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.