- T.fc'Irf'l{ "^iferf??

5'

m^jfi

60 60

( )

60


60

( )

2

3

3


60

60

( )

60

3 1 .. 2525
2 .. 2544 3 .. 2549







3








3

1.

2.
3.
Program computer

2





3

.

( )


-
1.
2.
3.

4.

5.

6.
7.

8.
9.

10.

()
1.

2.

3.

()

1.

2.
3. .

4.

5.

()
1.

2.

3.

4.

 ()
1.

2.
3.
()

1.
2.

3.
4.

5.

()

1.

2.

3.

4.
()

1.
2.

3.

4.

()

1.

2.

3.

 ()

1.

2.

3.

4.
()

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
11.

12.

()

1.
2.

3.

4.

5.

 ()

1.
2.

3.

4.

5.

()
1.

2.
3.

4.

5.
6.

7.
8.

()

1.

2.


3.

()

1.


2.

3.




  
- 

 
 

 

  
 

  ! 3
1. %

& '

(

2. *+

%' 
+%+
 ,&
% 

3. % %
-%.'/*- 0%


4. %(2
(
 
3


5. %(

5'!


6. ,.,789(

%


 
' ': 

- 7
5 -
1. 

%
2. ('
3. 
%


*- 0%

+

;:

':( 
! 
 

 ':( 
! 
 
<,! 
!    

- <,/
/= 



1. 
'* '*
2. %
+
3. 
&
/++%
4. 

(
>
5. 


 '7
6. 

%

&(
':(?: ! 
 



ISBN :

978 - 974 - 7894 - 47 - 9

Created by trial version, http://www.pdf-convert.com

1
1
2 ()
13
3 ()
187
4 ()
265
5
365
6
421
7
439
8
473
9
489
10 ()
513
11 ()
561
12
593
13
619
14
627
15
633
16
643
17
665
18
699
19
723

727

745

1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11

1.1
1










.. 2499
.. 2515




.. 2427 (.. 1884)
.. 2440 .. 1897)
.. 2451 (.. 1908)
103 16 .. 2515



.. 2517 2
.. 2533 .. 2537 ..
2537 9 70 18

3
1.

2.

3.

4.

5.








25 .. 2547 121 113 23
2547 24 2547
1.2

(Whole Person Impairment)

1.

100
2.


14
2.1
2.1.1
2.1.2
2.1.3
2.2
2.3
2.4

4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13

2.13.1
2.13.2
2.13.3
2.14

(Metatarso-Phalangeal Joint Disarticulation)
100
1


100

(Metacarpo-Phalangeal Joint
Disarticulation) 100
3
(Hand Amputation at Wrist) 100
54
(Shoulder Joint Disarticulation)
100
60
(Foot Amputation at Ankle) 100
25
(Hip Joint Disarticulation) 100
40
100
85

5
3.

100

% % = % + % (100% %)
1

60
40

% %
= % + % (100% %)
= 60 % + 40 % (100% 60%)
= 60% + 16%
= 76%
76
2
2
16

30, 20 10
20 10 28 28 30
50 30, 20 10 50
4.
Maximal Medical Improvement (MMI)

(Permanent Impairment)

5.

:
:

:
9
9 2

:


15

:
:

1.3 (Impairment)
(Impairment)
(Derangement)

( 1)

1-1 (Activities of Daily Living or ADL)

, , , , ,

, , , ,

, , , ,

, , ,

, ,

, , , ,

, ,

1.4 (Permanent Disability)

1.5



(.16) (.44)

1.

2.

3.

4.


5.

5.1

8
5.2

5.2.1
5.2.2 (

)
5.2.3
5.2.4

5.2.5
5.2.6
5.2.7
5.2.8

1.6




(18)

1.7



(Combined Value Chart) 19
95-100
(Total Impairment, A State That Is Approaching Death)


10

1.8



Contact Lens Contact
Lens

1.9



(Maximal Medical Improvement : MMI)

1.10


1.
1.1 ( )

10
1.2
1.2.1
1.2.2
1.2.3
1.2.4
1.2.5
1.2.6 Intellectual Functioning, Characteristic Traits
1.2.7
1.3

1.4
1.5
2.
2.1
2.2
2.3

2.4 /

2.5

3. 1 2

3.1

3.2
3.3

11

1.11

...

...
......
....
/.../

1.
1.1
1.2
1.3 ()..
..
2.
2.1
2.2
2.3
2.4
3. () ...
..
..
4. ( ICD 10) ....
ICD 10....
5. /

5.1
5.1.1
5.1.2
5.1.3
5.2 /
5.3

12
6.
6.1 (///
///////
..)
6.2 /

.....
6.3
.
6.4
....
7.

.......
.....
8.

8.1
8.2
8.3
8.4
9. ..................

(..)
..
.

13

2
()

(THE UPPER EXTREMITIES)

2.1 (Principles of Assessment)
2.1.1 (Principles of Impairment Evaluation)
2.1.2 (Impairment Evaluation :
Documentation and Recording)
2.1.3 (Combining Impairment Ratings)
2.1.4 (Principles for Adding Impairment Value)

2.2 (Amputation)
2.2.1 (General Principles)
2.2.2 (Amputation Impairment : Levels Proximal
to Digits)
2.2.3 (Amputation Impairments : Digital Levels)
2.2.4 (Impairment Rating For Digital Amputation)
2.2.5 (Conditions
Associated with Amputation)

2.3
(Sensory Impairment Due to Digital Nerve Lesions)
2.3.1 (Clinical Evaluation)
2.3.2
(Digital Nerve Sensory Impairment Evaluation ; Principle)
2.3.3 digital neuromas
(Rating Impairment Due To Digital Neuromas)
2.3.4
(Digital Nerve Sensory Impairment Determination Method)

14

2.4
(Evaluating Abnormal Motion)
2.4.1 (Clinical Measurements of Motion)
2.4.2 A = E + F
(Principle for Motion Impairment Calculation : A = E + F)
2.4.3
(Method for Motion Impairment Calculation)
2.4.4
(Thumb Ray Motion Impairment)
2.4.5 (Finger Motion
Impairment)
2.4.6
(Multiple Digit Impairments)
2.4.7 (Wrist Motion
Impairment)
2.4.8 (Elbow Motion
Impairment)
2.4.9 (Shoulder Motion
Impairments)

2.5
(Impairment of the Upper Extremities Due to Peripheral Nerve Disorders)
2.5.1 (Impairment
Evaluation Principles)
2.5.2 (Impairment Evaluation
Methods)
2.5.3 (Regional
Impairment Determination)
2.5.4 (Entrapment/ Compression
Neuropathy)
2.5.5
(Complex Regional Pain Syndromes CRPS, Reflex Sympathetic Dystrophy:CRPS
, Causalgia :CRPS )

15

2.6
(Impairment of the Upper Extremities Due to Vascular Disorders)
2.7
(Impairment of the Upper Extremities Due to Other Disorders)
2.7.1 (Bone and
Joint Deformities)
2.7.2 (Arthroplasty)
2.7.3
(Musculotendinous Impairments)

2.8
(Strength Evaluation)
2.8.1 (Principles)
2.8.2
(Grip and Pinch Strength)
2.8.3
(Manual Muscle Testing)

2.9 (Summary of Steps

for Evaluating Impairments of the Upper Extremities)
2.10
(Clinical Examples)

16


(Amputation) (Ankylosis)
Swanson 2

1.
2.
3.

4.
(Nerve Entrapment Syndrome )
5.
(Complex Regional Pain Syndrome)

6.
(Carpal Instability)
7.

2.1 (Principle of Assessment)

2.1. (Principles of Impairment Evaluation)
1 2
1 2

3
1. (Anatomic Impairment)

2. (Cosmetic Evaluation)

3. (Functional Evaluation)

17

(Ankylosis)
(Ankylosis)

(Transverse)
2 50
2-6 2-7

2.1.2 (Impairment Evaluation :

Documentation and Recording)

1 2

2-1 2-1
( 2-1)

(Digital Nerve)

18
2 ( 2-1)


(Grip Strength) 2-1 2-2

2-3

2.1.3 2.1.4 2-1 2-1

19
2-1 1 () [Upper Extremity Impairment Evaluation Record Part 4 (Hand)]
..................................................... ..... ........... ................... ................ ...........................................................
............................................................................... .......................................................................................................................................

**

MP

IP

%
O

%
O

CMC

%
[1]

(CMC + MP + IP)

MP

PIP

IP

[1]

[2]
[3]

[4]
* 1,2,3,4,

[2]

26
%

****
[5]
%
=
[2]

% =
[3]

% =
[4]

[3]

[4]
[1]

%
O

%
O

[2]
[3]

[4]
* 1,2,3,4,

[1]
* (MP , PIP , IP) = 56

% =
.
[2]

% =
[3] [3]

% =
[4]
[4]

PIP

IP

MP

**
%

[1]

%
O

**
%

[2]
[3]

[4]
* 1,2,3,4,

%
* (MP , PIP , IP)

56

[1]

% =
. [2]

% =
[3][3]

[4]
% =
[4]

**
%

20

PIP

MP

IP

%
O

IP

[2]

PIP

32

%
=
.

[3]

% =
[3]

[1]

[2]

[3]

[4]
* 1,2,3,4,

% =
[4]

**

[4]

[1]

[2]

[3]

[4]
* 1,2,3,4,

% =
[4]

**

%
O

[2]

%
[1]
=

56

%
=
[2]

[3]

% =
[3]

: % + + + +
*** ( 2 2 )
[5] ........% + ............ %
****
*
**
***
****

[4]

%
O

* (MP , PIP , IP)

**

[1]

MP

%
O

* (MP , PIP , IP)

2-1 ()
2-2 ()
2-3 ()

+9 =
=
=
=

..0%
..0%
..0%
..0%

21
2-1 2 ( ) [Upper Extremity Impairment Evaluation
Record Part 2 (Wrist, Elbow, and Shoulder)]
..................................................... .... .................. .............. ............. ....................
...................................................................................... ........................................................................................

%
* [1] , [2]

%
[1]
% / + / =
17

%
O

%
O

4
%
[1]
% / + / = 4

%
O

%
O

[2]
%

=
17

[2]
%

%
[1]
[2]
% =
% / + / +
/ =
1. ()
=
2.
* ( ...............% , ...............% , ...............% , ...............%) =
3.
=
4.
=
5. () =
(* 1,2,3,4,5)
=
( 2-3) =

%
%
74

%
%
%
%
74 %
44 %

22
2-1 *
(Conversion of Impairment of the Digits to Impairment of the Hand*)

01
=
0
02
=
0
23
=
1
37
=
1
46
=
2
8 12
=
2
78
=
3
13 17
=
3
9 11
=
4
18 22
=
4
12 13
=
5
23 27
=
5
14 16
=
6
28 32
=
6
17 18
=
7
33 37
=
7
19 21
=
8
38 42
=
8
22 23
=
9
43 47
=
9
24 26
=
10
48 52
=
10
27 28
=
11
53 57
=
11
29 31
=
12
58 62
=
12
32 33
=
13
63 67
=
13
34 36
=
14
68 72
=
14
37 38
=
15
73 77
=
15
39 41
=
16
78 82
=
16
42 43
=
17
83 87
=
17
44 46
=
18
88 92
=
18
47 48
=
19
93 97
=
19
49 51
=
20
98 100
=
20
52 53
=
21
54 56
=
22
57 58
=
23
59 61
=
24
62 63
=
25
64 66
=
26
67 68
=
27
69 71
=
28
72 73
=
29
74 76
=
30
77 78
=
31
79 81
=
32
82 - 83
=
33
84 86
=
34
87 88
=
35
89 91
=
36
92 93
=
37
94 96
=
38
97 98
=
39
99 100
=
40
* 2 2

04
5 14
15 24
25 34
35 44
45 54
55 64
65 74
75 84
85 94
95 100

=
=
=
=
=
=
=
=
=
=
=

0
1
2
3
4
5
6
7
8
9
10

23
2.1.3 (Combining Impairment Ratings)
()

( )









()
2-3

% % = % + % (100%-%)
3
2
3

24
2-2 *
(Conversion of Impairment of the Hand to Impairment of the Upper Extremity*)

0
=
0
1
=
1
2
=
2
3
=
3
4
=
4
5
6
7
8
9
10
11
12
13
14
15
16
17

=
=
=
=
=
=
=
=
=
=
=
=
=

5
5
6
7
8
9
10
11
12
13
14
14
15

18 = 16
19 = 17
20 = 18
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

=
=
=
=
=
=
=
=
=
=
=
=
=
=
=

19
20
21
22
23
23
24
25
26
27
28
29
30
31
32

36 = 32
37 = 33
38 = 34
39 = 35
40
41
42
43
44
45
46
47
48
49
50
51
52
53

=
=
=
=
=
=
=
=
=
=
=
=
=
=

36
37
38
39
40
41
41
42
43
44
45
46
47
48

54 = 49
55
56
57
58
59

=
=
=
=
=

50
50
51
52
53

60
61
62
63
64

=
=
=
=
=

54
55
56
57
58

65
66
67
68
69

=
=
=
=
=

59
59
60
61
62

70
71

=
=

63
64

* 2-3

72 = 65
73 = 66
74 = 67
75
76
77
78
79

=
=
=
=
=

68
68
69
70
71

80
81
82
83
84

=
=
=
=
=

72
73
74
75
76

85
86
87
88
89

=
=
=
=
=

77
77
78
79
80

90 = 81
91 = 82
92 = 83
93 = 84
94 = 85
95
96
97
98
99
100

=
=
=
=
=
=

86
86
87
88
89
90

25
2-3
(Conversion of Impairment of the Upper Extremity to Impairment of the Whole Person)

0
=
0
1
=
1
2
=
1
3
=
2
4
=
2

20
=
12
21
=
13
22
=
13
23
=
14
24
=
14

40
=
24
41
=
25
42
=
25
43
=
26
44
=
26

60
=
36
61
=
37
62
=
37
63
=
38
64
=
38

5
6
7
8
9

=
=
=
=
=

3
4
4
5
5

25
26
27
28
29

=
=
=
=
=

15
16
16
17
17

45
46
47
48
49

=
=
=
=
=

27
28
2/8
29
29

65
66
57
68
69

=
=
=
=
=

10
11
12
13
14

=
=
=
=
=

6
7
7
8
8

30
31
32
33
34

=
=
=
=
=

18
19
19
20
20

50
51
52
53
54

=
=
=
=
=

30
31
31
32
32

70
71
72
73
74

15
16
17
18
19

=
=
=
=
=

9
10
10
11
11

35
36
37
38
39

=
=
=
=
=

21
22
22
23
23

55
56
57
58
59

=
=
=
=
=

33
34
34
35
35

75
76
77
78
79

2.1

80
81
82
83
84

=
=
=
=
=

48
49
49
50
50

39
40
40
41
41

85
86
87
88
89

=
=
=
=
=

51
52
52
53
53

=
=
=
=
=

42
43
43
44
44

90
91
92
93
94

=
=
=
=
=

54
55
55
56
56

=
=
=
=
=

45
46
46
47
47

95
96
97
98
99

=
=
=
=
=

57
58
58
59
59

100

60

45 2-4 90
75 2-23
17
1. 2 45%
75% 86% ()
% %
= % + % (100-%)
= 45% + 75% (100-45%)
= 86%
2. = 20% ( 2-1)
20% X 86%

( 20 x 86 x 17 ) = 17%
100
100 100
* 86 17 ( 2-1)

26
2.1.4 (Principles for Adding Impairment Value)

100%
(Add) (Combine)

1.

