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Musculoskeletal Impairment Rating
Musculoskeletal Impairment Rating
Musculoskeletal Impairment Rating
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
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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.
"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
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"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
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