Evaluation Of Permanent Impairment Research Articles

The Intersection of Medicine and Disability

Abstract Many physicians were not formally trained in the evaluation and management of disability and must understand the language of disability, how disability is evaluated, what to expect from a medical evaluation, and how to communicate effectively to achieve the best outcomes. The very language of disability is complex and often is misunderstood. For example, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, defines impairment as “a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder, or disease.” In contrast, disability is variously defined by the administrative or legal system with jurisdiction, and the AMA Guides broadly defines disability as “activity limitations and/or participation restrictions in an individual with a health condition, disorder, or disease.” Another useful concept is “needless disability” or days away from work that are not medically necessary; workless populations experience a two- to threefold increased risk of poor general health, including higher rates of cardiovascular disease, lung cancer, and respiratory infections, among other problems that contribute to an excess mortality of 20% among individuals in this group. Physicians help establish but are not the final arbiters of disability determinations; their role is to provide accurate, complete, and clear information that allows others to determine the presence, extent, and compensability of disability.

Reliability of Cervical Spine Palpation

Abstract Palpitation is an important component of a comprehensive musculoskeletal and neurologic examination of the cervical spine in individuals with neck pain, but examiners should not base diagnostic conclusions (eg, facetogenic pain) and interventional procedures on palpatory findings alone. A methodological approach to palpation of the posterior neck includes evaluation of the paraspinal musculature, the tissues that overlie the facet (zygapophyseal) joints, and the midline spinous processes. Although studies have shown low interexaminer reliability, palpation is an important component of the physical examination for determining general anatomic regions of symptoms and in establishing rapport with the examinee. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the diagnosis-related estimate (DRE) or injury method lists both muscle spasm and muscle guarding as potential physical exam findings by palpation. In this edition, the range-of-motion method for rating spinal impairment states that an examiner cannot find muscle spasm on exam and rate the individual's impairment on the same day because, by definition, the individual is not at maximum medial improvement. Despite acceptance by the AMA Guides, Fifth Edition, neither spasm nor guarding appears to be a reliable finding on palpation. The AMA Guides, Sixth Edition, provides a different method for determining spinal impairment, and the authors recommend limiting physical examination findings used in impairment rating to those with acceptable interrater reliability.

Maximum Medical Improvement: Jurisdictional Perspectives

Abstract Maximum medical improvement (MMI) and its multiple synonyms are important terms to understand because one cannot determine permanent impairment until a condition has resolved or reached a stable plateau with respect to improvement. Further, in many jurisdictions MMI represents the date beyond which temporary or all benefits cease or time-loss compensation (temporary disability benefits) may be terminated. Because each arena is to some extent unique, evaluating physicians should become familiar with MMI or the term used and its definition in the applicable federal, state, or provincial law or insurance policy. A table shows the terminology used by various US workers’ compensation jurisdictions, but there is no universal definition for MMI. The fourth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) says only that “an impairment should not be considered ‘permanent’ until the clinical findings, determined during a period of months, indicate that the medical condition is static and well stabilized. The AMA Guides, Fifth Edition, defines MMI as “a condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment” but acknowledges the possibility of “some change.” Similarly the sixth edition states that MMI is the “point at which a condition has stabilized and is unlikely to change (improve or worsen) substantially in the next year, with or without treatment”; signs and symptoms may wax and wane, but further recovery or deterioration is not anticipated.

Rating Physical Residuals of Breast Disfigurement

Abstract A 48-year-old woman was working as a hostess in a lounge and was struck in the chest when a fight arose; afterwards, she noticed discomfort and a warm sensation in her left breast, which over the course of months remained smaller and also became distorted in comparison with her previous size, shape, contour, and comparison with her right breast. Ten years previously, she had received double lumen prostheses (saline on the outside and silicone gel on the inside). One year later she was found to be at maximum medical improvement (MMI) and described no signs or symptoms although her sexual life reportedly changed, with less frequency and satisfaction. Tables present the fifth edition criteria for rating permanent impairment due to skin disorders; fifth edition criteria for rating permanent impairment due to facial disorders and/or disfigurement; and sixth edition criteria for rating permanent impairment due to mammary disorders. Section 10.9 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, mentions that coexisting psychiatric impairment would be rated using the mental and behavioral disorders chapter, which contains one reference to cosmetic abnormalities and requires a “severe cosmetic deformity with no ability to lactate.” Thus the only way to provide an impairment rating using the fifth edition for this individual is to perform a psychological evaluation; in the sixth edition, it is the only permissible rating.