(100%) 40
20 10 ( 2-1 2-4)
2. ( 2-4)
(37% 38% )
(36%) 2-4

(Amputation of
Thumb kay)
3. (Thumb Ray Motion
Impairment)
100% (Carpometacarpal
Joint) 75% (Metacarpophalangeal Joint) 10% (Interphalangeal Joint)
15%
100%
80% 45% 100%

4.
A% = E% + F%


(IF% + IE%)
(Pronation) (Supination) (IP%+IS%)
= (IF% + IE%) + (IP% + IS%)
5. 2.7
100 % (Carpormetacarpal-CMC)
60% 15 % 25%
(MP) 50% (PIP) 30% (DIP) 20% ( 2-18)

27
2-18
2-4

2.2 ( Amputation)
2.2.1 (General Principles)

1.
2. (Stump) 2.2.4
3. (Central
Pain
Syndrome)
4. 2.4 (Proximal Joint)
(Upper Limb)

(Whole
Person)

21 , 22 , 23 24 22 , 23

60% , 70% , 60%
2 4 , 2 18 2.4
2.2.2 (Amputation Impairment : Levels
Proximal to Digits)
70
scapulothoracic forequarter amputation ( 2 2 2 4)
(Humerus) deltoid (Deltoid tubercle)
100 60
deltoid tubercle deltoid bicipital tuberosity biceps
brachii 95 57

28
bicipital tuberosity (Metacarpophalangeal Joint)
94 90 56 54

Krukenberg

29
2-4
(Impairment Estimates for Upper Limb Amputation at Various Levels)

Scapulothoracic
(forequarter)
Shoulder disarticulation
Arm: deltoid insertion and proximally
Arm/Forearm:from distal to deltoid
insertion to bicipital insertion
Forearm/hand:from distal to bicipital
insertion to transmetacarpophalangeal
loss of all digits
Hand: all digits at MP joints
Hand: all fingers at
MP joints except thumb
Thumb ray* (1st metacarpal bone)
at/or near:
CMC joint
Distal third of 1st metacarpal
Thumb at :
MP joint
IP joint
Index or middle finger at:
MP joint
PIP joint
DIP joint
Ring or little finger at:
MP joint
PIP joint
DIP joint

70

100
100
95

60
60
57

94-90

56-54

100

90

54

60

54

32

38
37

23
22

100
50

40
20

36
18

22
11

100
80
45

20
16
9

18
14
8

11
8
5

100
80
45

10
8
5

9
7
5

5
4
3

* Thum ray (CMC joint)

30
2.2.3 (Amputation Impairments : Digital Levels)
( )
100 90
60
90% x 60% 54 ( 2 - 2
2 - 3 2 - 1 , 2 - 2 , 2 - 3 , 2 - 4)

(DIP) 45
(PIP) 80 (MP)
100 ( 2-3 , 2-4)
2-5
(IP) 50
(MP) 100 ( 2-3)
36 ( 2-4) 2-4

metacarpal bone
37 (First carpometacarpal joint)
38 ( 2-4)

5
40 20
10 ( 2 3 2 1 2 4)

2 1 ,
2 2 , 2 3 , 2 4

31
2-2

(Impairment Estimates for Upper Extremity Amputation at Various Levels)

2-3

() ()
[Impairment of the Digits (values outside digits) and the Hand
(values inside digits) for Amputations at Various Levels]
100

32
2-4 2-5

2.2

(PIP)
8
(PIP) 80 ( 2-3)
20
80% x 20% 16 ( 2 1)
90
90% x 16% 14 ( 2 2)
60
60% x 14% 8 ( 2-3)

2.2.4 (Impairment Rating for Digital

Amputation)
1.
2 4 4 2 5
100 4
2.


2-1

33
3.


90% ( 90 ) ( 2-2)
60% ( 60 )
( 2-3)
4.
37-38 ( 2-4)
36

(Amputation of the Thumb Ray)

5. 2-2 2-3
2.3

(Proximal Phalanx)
19
1. (Proximal Phalanx) (MP)
90 ( 2 4)
40 ( 2-3 2-1)
(90% x 40% = 36%) 36
( 2-1) 36
(36% x 90% = 32%) 32 ( 2-2)
2. 32
(36% x 60% = 19%) 19 ( 2-3)

2.4

26
1. 40 (100% x
40% = 40% 2-1)
9 (45% x 20% = 9% 2-1)
2 (40% +

34
9% = 49%) 49
(49% x 90% = 44%) 44 ( 2-2)
2. 44
(44% x 60% = 26%) 26 ( 2-3)
2.5

(CMC Joint)
34
1. 38
( 2-4) 20
( 2-4 2-3) 18 ( 2-2)

(38% + 18% = 56%) 56

2. 56 34
( 2-3)

2.2.5
(Conditions Associated with Amputation)
(Stump)


8
neuromas
(Complex Regional Pain Syndrome) 2.5
5
Phantom pain

2.6 10 Systemic and Pulmonary Arteries

2.4

35
2.6

bicipital tubercle radius

58
1. bicipital tubercle
94 ( 2-4 2-2)
50
2.
2 94 50
97
58 ( 2-3)

2.3 (Sensory
Impairment Due to Digital Nerve Lesions)

(Sensation)
(Sensibility) .. 2517 (George Omer)
2 (Afferent Nerve
Fiber)
,
(Sensibility Impairment)
neuroma 2.5 5

(Free Nerve Ending)


2.3.1 (Clinical Evaluation)


(Vibration)
.. 2497
6

36
S0
S1

S2

S3
S4 two point discrimination
S5

two point discrimination

monofilament touch pressure threshold test
(Pin Prick Test)

ninhydrin (Ninhydrin Sweat Test)

(Iodine Starch Sweat Test) (Wrinkle Test)



Semmes Weinstein Monofilament Pressure
Aesthesiometer (Deep Pressure Threshold)
two point
discrimination two point discrimination (Moving Two Point Discrimination)

two point discrimination (Static Two Point Discrimination)



(Neuropathy)
two point
discrimination
Semmes - Weinstein
Monofilament Pressure Aesthesiometer electromyography

37
two point discrimination
two point discrimination
Weber Static Two- Point Discrimination Test
Moberg
Caliper Disk - Criminator, DeMayo
2 Point Discrimination Device Boley Gauge
2 5 2
(Pulp)
(Light- Touch Discrimination)
3-5
1 2 1 2
2
2 2 3
2




(Callus)



two-point
monofilament

2.3.2 (Digital
Nerve Sensory Impairment Evaluation ; Principle)
(Principle)
(Unequivocal)

two point discrimination

38
3 2 5
(Two Point Discrimination 15 )
(Pinprick)
(two - point discrimination 7 15 )

2-5 (Sensory
Quality Impairment Classification)
Two-Point

Discrimination

0%
6
7-15

50%
> 15

100%
2-5

2-10 2-5
spinal nerve ( 2-13) ( 2-14)
( 2-15)

()

()


(Longitudinal Sensory Loss)

(Transverse Sensory Loss)
2 - 6
2 - 7
(Total
Transverse Sensory Loss) (> 15 )
2 () 50
2 6 , 16 7 2 - 6 2 - 7

39
2-6

(
) () ()
[Digit Impairment Due to Thumb Amputation at Various Lengths (top scale) or Total
Transverse Sensory Loss (bottom scale)]
50

40
2-7

()
() ()
[Digit Impairment Due to Finger Amputation at Various Lengths (top scale) or Total Transverse
Sensory Loss (bottom scale)]
50

(Partial Transverse Sensory Loss)
50 (7-15 ..) ()
25
2-6 2-7

41

2-6

(Digit Impairment for Transverse and Longitudinal Sensory Losses in Thumb and Little
Finger Based on the Percentage of Digit Length Involved)

30
15
20
10
27
14
18
9

100
90

50
45

25
23

80
70

40
35

20
18

24
21

12
11

16
14

8
7

60
50

30
25

15
13

18
15

9
8

12
10

6
5

40
30

20
15

10
8

12
9

6
5

8
6

4
3

20
10

10
5

5
3

6
3

3
2

4
2

2
1

42
2-7

(Digit Impairment for Transverse and Longitudinal Sensory Losses in Index , Middle , and Ring
Fingers Based on the Percentage of Digit Length Involved)

20
10
30
15
18
9
27
14

100
90

50
45

25
23

80
70

40
35

20
18

16
14

8
7

24
21

12
11

60
50

30
25

15
13

12
10

6
5

18
15

9
8

40
30

20
15

10
8

8
6

4
3

12
9

6
5

20
10

10
5

5
3

4
2

2
1

6
3

3
2

43
2.7

50
10
1. (
50%) 50
( 50%)
= 50% () X 50% ()
= 25% ( 2 - 6 2 - 6)
= 10% ( 2 - 2)
2. 10

2. 8

25
6

80
4
1. ( 25%)
80%
= 25% () X 80% ()
= 20% ( 2-7 2-7)
= 4% ( 2-2)
2. 4

44
(Longitudinal Sensory Loss Impairment)

60 40
1. 40
60
2. 60
40

()
60
40

2 6 2 7
2 1 2 8

2-8

(
) (
)
(Hand Impairment Values for Total Transverse Sensory Loss (numbers at tips of digits) and
Total Longitudinal Sensory Loss on Radial and Ulnar Sides (numbers at sides of digits)
Involving 100% of the Digit Length)

45

(Palmar Surface)
palmar dorsal ulnar cutaneous median palmar cutaneous nerve
superficial radial nerve ( 2 48) 5 (
5 2 - 2)
2.3.3 digital neuromas (Rating
Impairment Due To Digital Neuromas)
neuroma
neuroma
2 10 .
( 2-6 , 2-7)
2 10
2 6
2 7 (
)
(100%) 2 8 2 1


neuroma

2.3.4 (Digital
Nerve Sensory Impairment Determination Method)
1.
( 15 ) (7 - 15 ) two - point discrimination
( 2 - 5)
2. (Longitudinal
Sensory Loss) (Transverse Sensory Loss)
3.
2-6 2 - 7

46
4.
()
2-6 2-7
5.

6. (
16 1, 16 2 16 3)
7.
()

2.9

2.10

22
6
two point discrimination 15 ..
(PIP) (80
)
8
2 7 2 7
40 8 ( 2 1)

25
8

two point discrimination 10

10
25 2 6 2 6
10 ( 2 1)

47
2.11

2.12

30
8

two point discrimination 15

(IP) ( 50
)
6
50
( 2 6 2 6) 15
6 ( 2 1)

28
6
two point discrimination 9
(MP)
3

15 ( 2 7 2 7) 3 (
2 1)

2.4 (Evaluating Abnormal Motion)

2.4.1 (Clinical Measurements of Motion)
(ROM) 2-9 0
( 0 180)
0

(Extension) (Flexion)
(Extension Lag)
0 ()
(Hyperextension) 0
(Metacarpophalangeal Joint) + ()
15 45 + 15 45 ( 2 9 )
(Ankylosis)

48
(Flexion Contracture)
15 45 15 45

(PIP)
(Unit of
Motion) 2 /
/
(Functional Position of a Joint)

80 20
2-9

(MP)

(Measurements of MP Joint Position in Flexion, Extension Lag, Full Extension, and

Hyperextension)

() 0

49






2
1. (Active Motion)
2. (Passive Motion)
(Active Motion)

(Passive Motion)

Bunnell (BunnellTest) (Intrinsic Tightness)
(Assisted Active Motion)

2 0.5

(Contracture)

(Neutral Position)

50

(Excursion)

3 3

2.4.5.4

2.4.2
A = E + F (Principle for Motion Impairment Calculation : A = E + F)


(Ankylosis) (A)
(E) (F) A = E + F A

V

V ext
V flex
0O 90 O
V ext = 0O V flex = 90O
F
V flex V flex
90O V flex = 60
F = 90O- 60O = 30O 30O
E
Vext Vext ()

Vext = 20O

0O

E = 20O- 0O (= 20O) 20O

Vflex Vext

() Vflex Vext Vflex = Vext
(A)

51
0O 90O 40O
Vext = Vflex
= 40O
E
= 40O- 0O = 40O
F
= 90O- 40O = 50O
A
= E+F
= 40O + 50O
= 90O

(E) (F) (A)
IE% , IF% , IA% =
V
IE% = 0% Vext ()
IF% = 0% Vflex ()
IA% = = IE% + IF% Vext = Vflex
A% = E% + F% E% = A% - F%
(IE%)
IE% = IA% = - IF%
IE% IF%

A% =
E%+ F% 100%
(
16 11) A% 100%

100% (Pie Chart)

2-12
(Functional Unit) 60
70 42 (70% x 60% = 42%)
30 18 (30% x 60 % = 18 %)
2 27
42% / ( 2 - 28)
/ (
2 - 30) 18% ( 2 - 31)

52

2.4.3
(Method for Motion Impairment Calculation)

2 ( )
/ IF% + IE%
//
(MP)
IA%

(IA%)

2.13

2.14

10O 10O 0O 10O

24
2-28

IF% 10 O
(10OVFlex)
= 8% ( 2-28)
O
O
IE% 10
(10 VExt)
= 8% ( 2-28)
O O
IRD% 0 (0 VRD) = 4% ( 2-31)
IUD% 10 O (10O VUD) = 4% ( 2-31)

= (IF% + IE%) + (IRD% + IUD%)
= (8% + 8%) + (4% + 4%)
= 24
0O 0O
30
2 - 28
IA% / 0O VFlex / VExt = 21% ( 2 - 28)
IA% 0O
IRD / IUD
= 9% ( 2 - 31)

53

30 (21% + 9% = 30%)

(Pie Chart)

2.15

(MP) 25O (
25O) 65O (2-25)
25
2-25

= 12%
IE% -30 O VExt
O
= 10%
IE% -20 VExt
12% 10% 2%
20 O - 30 O 25
O

IE% - 25 O VExt = 10% + 1% = 11%

IF% 70 O VFlex
= 11%
O
IF% 60 VFlex
= 17%
11% 17% 6%
60 O 70 O 65 O
IF% 65 O VFlex = 14% (11%+3%)
IF% IE% 11% (IE% )+ 14% (IF%) = 25%
25

2
()

()

54
2.16

2.17

30O 50O
( 2-28)
3
2-28 IE% 30 OVEXT = 5%

IE% 50 OVEXT = 2%

5% - 2% = 3%

(
) (Hyperlaxity)
(Subluxation) (Dislocation)
2-22 2-26

2

60O
80 O
1
= 42%
2
()

= 42% x 2%
= 0.84%
= 1%

55

1. (Thumb Ray)
2.
3.

4. (Determining Hand
Impairment from Two or More Digits)
5.
6.
7.
2.4.4 (Thumb Ray
Motion Impairment)
(Interphalangeal Joint - IP) (Metacarpophalangeal
Joint - MP) (Carpometacarpal Joint - CMC) 5
100
1. 15
2. 10
3. 75
3.1 (Adduction)
20
3.2 (Abduction) 10
3.3. (Opposition)
45
2-11,2-14,2-18, 2-19
100% (Pie Chart)

(Conversion Factor) 2-12 2-15 2-8 , 2-8 2-9

2.4.4.1 : (Thumb IP Joint :Flexion and Extension)
(Hyper extension) + 30O
80O (Functional Position) 20O
15

56

1.
(V) ( 2-10)
2. 2-12 (V)
( IF%) ( IE%)
0 (Pie Chart)
( 2-12)
3.
IF% + IE%
4. (Ankylosis) (V)
( IA %) ( 2-12)
( 2-12)
20O 7

2-10

() ()
(Neutral Position (top) and Flexion (bottom) of Thumb IP joint)

57
(IA %)
(IF%) (IE%)
(Motion Unit Impairment Curves for Ankylosis (IA %), Loss of Flexion (IF%), and Loss of
Extension (IE%) of IP Joint of Thumb)
20O
70

2-11

2.18

10O 50O
2
2-12
IE% 10O 2%
2%
IF% 50O
(IE% + IF%) = 2%+ 2%
= 4%
= 2% ( 2 - 1)

58
2.19

2-12

65O
5
2-12
IA% 70O 14%
IA% 60O 12%
IA% 65O IA%
60O 70O
IA% 65O 13
5 ( 2-1)

(Pie Chart of Thumb Impairments Due to Abnormal Motion at the IP Joint)

15

IA % =
I % =
2.4.4.2 E : (Thumb MP Joint : Flexion and Extension)
IF% =
V
=
*
=

59
+40O 60O
20O 10

1. (V)
( 2 - 13)
2-13

[Neutral Position (Top) and Flexion (Bottom) of Thumb MP Joint]

2. 2-15 (V)
( IF%) ( IE%)
0 2 - 15

3.
(IF% + IE%)
4. (V)
( IA %) (2-15)
20O
5

60
(IA %)
(IF%) (IE%) (Motion Unit Impairment for Ankylosis , Loss of
Fexion (IF%) and Loss of Extension (IE%) of Thumb MP Joint)
20O
5

2-14

61
2-15
(Pie Chart of Thumb Impairments Due to Abnormal Motion at the MP Joint)

10

IA %
IE%
I F%
V
*

=
=
=
=
=

62

2.20

2.21

2.22

10O 40O
1
2-15
IE% 10O 0%
IF% 40O 2%
(IE% + IF%) (0% + 2%) 2
1 ( 2 - 1)

- 25 O 60O
2 1 ( 2-1)
2-15
IE % - 25 O 2%
( 20 O 30O 1% 3%)
IF % 60 O 0 %
(IE% + IF%) (2% + 0%) 2
1 ( 2-1)

60 O
4
2-15
IA% 60O 10
4 ( 2 - 1)

2.4.4.3 (Thumb Radial Abduction)

1 2
coronal plane ( 2-16)
2 1 50 O
15 O ()
10

63

1.

