination findings to rate for grip under Section 16.8.
Sincerely,
iRatings LLC
Need a Physician Signature on Your Report?
iRatings is now proud to announce the enlistment of David Bachman, MD, to provide a physician peer review to our rating reviews.
Dr. Bachman is a board-certified Orthopaedic Surgeon with over 40 years of experience practicing as a Specialist in private practice and as a Senior Area Medical Director and National Medical Administrator for the U.S. Postal Service. He received his medical degree from Northwestern University Medical School and Orthopaedic training in the Northwestern Orthopaedic Residency Program. He is well qualified in the use of the AMA Guides to the Evaluation of Permanent Impairment and has worked with the U.S. Department of Labor to assist in implementing appropriate impairment rating protocols.