Challenges in Rating Multiple Upper Extremity Conditions: A Case of Quadrilateral Space Syndrome and Medial Elbow Injury

Abstract Physicians sometimes are challenged with clinical presentations that do not fit perfectly within the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides); in such cases, the evaluator is instructed to apply clinical judgment and common sense when determining an impairment, with particular consideration of the effect of the medical condition on the individual's activities of daily living. In this case presentation, a 35-year-old male private security guard injured his right elbow performing a bench press while on assignment. After magnetic resonance imaging and electrodiagnostic evaluation, the patient underwent surgery that included a medial elbow Nirschl procedure and an ulnar nerve submuscular transposition. The patient underwent twelve months of rehabilitation, but he continues to experience a pins-and-needles sensation and perceives upper arm strength loss. Twenty-four months after surgery, the patient declines surgical treatment for quadrilateral space syndrome and presents for an impairment rating evaluation. Accepted medical conditions under the workers’ compensation program include quadrilateral space syndrome, medial epicondylopathy, and ulnar nerve entrapment at the elbow (cubital tunnel syndrome). The AMA Guides, Sixth Edition, does not include a listing for quadrilateral space syndrome, and the author discusses the challenges of teasing out functional limitations when multiple diagnoses are present within the same limb. Evaluators should note that the AMA Guides recommends using the impairment rating that most closely represents the actual functional loss.

Rating Knee Impairments

Abstract Workers who kneel for major portions of their workday (eg, floor and roof installers) may be prone to inflammation of the knee bursae and patellofemoral pain. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), range-of-motion (ROM) and diagnosis-based impairment (DBI) are the two possible stand-alone methods for rating knee impairment. The ROM method was widely used in previous editions of the AMA Guides, but at present DBI is the method of choice for calculating impairment. To rate knee impairment using the DBI method, the physician first chooses the appropriate diagnosis from the Knee Regional Grid in the AMA Guides, Sixth Edition. Next, the physician chooses the appropriate impairment class for the diagnosis and then selects the appropriate grade modifiers. The physician applies the net adjustment formula to determine lower extremity impairment and finally converts the final lower extremity impairment to whole person impairment. Two or more conditions often are found in the knees and require causation analysis in which the physician should choose the single causally related diagnosis that will yield the highest impairment rating. Modifiers should be chosen based on reliable findings that have not been used previously to assign either the diagnosis or impairment class. The ROM method can be used to select the physical examination grade modifier or as a stand-alone rating if the physician offers a rationale that is supported by the AMA Guides.

The Road Accident Fund and serious injuries: the narrative test.

The Road Accident Fund Amendment Act 19 of 2005 came into effect on 1 August 2008. This Act limits the Road Accident Fund’s liability for compensation in respect of claims for non-pecuniary loss to instances where a “serious injury” has been sustained. A medical practitioner has to determine whether or not the claimant has suffered a serious injury by undertaking an assessment prescribed in the Regulations to the Act. The practitioner has to complete a RAF 4 report. In doing so the practitioner must assess the injury in terms of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (6th ed). If the injury is considered to have resulted in less than 30 per cent of the whole person impairment the medical practitioner should apply the narrative test. The article focuses on the narrative test but also discusses reasons why the regulations do not fulfil the requirements of the Act; reasons why the Guides is not adequate to the task; the impact of the circumstances of an injured person on disability; problems with the existing wording of the narrative test; shortcomings on the RAf 4 form; the administrative process as well as the appeal tribunals.
 

