The Twisted Story of Asymmetric Spinal Motion and Your PR-4 Report

What is Asymmetric Spinal Motion?

Asymmetric means not symmetric, or unequal. Asymmetry of spinal motion means more movement in some directions than others.

A physical exam finding of asymmetric spinal motion is a gateway to a Diagnosis-Related Estimate (DRE) class II rating in the AMA Guides 5th Edition.

The AMA Guides 5th Edition in Chapter 15 The Spine on page 382 defines asymmetry of spinal motion as “Asymmetric motion of the spine in one of the three principle planes.”

But the AMA Guides goes to a little more effort here to help the medical examiner by stating: “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.”

How to Document Asymmetric Spinal Motion in Your Report

When documenting asymmetry of spinal motion in an impairment report for rating purposes, it is helpful to the reader of your impairment report if you provide comments on muscle spasm, muscle guarding and employee cooperation. These comments also makes the observation more compelling.

When reading a report that includes the finding of asymmetry of spinal motion look for comments on muscle spasm, muscle guarding and employee cooperation.

California PR-4 Reports are about reproducible observations and findings. Reports that are minimally supported may be more confusing than helpful, and lead to costly delay for the medical examiner, the insurance administrator, and, of course, the injured worker and the employer.

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What Is Muscle Spasm Anyway?

Muscle spasm is probably the most elusive and non-reproducible exam finding on spine examination. It is difficult to assess because it is ambiguous and a continuum between examiners.

For example, a spasm on your examination may not be considered a spasm on mine. If findings are suppose to be reproducible between two examiners, you can see how this might pose a problem.

A physical exam finding of muscle spasm is a gateway to a Diagnosis-Related Estimate (DRE) class II rating in the AMA Guides 5th Edition.

The AMA Guides 5th Edition in Chapter 15 The Spine on page 382 defines muscle spasm as “involuntary contraction of a muscle or group of muscles.” It is a diagnosis made by feeling “a hard muscle”. Is should be present in both the standing and lying position, and “frequently” causes a scoliosis.

How To Document Muscle Spasm in Your Impairment Report

When documenting muscle spasm in an impairment report for rating purposes, it is helpful to the reader if the side, and spine level of the spasm is documented. Additional comments on persistence with positional change and influence on spinal alignment is useful and makes the observation more compelling.

When reading a report which includes the finding of muscle spasm, look for the associated findings positional persistence and scoliosis.

California PR-4 Reports are about reproducible observations and findings. Reports that are minimally supported may be more confusing than helpful, and lead to costly delay.

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Work Restriction Management: The 300 Level Course

Imagine This

An injured worker has a chemical exposure on the job to the left eye which results in redness burning of the eye with minor changes in vision acuity which corrected to normal (20/20) with lenses. Skin examination is clear. The employee is placed off work for three days for rest, prescription treatment and recovery.

In the interval of the following 72 hours, the employee develops a blistering rash limited to the 2nd branch (V2) of the trigeminal nerve, and is diagnosed with “shingles” by her primary care doctor, and placed off work for a week. The employee is not able to appear for follow up and a status check because the primary care doctor instructed her not to drive.

The employer’s insurance adjuster wants to know the work status at 73 hours. How does the managing industrial provider respond?


The correct response to the insurance adjuster is “Work status is unknown, pending additional clinical evaluation.”

The above scenario is difficult to navigate because an industrial event has a non-industrial overlay, making opinions on work status confusing. The key is to clearly separate the two events, and simply report the objective information available to the industrial medical provider to comment on the ability to work.

Remember, the answers to work status, when given limited medical information and clinical exam information is yes, no, or I don’t know. All are acceptable answers if the circumstances are clearly communicated to the employer and the insurance adjuster.

All three parties (employee, adjuster and employer) are anxious to understand their responsibilities in a situation such as this. Is the employee to be compensated with workers’ comp benefits or sick leave on a non-industrial basis? It’s an excellent question.


