Semiologia ortopedica pericial

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Guides to the Impairment Rating of the Lumbar Spine
5th Edition
By Paul E. Wakim D.O., F.A.A.O.O.S.

Paul Wakim, D.O., F.A.A.O.O.S. Orthopedic SurgeonQME, AME, IME Emile P. Wakim, M.D.Orthopedic Surgeon,QME, AME, IME Robert Ahearn, M.D. Orthopedic Surgery &Disorders of the Spine, QME Kelsey Peterson, M.D. Orthopedic SurgeonM. Mike Kreidie, M.D. Neurologist, QME, AME, IME Jeffrey Bone, Psy.D.Psychologist-EEG/HEG Neurofeedback, QME Kevyn Dean, M.S.P.T.O.C.S.Physical Therapist

Definition of Terms:
• • • • • • Muscle Spasm/Muscle Guarding Asymmetric Range of Motion Nonverifiable Radicular Root Pain Reflexes/Sensory Loss/Atrophy EMG/NCV Alteration of Motion Segment Integrity

Muscle Spasm/Muscle Guarding
A. Muscle Spasm is a sudden involuntary contraction of a muscle or a groupof muscles. To differentiate true muscle spasm from voluntary muscle contraction, the individual should not be able to relax the contractions. The spasm should be present standing as well as in the supine position and frequently causes a scoliosis. B. Muscle Guarding is a contraction of a muscle to minimize motion or agitation of the injured or diseased tissue. It is not true muscle spasm becausethe contraction can be relaxed. In the lumbar spine, the contraction frequently results in loss of the normal lumbar lordosis, and it may be associated with reproducible loss of spinal motion.

Asymmetric Range of Motion
Asymmetric motion of the spine in one of the three principal planes is sometimes caused by muscle spasm or guarding. If an individual attempts to flex the spine, he or she isunable to do so moving symmetrically; rather, the head or trunk leans to one side To qualify as true asymmetric motion, the finding must be reproducible and consistent and the examiner must be convinced that the individual is cooperative and giving full effort.

Nonverifiable Radicular Root Pain
Nonverifiable pain is pain that is in the distribution of a nerve root but has no identifiableorigin; ie, there are no objective physical, imaging, or electromyographic findings.

Reflexes/Sensory Loss/Atrophy
For Reflex abnormalities to be considered valid, the involved and normal limb(s) should show marked asymmetry between arms or legs on repeated testing Sensory findings must be in a strict anatomic distribution. Motor finding should be also consistent with the affected nervestructure(s). Atrophy is measured with a tape measure at identical levels on both limbs. For reasons of reproducibility, the difference in circumference should be 2 cm or greater in the thigh and 1 cm or greater in the arm, forearm, or leg.

Unequivocal electrodiagnostic evidence of acute nerve root pathology includes the presence of multiple positive sharp waves or fibrillation potentials inmuscles innervated by one nerve root. However, the quality of the person performing and interpreting the study is critical. Electromyography should be performed only by a licensed physician qualified by reason of education, training, and experience in these procedures. Electromyography does not detect all compressive radiculopathies and cannot determine the cause of the nerve root pathology. On theother hand, electromyography can detect noncompressive radiculopathies which are not identified by imaging studies.

Alteration of Motion Segment Integrity
Motion segment alteration can be either loss of motion segment integrity (increased translational or angular motion) or decreased motion secondary to developmental fusion, fracture healing, healed infection, or surgical arthrodesis. Anattempt at arthrodesis may not necessarily result in a solid fusion but may significantly limit motion at a motion segment. Motion of the individual spine segments cannot be determined by a physical examination but is evaluated with flexion and extension roentgenograms.

Determining Appropriate Method of Assessment of Impairment:
DRE (diagnosis related estimates) is the principal methodology...