In the Literature

Abstract A method for determining the severity of a presentation of cognitive impairment has been developed and scientifically validated specifically for use with cases in which the causative diagnosis is traumatic brain injury. The method determines if the impairment, as demonstrated on neuropsychology testing, is consistent with the severity of the claimed cause. Such scientific linkage of an objective measurement of impairment severity and the severity of the cause is quite rare. The research related to this method did not consider methodology for impairment rating presented in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), so this article compares the new method to the impairment rating methodology from the AMA Guides, Sixth Edition, Section 13.3d, Mental Status, Cognition, and Highest Integrative Function. This article offers an example of how neuropsychology test results for an individual case can be applied to the classes of impairment that are included in Table 13-8, Criteria for Rating Neurologic Impairment Due to Alteration in Mental Status, Cognition, and Highest Integrative Function. This method has the advantages of standardization, objectivity, and being based on scientific findings that make the unique contribution of actually linking severity of impairment to severity of the causative factors. The authors caution that the method is only a subset of the methodology from Section 13.3d and does not justify abandonment of the remainder of this section of the AMA Guides.

CASE STUDY: Gender-Specific Impairment Rating Examples

Abstract Accurate pulmonary impairment ratings depend on a valid and reliable lung function test and appropriate application of the criteria provided in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. The two lung function tests are dynamic and static; the principal dynamic test is the cardiopulmonary stress test [see sidebar, “Cardiopulmonary Exercise Testing,” in this issue of The Guides Newsletter]. To rate pulmonary impairment using Chapter 5 of the AMA Guides, Sixth Edition, a physician should obtain the spirometric results and the value for the diffusion of carbon monoxide across the alveolar capillary membrane of the lung (DLCO); the latter should be administered according to American Thoracic Society criteria. A six-minute walk test is a standard test of pulmonary reserve in lung disease patients and may be part of the individual's physical examination. Each diagnosis table in Chapter 5 is divided into variables or factors that determine the impairment rating. Each impairment class (except 0) has five grades (A through E). Once the evaluator uses objective test results to assign the impairment class, the non-key factors are considered to determine whether the impairment should be adjusted from the default value. To determine the adjustment, the evaluator subtracts the impairment class integer from each non-key factor integer, and the differences are summated for the net adjustment.

Impairment Assessment of Female Sexual Dysfunction

Abstract Impairment assessment of female sexual dysfunction using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth or Sixth Edition, must be performed using appropriate evaluation and objective findings to support ratable sexual dysfunction. In both editions, sexual dysfunction is discussed in Chapter 7, The Urinary and Reproductive Systems, and Chapter 13, The Central and Peripheral Nervous System. In the fifth edition, the maximum impairment rating for female sexual functioning is 35% whole person impairment; in the sixth edition, the maximum is 20%. In terms of rating female reproductive organ impairment, the fifth edition gives consideration to the differences between premenopausal and postmenopausal women. Table 7-9, Criteria for Rating Permanent Impairment Due to Vulval and Vaginal Disease in the fifth edition is used to rate female sexual dysfunction; three classes are identified, and, although age is not a specific consideration, this edition discusses differences between premenopausal and postmenopausal women. In the AMA Guides, Sixth Edition, Table 7-10, Criteria for Rating Permanent Impairment Due to Vulval and Vaginal Disease, is used and provides four classes, two of which have severity grades. Each class addresses historical signs and symptoms of vulvar or vaginal diseases, vulval and vaginal physical alterations, and potential effect of altered vaginal anatomy for vaginal delivery (if premenopausal). Neurogenic sexual dysfunction is combined with other related impairments using the Combined Values Chart.