This particular case resulted in a follow up call to the employee from the industrial medical provider. At this discussion it was determined that the symptoms from the original chemical work exposure had not improved, and now additional overlay of the shingles causes a new set of symptoms and pain. It was carefully determined that the original symptoms have persisted, and the symptoms of shingles have now added an additional set of problems. The industrial medical provider outlined to the employer that the employee has persistent baseline symptoms that continue, despite the complication of the shingles. The employee was referred to an ophthalmologist on an industrial basis to investigate the ongoing complaints of the pain and redness, and to see the health plan ophthalmologist for shingles treatment recommendation.

Keeping a clear separation between industrial injury circumstances and non-industrial conditions is essential for clear and well reasoned management of work restrictions. Remember, everyone has a vested interest in honoring work restrictions and making reasonable accommodations available for the injured worker.

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What You Need to Know About Percentages in Work Comp

The AMA Guides are full of percentages and a strong conceptual understanding of “percentage” is essential. We know there may be those of you among us who don’t care for math or who downright don’t like it. Not to worry, the concept of percentage is a fun and easy topic when introduced properly.

There is a hierarchy of percentage values in the AMA Guides 5th Edition. For example the AMA guides are calculated in digits impairment, hand impairment, upper extremity impairment, whole person impairment. Likewise foot impairment, and lower extremity impairment. We would like to untap the sometimes confusing concepts of percentages.

On behalf of Rate Fast we have today Steve Williams who is a science and math educator at Santa Rosa Accelerated Charter School. Sit back, relax, and take a front row seat in the class as we explore a better understanding of percentage.

Listen to our special lecture by clicking the link below:

The Importance of Activities of Daily Living

Activities of Daily Living are among the most neglected topics to be reported in impairment reports. The AMA Guides to the Evaluation of Permanent Impairment Fifth Edition clearly defines activiites of daily living (ADLs) as essential for understanding the impact and creation of impairment ratings (Chapter 1; Philosophy, Purpose, and Appropriate Use of the Guides).  Table 1-2 Page 4 lists 34 defined activities of daily living.

Every impairment report created under the AMA Guides should have a clear review of all 34 ADLs. The report should indicate positive and negative responses. It is essential to understand that the goal of the ADL is not to identify functional issues in the workplace. The goal is actually quite the opposite. The goal is to identify an individual’s ability to perform “common activities of daily living (ADL), excluding work.” (Page 4). This allows all individuals to be evaluated on a common basis, the actives necessary in daily living. Remember, this table has nothing to do with the work place.

ADLs have various levels of impact on the impairment calculations depending on the chapter in the Guides 5th Edition. In Chapter 8, The Skin, ADLs are used as primary determination for impairment class assignment (Table 8-2 Page 178). In Chapter 15, The Spine, ADLs are used to adjust the impairment value range (Section 15.4, Page 384). In Chapter 16, Upper Extremity, ADLs are used very little in the rating methods.

Finally, remember as you view activities of daily living some simply cause pain but do not disrupt an activity. Other times the the condition may completely preclude an activity. A well crafted impairment report will make these distinctions. Also, do not simply “write-off” some ADL activities as not relevant. For example, an individual with a shoulder injury may report difficulty with the activities of walking because of pain when the arm swings with the gait motion, or climbing stairs because of pain using the handrail. Traditionally we do not think of walking and climbing steps as being important with a shoulder injury.

A strong understanding of how the ADLs are used in the creation of impairment values will serve you well when discussing and analyzing report conclusions. Require reports to be standardized with this section, and use attention to detail in the ADL section to assess the level of detail that has gone into the report.

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Functional Limitations Explained

There’s a lot of confusion and misconception about the terms of use of “work tolerance”, “work capacity” and “work restrictions”.  When we read impairment reports “work restrictions” tend to be the term utilized most frequently. Actually, the exact opposite is true.

We’re here to help set the record straight on definitions.

A Physician’s Guide to Return to Work (Talmage et al., 2005. A Physician’s Guide to Return to Work. AMA Press) offers useful definitions for these terms  to better describe and communicate these concepts.

