CHAPTER 4

AssessmentTools for Musculoskeletal

Impairment Rating and Disability
Assessment
Ami1: Patel,MD Andrew J. Haig, MD Mikel Cook,Rn: MPA

The AMA Guides encouragesthe disability physician examiner to utilize his or

her "entire gamut of clinical skill and judgment in assessingwhether or not the
resultsof measurementsor testsare plausible and relate to the impairment being
evaluated."2 The purpose of this chapter is to clarify the applications and
limitations of physical tools and tests readily available to the clinician and
typically used in the assessmentof musculoskeletalimpairment and disability.
The three main areas of interest and discussioninclude measurementtools to
assessjoint range of motion (ROM) and muscle strength, radiographic assess-
ment of bone and joint pathology, and electrophysiological assessmentof
neuromuscular function.

TOOLS FOR ASSESSING JOINT MOTION AND MUSCLE STRENGTH

AND ENDURANCE

The disability examiner is frequently called on to objectively describe and

identify impairment to the musculoskeletal system in terms of joint flexibility
and muscle strength and endurance.There are a number of devicesavailable to
assistwith the physical examination in this regard.

Range of Motion
Gon;ometers
Goniometers are used to measure joint ROM (flexibility). The most common
and leastexpensivegoniometer is the simple two-arm plastic or metal goniom-
eter.The clinician can be trained to usethis simple goniometer,and it remains by
far the most widely used tool for measuring ROM. Electrogoniometers,
computerized goniometers, and the bubble goniometer (also known as the
in.:;!inometer)are also used and have proved to be reliable.23.52The simple
goniometer is the primary tool used in extremity ROM testing, whereas the
surface inclinometer (one inclinometer or two inclinometer methods)is primar-
ily used in spine ROM testing.42.53.54The Back Range of Motion (BROM)
device has also been used in lumbar ROM research.9

55
60 Chapter 4 AssessmentTools for Musculoskeletal Impairment Rating and Disability Assessment
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testing from smaller to larger grip and usually reveals greatest strength
measurementwith the middle position. The subjectis tested in all five positions,
with resulting grip pressuresrecorded on a graph, which is expectedto be bell
shaped. If the bell-shaped curve is not generated, submaximal effort is sug-
gested.68This approach has been refined by examining peak and average
force-time curves generated with side-to-side and gender-specificcomparisons
for normative data64and for subjectswith unilateral hand injuries.l1 However,
the utility of hand-held dynamometers to determine maximal effort has been
critically reviewed,51,69and results should be interpreted with considerable
caution by the clinician.
Computerized isometric and isokinetic dynamometershave also beenusedto
assessconsistency of effort. When performing a task, a strength curve is
generated.In the normal or affected subject, this curve should remain consistent
from test to test. If the affected subject shows marked weakness at a certain
ROM, it should be consistently reproducible. The computer program can
calculate a "coefficient of variation" (COV) as the standard deviation among
trials, divided by the meanx 100 asa unitless measureof consistencyofeffort.41
However, the range of acceptableCOY varies by anatomical region, test mode
(isometric versus isokinetic), and according to specificity of strength test (i.e.,
whole body lift versusisolated muscletesting).61
Sincethere is no uniform agreementon norms and acceptablerange of COY s,
they should also be used only with considerable caution in interpreting
consistencyof effort during isometric or isokinetic testing.

Summary of muscle strength and endurance testing

Muscle strength and endurance testing is a key element of musculoskeletal
assessment.The use of manual muscle testing and dynamometers can help the
evaluator to objectively assessimpairment and disability. Isokinetic and isomet-
ric dynamometers are available to assist with strength and endurance assess-
ments of complex movement and functional performance abilities. The appli-
cation of suchobjective testing to the assessmentof symptom magnification (in
terms of degreeand consistencyof effort) warrants considerable caution on the
part of the clinician at this time.

Radiological Assessment of Bone and joint Pathology

It is a common attorney strategy to show a radiograph at trial. The public puts
stock in radiological examinations, and attorneys utilize that confidence to
promote their cases. At face value, one might assume a strong correlation
betweendisease,radiographic impairment, and disability or handicap. If this
were true, however, then a simple interpretation of radiographic tests would
often be sufficient evidence for a disability determination. In reality, disability
determination is a complex process that remains highly subjective, and the
functional significance
ment is likely of radiographic
to be debated and
in any given other objective indicators of impair- '
case.
The purpose of this sectionis to review common radiographic proceduresas
they apply to musculoskeletal impairment rating and to examine functional
interpretations that may be drawn from radiographic findings when making
disability determinations.
Plain-film radiographs are obviously useful in documenting the precise level
of amputation, fracture, nonunion, ankylosis, severesprain, sur~cal interven-
 Chapter4 AssessmentTools for Musculoskeletal Impairment Rating and Disability Assessment 61