Carpal Tunnel Syndrome and Trigger Fingers in a Patient with Rheumatoid Arthritis and Systemic Lupus Erythematosus: Case Example

Abstract Causation analysis involves determining what conditions are related to a compensable injury or illness; apportionment is the allocation of responsibility among two or more probable causes; and assessing impairment is based on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). These three are separate activities, but sometimes all three must be addressed in a single evaluation and may be required for a specified jurisdiction (eg, California). Evaluators thus must ask if jurisdictional issues dictate or influence the approach to causation and apportionment; which edition of the AMA Guides to use; and how to approach causation and apportionment in the present case example: A 63-year-old woman with rheumatoid arthritis and systemic lupus erythematosus is assessed by an orthopedic surgeon who is the agreed medical evaluator (AME). In addition to her pre-existing rheumatoid arthritis and lupus, the individual also had Sjogren's syndrome, osteoarthritis, degenerative disc disease, left carpal tunnel syndrome, osteopenia, and obesity. She has undergone multiple surgical procedures, and treatment for her collagen vascular disease includes leflunomide (immunosuppressant), hydroxychloroquine, and prednisone. In this case, impairments were not the result of “cumulative trauma” but rather were secondary to underlying chronic inflammatory disease, and her occupational permanent impairment rating accordingly would be zero.

"Chronic Pain and the Brain" Impairment: Introducing a Translational Neuroscience-Based Metric.

This commentary is in response to Drs. Feinberg and Brigham’s request for reader feedback of their 2014 revision of their 2006 “Guide to the Guides…” [1]. They teach that its use improves rating accuracy. We concur. Their 2014 revision generates impairment rating protocols in injured workers that are based on the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition (GUIDES) [2]. In response to their request for feedback, we wish to bring attention to published rating inaccuracies in the GUIDES and the unreliability of measuring chronic pain based only on self-report [3–6]. We have two goals. One is to introduce a neuroscience-based metric and related protocol that eliminates all identified GUIDES defects when rating chronic pain whole-person impairment. A second is to stimulate evaluation of this neuroscience-based assessment protocol as a potential gold-standard diagnostic benchmark in chronic pain medicine that currently does not exist. The search for a reliable chronic pain metric is the “holy grail” in all of pain medicine that challenges pain medicine practitioners, patients, drug developers, and the medical-legal community at large [6]. Historically we learn that the GUIDES is developed, “ To enable physicians to evaluate functional impairment in an objective and consistent manner… ” (p. 286 [5]). Seabury et al. challenge its “ …controversial use when measuring impairment versus disability. ” They, along with others, identify numerous “Catch 22s” that question GUIDES-derived impairment ratings as reliable and address them in detail [3–5]. As an example, we cite Dr. Rondinelli’s 2010 “Commentary” [4]. He writes “…that the ratings themselves remain largely consensus-based …and subject to various stakeholder priorities and biases… (p. 1204 [4])” In our experience this invites speculative expert examiner opinions. Our first goal is to …

Impairment Assessment of Male Sexual Dysfunction

Abstract Impairment assessment of male sexual dysfunction using both the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions, must be done with appropriate evaluation and objective findings in order to support ratable sexual dysfunction. The fifth edition specified that the absence of sexual functioning results in a maximum rating of 20% whole person impairment (WPI); in the sixth edition, the maximum is 15%. In the AMA Guides, Fifth and Sixth Editions, sexual dysfunction is discussed in Chapter 7, The Urinary and Reproductive Systems, and in Chapter 13, The Central and Peripheral Nervous System. In the fifth edition, Section 7.7, Male Reproductive Organs, provides guidance for impairment percentages for male reproductive organs for men aged 40–65 years; age adjustment is made for males younger than 40 (WPI is increased 50%) and older than 65 (WPI is decreased 50%). Section 13.7d, Sexual System Neurologic Impairments, in the fifth edition of the AMA Guides directs evaluators to use Table 13-21, Criteria for Rating Neurologic Sexual Impairments. In the sixth edition, Section 7.7 similarly offers guidance for impairment percentages for male reproductive organs for men aged 40–65 years but, unlike the fifth edition, allows a 10% upward or downward adjustment at the evaluator's discretion based on the individual's age and level of premorbid sexual functioning. In the sixth edition, Table 7-6, Criteria for Rating Permanent Impairment Due to Penile Disease, presents four classes and three grades.