Work tolerance is the most common of all work limitations encountered. Tolerance simply means the patient’s symptoms preclude them from participating in certain activities. For example, the employee may have a normal MRI of the shoulder, a normal range of shoulder motion on exam, yet pain symptoms preclude work at or above shoulder level height.

Work capacity is the second  most common of all work limitations encountered. Work capacity refers to a well defined underling medical condition which precludes the patient from performing an activity. In this example a patient with shoulder adhesive capsulitis may demonstrate specific findings on MRI and the condition may also be verified on physical exam testing. For example, the patient may have mechanical limitation preventing motion of the shoulder above 90 degrees. In this situation patient has a medical capacity which limits working at or above shoulder level height.

Work restrictions are the least common of all work limitations encountered. Work restrictions are activities the patient can do, but should not perform because of the risk of significant injury or loss of life. For example,  the patient who has a seizure disorder may have a restriction precluding the driving of a car, because of the possibility of losing control of the vehicle.

We understand that the term “work restriction” has become a cultural term used in many administrative forms, however, inappropriate usage causes unnecessary confusion and delay. Begin using the correct terminology for tolerance, capacity and  restriction to more effective communication in reports and correspondence. Your reward will be faster and more accurate results.

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How to use an inclinometer to measure the spine’s range of motion

Pronunciation: /ˌinkləˈnämitər

The inclinometer is a tool used to determine angles of motion—particularly when measuring the spine.

Besides being fun to say, an inclinometer is nothing more than a fancy level with a protractor on it.

How to use an inclinometer

Because the spine has motion at both the top and lower segments its necessary that two inclinometers be employed simultaneously for recording the dynamic motion. One inclinometer is placed at the top of the measured spine segment, and the other at the lower spine location. The measurement value of the lower spine is subtracted from the upper spine value. This result is known as the “true angle”.

Types of inclinometers

There are two types of inclinometers: manual and digital.

The manual inclinometer, sometimes referred to as a “bubble inclinometer” has a fluid filled face in a circle. The fluid is a combination of a colored fluid and a clear fluid. The fluid interface moves with gravity, and the movement of the interface is used to read the measurement off a rotating 360 degree face dial.

Manual inclinometers

Measuring spine motion with the manual inclinometer requires a bit of practiced talent. The patient is instructed to stand in the upright position and the dial faces are set to the 0 degree position. The user must then hold the two inclinometers at once on the spine while movement is measured. It sounds easy, but in practice for the first several exams, it is difficult. The user must coordinate the physical control of the inclinometer while also performing the calculations and documenting the findings. When using the dual manual inclinometers for the first time, it is like trying to catch a falling snake. Patience is a virtue and persistence is necessary to capture accurate and consistent measurements.  The upside of the manual inclinometer is that they are relatively inexpensive ($50 each on Amazon as of the writing of this article), and no batteries are necessary. The down side is they do take some practice and can be difficult to read due to the small print face. A good pair of reading glasses are recommended.

Digital inclinometers

Digital inclinometers have been gaining some popularity because of ease of use and automatic calculation of the true angle. Digital inclinometers are two electronic gravity sensors which have ability to standardize a zero measuring reference with the click of a button. They are approximately the size of a pocket-watch and are typically connected by an electronic cord. One end is the measurement reading end (typically referred to as the “master”) placed at the top of the spine. The other device is placed at the lower segment of the spine section (typically referred to as the “slave”). The upside of the digital inclinometer is the ease of use during exam, and it automatically calculates the true angle. The downside is the device may not have an auto off feature.  This means it is easy to leave on, and may be found dead for the next exam. Additionally, digital inclinometers are expensive and can range into the hundreds of dollars.


Regardless of the style of inclinometer used, understanding the inclinometer and its function is essential for accurate and well supported impairment report (PR-4 Report) conclusions. The time invested in becoming familiar with the inclinometer will result in faster and more accurate report for patients, workers’ compensation insurance carriers, employers, and administrators.

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A Stretch In Time Saves Nine

This quick and simple trick will greatly improve the accuracy of your impairment rating reports.