2. 2-8

3.
2-8
4. 2-1
2-16

1 2
coronal
(Thumb Radial Abduction Measures in Degrees the Angle of Separation Formed Between the
First and Second Metacarpal in the Coronal Plane)

2.23

25O
7
25 O 8 ( 2-8)

64
2 8

(Thumb Impairment Values Due to Lack of Radial Abduction and to Ankylosis)

(O)

15
20
25
30
35
40
45
50

10
9
7
5
3
2
0
0

0
1
1
1
3
5
8
9

10
10
8
6
6
7
8
9

10
(15O) (50O)
2.4.4.4 (Thumb Adduction)

(Flexion Crease of Thumb IP Joint) (Distal Palmar Crease)
( 2 - 17 2 - 18) 8 0

20

65
2 - 17
(*)
(Adduction of Thumb Measured in Centimeters From the Flexion Crease of the Thumb IP Joint
to the Distal Palmar Crease Over the Level of the MP Joint of the Little Finger)

66
2 - 18

(Linear Measurements of Thumb Adduction in Centimeters at Various Positions and Motion

Unit Impairment Curve for Lack of Adduction)

1.

2.
2 8 2 8

67
2 8

(Thumb Impairment Values Due to Lack of Radial Adduction and to Ankylosis)

(.)
8
7
6
5
4
3
2
1
0

20
20
13
19
8
17
6
15
4
10
3
15
1
17
0
19
0
20

20
8 0
2.24

3
3 ( 2 - 8)
3 (8 - 3)
5 6
( 2 8 )

2.4.4.5 (Thumb Opposition)

(Thumb Opposition)
(Thumb Opposition)
( 2 - 19)
( 2-9) 45
8

68
2-19

(Linear Measurements of Thumb Opposition (cm) at Various Positions and Motion Unit
Impairment Curve for Lack of Opposition )

1.

2.
2 9
2 9

69
2-9

(Thumb Impairments Values Due to Lack of Opposition and to Ankylosis)

()
0
1
2
3
4
5
6
7
8

45
45
31
40
22
36
13
31
9
27
5
22
3
24
1
27
0
29

45
0 8

2.4.4.6 2
(Adding Two or More Abnormal Thumb Motions)
1.
( 2 - 12 2 - 15) ( 2-8 )
( 2-8 ) ( 2-9)
2.

100%

100


( ) 100

70
2.25

4
4 0
10
18

(4% + 4% + 0% + 10% = 18%) 18

2.4.5
(Finger Motion Impairment)
3
45% 80%
100% ( 2 4)

A = E + F (Pie Charts)
( 2 - 21 , 2 23 2 - 25)
(Hyperextension) + 20O
( 2-25)
IE% = 5%
IE% = 0%
+30O
30O
80 ( 2 23)

(Pie Chart)

2.4.1
2
1.
2. 3

2.4.5.1 : (DIP Joint : Flexion and Extension)

0 70
20 45

71
2-20

(Neutral Position)
(Flexion of Finger DIP Joint)

72
2-21

(Finger Impairments Due to Abnormal Motion at the DIP Joint)

45
20 O
30
IA% =

IE% =

IF % =
V =

* =

1. (V)
( 2 - 20)
2. 2-21 (V)
( IF%) ( IE%)
0 2 - 21

73
3. IF% IE%

4. (V)
( IA%) 2 - 21 2-21
20O
30
2.26

2.27

2.28

10O 50 O
2
2-21
IE% -10 O
IF% 50 O
(IE% + IF%)

= 2 %
= 10 %
= 2% + 10%
= 12%
2 ( 2-1)

+30 O 0 O
36
2-21
IE% = 0% IF% = 36%
(IE% + IF%) = 0% + 36% 36
35 O
34
2-21
IA% = 30 O = 33 %
IA% = 40 O = 35 %
30O 40O
IA% 35 O 34

74
2.4.5.2 : (PIP Joint : Flexion and Extension)
0 O 100 O
40 O 80

1. (V)
( 2-22)
2. 2-23 (V)
( IF%) ( IE%)
0
2-23
2-22

Neutral Position (top) and Flexion (bottom) of Finger PIP Joint

3.
(IF% + IE%)
4. (V)
( IA%) 2-23 2-23
40O
50

75
2.29

15 O 60O
6
2-23
-10O 20O
-20O 7
-10O 3
10O 7% - 3% = 4%
5O 4% x 5 = 2%
10
O
IE% 15 3% + 2% = 5%
IF% 60O = 24% ( 2-23)
= 5% + 24% 29
6 ( 2-1)

2-23
(Finger Impairments Due to Abnormal Motion at PIP Joint)

80
40 O 50
IA% =
IE% =
IF% =
V
=
*
=

76
2. 30

40 O
50
40 O 50 ( 2-23)

2.4.5.3 (MP Joint : Flexion and Extension)

+20O 90O
30O 100

1. (V)
( 2-24)
2. 2-25 (V)
( IF%) ( IE%)
0 2-25

2-24 (0O)
Neural Position (top) and Flexion (bottom) of Finger MP Joint

77

2-25
(Finger Impairments Due to Abnormal Motion at the MP Joint)

100
30O 45
IA% =
IE% =
IF% =
V =
* =

78
3.
(IF% + IE%)
4. (V)
( IA%) 2-25 2-25
30O
45
2.31

2.32

0 50O
27 5
2 25
0 O , IE% = 5%
50O ,IF% = 22%

(IE% + IF%) = 5% + 22%

= 27
= 5 ( 2- 1 )

55O
68
55O
50 O 60O
50O 60O
2 - 25
60O IA% = 73%
50O IA% = 63%
IA% 10% (73% 63%)
10O (60O 50O)
O
5
IA% 5%
O
O
50 + 5 IA% = 63% + 5%
55O
IA% = 68%

79
2.4.5.4
(Combining
Abnormal Motion at More Than One Finger Joint)

3 2
3

1. IE% 3
2. IF% 3
3. 3 (IE%)
3 (IF%)

( 2 1
2 3)
2.33

(DIP) 12 (PIP)
31 (MP) 27

6
12 31
39
39 27
55
11 (
2 1) 10 ( 2 2)
6 ( 2 3)

80

2.4.6 (Multiple Digit

Impairments)
2.4.6.1
(Combining Digit Amputation, Sensory Loss , And
Abnormal Motion Impairments of the Hand)
1.

2. 1

3. 2
( 2 1 2 3)


( 2 2 , 2 3)
2. 34

2. 35

20
10
10
4
20
10
10
10 10 19
19 20 35
35 7 ( 2-1)
6 ( 2 2) 4
( 2-3)
4

30
10
10
9

81

30
10
10
10 10 19
19 30 43
43 17
( 2-1)
15
( 2-2)
9 ( 2-3)
9

2.4.6.2
(Determining Hand Impairment From Two or More Digits)
1.

2. ( 2-1)
3. 2

4.


( 2-2)
( 2-4)
5. 2-2 2-3

2.36

10 20
30 40
50
13
2 2

82

10
4
20
4
30
6
40
4
50
5

23
2 2 2 3 23
21 13
13
2.4.7
(Wrist Motion Impairment)
60 2
( 2 26 2 29)

60 %
1. 70
42 (70% x 60% = 42%)
2. 30
18 (30% x 60% = 18%)

A = E + F 100 ( 2 27
2 30)
(Pie Charts Of Upper Extremity Impairment)
( 2-28 2-31)

83
2 26
(Wrist Flexion (above) and Extension (below)

(V)
(V) 2 28 2-31

84
2 27
(IA%) , (IF%) (IE%)
(Motion Unit Impairment Curves of Ankylosis (IA%), Loss of Flexion (IF%) , and Loss of
Extension (IE%), of Wrist Joint)
10O 10O
50

85
2 28
(Pie Chat of Upper Extremity Motion Impairments Due to Lack of Flexion and Extension fo
Wrist Joint)

42
IA%
IE%
IF %
V
*

=
=
=
=
=

86
2.4.7.1
(Flexion And Extension)
60O 60O
10O 10O
( ) 42

1. (
2-26) (V)
2. 2-28 (V)
( IF%) ( IE%)
2 28
3. IF% IE%

4. (V)
( IA% = ) 2 28 2 28

10 10
50% ( 2-27) 21 ( 2-28)
60 60 100
( 2-27) 70
42 (70% x 60% = 42%) ( 2-28)
2.37

30O 10O
16
2-28 10O , IE% = 8%
10O , IF% = 8%
IE%+IF% = 8% + 8%
= 16%
16

87
2.4.7.2
(Radial and Ulnar Deviation)
20 O 30 O
0O 10O 18

1.
( 2-29) (V)
2. 2-31 (V)
( IRD%) ( IUD%)
2-31

3. IRD% IUD%

4. (V)
( IA% = ) 2-31 2-31

0O 10O
50% ( 2-30) 9% ( 2-31)
30 O 20 O 100 ( 2-30)
30 18 (30%
x 60% = 18%) 2-31

2-29

88

2-30

(IA%) (IRD% , IUD%)

(Motion unit Impairment Curves of Ankylosis, Loss of Radial Deviaton (IRD%) , and Loss of
Ulnar Deviation (IUD%) of Wrist Joint)
0O 10O

50

89
2-31

(Pie Chart of Upper Extremity Motion Impairments Due to Abnormal Radial and Ulnar
Deviations of Wrist Joint)

18
IA% =
IRD% =
IUD% =
V =
* =

90
2.39

2.40

0O 10O ( 2-31)
27
2-31
0O, IUD% = 5%
10O, IRD% = 2%
2 (IUD% + IRD%) = 5%+2% = 7%
7

15O
16
2-31 15O , IA% = 16%

2.4.7.3
(Determining Impairment Due to Abnormal Wrist Motion)
1. 2-28 2-31

2.
(IF%+IE%) + (IRD%+ IUD%)

(Impairment Pie Chart)

3.

4. 2-3
2.41

16
7

14
2-31 16

7 23 14
( 2-3)

91
2.42

0O 0O ()
18
2-28 2-31 0O , IA% = =
21% 0O , IA% = = 9%
21% + 9% 30
18 ( 2-3)

2.4.8
(Elbow Motion Impairment)
70 2
( 2-32 2-35)
70%
60%
60% x 70% = 42%
(Pronation and Supination) 40%
40% x 70% = 28 %

A = E + F 100% ( 2-33 2-36)

(Pie Chart)
( 2-34 2-37)



(V) (V) 2-34 2-37

2.4.8.1
(Flexion and Extension)
140O
0O 80 O
42%

1.
( 2-32) (V)

92
2. 2-34 (V)
( IF%) ( IE%)
2-34
3. IF% IE% (IF% +IE%)

4. (V)
( IA%) 2-34 2-34

80O 50%
( 2-33) 21% ( 2-34)
0O 140O 100%
( 2-33) 60% 42
(60% x 70% = 42%) ( 2-34)
2-32

(Flexion and Extension of Elbow)

93
2-33

(IA%) (IF%) (IE%)
(Motion Unit Impairment Curves of Ankylosis (IA%), Loss of Flexion (IF%), and Loss of
Extension (IE%) Elbow Joint

94
2-34

(Pie Chart of Upper Extremity Motion Impairments Due to Lack of Flexion and Extension of
Elbow Joint)

42
IA% =
IE% =
IF% =
V
=
*
=

95
2. 43

2.44

-40O 65O
21
2-34 -40O , IE% = 4%
65O
60O 70O ( IF% 65O = 17% )
IF% 70O - 60O = 19% - 15% = 4%
IF% 10O = 4%
IF% 5O = 2%
IF% 65O = 15% +2% = 17%
IE% IF%, ( IE% + IF%) 4% + 17% = 21%
21

80O
21
80O , IA% = = 21%
2-34 21

2.4.8.2
(Pronation and Supination)
80O 80O
20O
28

1.
( 2-35) (V)
2. 2-37 (V)
( IP%) ( IS%)
2-37

96
3. IP% IS%
()
4. (V)
( IA%) 2-37 2-37

20O
30 ( 2-36) 8 (
2-37) 80O 80O 100
( 2-36) 40% 28
(40% x 70% = 28%) (Forearm Rotation)
( 2-37)

97
2-35

(Pronation and Supination of Forearm)

98
2-36

(IA%) (IP%) ( IS%) ()
(Pronation and Supination of Forearm)
20O
30

2.45

30O 10O
6
2-37
30O , IP% = 3%
10O , IS% = 4%
IP% IS% (IP% + IS%) = 3% +4% = 7%
7

99
2-37

(Pie Chart of Upper Extremity Motion Impairments Due to Lack of Pronation and Supination)

28
IA%
=
=
Ip%
I s%
=
V
=
*
=
2.46

30O
23
2-37 30O , IA% = = 23%

100
2.4.8.3
(Determining Impairment Due to Abnormal Elbow Motion)
1. 2-34 2-37

2.
(IF%+ IE%)+( Ip% + Is%)

(Impairment Pie Chart)

3.

4. 2-3
2.47

60O 0O 10O 10O

18
2-34 2-37
IF% = 19%
60O ,
O
IE% = 0%
0 ,
O
10 ,
Ip% = 8%
O
Is% = 3%
10 ,
(IE% +IF%)=19%+0% = 19%

(Ip%+ Is%) =8%+3% =

11%

19%+11% = 30%
2-3
18
18

101
2.48

80O 30O
16
2-34 2-37
IA%
= 21%
80O
O
30
IA%
= 23%
21%+ 23% = 44%
2-3 26

26

2.4.9
(Shoulder Motion Impairments)
60
3 3 ( 2-38, 2-41 2-44)

60%
1. 40
10
50
30 (50% x 60% = 30%)
2. 20
10
30
18 (30% x 60%= 18%)
3. 10
10
20
12 (20% X 60%= 12%)

A = E + F
100 ( 2-39 , 2-42 2-45)
(Pie Chart)
( 2-40 , 2-43 2-46)

102

3
(V) (V)
2-40, 2-43, 2-46

2.4.9.1
(Flexion and Extension)
180O
50O 20O 40O
30

1. (v)
( 2-38)
2. 2-40 (V)
( IF%) ( IE%)
2-40
3. IF% IE% (IF% + IE%)

4. (V)
( IA% = ) 2-40 2-40

20O 40O
50 ( 2-39) 15 ( 2-40)
50 O 180O 100
( 2-39) 50 30
(50% x 60% = 30%) 2-40

103
2-38 (Shoulder Flexion and Extension)

104
2-39

(IA%) (IF%) (IE%)
[Motion Unit Impairment Curves for Ankylosis (IA%) , Loss of Flexion (IF%), and Loss of
Extension (IE%) of Shoulder]
20O 40O
50

105
2-40

(Pie Chart of Upper Extremity Motion Impairments Due to Lack of Flexion and Extension of
Shoulder)

30
IA% =
IE% =
IF% =
V =
* =

106
2.49

2.50

90O 0O ( 2-38,2-39)
9
2-40
90O , IF% = 6%
0O , IE% = 3%
IF% + IE% = 6% + 3% = 9
9

30O ( 2-38 , 2-39)

15
2-40
30O, IA% = 15
15

2.4.9.2
(Abduction and Adduction)
180O 50O
20O 50O
18

1. (V)
( 2-41)
2. 2-43 (V)
( IABD%) ( IADD%)
2-43
3. IABD% IADD% (IABD% + IADD%)

4. (V)
( IA%) 2-43 2-43

107
20O 50O
50 ( 2-42) 9 ( 2-43)
50O 180O 100 ( 2-42)
30 18 (30% x
60% = 18%) ( 2-43)
2- 41

(Shoulder Abduction and Adduction)

108
2- 42

(IA%) (IABD%) ( IADD%)
20O 50O
50 9

109
2- 43

(Pie Chart of Upper Extremity Motion Impairment Due to Lack of Abduction and Adduction
of Shoulder)

18
IA%
IABD%
IADD%
V
*

=
=
=
=
=

110
2.51

2.52

100 O 0O ( 2-41, 2-42)

6
2-43
100O , IABD% = 4%
0O , IADD% = 2%
IABD% IADD% (IABD% + IADD%) = 4% +2% = 6
6

40O
9
2-43
40O , IA% = 9
9

2.4.9.3
(Internal and External Rotation)
90O
90O 30O 50O
12

1.
(V) ( 2-44)
2. 2-46 (V)
( IIR%) ( IER%)
2-46

3. IIR% IER% (IIR% + IER%)

4. (V)
( IA%) 2-46 2-46

111
30O - 50O
50 ( 2-45) 6 ( 2-46)
90O 90O 100 ( 2-45)
20 12 (20% x 60% = 12%)
( 2-46)
2- 44

(Shoulder Internal and External Rotation)

112
2-45

(IA%) (IIR%) (IER%)

[Motion Unit Impairment Curves for Ankylosis (IA%) , Loss of Internal Rotation (IIR%), and Loss
of External Rotation (IER%) of Shoulder]

30O - 50O
50 6

113

2-46

(Pie Chart of Upper Extremity Motion Impairment Due to Lack of Internal and External Rotation
of Shoulder)

12
IA%
IIR%
IER%
V
*

=
=
=
=
=

114
2.53

2.54

40O 50O
12
2-46
40O, IIR% = 8 %
50O, IER% = 4 %
2 (IIR% + IER% )= 8%+ 4% = 12
12

10O
7
2-46
10O , IA% = 7
7

2.4.9.3 (Determining
Impairment Due to Abnormal Shoulder Motion)
1. 2-40, 2-43 2-46

2.
(IF% + IE%) + (IABD% + IADD%) +
(IIR% + IER%)
(Impairment Pie Chart)
3.

