This article discusses the various non-key factors that are specifically associated with the Spine & Pelvis. The text is taken directly from the AMA Guides, 6th edition, page 560.
Functional History
A proper functional history enables the physician to determine the impact of a given spine- or pelvis- related condition on basic function and activities as they pertain to Activities of Daily Living (ADLs). Cross-validation of the patient’s reported functional limitations can occur by observing his or her activities in the examination room. The patient will usually be observed performing simple routine activities, including sitting, standing, walking, and transitioning from sit to stand or supine to stand. The physician should note inconsistencies and lack of congruence between reported limitations and observed activities when evident.
A functional assessment tool may be used in addition, to further evaluate this parameter. One example of a functional assessment tool, the Pain Disability Questionnaire (PDQ), is included in this chapter’s appendix for convenience. The PDQ has been validated as an instrument for quantifying patient reports of function. The physician is expected to weigh the patient’s subjective complaints and score on the functional assessment tool, relative to the expected severity for a given condition. The grade modifier that reflects functional assessment may or may not be accepted as a variable in the impairment calculation.
If multiple regions of the spine are being rated, the examiner should consider the relative contribution of each of these diagnoses to the functional complaints.
Physical Examination
Guided by the history, a physical examination is performed, documenting spine- and/or pelvis-related physical findings such as spinal alignment and the need for assistive devices. Neurologic findings, including root tension signs and sensory and motor deficits in the upper and/or lower limbs, should be described. The examiner may remove a collar or lumbar support or other external devices as appropriate, to permit adequate and thorough examination. The examiner should consider the patient’s diagnosis, the reliability of findings on examination, and the results of previous examinations and observations as recorded in the medical records documenting previous treatment.
Positive, negative, and non-physiological findings should be documented in the evaluation report. Whenever possible, quantitative findings should be reported, rather than general descriptions (ie, document specific measurements of limb girth as opposed to reporting extent of atrophy). More objective findings, such as atrophy, are given greater relative weight over findings that require patient participation, including active range of motion or strength testing, and subjective reports of tenderness. Inconsistencies and discrepancies between what is observed and what has been reported previously, or what is otherwise expected, sh ould be noted. Examination findings that differ significantly from previously recorded observations after the probable date of MMI should be reported, with comments noting the discrepancy. Some findings may be excluded from the impairment calculation, as described later in this chapter.
Clinical Studies
The physician needs to review and document actual studies and findings from relevant diagnostic studies, including laboratory tests, roentgenographic (X-ray) studies, computed tomographic (CT) scans, magnetic resonance images (MIR)< nuclear medicine scans, ultrasound exams, and electrodiagnostic testing (EMG/NCS). In some cases, only reports may be available, and that should be noted in the record. Although imaging and other studies may assist physicians in making a diagnosis, they are not the sole determinants of a diagnosis. The examiner should comment on clinical test results that do not correlate with the patient’s symptoms or support the patient’s diagnosis.