Case Study: Use of Electrodiagnostic Evaluation to Assess Lumbar Radiculopathy

Abstract The electrodiagnostic examination is an important diagnostic tool that defines the location, pathophysiology, severity, and chronicity of a wide array of neuromuscular disorders. The test comprises two parts, a nerve conduction study (NCS) and needle electromyography (EMG), and is an extension of the neuromuscular portion of the physical examination. Together, NCS and EMG provide complementary information about the integrity of the peripheral nervous system. The article presents a case example that is evaluated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. The case describes a 52-year-old woman who had a back injury that was managed conservatively for fifteen months and then underwent a three-level lumbosacral instrumented posterolateral fusion (the rationale is unclear from the records). Her pain persisted and treatment has included chronic narcotics; she reported multiple physical and psychological complaints and difficulties, and illness behavior and unreliable self-reports failed to corroborate her reports. Needle EMG must be performed on the patient's paraspinal muscles for proper evaluation of radiculopathy, and in this case there was no evidence of involvement of any ventral ramus and thus no evidence was documented of nerve root abnormality involving two or more limb muscles that receive innervation from the same nerve root. For this individual, the changes seen in paraspinal EMGs were unlikely to be due to a true lumbar radiculopathy, which was not convincingly established.

A Review of the Evaluation, Treatment, and Rating of Lateral Epicondylitis

Abstract Lateral epicondylitis, often called “tennis elbow,” is a musculoskeletal condition characterized by pain around the lateral elbow and adjacent forearm with resisted wrist extension or passive terminal wrist flexion with the elbow in full extension, plus tenderness over and/or just distal to the lateral epicondyle. The name is a misnomer because the pathology is neither inflammatory nor located in the lateral epicondyle but rather represents a chronic tendinosis with disorganized tissue and neovessels of the tendon originating from the extensor carpi radialis brevis muscle and less commonly the extensor digitorum communis muscle, which originate on the lateral epicondyle. Clinical assessment involves understanding the chronology, precipitating activities, current symptoms, and interference with activities of daily living. Physical examination is performed bilaterally and includes palpitation provocative testing, measuring elbow and wrist motions, and neurological evaluation. Many treatments have been proposed, but little quality evidence supports any specific approach; more than 90% of cases are managed nonoperatively. Severe cases that have failed at least months of nonoperative management may warrant surgical assessment, but studies of surgical results for treatment of lateral epicondylitis are limited. Impairment rating may be necessary in a minority of cases and involves using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, based on diagnosis-based impairment and using Table 15-4, Elbow Regional Grid: Upper Extremity Impairments.

Cardiovascular Impairment Evaluation: Sixth Edition

Abstract To assess medical impairments, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) divides cardiovascular diseases into the following eight groups, each of which has its own grid: valvular heart disease; coronary artery disease; cardiomyopathies, pericardial heart disease, dysrhythmias, hypertensive cardiovascular disease, vascular diseases affecting the extremities, and diseases of the pulmonary artery. An accompanying table shows the criteria for rating permanent impairment due to valvular heart disease. Within the grids, the rows are divided into three main impairment variables: history, physical findings, and objective test results. The latter are essential in assigning cardiovascular impairment ratings. The AMA Guides names the objective test results variable as the key factor to underscore its role in assigning the impairment class in the cardiovascular chapter. For cardiovascular impairments, objective test results are always used to place the injury in its impairment class; therefore, objective test results are never used to modify the rating once the evaluator chooses the impairment class. Not all internal medicine chapters designate objective test results as the key factor, but all use one key factor that is clearly indicated in a footnote and one or two non-key factors. This rating scheme emphasizes objective test results, history, and physical findings and avoids incorporating variables twice.

Shoulder Impairment Ratings: Sixth Edition

Abstract In many workers’ compensation systems, shoulder injuries are among the most common reasons for filing a claim, and greater familiarity with the significant differences in rating processes between the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions will help physicians avoid common pitfalls and improve the reliability of impairment ratings. One source of confusion associated with rating a shoulder is determining whether to use the range-of-motion (ROM) method or the diagnosis-based impairment (DBI) method. The AMA Guides, Sixth Edition, clearly states that DBI is the primary method of evaluation for the upper limb and that range of motion is used primarily as a physical examination adjustment factor and only when a grid permits its use as an option. An impairment rating that is calculated using ROM may not be combined with a DBI-based impairment rating; DBI is the primary method, and ROM should be used “only under specific circumstances.” When measuring ROM, evaluators should record all six measurements of shoulder motion for each arm and use the injured arm as a baseline. If two or more diagnoses are possible under the DBI method, evaluators should choose the highest causally related impairment rating from the shoulder grid and modify the clinical studies grade modifier.