4. 2-3

115
2.55

2.56

9
5
2
10
2 - 40 , 2 - 43 , 2 - 46
3 9% + 5% +
2% = 16% 10% ( 2-3)
10

0O, 0O 0O
27
2 - 40 , 2 - 43 , 2 - 46
0O, IA% = 24%
0O , IA% = 14%
0O, I,A% = 7%
IA% 3 24% + 14% + 7% = 45%
27 ( 2-3)
27

116

2.5
(Impairment of the Upper Extremities Due to Peripheral Nerve Disorders)


5
5 8 1 2
(Spinal Nerve Root C5-C8 T1 ,T2) 5 (Brachial
Plexus) ( 2-50)
3
1. (Sensory or Afferent Fibers)

2. (Motor or Efferent Fibers) (Large Alpha
Motor Neuron Fiber)

3. (Autonomic Fibers)

2-12 , ( 2-50)
2-48 , 2-49
2-47

117
2-47

118
2-48

(Cutaneous Innervation of the Upper Extremity and Related Peripheral Nerves and Root)

119
2-49

(Dermatomes of the Upper Limb)

120
2-50

(The Brachial Plexus)

2.5.1 (Impairment
Evaluation Principles)

1.

2.
2.1
2.2

3.

121
4.


(Complex Regional Pain Syndromes I (CRPSI)/Reflex
Sympathetic Dystrophy) 2.4

2.5.2
(Impairment
Evaluation Methods)
2.5.2.1

(Anesthesia, Hypesthesia)
(Dysesthesia Paresthesia) (Hyperesthesia), nonnoxious stimuli
(Allodynia) (Hyperpathia) CRPS I (Reflex Sympathetic
Dystrophy) CRPS II (Causalgia)

1.

2.

3.

4.

122
2-10

(Determining Impairment of the Upper Extremity Due to Sensory Deficits or Pain Resulting
From Peripheral Nerve Disorders)

0
.
1.
2.
3.
4.

5.

() 1 25

( two- 26 60
point discrimination )

61 80
()

( 81 99
)

100

( 2-48) Dermatome ( 2-49 )

2-12 2-48,
2-49, 2-50

.

(Spinal Nerve) 2-13 2-14

2-15
3
4

123
2-11

(Determining Impairment of the Upper Extremity Due to Motor and Loss of Power
Deficits Resulting From Peripheral Nerve Disorders Based on Individual Muscle Rating)

1 - 25

26 - 50

2
1

51 - 75

76 - 99

100

.
1

2
3
4

1

.

(Spinal Nerve) 2-13 2-14

2-15
3
4

124
2-12

(Origins and Functions of the Peripheral Nerves of the Upper Extremity Emanating From the Brachial Plexus)

Muscular branches
Dorsal scapular (C5)
Long thoracic (C5, C6, C7)
Suprascapular (C5, C6)
Lateral pectoral (C5, C6, C7)
Medial pectoral (C8, T1)
Upper subscapular (C5, C6)
Lower subscapular (C5, C6)
Thoracodorsal (C6, C7, C8)

Medial brachial cutaneous (T1)

Intercostobrachial (T2)
Medial antebrachial cutaneous (C8, T1)
Musculocutaneous (C5, C6, C7)

Axillary (C5, C6)

Lateral antebrachial cutaneous

Teres minor branch
Anterior
Posterior Muscular branches
Upper lateral brachial cutaneous

- longus colli, scalenes, and subclavius

- rhomboideus major and minor, levator scapulae
- serratus anterior
- supraspinatus and infraspinatus
- pectoralis major
- pectoralis major and minor
- subscapularis
- teres major and subscapularis
- latissimus dorsi
- anteromedial surface of arm (with intercostobrachial)
- posteromedial surface of arm (with medial brachial cutaneous)
- anteromedial surface of arm, anteromedial half of forearm
, and posteromedial third of elbow, forearm, and wrist
- coracobrachialis, biceps brachii, brachialis
- anterolateral half and posterolateral third of forearm
- teres minor
- deltoid ()
- deltoid ()
- deltoid

125
2-12

(Origins and Functions of the Peripheral Nerves of the Upper Extremity Emanatng From the Brachial Plexus) ()

Radial (C5, C6, C7, C8, + T1)

Ulnar collateral
Posterior brachial cutaneous
Inferior lateral brachial cutaneous
Posterior antebrachial cutaneous
Dorsal Branches
Superficial terminal
Dorsal Digitals
(5 Branches)

Superficial Branch
Deep terminal
Deep Branch

- triceps brachii, anconeous, brachio radialis, extensor

carpi radialis longus, brachialis (lateral part)
- medial head of triceps brachii
- distal posterocentral surface of arm as far as olecranon
- distal posterolateral surface of arm and elbow
- posterocentral surface of forearm
- posterolateral half of wrist and hand
- dorsum of thumb, index, middle, and ring (radial half) fingers
up to middle phalanx
- extensor carpi radialis brevis, supinator
- extensor digitorum communis, extensor digiti minimi,
extensor carpi ulnaris
- extensor pollicis longus, extensor pollicis brevis, abductor
pollicis longus, extensor indicis proprius
- wrist joint capsule

126
2-12

(Origins and Functions of the Peripheral Nerves of the Upper Extremity Emanatng From the Brachial Plexus)

Median ( + C5, C6, C7, C8, T1 )

Cubital fossa and - pronator teres, flexor carpi radialis, palmaris longus,
forearm branches
flexor digitorum superficialis
Anterior interosseus
- radial half of flexor digitorum profundus of the index and
middle fingers, flexor pollicis longus, pronator quadratus
Palmar cutaneous
- raidal surface
Thenar muscular
- abductor pollicis brevis, flexor pollicis brevis (superficial
head) and opponens pollicis
- first web space, palmar and distal dorsal surfaces of thumb,
index (radial side)
st
Common palmar radial 1 lumbrical branch
- 1st lumbrical
digital
Proper palmar digitals - 1st web space (palmar), palmar, and distal dorsal surfaces of
(3 branches)
thumb (both sides) and index (radial side)
nd
Common palmar central 2 lumbrical branch
- 2nd lumbrical
digital
Proper palmar digital - 2nd web space (palmar), palmar and distal dorsal surfaces of
(2 branches)
contiguous sides of index and middle fingers
Common palmar ulnar Proper palmar digital - 3rd web space (palmar), palmar and distal dorsal surfaces of
digital
(2 branches)
contiguous sides of middle and ring fingers

127
2-12

Ulnar ( + C7, C8, T1)

(Origins and Functions of the Peripheral Nerves of the Upper Extremity Emanatng From the Brachial Plexus) ()

Palmar cutaneous
Dorsal cutaneous

Superficial palmar

Deep palmar

Forearm branches

Dorsal branches
Dorsal digitals
(3 branches)
Palmaris brevis br.
Proper palmar digitals
(3 branches)

- flexor carpi ulnaris, ulnar half of flexor digitorum

profundus (ring and little fingers)
- surface of palm and wrist
- dorsum of wrist and hand
- dorsum of ring finger (ulnar proximal half), little finger (up
to nail root) and 4th web space
palmaris brevis
- palmar and distal dorsal surface of ring (ulnar half) and
little finger (both sides)
- adductor pollicis, flexor pollicis brevis (deep head),
abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi, 3rd and
4th lumbricals, all interossei

 2-13

(Maximum Upper Extremity Impairment Due to Unilateral Sensory or Motor Deficits of
Individual Spinal Nerves or to Combined 100% Deficits)

5 (C5)
6 (C6)
7 (C7)
8 (C8)
1 (T1)

**

5
30
34
6
35
40
5
35
38
5
45
48
5
20
24

* 2-10
** 2-11

 2-14

(Maximum Upper Extremity Impairments Due to Unilateral Sensory or Motor Deficits of
Brachial Plexus or to Combined 100% Deficits)

- (C5C8, T1)
- (Upper trunk, C5, C6
Erb-Duchenne)
- (Middle trunk, C7)
- (Lower trunk, C8-T1,
Dejerine-Klumpke)

**

100
100
100
25
75
81
5
20

* 2-10
** 2-11

35
70

38
76

 2-15

(Maximum Upper Extremity Impairment Due to Unilateral Sensory or Motor Deficits or to

Combined 100% Deficits of the Major Peripheral Nerves)

Pectorals (medial and lateral)

Axillary
Dorsal scapular
Long throacic
Medial antebrachial cutaneous
Medial brachial cutaneous
Median (above midforearm)
Median (anterior interosseous branch)
Median (below midforearm)
Radial palmar digital of thumb
Ulnar palmar digital of thumb
Radial palmar digital of index finger
Ulnar palmar digital of index finger
Radial palmar digital of middle finger
Ulnar palmar digital of middle finger
Radial palmar digital of ring finger
Musculocutaneous
Radial (upper arm with loss of triceps)
Radial (elbow with sparing of triceps)
Subscapulars (upper and lower)
Suprascapular
Thoracodorsal
Ulnar (above midforearm)
Ulnar (below midforearm)
Ulnar palmar digital of ring finger
Radial palmar digital of little finger
Ulnar palmar digital of little finger

**

0
5
0
0
5
5
39
0
39
7
11
5
4
5
4
3
5
5
5
0
5
0
7
7
2
2
3

5
35
5
15
0
0
44
15
10
0
0
0
0
0
0
0
25
42
35
5
16
10
46
35
0
0
0

5
38
5
15
5
5
66
15
45
7
11
5
4
5
4
3
29
45
38
5
20
10
50
40
2
2
3

* 2-10
** 2-11

 4 two-point discrimination
6-10 . 3 (Protective Sensibility) 2
1
(Deep cutaneous pain)
0


( 2-10)
2.3

1.
6
( 2-10)
2. 1.
2-48, 2-49
3.
() 2 2-13
2-14 2-15

4.
3.
1.
2.57

superficial dorsal radial

1
1. superficial dorsal radial (
2-12 2-48)
2. 4
1-25 ( 2-10 )
20

3.
5 ( 2-15)
4. 2. 3. 20% x 5%
= 1%
5.
1 1 ( 2-3)
2.5.2.2 (Motor Deficit
Calculation)

/

(EMG)

2.8 2

1.
6
( 2-11)
2. ()
( 2-12 , 2-47)
3.
() 2. 2-13, 2-14, 2-15 (,
, )
4.
3.
1.

 2.58

10 6

1.
1.1 deltoid
axillary ( 2-12 2- 47)
1.2
2-11 deltoid 4
( 1-25 % 2-11.)
25
1.3
axillary 35 ( 2-15)
1.4 deltoid
axillary 25% x 35% = 8.75%
9
2.
2.1
axillary ( 2-48 2-12)
2.2
axillary 5 ( 2-15)
2.3 4 ( 1-25 %
2-10)
2.4
5% x 25% =1.25% 1
3.

axillary 9% 1%
10 ()
10
6 ( 2-3)

2.5.3
(Regional Impairment Determination)

1. 5 1 (Spinal Nerve C5-T1)

2. (Brachial Plexus)
3. (Major Peripheral Nerves)
2.5.3.1
(Spinal Nerve Injury)

( 2-14)


(Upper trunk) 5 6 2-14
81
5 6 34 40 ( 2-13)
34 40 60 81

2-13 2.5.2


( 2-3)

(Spinal Nerves)
1. . 2-10
. 2-11
2.
( 2-13,2-14)
3.
( 1 .)
( 2)
4.

( 1 .)
( 2)

5. ( 3)
( 4)

6. 2-3
2.59

42

18
5 20
5 50

10
1. 20
50
2. 2-13
5 5
5 30
3. 20% x 5%
1
50% x 30% 15
4.
1% 15% =16% () 16
10 ( 2-3)

2.5.3.2
(Brachial Plexus)

anterior division 5 8 1 anterior division
(Nerve Trunk) 3 (Upper Trunk - C5 , C6) (Middle
Trunk - C7) (Lower Trunk - C8 T1) 2-50

1. (Total Brachial Plexus Paralysis)

2. (Upper Trunk Paralysis) Erb-Duchenne
type
deltoid, biceps, brachialis, supraspinatus infraspinatus rhomboid
triceps, pectoralis major, extensor carpi radialis brevis, extensor carpi radialis longus

 biceps reflex
5 6 ( 2-49)
3. (Dejerine-Klumpke type)
(Intrinsic Muscle) flexor carpi ulnaris flexor digitorum
profundus 1 (Avulsion)
Horner syndrome ( ptosis, myosis enophthalmos)
8 1 ( 2-49)
(Brachial
Plexus)

1. 2-10
2-11
2.
( 2-14, 2-15)
3.



4.

()
5. ( 2-3)
2.60

22

5 6 nerve graft
4
5 6 supraspinatus
4, infraspinatus 3, deltoid
3, biceps-brachialis 4, brachio
radialis 3 supinator 3
22


1. supraspinatus infraspinatus suprascapular
( 5 6 2-12) 4
2-11 25
suprascapular
16 ( 2-15)
supraspinatus
infraspinatus
25% x 16% = 4 % 4
2. deltoid axillary ( 5 6
2-12) 3 2-11
50
axillary 35 ( 2-15)
deltoid 50% x
35% = 18 % 18
3. biceps-brachialis musculocutaneous
( 5 6 2-12) 4
2-11 25
musculocutaneous
25 ( 2-15)
biceps - brachialis
25 % x 25 % = 6 % 6
4. brachio radialis supinator radial
( 5 6 2-12) 3
2-11 40

radial 35 ( 2-15)
brachioradialis
40 % x 35 % = 14 % 14
5.
()
4% 18% 21%
21% 6% 26%
26% 14% 36%
6. 36
22 ( 2-3)

2.5.3.3
(Major Peripheral Nerve)
2-47, 2-48,
2-49, 2-50 2-12 (Dermatomes)

2-15
()

(Mixed Nerve)
(Mixed Nerve)

(Mixed Nerve) 7
1. (
) /
2-12 2-47 2-50
2. 2-10
2-11
3.
( 2-15)
4. 2.

3.

5.

6.

1 5

7.
( 2-3)
2.58

2.5.4
(Entrapment/Compression Neuropathy)


myeloma, neurofibromatosis

, (Scar),

cervical rib

median
(Capal Tunnel Syndrome) ulnar

2.5.4.1
(1)
(2)
(3) (Electroneuromyographic Studies :
ENMG),

1.


