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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Muscle Guarding

Muscle guarding is simply the body trying to avoid a painful stimulus. When irritable muscles are touched, they don’t like it and try to pull away.

A physical exam finding of muscle guarding 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 Guarding” as “a contraction of of muscle to minimize motion or agitation of the injured or diseased tissue.” Don’t confuse this with muscle spasm, which is an “involuntary contraction of a muscle or group of muscles.”

Associated finding may include loss of the low back contour (lordosis) and may have “reproducible loss of spinal motion.”

If you’re writing a PR-4 report

When documenting muscle guarding in an impairment report for rating purposes, it is helpful to the reader if comments on lordosis and actual measured spinal motion are provided. These comments also makes the observation more compelling.

If you’re reading a PR-4 report

When reading a report which includes the finding of muscle spam look for comments on lordosis and evidence of loss of spinal range of motion.

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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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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How to Correctly Document Your Patient’s Job Description

Getting A Job Description Is A Hassle

Yes it is.

Imagine This

Adjuster M.A. from a major insurance carrier writes in today after reviewing a RateFast PR-4 report created on one of her injured workers. The worker is a firefighter who has been provided shoulder limitations precluding lifting and carrying more than 10 pounds, no pushing or pulling more than 11-25 pounds, no climbing ladders and no crawling. The report comments that, “Ability to return to her usual occupation is deferred pending the carrier providing a formal job description (RU 91 Format)”.

It’s obvious this injured worker cannot return to their job… Or is it?

When we talk about job activities, what people are expected to do, and what they don’t do all the time is casually listed in the clinic, but it’s what written down in the official job description that counts.

The Real Question

An accurate job description is actually a pretty rare event in the impairment report writing business. Probably less than 5% of claims have a usable job description. This is frustrating because one of the most important questions to be answered in a medical legal report or PR-4 report is, “Can the employee return to their job?”

Employees Don’t Know What Their Jobs Are

An employee’s understanding of his or her job is often very different than the official job description. A job description may include an activity that is rarely required, but is considered essential to perform the job safety and correctly.

…And Employers Don’t Either

To cause further frustration, the employer will sometimes provide the carrier an “administrative” job description and not an actual physical activity job description (RU 91). An administrative job description talks about job requirements such as personal temperament, educational requirements, and ability to concentrate, complete tasks etc. For orthopedic injuries, an administrative job description doesn’t cut it.

Get the RU 91

The RU 91 format is a systematic, standardized review of physical activities, specific weights and endurance requirements that guide the medical examiner. It should also be signed by both the employee and employer to confirm agreement.

And let’s not forget the Americans with Disability Act. Here it is required for an employer to make “reasonable accommodations” for employees with disability for the essential activities of the job. Think about this… How can we do that without looking at an actual job description? The answer: we can’t.

So, let’s get back to our adjuster’s question. The most correct approach for return to work opinion is based on a job description review. It may or may not change the opinions of the medical examiner, but everyone will have a better understanding of the final determination about return to work if there is a firm guideline cited in the report (RU91). Yep, we need the job description to give a correct and complete opinion on the return to work evaluation.

This simple systematic approach to thinking about the job description will pay dividends in the way of avoiding legal delay and confusion in the management of claim.

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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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RateFast: Now With Built In Billing Calculator

Built In Billing Calculator:  Enough said.

Think of the time and money spent when you have to create PR-4 report billing codes.

RateFast now saves you this time and money by creating codes automatically based on user input.  The codes may be printed along with the documentation in your report.

This is a free optional feature, and is updated for the January 1st 2014 RBRVS (Research Based Relative Value Scale) new billing requirements.

Insurance carriers pay for accurately documented and correctly coded reports. Create one today with RateFast Express.