What’s the secret of reproducible measurements? Having patients do warm up exercises before taking down the exact numbers.

You’ll find that taking the the time to encourage your patient to do two or more warm up exercsises before taking measurement is absolutely worth it.

Your results will be more accurate and consistent, with greater reproducibility. Reproducibility within 10% is necessary for measurements to be considered valid by the AMA guides. Reproducible measurements also support stronger impairment conclusions. Although it may seem like extra work, the time you’ll save doing measurements on a patient that is properly warmed up will limit the need to reproduce measurements later on because your exam findings were off by more than 10%.

Don’t forget to do both the right and left side (yes, even the non-injured side!) so that you may compare measurements.

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The RateFast Philosophy

A lot of impairment rating reports (like PR-4 reports) are wrong. By “wrong,” we mean that many impairment ratings are not calculated according to the rules in the AMA Guides.

The insurance company has no standardized easy method to verify the doctor’s conclusions. The patient who depends on the doctor and the insurance carrier to correctly assign some monetary value to the injury is doubly in the dark.

Who loses when the impairment report is incorrect?


The doctor often needs to create a supplemental report to correct the rating and do the work twice. The insurance carrier has to re-issue a settlement and do the work twice. The patient loses faith in the accuracy of the doctor’s abilities, and has no choice but to endure additional delay. The employer’s insurance premiums are affected by the overall cost of the process.

There is good news, however. This story doesn’t need to happen anymore because doctors, carriers and patients can use  RateFast. RateFast is a web based program designed specifically to create or check the accuracy of California PR-4 reports.

The RateFast philosophy is simple: “Impairment ratings should be done right the first time.”

The RateFast answer is waiting for you now, just a click away on any internet device.

RateFast For Doctors

Doctors, you can start doing California PR-4 reporting accurately, quickly and confidently using RateFast.

Simple exam menus speed up reporting time and accuracy. RateFast is transcribing your report and preparing the impairment rating, leaving you free to communicate more meaningfully with the patient. Submit the report for rating with the click of a mouse or a tap on your iPad.

RateFast stores all of your workers’ compensation reports in digital form. You can also write Doctor’s First and PR-2 reports.

Doing work right the first time means more time getting paid, and less time fixing mistakes.

RateFast for Insurance Carrier Adjusters and Attorneys

Insurance carrier adjusters, start verifying the correct values of California PR-4 reports using our administrative portal. Simply provide the information for the PR-4 report that you need to review. Based on the hard facts of the claim, you’ll receive an impairment rating that is completely justified according to the AMA Guides.

RateFast for Patients

Patients, make sure your doctor is using RateFast. Ensure that your California PR-4 reports are complete and consistent with the California AMA Guides 5th Edition guidelines.


To check us out, go to our main website, Simply create an account, log in, and in seconds find out how easy and accurate California PR-4 report is done.

RateFast: Finally, A Solution That Works

Who among us is frustrated with the broken process of creating California PR-4 reports?

See the patient in a hurried clinic schedule. Take some measurements, or maybe not. Scribble some notes on the paper chart. Place it on a stack to be done later, much later. Because there are so many other tasks to do without the required block of time necessary to write a PR-4 report.

Why do we repeat this process day after day, month after month, year after year?

Why? We’re too busy to find a solution.

Well, a solution just found you. The solution is RateFast.

RateFast is a web-based application like no other solution you have ever imagined. RateFast is complete point of service impairment reporting.

RateFast turns the ugly PR-4 report cycle on its head, and makes reporting simple, fast, profitable, and fun. Yep, we said “fun”.

Simply create an account, log in and in seconds you will be interviewing patients, taking guided measurements instructed by our interactive menus. All the while RateFast is transcribing your report and preparing the impairment rating while you are with the patient. Submit the report with the click of a mouse or the tap of an iPad.

At the end of your office visit your report is done. Yes, we said “done”, and that rhymes with “fun”.

…and best of all, with the extra time you finally get to meet those people who live in your house. They’re called your family.

Click here to start today and receive your first two reports entirely free.
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