(Autonomic Function)

2. (Sensibility)
, , (Grip Strength) reflexes
Phalens test, Adsons
test, nerve percussion test

3. (Electroneuromyographic Studies :
ENMG) (EMG) motor unit potentials
(Motor and Sensory Nerve Conduction Studies)
myelinated
() patho physiology

3.1 (Axonotmetic Lesion)

(Conduction Failure)
3.2 myelin sheath (Focal Demyelination Neuropraxic
Lesion)


axon

2.5.4.2

1.

(EMG)
2.
( )


6-9 1-2

2.5.3.3

2.3

CRPS CRPS II
(Causalgia) CRPSII 2.5.5

 2.61

30
20
ulnar
ulnar

(IP Joint) (MP Joint)
hypothena interosseous
two-point discrimination 20 flexor carpi ulnaris,
flexor digitorum profundus (), adductor pollicis
(Nerve Percussion Test) ulnar

ulnar
ulnar
30
1.
1.1 0 (100%) 2-10
1.2
ulnar (Above Midforearm) 7
2-15
1.3 (100% x 7%)
7
2.
2.1 0 (100%) 2-11

2.2
ulnar (Above Midforearm)
46 2-15
2.3 (100% x 46%)
46

3.

( 46)
7 50 (
2-15
ulnar )
30 ( 2-3)
(Carpal Tunnel Syndrome CTS)

median
median
thenar
Phalens sign (EMG) motor sensory
reflex sympathetic dystrophy (CRPS )
5% CTS EMG
median
, 3
median

(Two-Point Discrimination Semmes-Weinstein

Monofillament Test) (Opposition Strength)
EMG thenar
5
(Two-Point
Discrimination Semmes-Weinstein
Monofillament Test) (Opposition Strength)

2.5.5
(Complex Regional Pain Syndromes CRPS, Reflex Sympathetic Dystrophy:CRPS , Causalgia
:CRPS )


(Vasomotor and Sudomotor
Dysfunction) ( 2-16)

 sympathetic (Sympathetic Nervous System

Dysfunction) reflex sympathetic dystrophy (RSD) causalgia
causalgia
motor sensory (mixed nerve) major causalgia
minor causalgia
(International Association for the Study of Pain)
(Complex Regional Pain Syndromes : CRPS)
RSD CRPS causalgia CRPS sympathetic
sympathetic
CRPS sympathetic (Regional Sympathetic Blockade)

somatoform pain disorder,
factitious disorder, malingering, somatoform conversion disorder
2-16 8

2-16

[Objective Diagnostic Criteria for CRPS (RSD Causalgia)]

(Local Clinical Signs)
(Vasomotor Changes)
1. :
2. :
3.
(Sudomotor Changes)
4.
(Trophic Changes)
5. :
6.
7.
8. : ,
9. : , ,
(Radiographic Signs)
10. : (Osteoporosis), trophic bone changes
11. Bone Scan : CRPS
(Interpretation)
8 CRPS (Probable CRPS)
8 CRPS

2.5.5.1 CRPS I (RSD)

1. 2.4
2.
2-10

3. 1 2
CRPS I
4. ( 2-3)
1. CRPS I CRPS II

CRPS I
2.

3.
2.3 CRPS
2.5.5.2 CRPS II (Causalgia)
CRPS II

1. 2.4
2.
2.5.2 2-10

( 2-15)
3.
2-11
( 2 15)
4. 1 2 3 (
100)
5. (
2-3)

(Pinch/Grip Strength)
( 2.3)

2.6
(Impairment of the Upper Extremities Due to Vascular Disorders)
Raynauds phenomenon
11 11.3
Raynaud (Raynauds phenomenon)
(Cyanosis) (Erythema)

2.2
2-17
Raynauds phenomenon
(Vasoreactivity) (Obstructive physiology)

1.
2. (Finger- Brachial Index) 0.8
Raynauds phenomenon
3. laser Doppler flowmetry

 2-17

(Impairment of the Upper Extremity Due to Peripheral Vascular Disease)

1
2
0-9
10-39

(Claudication)

- 1
-

(Arterial Calcifications)

Raynauds Raynauds
phenomenon
phenomenon Raynauds
( phenomenon
finger-branchial index
0.8 ( finger laser brachial index
Doppler 0.8
)

/ laser Doppler

3
40-69

4
70-89

5
90-100

- 2

-
2

 2-17

0 - 9% Raynauds phenomenon
finger - brachial index 0.8 laser Doppler

/
10-39% Raynauds phenomenon
/
2. 62

45 Raynauds phenomenon scleroderma

9 prazosin hydrochloride

(Autoamputation), finger-brachial index 0.6 laser Doppler
(Microcirculatory
Impairment)
45
1. : 2 17 3
55
7 ( 2-5) (55% 7%)
58 35
( 2-3)
2. : 2 17 2
25 15 ( 2-3)
(35%
15%) 45

2.7 (Impairment of
the Upper Extremities Due to Other Disorders)

- (Bone and Joint Deformities) ( 2.7.1)
- (Resection/Implant Arthroplasty) ( 2.7.2)
- (Musculotendinous Impairments) ( 2.7.3)
- (Tendinitis) ( 2.7.4)
- (Loss of Strength) ( 2.8)
2-19 2-30

( 2-18)

2-18



2. 4 2-18
2-4
2-18 100%
2-4 2.4

 2-18

*
(Maximum Impairment Values for the Digits; Hand, Wrist, Elbow, and Shoulder Due to Disorders
of Specific Joints or Units*)

Glenohumeral
Acromioclavicular
Sternoclavicular

60
25
5

36
15
3

70
50
20

42
30
12

100

60
40
20
30
90

36
24
12
18
54

100
60
15
25

40
24
6
10

36
22
5
9

22
13
3
5

100
50
30
20

20
10
6
4

18
9
5
4

11
5
3
2

100
50
30
20

10
5
3
2

9
5
3
2

5
3
2
1

Ulnohumeral
Proximal radio ulnar

Radiocarpal
Distal radio ulnar

()
(CMC)
(MP)
(IP)

2.7.1
(Bone and Joint Deformities)


1. (Translocation) (Lateral
Deviation), (Rotational Deformities) (Dislocation
or Subluxation)

2.
2.4
(Synovial Hypertrophy),
(Persistent Joint Subluxation or Dislocation)
(Musculotendinous Disorders 2.7.3)
3. (Joint Instability)

(Arthroplasty)
4. (Synovial Hypertrophy)

5. (Joint Crepitation)

2.7.1.1 (Synovial
Hypertrophy)


( 2-19)
( 2-18)


2-19

(Joint Impairment From Synovial Hypertrophy)

:
:
: 10

*
10
20
30

*
2-18

2.7.1.2 (Digit Lateral

Deviation)


( 2-20)

2.7.1

( ) (Digit Impairment From Active Ulnar or Radial
Deviation)

*
: 10
10
:
10-30
20

:
30
30

2-20

*
2-18

2.63

35
20 30
6 5
35 2-20
30
100

30 (30% x 100% = 30%)

20 30
2-23
IE%, = 7%

IF%, = 42%
(7%+42%=49%)
49

 64 (30% 49%
64%) 6 ( 2-2) 5
( 2-3)
2.7.1.3 (Digit Rotational
Deformity)

(Pronation Deformity)


()

2-21
2-18

/
2-21

(Digit Impairment From Rotational Deformity)

*
: 15
20
: 15-30
40

: 30
60

*
2-18

2.64

(Metacarpal)

20
7
2-21
40 2-18
20 8 (40%
x 20% = 8%) 7 ( 2-2)

2.7.1.4 (Persistent
Joint Subluxation or Dislocation)

( 2-22)
( 2-18)
2-22

(Joint Impairment From Persistent Subluxation or Dislocation)

*
:
20
:
40

:
60

*
2-18

2.7.1.5 (Joint Passive Mediolateral

Instability)


(Mediolateral Angulation)
( 2-23)
( 2-23)
( 2-18)


(Arthroplasty)
2.7.7 2.7.8
2-23

(Joint Impairment Due to Excessive Passive Mediolateral Instability)

: 10
20
:
10-20
40

: 20
60
*
2-18

 2.65

20

60
30
2

1. 60
30
60 ( 2-23)
2.
15 ( 2-18)
9 (60% x 15% = 9%)
4 ( 2-1) 4
( 2-2) 2 ( 2-3)
2.7.1.6
(Wrist, Elbow Joint Active Radial and Ulnar Deviations)

(neutral)


( 2-24)
( 2-18)


2-24

(Wrist and Elbow Joint Impairment From Excessive Active Mediolateral Deviation)

*
: 20
10
:
20-30
20

: 30
30
*
2-18

 2.66

displaced
supracondylar fracture humerus

1 6 (Cubitus Varus)
10 (Cubitus Valgus)
15
8
1. = 10o (Varus)+15o (Valgus)
25o
20 ( 2-24)
2. 70
42 ( 2-18)

14 (20% x 70% = 14%) 8 (20% x 42% =
8.4%)

2.7.1.7 (Carpal Instability)

3
2-25
(MRI)

dynamic non dissociative
non dissociative


scaphoid lunate (Scapholunate Angle)
radius lunate (Radiolunate Angle) (Lateral View)
(Neutral)
radius, scaphoid
(Palmar Surface) distal pole
lunate ( 2-51)

 2-51

scaphoid lunate

1. radiolunate 10 lunate (Dorsal)

(Volar)
2. scapholunate 30 60 ( 47)
3. triquetrolunate step off PA view
(Neutral) triquetrolunate lunate proximal
triquetrolunate step off ( 2-51)
4. scaphoid lunate scapholunate gap
PA 10 15 scapholunate gap
AP (Neutral)
5. Ulnar translation PA view
(Neutral) ulnar translation (Carpal Bones)
radius 50% lunate
ulnar radius ( 2-51) ulnar translation lunate
radius

- (Mild) 50% 8
- (Moderate) 25% 16
- (Severe) lunate radius
24 ( 2-35)


3
( 2-35)

2-25
(Upper Extremity Impairment Due to Carpal Instability Patterns)

*
(8%)
(16%)
(24%)
o o
o o
radiolunate **
11 -20
21 -30
30o
scapholunate
61o-70o
71o-80o
80o
scapholunate gap
> 3 .
> 5 .
> 8 .
triquetrolunate step off
> 1 .
> 2 .
> 3
Ulnar translation

* PA (Clenched Fist Neutral PA Views)

** VISI (Volar Intercalated Segmental Instability)
DISI (Dorsal Intercalated Segmental Instability)

1. (Radiocarpal joint) (Maximum

Impairment Value) 40 ( 2-18)
20 40 60
8, 16 24 ( 2-25)
2-25

()
2.
carpal bone resection
arthroplasty

2.67

scapholunate 65 radiolunate 5
scapholunate gap 6 .

16

2-25
scapholunate
=
65 8
radiuolunate
=
5
scapholunate gap =
6 . 16
16 (
)

2.7.1.8 (Shoulder Instability)

(Recurrent Shoulder Subluxation, or Dislocation)
glenoid labrum /
(Capsularligament) (Musculotendinous Structures)
(Repetitive
Microtrauma)
Ehlers-Danlos syndrome
(Musculotendinous Imbalances)

1. (Anterior)
(Posterior) (Inferior)
2. (Traumatic) (Atraumatic)
3. (Voluntary)
(Involuntary)

(MRI)



(Hyperlaxity) humerus (Humeral
Head) (Socket) humerus

(Provocative Test) humerus

impingement
(Radiating Pain) dead arm syndrome
(Brachial Plexus)
humerus glenoid (Humeral Head Subluxation)

1. sulcus sign
humerus glenoid humerus

(Sense of Instability)

2. loading posterior/anterior drawer test

(Neutral Rotation) 60o (Flexion) 30o
(Posterior)
(Anterior)
humerus glenoid posterior/anterior glenohumeral translation

humerus glenoid 4
(Trace) humerus
1
humerus glenoid
2
humerus glenoid

3
humerus glenoid
3. anterior apprehension test 90o
(External Rotation)
humerus (
)
4. anterior relocation test (Jobes test)
90o humerus (Posteriorly
Directed Force) humerus
anterior instability
2-26
3
1. (Occult Shoulder Instability) 10
2. humerus (Shoulder Instability with Subluxating Humeral
Head) 20
3. humerus (Shoulder Instability with Dislocating Humeral Head)
40
60 ( 2-18)
3 6, 12 24

 2-26

(Upper Extremity Impairment Due to Symptomatic Shoulder Instability Patterns)

humerus humerus
(6%)

(24%)
(12%)

Glenohumeral translation *

1+2

2.68

30

(Anterior Shoulder Subluxation)
18 25

130o 50o
80o anterior
instability, anterior apprehension test anterior relocation test (Jobes test)
axial load test anterior glenohumeral translation 2

MRI anterior glenoid labrum

8

humerus
(Shoulder Instability with Subluxating Humeral Head)
glenohumeral translation 2 MRI anterior glenoid
labrum ( 2-26) 12
2.4

(IADD%)
0 ( 2-43)
(IABD%)
2 ( 2-43)
(IIR%) 0 ( 2-43)
(IER%) 0 ( 2-43)
2
14 (
12
2 )
8 ( 2-3)

2.7.2 (Arthroplasty)
2
1. (Resection Arthroplasty)
2. (Implant Replacement)
(Arthrodesis)
2.4
2-27

( 2.4)

(2.7.1.4) (2.7.1.5)

100 ( 2-18)

 2.69

( Radiocarpal Distal radioulnar)
30o 20o
0o 30o
36
1.
- 24 ( 2-27)
2.
- 30o ( 2-28) IF% = 5 %
- 20o ( 2-28) IE %= 7%
- 0o ( 2-31)
IRD%= 4%
- 30o ( 2-31)
IUD%= 0%
16 (5%+7%+4% = 16%)
24
16 36

3. 36 (24% 16% 36%
)

 2-27

(Impairment of the Upper Extremity After Arthroplasty of Specific Bones or Joints)

24

30

10

28

35

10

24

radius (Styloid)

ulnar (Ulnar Head)

10

radius

16

(Proximal row carpectomy)

12

10

11

radius

2.7.3
(Musculotendinous Impairments)
2.7.3.1 (Intrinsic Tightness)
(Intrinsic Muscle)
intrinsic
tightness

(Hyperextension)
intrinsic tightness (Bunnell Test)
intrinsic tightness 3

hyperextension ( 2-28)

1.
( 2-28)
(Hyperextension)
2. 2-18
3. ( 1)
( 2)

2-30
2-28

(Digit Impairment Due to Intrinsic Tightness)

: 80o-60o
: 59o-20o

: 20o

20
40
60

* ( 2-18)

2.7.3.2 (Constrictive Tenosynovitis)

trigger finger trigger thumb
3
( 2-29)

( 2-18)

2-29

(Digit Impairment Due to Constrictive Tenosynovitis)

:
:

*
20
40
60

* ( 2-18)

2.7.3.3 (Extensor Tendon Subluxation at the

MP Joint of the Fingers)

3
( 2-30)

( 2-18)

 2-30

(Digit Impairment Due to Extensor Tendon Subluxation Over the MP Joint)

*

:
10
:
20

:
30
* ( 2-18)

2.7.4 (Tendinitis)
(Tendinitis)
(Fasciitis) (Epicondylitis)
(Origin)
(Grip Strength)
2.8.2

2.8
(Strength Evaluation)
2.8.1 (Principles)

2
1. (Grip Strength) (Pinch Strength)

2. (Manual Muscle Testing)

2.8.2
(Grip and Pinch Strength)



3
20 20
(Grip Strength)

Jamar
dynamometer

dynamometer 5
(Normal BellShaped Curve)
5


(Pinch Strength) chuck three digit pinch, key
pinch tip pinch key pinch 3 pinch gauge

Swanson, Matev deGroot 2-31 2-33

2.1.2
2-31

100
(Average Strength of Unsupported Grip by Occupation in 100 Subjects)

()

47.0
45.4
26.8
24.4
47.2
44.1
23.1
21.1
48.5
44.6
24.2
22.0
47.6
45.0
24.6
22.4

 2-32 100
(Average Strength of Grip by Age in 100 Subjects)