International Classification of Functioning, Disability, and Health: A Contemporary Model of Disablement

Abstract This article begins with a consult of a patient using the International Classification of Functioning, Disability, and Health (ICF), published by the World Health Organization in 2001. The ICF framework serves as the conceptual model for the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. In contrast to the issues of morbidity-centric documentation schemas, the ICF platform provides a standardized nomenclature to chart functioning, specifically an integrative biopsychosocial model of functioning that defines the components of functioning. The ICF qualifier serves as the titratable dimension of function; the qualifier not only satisfies the need for charting progress but also, when aggregated, provides the possibility of identifying the quantitative metrics of a cohort (eg, service needs, length of hospitalization, level of care, functional outcomes, and return-to-work potential). Implementing ICF into routine documentation moves practitioners toward the concept of functioning not as a consequence of disease but rather toward the real-life dynamics among health condition, body function, body structure, and environmental factors that determine functioning. ICF will be an essential basis for the standardization of data concerning all aspects of human functioning and disability around the world. ICF will be useful for persons with all forms of disabilities, not only for identifying health care and rehabilitative needs but also in identifying and measuring the effect of the physical and social environments.

GUEST EDITORIAL: In the Line of Fire: IME Burnout

Abstract Physicians suffer more burnout than many other American workers and rank near the top of all professions in burnout. Physicians who perform independent medical evaluations (IME) face the usual challenges (too many bureaucratic tasks, too many hours of work, insufficient income, and loss of status) that contribute to burnout among all physicians. Both “innate personality traits” and external factors (circumstances, examinees, time, performance, and risk) contribute to burnout among physicians who perform IME. Stressed because of multilayered litigation, insurance, and bureaucratic processes, IME physicians face a high concentration of difficult patients who are disgruntled with their jobs and, often, their lives. Examinees’ negative attitudes and outlooks contribute to pessimism and depression that can be contagious to the examiner, and because IMEs are one-time evaluations with no longitudinal care, the opportunity to establish rapport is limited. Physicians who are coping with the pressures of the IME milieu may need to realize that they have a greater sphere of positive influence than they realize: By conducting oneself in a professional and ethical fashion, writing fair reports, relying on evidence-based medicine, and applying the AMA Guides to the Evaluation of Permanent Impairment in a proficient manner, physicians who conduct IMEs can recognize and, one hopes, avoid IME burnout.

Q&A: Rating Multiple Pelvic Fractures

Abstract Part 1 of this series examined many of the rules in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, regarding rating nerve entrapment or focal neuropathies; the current article, part 2, examines how to read and match the findings in an electrodiagnostic report to the criteria in Appendix 15-B, Electrodiagnostic Evaluation of Entrapment, as explained in Section 15.4f, and determine the severity of the test findings as listed in Table 15-23. Physicians who perform nerve conduction studies often use their own definitions of mild, moderate, and severe; these definitions are not standardized and frequently differ from the electrophysiologic definitions used in the AMA Guides, Sixth Edition. When examiners rate focal entrapment neuropathy, they must match data from the electrodiagnostic report to the criteria in Appendix 15-B, and a figure shows a hypothetical motor nerve conduction report for a case that shows both mild neuropathy (conduction delay) of the median nerve at the wrist (carpal tunnel syndrome) and severe neuropathy (axon loss) of the ulnar nerve at the elbow (cubital tunnel syndrome). If both fibrillations and positive waves are seen in the same muscle, the reviewer can be more confident that other electromyographic potentials were not misinterpreted as fibrillations. Prepared with the results of electrodiagnostic studies, the evaluator can work through the steps of history, physical findings, and functional scale to determine the final upper limb impairment according to the AMA Guides.