"7th tion such as rods or screws, and heterotopic ossification. The relationship
os, betweenthese medical diagnosesand impairment is rather direct and unchang-
)ell ing. Still, when asked about disability or handicap, the physi~ianmust use other
19- factors to modulate the effect of thesediagnoseson the tasks at hand.
1ge A number of other diagnoses can be proved with radiography, but the
>ns relationship betweenthe severity of radiographic findings and function is more
fer, variable. For example, radiographic findings of recurrent patellar subluxation
~en have a highly variable relationship with actual function.14 Various arthritide~
hIe are also diagnosedwith radiography. Although the extent of erosion, joint-space
narrowing, or bony spurring correlates somewhatwith functional disability, the
Ita relationship is not direct. For example, in rheumatoid arthritis (RA), there are
is three common schemasfoJ;r,ating radiological findings: the Steinbrocker Stage,
ent Kaye Modified Sharp Score, and the Larsen Score.46The Larsen system
am appearsto correlate with elbow disability59 and total disability,34but not hand
::an function.57 Although thesescalesprovide similar quantitative data concerning
>ng
radiographic damage in patients with RA, weak correlations are seenbetween
t.41 radiographic scoresand joint count scoresfor tenderness.47It is for this reason
)de that indications for joint replacement surgery in arthritis include pain and
.e., dysfunction.
The presenceof radiographic findings alone is often not sufficient to predict
Vs, extent of functional limitations. Radiographs may reveal disorders or condi-
ing tions that put an individual at risk for future injury or illness despiteadequate
current function. For example, severeosteopenia may be a relative contraindi-
cation to heavy lifting or repetitive activity, regardlessof current function. The
extent to which osteopeniawarrants restrictions to protect the individual from
etal trauma is further modulated by the individual's body habitus and strength, the
the particular activity in question, and other factors that are difficult to measure,
aet- such as the physician's personal belief regarding acceptablerisk. Joint disrup-
ess- tions, such as fractures through cartilage, spondylolisthesis, or avascular
necrosis of the femoral head, are thought to degeneratemore quickly with
'pli-
l (in increased weight bearing and activity. Although radiographs can demonstrate
the these findings effectively, the relationship between future activity and joint
degenerationis variable.
Even with similar radiographs and levels of function, the extent of disability
may demonstrate an inverse relationship to age. Younger persons with hip
replacementswill likely wear out the artificial joints, leading to multiple joint
replacementsand possibly a girdlestone procedure requiring modified weight
puts bearing or wheelchair use; older persons, in contrast, are likely to retain
e to
ambulatory function with a single prosthesis for the duration of their life.
tion
Radiographic findings can be used to document spinal impairment from
this fracture, instability, or degenerativearthritis. Radiographs are lessapplicable in
ould assessingspinal disability. For example, most researchshows little correlation
bility betweenmore subtle spinal radiographic findings and pain (let alone disability
,l\ the. or handicap). Functional outcome after surgical fusion has been shown to be
npalr- similar whether successful fusion or pseudoarthrosis occurs.20 Population-
based studies have demonstrated little correlation between degenerative
lIes as changes shown on radiographs and pain21,45;however, some notable excep-
:tional tions occur. Radiographic findings that correlate somewhat with back pain
flaking include disc-spacenarrowing at L4 without changesat L5, high-degreescoliosis
(greaterthan 600 in an adult), large leg-lengthdiscrepancies(5 cm or more), and
e level severemultilevel degenerativechanges.These findings reflect statistical signifi-
:erven-
 =
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62 Chapter 4 AssessmentTools for Musculoskeletal Impairment Rating and Disability Assessment
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cance of risk factors in a sample population that are insufficient criteria to
~
"prove" pain or disability in the individual case,and are perhapsmore useful to
support the probability that an objective pain generator exists. ,
Radiological imaging during motion can det~rmine instability in some
extremity joints. Radiological assessmentof spinal instability is much more
complex. The AMA Guides2gives criteria for spinal instability, which it calls
loss of motion segment integrity (LOMSI). This is based on comparison of
flexion and extension views of lateral radiographs. Vertebral injury related to
translational (anterior-posterior) motion that is 5 mm or greater than that seen
at an ~djacentintervertebral segmentis the first diagnostic indicator of LOMSI.
Angular motion is the second indicator. If comparing adjacent levels such as
~fi I
L4-LS or above, any angular motion 11° or greater at one level over another
also implicates LOMSI. When comparing the LS-SI interspacewith L4-LS, the
difference must be greater than 15°. Strangely, these criteria are not widely
utilized by neuroradiologists, but are based on cadaverstudies with no known
':
~
!

clinical correlate.49,55Simply put, the association betweeninstability and pain

is yet undefined.48
Advanced radiologic imaging tests, including computerized tomography
/ (CT), magnetic resonance imaging (MRI), and myelograms, are subject to

\ additional concern becausethey are highly sensitiveto conditions of question-

able clinical significance. There is a great potential for these tests to reveal
soft-tissue lesions, but the clinical significance of these findings is variable.
Although lesions such as supraspinatus tendon tear are fairly reliable findings
on MRI,26 it is well documented that MR!, CT, and myelogram can demon-
strate disc pathology in one third to two thirds of asymptomatic individuals
studied.5,28 Clearly, imaging test results require clinical correlation, and the
examiner should avoid inappropriate weighting of nonspecificfindings that are
likely to occur as a result of developmental changes or the normal aging
process}
Bone scans are useful indicators of ongoing bone repair, thus providing
evidence of a fracture up to 1 year after an injury. They may be useful to
documentthe presenceor absenceof a fracture (including hairline fractures) or
to determine that fracture healing is complete, and thus a permanent impair-
ment rating of the healedfracture can be assigned.Other potentially useful tests
involve the injection of radiopaque agents under fluoroscopy for diagnostic
provocation or palliation. Such tests include discography,62facet injection,16
sacroiliac joint injection,31 and selectivenerve root block.63For all of thesetests,
the actual photographic evidence of an abnormality is not considered patho-
gnomonic for a disabling lesion. Instead, they all rely on the client's report that
the test reproduced his or her symptoms. Some progress has been made in
protocols with placebo injections, injections at other "control" levels, blinded
observers, etc., to avoid suggesting responsesto the client, but the clinical
applications of tests to document impairment and disability appear limited at
this time.

Summary of radiological testing

Radiographic proceduresprovide objective evidenceof bone and joint pathol-
ogy useful to the diagnosis of musculoskeletal impairment. However, the
disability examiner must exercisedue caution when drawing functional infer-
encesfrom radiographic findings as they penain to disability in the panicular
case. Clinical correlation of radiographic findings to appropriate subjective