()
20
20 29
30 39
40 49
50 59
2-33

()

45.2
42.6
23.8
22.8
48.5
46.2
24.6
22.7
49.2
44.5
30.8
28.0
49.0
47.3
23.4
21.5
45.9
43.5
22.3
18.2

100
(Average Strength of Lateral Pinch by Occupation in 100 Subjects)

()

6.6
6.4
4.4
4.3
6.3
6.1
4.1
3.9
8.5
7.7
6.0
5.5
7.5
7.1
4.9
4.7

1.
2. 2-31
2-33
3. (Srength Loss Index)
- x 100 = (Strength Loss Index %)

4.
2-34
5. 4
( 2-18)

 2-34

(Upper Extremity Joint Impairment Due to Loss of Grip or Pinch Strength)

10 30
31 60
61 100

2.70

10
20
30

30 Bennetts fracture
(CMC Joint) (Pinch
Strength) 6 10

1. 10 6 x 100 = 4 x 100 = 40%

10
10
2. 40 1
2-34 20
(
2-18) 22
4 (20% x 22% = 4%)
2.8.3
(Manual Muscle Testing)



2
2-35

2.4

( 2-11) 6 5 4 3
2 1 0

 4
3
3
100 %

2.71

2.72

25
extensor carpi radialis longus, extensor carpi radialis brevis pronator
teres lateral epicondyle humerus


4 ( 2-11)
9
2-35
5
4
9 (5 %+4 % =
9 %)

MRI (Full-Thickness Tear of The Rotator Cuff)
MRI

( 4
2-11)
9
2-35
3
6
9 (3 % + 6 % = 9 %)

 2-35

(Impairment of the Upper Extremity Due to Strength Deficit From Musculoskeletal
Disorders Based on Manual Muscle Testing of Individual Units of Motion of the Shoulder
and Elbow)

5% - 25% **
30% - 50% ***
(60%)
7 - 12
1-6
24
(Flexion)
2-3
0-2
6
(Extension)
4-6
1-3
12
(Abduction)
2-3
0-2
6
(Adduction)
2-3
0-2
6
(Internal rotation)
2-3
0-2
6
(External rotation)
(70%)
6 - 11
1-5
21
(Flexion)
6 - 11
1-5
21
(Extension)
4-7
1-4
14
(Pronation)
4-7
1-4
14
(Supination)
* ()
**
***

2.9
(Summary of Steps for Evaluating Impairments of The Upper Extremities)
2.9.
1 ( 2-1 )

1. ( 2.2.3 2.2.4)

( 2-4) 8

2.
(Digital Nerve) ( 2.3 2-6 2-7 2-6 2-7)
neuroma
2.3.3
3.
( 2.4)

4. ( 2.7)
5. 1 4

6.
( 2-1)
7. ( 6)
(
)
8. ( 2-2)
9. ( 2-4)
1
8
10.
( 2.8) 9

11.
( 2-3)
12.
2.9.2
2
2.9.2

2 ( 2-1)
1.
( 2.4.7)
( 2.7)

2.
( 2.4.8)
( 2.7)

3.
( 2.4.9)
( 2.7)

2.9.3 humerus
(2.2.2) 2 ( 2-1.)
2.9.4
(2.5) 2 ( 2-1.)
2.9.5
(2.6) 2 ( 2-1.)

(2.7) 2 ( 2-1
2.9.7 2.9.2-2.9.6
2
2.9.8 2.9.7
2-3
2.9.9

2.10
2.73

neuroma
(Digital Nerve)

31
1. 45 ( 2-5)
9 ( 2-1)
8 ( 2-2)
neuroma
1 95 ( 2-10 .)

5 ( 2-15)
neuroma (95 % x 5 %)
5 ()

 8 ()
5 neuroma 13
2. : 38 (
2-4)
51
13 % () 38 % ()
31 ( 2-3)
2.74

2.75

45

( 2-52)
( 2-52)
( 2-52)
1. ( 2-5
2-4)
2.
( 2-12, 2-15 2-8 , 2-8 2-9)
3.
( 2-21, 2-23, 2-25 )
4.
( 2-6, 2-7) ( 2-6, 2-7)
5.
( 2-1)

6.
( 2-2)
7.
( 2-3)

40
flexor digitorum
profundus, flexor digitorum sublimis

80 two-point discrimination 9
0o 50o, 20o 60o ( 20o) +20o (
20o) 90o
5
1.
- two-point discrimination 9 .
( Partial Sensory Loss) ( 2-5)
- 80
( 2-7) 12
( 2-7)
2.
IE% + IF %
0o 50o (0 % + 10 %) 10
( 2-21)
-20o 60o (7 % + 24 %)
31 ( 2-23)
+20o 90o (0 % + 0 %) 0
( 2-25)
10 31
38 ()
3.
( 12)
( 38)
45 9 ( 2-1) 8
( 2-2) 5 ( 2-3)

2.76

40

( 2-53 2-53)
two-point discrimination 7-12 .
44

2.77

( 2-53 2-53 )
-
( 2-12, 2-15 2-8 , 2-8 2-9)
-
( 2-21, 2-23 2-25)
- (
2-28 2-31)
-
( 2-37)
-
( 2-6, 2-7 2-6, 2-7)
-
( 2-1)

-
( 2-2)
-
( 2-3)
30


(Middle phalanx)
( 2-54)
neuroma
45
( 2-54)
- ( 2-5, 2-4)
-
( 2-21, 2-23, 2-25)
- ( 2-6, 2-4)

-
( 2-1) ( 2-2)
-

-
( 2-3)

 2.78

40
(Colles Fracture)
30o
40o 20o 10o
40o 30o
(Grip
Strength Loss Index) 40
10

( 2.8)

(CRPS) ( 2.5.5)

1.
- 30o 5 ( 2-28)
- 40o 3 ( 2-28)
- 20o 0
( 2-31)
- 10o 4 ( 2-31)
-
= (5 % + 3 % + 4 %= 12%) 12
2.
- 40o 3 ( 2-36)
- 30o 2 ( 2-36)
-
(3 % + 2 %=5%) 5
3.
-
12 5
16 10
( 2-3)

 2.79

50, 10
5 2
16
1.
- 50
20 ( 2-1)
- 10
2 ( 2-1)
-
(20% + 2% = 22%) 22
20 ( 2-2)
2.
- 5
3.
- 2
20
5 24
24 ( )
2 () 26
16 ( 2-3)

 2-52 1 ()
....................... ( 2-74) .............................. ...45.. ...... ............. ...... ....................
........................................................ .......................................................................................

MP

IP

30

-10

30

-15

%
6

4
4
9

9
[1]

IP

PIP

MP

30

-10

21

70

-10

18

50

-10

22

26

23

21

IP

PIP

MP

30

-10

21

70

-10

18

50

-10

22

[2]
% =
[2]

[3] [4]
% =
[3]
% =
[4]

23

21

56

[3]

[4]

26

**
%

10

[1]

56

[2]

[3]

[4]
56

**
%

11

[1]

56

[2]

[3]

[4]

29
[1]

* (MP , PIP , IP)

56

[2]

29
[1]

* (MP , PIP , IP)

26

% = [5]
[3]
[4]
**** [2]

%
% =
[3]
% =
[4]
=
[2]

[5]

[2]

[1]

30

(CMC + MP + IP)

**

CMC

[2]
% =
[2]

[3]
% =
[3]

[4]
% =
[4]

**
%

56

11

PIP

12 .

50

-20

22

10

10%

32
[1]

IP

PIP

MP

32

10

[2]
% = 80 [2]

33

60

60

[3]

40

-20

22

10

84

15%

32
[1]
=

84

10 .

[2]
% =
[2]

**
****

[2]

[3]

[4]

10%

[3] [4] **
% = 25 [3]
% =
[4]
%

: % + + + + = 10+11+11+9+9 =
*** ( 2 2 ) =
[5] ........% + ............ %=
**** =

2-2 ()

92

[1]

50

[4]

8 .

60

* (MP , PIP , IP)

*
***

80

[3] [4] **
% = 40
[3]
% =
[4]
%

[2]

33

30%

32

[1]

> 15 .

**

* (MP , PIP , IP)

MP

IP

2-1 ()
2-3 ()

50%
45%
%
27%

25

88
9

 2-53 . 1 ()
....................... ( 2-76) .............................. ...40.. ...... ............. ...... ....................
........................................................ .......................................................................................

MP

IP

40

-20

10

[1]

13

[1]

PIP

MP

IP

42

10

60

-40

33

8 ..

24

14

IP

PIP

54

81

[2]

% =
[2]

% = 25 [3]

[3]

% =

[4]

8 ..

33

33

24

14
0

86

**
%

17

[1]

81

54

54

[1]
=

81

25

[4]

[2]

[3]
38

* (MP , PIP , IP)

[2]

-40

81

10

60

[1]

54

23

[3]

**
%

38

[1]

MP

[3]

[4]

% =
[4]

* (MP , PIP , IP)

[3]

57

33

[2]

% = 25

[2]

****

% =

25

[4]

% = [5]

13

[5]

42

[2]

[3]

[2]

%
9

(CMC + MP + IP)

**

8 ..

10

CMC

[2]

% =

% = 25 [3]

[3]

% =

[4]

25

[4]

86

**
%

17

PIP

MP

IP

60

-40

24

14

IP

PIP

MP

[1]

8 ..

38
0

81

[2]
% =
[2]

[3]
% = 25 [3]

18

25

33

8 ..

54
=

86

[2]

[3]

[4]

54
[1]

* (MP , PIP , IP)

[4]

83

25

[1]

43
0

[3]

33
-50

70

[2]

81

[4] **
% =
[4]
%

10

54

54

**

[1]

* (MP , PIP , IP)

33

33

10

83

[2]
% =
[2]

[3]
% = 25 [3]

: % + + + + = (23+17+17+9+9)
*** ( 2 2 ) =
**** [5] ........% + ............ %=
=

***
2-2 ()
)

**
****

[4] **
% = [4]
%
75%
68%
%
%

2-1 ()
2-3 (

25

87
9

 2-53 . 2 ()
....................... ( 2-76) .............................. ...40.. ...... ............. ...... ....................
........................................................ .......................................................................................

40

20

10

-%

%
10

%
7

[1]
% / + / = 17

%
* [1] , [2]

50

40

[2]
%

17

4
[1]

% / + / = 4

[2]
4

%
[1]
% =
% / + / +
/ =
1. ()
=
2.
* ( 68% , 17% , 4% , - %)
=
3.
=
4.
=
5. () =
(* 1,2,3,4,5)
=
( 2-3)
=

[2]
%
%
74 %
%
%
%
74 %
44 %

 2-54 1 ()
....................... ( 2.77) .............................. ...30.. ...... ............. ...... ....................
........................................................ .......................................................................................

CMC

[5]

% =
[1]

(CMC + MP + IP)

PIP

IP

MP

****

% =

[2]

% =

[3]

%
O

60

-+20

17

0
[1]

17

[2]
% = 80 [2]
% =

[3]

30

42

70

+20

11

42

[1]
* (MP , PIP , IP)

48

17

[2]

80

[3]

[4]

83

[4] **
% =
[4]

17

[1]

48

[2]

60

[3]

[4]

11
%

[1]

[4]
**

% =

17
%

[1]

[2]
[3]

[4]

* (MP , PIP , IP)

IP

37

PIP

**

[2]
O

MP

MP

IP

[2]

% = 60 [2]

% =
[3]

[3]

[4]

**
% =
[4]
%

79

16

PIP

MP

IP

30

-10

21

70

18

80

+20

IP

PIP

23
%

[2]

18

[5]

30

21

90

90

+20

41

[2]

% = 25 [2]

[3]

% =
[3]

[4]

% =
[4]

21

26

[2]

% = [2]

[3]

% =
[3]

[4]

% =
[4]

: % + + + + = (17+16+6+3)
*** ( 2 2 ) =
**** [5] .37.% + 38 %=
=

*
***

2-2 ()

25
[3]
[4]
56

**
%

[1]

26

[2]

[3]

[4]

0
[1]

* (MP , PIP , IP)

[2]

41

[1]

**

[1]

MP

* (MP , PIP , IP)

**
****

2-1 ()
2-3 ()

42%
38%
75%
45%

**
%

26

(The Lower Extremity)

3.1 (Principles of Assessment)
3.1.1 (Interpretation of Symptoms and Signs)
3.1.2 (Description of Clinical Studies)
3.2 (Methods of Assessment)
3.2.1
(Converting From Lower Extremity to Whole Person Impairment)
3.2.2
(Limb Length Discrepancy)
3.2.3 (Rating
Impairment Due to Gait Derangement)
3.2.4 (Rating
Impairment Due to Muscle Atrophy Unilateral)
3.2.5 (Manual
Muscle Testing)
3.2.6
(Range of Motion)
3.2 7 (Joint Ankylosis)
3.2.8 (Arthritis)
3.2.9 (Amputations)
3.2.10
(Diagnosis Based Estimates)
3.2.11 (Skin Loss)
3.2.12 (Peripheral
Nerve Injuries)
3.2.13
(Causalgia and Complex Regional Pain Syndrome)
3.2.14 (Vascular
Disorders)
3.3

188

(Activity of Daily
Living - ADL) 7
1. (Foot)
2. (Hind Foot)
3. (Ankle)
4. (Leg)
5. (Knee)
6. (Hip)
7. (Pelvis)

(Maximum Medical Improvement-MMI) 1

1.

2. 3-2

3. (Causalgia Syndrome)
(Complex Regional Pain Syndromes)

4.
5. (Worksheet)

3.1 (Principle of Assessment)

1



(Activities of Daily Living
ADL)

189
3.1.1 (Symptoms and Signs)
(History)


,
(Paresthesia)

(Physical Examination)




(Atrophy)

(Bursitis)

(Motor)

3.1.2 (Description of Clinical Studies)

(EMG)
CT Scans MRI (Contrast)

190
3.2 (Methods of Assessment)
13 ( 3-1 , 3-2)
3
3-1

3.2.2
(1-9)
1.
3.2.4
2.
3.2.7
3.
3.2.9
4.
3.2.8
5.
3.2.11
6.
3.9.12
7.
3.2.14
8.
3.2.13
9.
(CRPS)* / Reflex
Sympathetic Dystrophy
(10-12)
10.
3.2.6
11.
3.2.3
12.
3.2.5
(13)
13.
3.2.10
-
3.2.10
-
3.2.10
- meniscus
3.2.10
-
3.2.10
-
- 3.2.10
* CRPS = Complex Regional Pain Syndrome (Causalgia) Reflex Symplathetic
Dystrophy,
1 (Anatomy) 9
1.1 (Limb Length Discrepancy)
1.2 (Muscle Atrophy)
1.3 (Ankylosis)
1.4 (Amputation)
1.5 (Arthritis of Joints)
1.6 (Skin Loss)
1.7 (Peripheral Nerve Injury)
1.8 (Vascular Disorder)
1.9 (CRPS)*
(Causalgia) Reflex Sympathetic Dystrophy

191
2 (Diagnosis based) 6
2.1. (Fractures)
2.2. (Ligament Injuries)
2.3. meniscus (Meniscectomies)
2.4. (Foot Deformities)
2.5. (Hip and Pelvic Bursitis)
2.6. (Lower Extremity Joint Replacements)
3 (Functional) 3
3.1 (Range of Motion)
3.2 (Gait Derangement)
3.3 (Muscle Strength)

1. (Anatomic Changes)
(Range of Motion - ROM),



(Stiffness)

(Causalgia) Reflex Sympathetic Dystrophy
(ROM)
2. (Diagnosis Based Estimates)

(Ligamentous Instability) (Bursitis)

(Meniscectomies)

3. (Functional Impairment)

( 3-10)
(Maximum Medical
Improvement-MMI)
3-10
(ROM)

192

(
)
(Cross - Usage Chart) 3-2

X
X

3-2 (Guide to the

appropriate combination of evaluation methods)

X
X
O

X =
O = (CRPS)

X
X

193
3.2.1
(Converting From Lower Extremity to Whole Person Impairment)


(.....) []
0.7
0.4
3-3
3-3
(Whole Person Impairment Values Calculated From Lower Extremity
Impairment)

0
=
0
1
=
0
2
=
1
3
=
1
4
=
2
5
=
2
6
=
2
7
=
3
8
=
3
9
=
4
10
=
4
11
=
4
12
=
5
13
=
5
14
=
6
15
=
6
16
=
6
17
=
7
18
=
7
19
=
8
20
=
8
21
=
8
22
=
9
23
=
9
24
=
10
25
=
10
26
=
10
27
=
11
28
=
11
29
=
12
30
=
12
31
=
12
32
=
13
33
=
13

34
=
14
35
=
14
36
=
14
37
=
15
38
=
15
39
=
16
40
=
16
41
=
16
42
=
17
43
=
17
44
=
18
45
=
18
46
=
18
47
=
19
48
=
19
49
=
20
50
=
20
51
=
20
52
=
21
53
=
21
54
=
22
55
=
22
56
=
22
57
=
23
58
=
23
59
=
24
60
=
24
61
=
24
62
=
25
63
=
25
64
=
26
65
=
26
66
=
26
67
=
27

68
=
27
69
=
28
70
=
28
71
=
28
72
=
29
73
=
29
74
=
30
75
=
30
76
=
30
77
=
31
78
=
31
79
=
32
80
=
32
81
=
32
82
=
33
83
=
33
84
=
34
85
=
34
86
=
34
87
=
35
88
=
35
89
=
36
90
=
36
91
=
36
92
=
37
93
=
37
94
=
38
95
=
38
96
=
38
97
=
39
98
=
39
99
=
40
100
=
40

194

13 3-1
3.2.2 (Limb Length
Discrepancy)

2
(Anterior Superior Iliac Spine) (Medial
Malleolus) 2
90
(Tibia)
iliac crest
iliac crest (Pelvic Obliquity)
(Flexion or Adduction Deformity of the Hip) iliac crest

(Apparent Leg Length Discrepancy)
2 0.5-1.0 ..
(Knee Flexion
Contracture)
teleroentgenography

3
3-4

195
3-4 (Impairment Due to Limb Length
Discrepancy)

( . )

0
0
0 1.9
5-9
2-3
2 - 2.9
10 - 14
4-5
3 - 3.9
15 - 19
6-7
4 - 4.9
20
8
5
3.1

3
30 90 .


6

2 2

2
93 . 96.5 . 3.5 .
teleroentgenography
81.5 . 84.3 2.8 ..
2.8 .
3

()
(Gait Derangement)


3-4 2.8 .
9 3

( 3.2)

196
3.2.3 (Rating Impairment
Due to Gait Derangement)


3-5
(Full-time Gait Derangement) (dependent
on assistive devices)

197

3-5
(Lower Limb Impairment Due to Gait Derangement)

.


. Trendelenberg sign

.
(Short Leg Brace, Ankle-Foot Orthosis
AFO)
.
(Long Leg
Brace, Knee-Ankle-Foot Orthosis-KAFO)
.

(AFO)
. 2 2

. 2 2

(AFO)
. 2

(KAFO)
. 2

10
15

15

20

30
40

50

60

70

(Two Lower Extremity Braces Either

Ankle-Foot Orthosis or Knee-Ankle-Foot Orthosis)

(KAFO AFO)
.

80

198
3.2

15

60

500


Trendelenburg gait 2


bone scan MRI
18
3 . 4 .

15 ( 3-5 .)


3-31 3
. 3
3-5
15

3.2.4 (Rating
Impairment Due to Muscle Atrophy Unilateral)




( 3-6)

199
3-6 (Impairment Due to Unilateral
Leg Muscle Atrophy)

( . )
()
. : 10 .
0

0 - 0.9
1-2 (3-8)

1 - 1.9
3 - 4 ( 8 - 13 )

2 - 2.9
5
( 13 )

3
. :

0 - 0.9
1-2 (3-8)

1 - 1.9
3 - 4 ( 8 - 13 )

2 - 2.9
5
( 13 )

3
(.)

3.3

58
1 3

1.3 . 10
. 1 .


2
3-6
1. 1 1

2. 1.3 1
= 1 + 1
2 ()

200

3.4

45
12
(MMI)


2 . 1 .

4






3-6
2 8 3
1 3
1 2 (3%
1%) 4

201
3.2.5
(Manual Muscle Testing)



compartment syndrome

( 3.2.1)
1 2
2






3-7 5

3-7
(Criteria for Grades of Muscle Function of the Lower Extremity)

5
4
3
2
1
0

( )

202
3-8
(Impairment Due to Lower Extremity Muscles Weakness)

() [ ]
0
1
2
3
4
2 (5)
4 (10)
6 (15)
6 (15)
6 (15)
7 (17)
15 (37)
15 (37)
15 (37)
15 (37)
10 (25)
15 (27)
25 (62)
25 (62)
25 (62)
10 (25)
10 (25)
10 (25)
7 (17)
5 (12)
10 (25)
10 (25)
10 (25)
7 (17)
5 (12)
7 (17) [24]
15 (37) [53] 15 (37) [53] 15 (37) [53] 10 (25) [35]
5 (12) [17]
10 (25) [35] 10 (25) [35] 10 (25) [35] 10 (25) [35]
2 (5) [7]
5 (12) [17]
5 (12) [17]
5 (12) [17]
5 (12) [17]
2 (5) [7]
5 (12) [17]
5 (12) [17]
5 (12) [17]
5 (12) [17]
3 (7) [10]
5 (12) [17]

3 (7) [10]
5 (12) [17]

3 (7) [10]
5 (12) [17]

3 (7) [10]
5 (12) [17]

1 (2) [3]
2 (5) [7]

(Hip Adduction) obturator nerve

( 3-37)

3.5

10

50


5
6
8



1 .
Quadriceps Hamstring 4 2

10


(Gait Derangement)

3-7

203
4 3-8
4 12 5
4
12 5

10 (5%
5%)
3.6

12
compartment syndrome
25

compartment
syndrome
(AnkleFoot Orthosis : AFO)

3
(AFO) (Extensor Hallucis Longus)
3 2

compartment syndrome
12
3 10
25
3 3 7
3-8
(10% 3%) 12

(
3-2)

3.2.6 (Range of
Joint Motion)

3
2

204
3-1 3-6
3-9 3-14

6
3-1 3-6
3-1

(Goniometer) *
(Using a Goniometer to Measure Flxion of the Left HiP)

. (Goniometer) (Neutral)

. anterior superior iliac spine

. (Flexion Contracture)



* (Inclinometer)

205
3-2 (Neutral Position)

. (Neutral Position)
. (Abduction)
. (Adduction)

3-3 (Measuring Internal and External

Rotation of Hip *

90o

206
3-4 (Measuring Knee Flexion)

.
0
.
3-5 (Measuring Foot Dorsiflexion
and Plantar Flexion)

45

207
3-6 [Evaluating the Range of Motion of a Toe: the
Metatarsophalangeal (MTP) Joint of the Toe]

. 45
(Neutral Position)
.
(Baseline) (Baseline Angle)
2

. .

208

3-9 3-14
3-9 ( 3-1 3-3
) (Hip Motion Impairment)
()

2 (5)
4 (10)
8 (20)
o
o
100
80
50o

o
o
20 - 29
(Flexion Contracture)
30o
10o - 19o
(0 o - 9 o )
10o - 20o
0o - 9o

o
o
o
o
20 - 30
0 - 19

o
o
o
o
15 - 25
5 - 14
5o

0o - 15o

o
o
(16 - 20 )
0o - 5o
6o - 10o
11o - 20o
*
(Abduction
Contracture)
* 200 15

3-10:

(Knee Motion Impairment) ( 3-4

)
()

4 (10)
8 (20)
14 (35)
o
o
110
80
60o 1 (2)

10o 60o
(110 o - 150 o
)
5o - 9o
20o
10o - 19o

(0 o - 4 o
(Flexion
)
Contracture)
2o - 0o
1o - 7o
8o - 12o 1 (2)
(Varus)
2o 12o
10o - 12o
13o - 15o
16o - 20o 1 (2) 5o
(Valgus)
20o
femur tibia 30 - 90
(Quadriceps Angle)

209
3-11 (Ankle Motion Impairment Estimates)

(Flexion)

(Flexion Contracture)
(0 o - 9 o )
(Extenion)

() []

3 (7) [10]
6(15) [21]
12(30) [43]
o o
o o
11 -20
1 -10

o
o
20o
--10 - 19

10o- 0o
()

---

---

3-12 (Hind Foot Impairment

Estimates)

(inversion)
(eversion)

() []

1 (2) [3]
2 (5) [7]
o o
10 -20
0o - 9o
0o () - 10o
---

3-13 (Ankle or
Hindfoot Deformity Impairments)

(Varus)
(0 o - 9 o )
(Valgus)
(0 o - 9 o )

() []

5 (12) [17]
10 (25) [35]
20 (50)[72]
o o
o o
15 -24
25o+
10 -14
10o-20o

---

---

210
3-14 (Toe Motion Impairments)

(Extenion)

(Flexion)
2-5*

(Extenion)

() []

1 (2) [3]
2 (5) [7]
15o-30o

15o

20o

---

10o

---

* 2 2

3.7

11

40



5 6 5
10 1 .

11
3-11
(1o 10o) 6
6o
3
3-14 10o
2

6% +3% = 9%

(9% 2%)
11

211

3-11 3-14 3-6

()
3.2 7. (Joint Ankylosis)
(Optimal Position)

()
100 (100%)
3.2 .7.1 (Ankylosis of the Hip)
(Optimal Position) 25o - 39
(Neutral position)
20 50
3-15 3-19

3-1 3-3

100
40

212
3-15

* (Impairment Due to Ankylosis in

Hip Flexion) ()

0 - 9o
10o - 19o
20o - 24o
25o - 39o
40o - 49o
50o - 59o
60o - 69o
70o

()
15 (37)
10 (25)
5 (12)
0 (0)
5 (12)
10 (25)
15 (37)
20 (50)

* ()

3-16

* (Impairment Due to
Ankylosis in Hip Internal Rotation*) ()

0o - 4o
5o - 9o
10o 19o
20o 29o
30o

()
0 (0)
5 (12)
10 (25)
15 (37)
20 (50)

* ()

3-17

* (Impairment Due to
Ankylosis in Hip External Rotation*) ()

()
o o
0 -9
0 (0)
o
o
10 - 19
5 (12)
o
o
20 - 29
10 (25)
o
o
30 - 39
15 (37)
o
40
20 (50)

* ()

213
3-18

* (Impairment Due to
Ankylosis in Hip Abduction*) ()

0o - 4o
5o - 14o
15o - 24o
25

()
0 (0)
10 (25)
15 (37)
20 (50)

* ()

3-19

*
Ankylosis in Hip Adduction Rotation*)

0o - 4o
5o - 9o
10o - 14o
15o

(Impairment

Due

to

()
0 (0)
10 (25)
15 (37)
20 (50)

* ()

3.8

40
54
central fracture dislocation

1




55o 12o 10o

214

40

(Optimal
Position) 50


55o 25
( 3-15) 12 o 12
( 3-17) 10o 25
( 3-18)
50% + 25% + 12% + 25% = 112 %

100 40

3.2.7.2 (Ankylosis of the Knee)

(Optimal Position) 10o-15o
27 67

(Varus) (Valgus) (Malrotation Deformisty) 3-20 3-23

3-20

* (Impairment Due to Knee

Ankylosis in Varus)* ()

0 9o
10o - 19o
20o

()
5 (12)
10 (25)
13 (33)

* ()

215
3-21

(Impairment Due to Knee

Ankylosis in Valgus)* ()

()
o
o
0 9
0 (0)
o
o
10 19
5 (12)
o
o
20 29
10 (25)
o
30
13 (33)

*
()

3-22

* (Knee Ankylosis in Flexion)

()

0o 19o
20o 29o
30o 39o
40o

()
0 (0)
5 (12)
10 (25)
13 (33)

*
()

3-23

(Knee Ankylosis in Internal or External Malrotation)* ()

0o - 9o
10o - 19o
20o - 29o
30o+

()
0 (0)
5 (12)
10 (25)
13 (33)

*
()

216
3.9

32
40

20o 7o

31
27
( 67 )
20o 5 (
3-22) 5 27
32

3.2.7.3 (Ankylosis of the Ankle)

(Optimal position) (Neutral position)
90O
4 10 14
3-24
3-28 25 62
88 ( 3-5 )
3-24 *
(Ankle Impairment Due to Ankylosis in Plantar Flexion or Dorsiflexion*) ()

() []
o
20
15
(37)
[53]
o o
10 -19
7
(17)
[24]
o o
0 -9
0
(0)
[0]
o o
0 -9
0
(0)
[0]
o o
10 -19
7
(17)
[24]
o o
20 -29
15
(37)
[53]
o
30
21
(52)
[74]
* ()

217
3-25

* (Ankle Impairment Due to

Ankylosis in Varus Position) ()

0o-4o
5o-9o
10o-19o
20o-29o
30o

() []
0
(0)
[0]
10
(25)
[35]
15
(37)
[53]
18
(43)
[61]
21
(52)
[74]

* ()

3-26

(Ankle Impairment Due to

Ankylosis in Valgus Position)* ()

0o- 9o
10o- 19o
20o-30o
30o

() []
0
(0)
[0]
10
(25)
[35]
15
(37)
[53]
21
(52)
[74]

* ()

3-27

*
(Ankle Impairment Due to Ankylosis in Internal Malrotation) ()

()
0o-9o
10o-19o
20o-29o
30o

() []

5
10
15
21

(12)
(25)
(37)
(52)

[17]
[35]
[53]
[74]

* ()

218
3-28

*
(Ankle Impairment Due to Ankylosis in External Malrotation) ()

()
0o-14o
15o-19o
20o-29o
30o-39o
40o

() []
0
5
10
15
21

(0)
(12)
(25)
(37)
(52)

[0]
[17]
[35]
[53]
[74]

* ()

3.10

20
50

external
fixator

15o 7o

(Fusion)
(Ankylosis)
20
(Neutral position)
4
15o 7

O
( 3-24) 7
10 ( 3-25)
()
11
4% 7% = 11%
7o 10
( 3-25)
21
11 10

219
( 3-33)

3.2.7.4 (Ankylosis of Foot ; Hindfoot Midfoot ,

Forefoot)
(Subtalar Joint) (Optimal position)
(0o)
4 10 14
25
3-25 3-26

(Tibia - Os Calcis Angle) Calaneus

3-29

(0o) ( 3-7)

3-7
(Neutral Position)
Tibia-Os Calcis Angle

(Os Calcis)

(Pantalar Ankylosis)
( )
10 25 35
3-25 3-29

220
3-29

(Impairments for Loss of the Tibia-Os Calcis Angle)*

() []
o
o
110 -100
5
(12)
[17]
o o
99 -90
8
(20)
[28]
o
90
1(2) [3]
15 (37) [54]

* (Tibia-Os Calcis Angle) 3-7

3.11

9
(Calcaneal Fracture)
40

()




5o
100o

14
5o

4 tibia-os calcis 100o

5 ( 3-29) 2
9 (4%
5%)

3.2.7.5 (Ankylosis of Toes)

3-6
3-30

3-6

221
3-30

(Impairment of the
Foot Due to Ankylosis of Toes)

,
, ,
, ,
, ,
, , ,
, , ,
, , ,
, , , ,
,
, ,
, ,
, , ,
,
, ,
,

,
, ,
, ,
, , ,
,
, ,
,

,
, ,
,

() []

(Full Extension)
(Position of Function)
(Full Flexion)
4 (10) [14]
4 (9) [13]
5 (13) [18]
5 (12) [17]
4 (11) [15]
6 (15) [21]
6 (14) [20]
5 (12) [17]
7 (17) [24]
6 (14) [20]
5 (12) [17]
7 (17) [24]
6 (14) [20]
5 (12) [17]
7 (17) [24]
6 (16) [23]
5 (13) [19]
8 (19) [27]
6 (16) [23]
5 (13) [19]
8 (19) [27]
6 (16) [23]
5 (13) [19]
8 (19) [27]
7 (18) [26]
6 (15) [21]
8 (21) [30]
5 (12) [17]
4 (11) [15]
6 (15) [21]
6 (14) [20]
5 (12) [17]
7 (17) [24]
6 (14) [20]
5 (12) [17]
7 (17) [24]
6 (16) [23]
5 (13) [19]
8 (19) [27]
5 (12) [17]
4 (11) [15]
6 (15) [21]
6 (14) [20]
5 (12) [17]
7 (17) [24]
5 (12) [17]
4 (11) [15]
6 (15) [21]
1 (2) [3]
0 (1) [2]
1 (2) [3]
2 (4) [6]
1 (3) [4]
2 (4) [6]
2 (6) [9]
1 (3) [4]
2 (6) [9]
2 (6) [9]
2 (4) [6]
2 (6) [9]
3 (8) [12]
2 (6) [8]
3 (8) [12]
2 (4) [6]
1 (3) [4]
2 (4) [6]
2 (6) [9]
2 (4) [6]
3 (8) [12]
2 (4) [6]
1 (3) [4]
2 (4) [6]
1 (2) [3]
0 (1) [2]
1 (2) [3]
2 (4) [6]
1 (3) [4]
2 (4) [6]
2 (6) [9]
2 (4) [6]
2 (6) [9]
2 (4) [6]
1 (3) [4]
2 (4) [6]
1 (2) [3]
0 (1) [2]
1 (2) [3]
2 (4) [6]
1 (3) [4]
2 (4) [6]
1 (2) [3]
0 (1) [2]
1 (2) [3]

222
3.12

3
45 70

15o 15o 4

3
15O
1 15O 1
1% + 1% 2
( 3-14) 2 5
2 ( 3-30)
2
4 (2% 2%)

3.2.8 (Arthritis)

(Osteophyte)




17 31
90 36
(Patellofemoral Joint) (Sun
Rise View) 40o (True Lateral View)

(Flexion Contracture)

223

()
- mortise view ( 10o)
10o

-

3.2.10
3-31
(Arthritis Impairments Based on Roentgenographically Determined
Cartilage Intervals)

()
sacroiliac (3 )
(4 )
(4 )
patellofemoral*
(4 )
subtalar (3 )
talonavicular (2-3 )
calcaneocuboid

() []

3
2
1
0
1 (2)
3 (7)
3 (7)
3 (7)
8 (20)
10 (25)
20 (50)
3 (7)
8 (20)
10 (25)
20 (50)
4 (10)
6 (15)
8 (20)
2 (5) [7]
6 (15) [21]
8 (20) [28]
12 (30) [43]
2 (5) [7]
6 (15) [21]
10 (25) [35]
4 (10) [14]
8 (20) [28]
4 (10) [14]
8 (20) [28]
2 (5) [7]
5 (12) [17]
1 (2) [3]
3 (7) [10]

* patellofemoral
(Joint Crepitus) 2 5

3.13

15

40 3
20
5-6

10o (Varus)
0o 125o

224

(Medial Side)
2

15


2
8 20 ( 3-31)
8
10o 3-33 ()
2 8 8
15

3.2.9 (Amputations)
3 32
3-32

(Impairment Estimates for Amputations)

(Hemipelvectomy)
(Hip Disarticulation)
(Above Knee)
(Proximal)
(Midthigh)
(Distal)
(Knee Disarticulation)
(Below Knee)
7.5
7.5
(Syme Amputation)
(Midfoot)
(Transmetatarsal)
(First Metatarsal)
(Other Metatarsals)
(MTP joint) *
(MTP joint)
(IP joint)**
(MTP joint)
* MTP metatarsophalangeal joint

() []
50
40
(100)
40
36
32
32

(100)
(90)
(80)
(80)

32
28
25
18
16
8
2
9
5
2
1

(80)
(70)
(62)
(45)
(40)
(20)
(5)
(22)
(12)
(5)
(2)

** IP interphalangeal joint

[100]
[64]
[57]
[28]
[7]
[31]
[17]
[7]
[3]

225
3.14

28
(Crush Injury)
30

(Phantom Pain)

13

13
28
13 28
( 3-32)

3.2.10 (Diagnosis Based

Estimates)

3-33

3-34 3-35
3-33
2

226
3-33

(Impairment Estimates for Certain Lower Extremity Impairments)

**

- , , ,

-

- sacroiliac
- ischium ( Weavers Bottom )

- Unipolar
Endoprosthesis Bipolar)
*
85 100
* 50 84
*
50
-

(Malunion)

( ) []

1-3 ( 2-7 )
3 (7 )

15 (37)
20 (50)
30 (75)

12(30)

227

(Nonunion)
-

(Girdlestone arthroplasty)

- trochanter
(trochanteric bursitis )

100 140
150 - 190
200

( ) []
15(37)

20(50)

3(7)

10 (25)
18 (45)
1 ( 2 )
25 (62)

-
-
,
3 .

-

- meniscectomy , (Medial) (Lateral)

- meniscectomy , (Medial) (Lateral)

3 (7)
3 (7)
5 (12)
7 (17)
3(7)
9 (22)
1 (2)
3 (7)
4 (10)
9 (22)

228

- (cruciate ligament)
(collateral ligament)

- tibial plateau

50 - 90
100 - 190
200
- (Supracondylar or
Intercondylar Fracture)

5O - 9O
10O - 19O
200
- (Total Knee
Replacement) (Unicondylar Knee
Replacement)

85 - 100*
50 - 84*
50*

( ) []

3 (7)
7 (17)
10 (25)
10 (25)
15 (37)
2 (5)
5 (12)
10 (25)
1 ( 2 )
20 (50)

2(5)
5 (12)
10 (25)
1 ( 2 )
20 (50)

15 (37)
20 (50)
30 (75)

229

- (Proximal Tibial
Osteotomy)

- (Tibial Shaft Fracture)

100 - 140
150 - 190
200

( ) []

10 (25)

8 (20)
12 (30)
1 ( 2 )
20 (50)

- ( Stress
view*** )
-
( 2 3 . )
-
( 4 6 . )
-
( > 6 . )
-

100 140
150 190
200

2(5) [7]
4 (10) [14]
6 (15) [21]

6 (15) [21]
10 (25) [35]
1 ( 2 ) [ 3 ]
15 (37) [53]
8 (20) [28]

230

( ) []

(Hindfoot)
-
(Calcaneus)
varus angulation
100 - 190

5 (12) [17]

varus angulation

200

0.5 ( 1 ) [ 1 ]
10 (25)

valgus angulation
valgus angulation

100 - 190
200

3 ( 7 ) [11]
0.5 ( 2 ) [ 1 ]
10 (25) [35]

- tibia os-calcis ****

1100 - 1000

990 - 900

900
-
subtalar
talonavicular
calcaneocuboid
(Midfoot Deformity)
- cavus

- rocker bottom

- talus

5 (12) [17]
8 (20) [28]
1 ( 2 ) [ 3 ]
15 (37) [54]
6 (15) [21]
3 ( 7 ) [10]
3 ( 7 ) [10]

1(2) [3]
3 ( 7 ) [10]
2(5) [7]
4 (10) [14]
8 (20) [28]
3 ( 7 ) [10]
6 (15) [21]

231

(Forefoot Deformity)
-
( 5 .
)*****
(1rt Metatarsal )
5 (5th Metatarsal)
(Other Metatarsal)
- plantar angulation
( metatarsalgia )
(1rt Metatarsal )
5 (5th Metatarsal)
(Other Metatarsal)
*
**
***
****
*****

( ) []

4 (10) [14]
2(5) [7]
1(2) [3]

4 (10) [14]
2(5) [7]
1(2) [3]

3-34 3 35
( 4 )
stress AP view varus valgus
3 34 tibia-os-calcis 3 - 7
5 .

( 3-2) sciatic
sciatic
sciatic

100% 40%

232
3-34

* (Rating Hip Replacement Results)

-
-
-
-
-

-
- ()
-
-
-
-
-
-
-
- 1
-
2
- 2
-
-
- 1
- 500
-
- ()

44
40
30
20
10

11
8
5
0
11
7
5
3
2
0
11
8
5
2
0

233
3 - 34 * (Rating Hip Replacement Results)
()

.
-

-
1

.
(Fixed Adduction)
< 100
> 100
(Fixed Internal Rotation)
< 100
> 100
(Fixed External Rotation)
< 100
> 100

4
2
1
0
4
2
0
4
2
0
1
0

1
0
1
0
1
0

234
3-34

* (Rating Hip Replacement Results) ()

(Flexion Contracture)
< 150
> 150
(Leg Length Discrepancy)
< 1.5 .
> 1.5 .
.

> 900
< 900

> 150
< 150

> 150
< 150

> 300
< 300

> 150
< 150

1
0
1
0

1
0
1
0
1
0
1
0
1
0

* . . 3-33

235
3-35

* ( Rating Knee Replacement

Results)

.
-
-

-
.
5 1
. (Stability)
()
- (Anteroposterior)
< 5 .
5-9 .
> 9 .
(Mediolateral)
5O
6O - 9O
10O - 14O
> 15O

50
45
40
30
20
10
0
25

10
5
0
15
10
5
0

236
( )
. ( Flexion Contracture )
5 0 - 90
100 - 150
160 - 200
> 200
. (Extension Lag)
< 100
100 - 200
> 200
. (Alignment) (Varus)
00 - 40
50 - 100
110 - 150
> 150
()

-2
-5
-10
-20
-5
-10
-15
-0
- 3
- 3
-20

* , , , ,
3-33

(Defect)

3.15

11
35

237

2.5
10o

(Varus) 2.5

11
10o
20 8 ( 3-33)
2.5 7 3
( 3-4) 8
3
11


( 3-2)

3.2.11 (Skin Loss)

(Full-Thickness)
3-36
(Chronic
Osteomyelitis)
3-36 (Impairments for Skin Loss)

( ) [ ]
- ischium
5
(12)

-
2
(5)
(Tibial Tubercle)
-
10
(25)
[35]

-
(Metatarsal Head)
1st metatarsal
5
(12)
[17]
th
5 metatarsal
5
(12)
[17]
-
-
3
(7)
[10]
-
3
(7)
[10]
-
10 (25)
[35]

238
3.16

10
50
Pseudomonas


45 1.6

10

10
3-36

3.2.12 (Peripheral
Nerves Injuries)
2
1. (Motor Deficit)
2. (Sensory Deficit)
3-8 3-9 (Motor Nerve)
3-37

2-10 2-11 2

1.
3-37
2. ()
2-11
3.

4.

( 2-10)

239
5. 3, 4

(40%
)
6. (Dysesthesia)

7.

3-2

3 - 8
(Sensory Nerves of the Lower Extremity, Their Areas of Innervation and Roots of Origin)

240

3 - 9
(Motor Nerves of the Lower Extremity, Their Muscle Innervations and Roots of Origin)
3-37
(Impairments Due to Nerve Deficits)
() []

Femoral
Obturator
Superior gluteal
Inferior gluteal
Lateral femoral
cutaneous
Sciatic
Common peroneal
Superficial peroneal
Sural
Medial plantar
Lateral plantar

(Motor)
15 (37)
3 (7)
25 (62)
15 (37)
0

(Sensory)
1 (2)
0
0
0
1 (2)

(Dysesthesia)
3 (7)
0
0
0
3 (7)

30 (75)
15 (42)
0
0
2 (5) [7]
2 (5) [7]

7 (17)
2 (5)
2 (5)
1 (2)
2 (5) [7]
2 (5) [7]

5 (12)
2 (5)
2 (5)
2 (5)
2 (5) [7]
2 (5) [7]

241
3-17

20

femoral
femoral

saphenous
( Femoral)


quadriceps 4

femoral

femoral

saphenous (Motor Weakwess)
quadriceps 4
femoral
3-37 2-10
3-37
(Loss of motor and sensory) femoral 9
(2% +7%)
4 1 25 20% 20%
9% 20% x 9% = 20/100 X 9/100 = 1.8/100 = 1.8% = 2%
2
(Motor Weakness)
3-37
femoral 37 quadriceps 4
( 2-11) 4 1% 25% 25%
25%
37% 25% x 37% = 25/100 x 37/100 = 9.25/100 = 9%
9
9% 2% 2
11% 4% (11% x 0.4 = 4%)

242
3.2.13
(Causalgia and Complex Regional Pain Syndrome)
(Causalgia)

(Complex Regional Pain Syndrome CRPS)
Reflex Sympathetic Dystrophy ( sympathetic)
sympathetic
(CRPS)

CRPS 5
5.8 CRPS
5
3.18

39
30

Allodynia
Bone Scan
3 4
(Osteoporosis)
(Causalgia)
39

(CRPS Type I)

(Causalgia)

243

5-13 4 6
(/) 5-15 4 6
20 39
39

3-5 2 2
39
39
39 (
)
3.2.14 (Vascular
Disorders)

3-38
3.2.9

3-38

244
3-38

(Lower Extremity Impairment Due to Peripheral Vascular Disease) ()

1
2

0 9

10 - 39
intermittent

claudication
(Claudication)

90

-
,

-


-

40 - 69
intermittent
claudication

20
90

70 - 89
intermittent
claudication

20

90 - 100

-



2

2


2
2
2

245
3.19

(Deep Venous Thrombosis DVT)

8
42

1.6 .

(Subtalar Joint)

(DVT)
(Varices) 2+
16



(DVT)

8
3-38
2
10 39

2 20
8 (20% x 0.4 = 8%)

3.3 (Lower Extremity Impairment

Evaluation Procedure, Summary and Examples)

1.
2.

3.

3-10
4. ( 3-1)
5.

246
6.
7.
(CRPS)
8.

9.
3-2
4 (
)

(Osteomyelitis)
3.2.11 3.2.12 3.2.14

10.

3 - 3

11.

3.20

20 5
Anterior Cruciate
Ligament Lateral Meniscus
Anterior Cruciate Ligament
Meniscus
Common Peroneal Nerve Neurapraxia

247

1.



1 1

(Evertor Muscle) 4/5
0o 130o
0o 138o
(Stability Test) Lachman
anterior drawer 1+ pivot shift test

superficial peroneal nerve

deep peronal nerve
2. 10o

Anterior
Cruciate Ligament 1/3
(Interference Screw) Lateral Meniscus

peroneal nerve
(Neurapraxia) lateral
meniscus

1.
1.1
1. anterior cruciate ligament
2. lateral meniscus
3. neurapraxia common peroneal nerve
1.2
(IP)
2.
2.1

2.2

248
3.

3.1
-

-
-
3.2

4.

4.1
4.1.1 1 .
3 1 ( 3-6)
4.1.2 lateral meniscus (Partial Meniscectomy)
2 1 ( 3-33)
4.1.3 anterior cruciate ligament (Laxity)
7 3 3-33
7
anterior cruciate ligament 2 lateral meniscus
9
4.2
10o 2
1 ( 3-14)
5.
5.1
common peroneal nerve

5.1.1 2-11 (Evertor

Muscles) 4/5 25 common peroneal
nerve 15 42 ( 3-37)
25% x 15% 4

5.1.2
2-10
4 25 superficial peroneal nerve
2 5 ( 3-37)
25% x 2% 0.5
1

249
( 4
1) 5
5.2

6.
6.1

6.2

7.

7.1

7.2

8.

8.1

8.2

9. 3-2 (Lower Extremity, Cross-Usage Table)

9.1

9.2

10.
/

10.1

9 5 14
/
10.2

2

250
11. 10

( 3-3)
2

11.1
14
common peroneal nerve 14
6
11.2
/
2
/
2
1

6 1
7
3.21

30


4

(Antalgic Gait)

50o 15o 15o 20o
20o 5o 3
2

251

3.22

8
3
(
3-2)

(
3-9) 50o
20

20
8
(20% x 0.4 = 8%)

10
40 Tibial
Plateau fibula
(Open Fracture of Tibia)
Rush pin tibial
plateau 3

2
2
(Valgus) 12 2 2
2

(Valgus) 12o 2 (Teleroentgenography)
1.5
tibial plateau
(Malalignment)
10

252

tibial plateau
5 (Valgus)
20 ( 3-33)
2
( 3-6)

20
0.4 8 (20% x 0.4 = 8%)
5
2 (5% x 0.4 = 2%)
8
2
10

3.23

tibial plateau
common peroneal nerve (Neuropathy) 10

50
lateral tibial
plateau fibula common peroneal

common peroneal
3 2

(Steppage Gait)
(AFO)
2 100
2.5

4 ( 2-10) common
peroneal 3 ( 2-11)
fibula

tibial plateau common peroneal

(Neuropathy)
10

253

3-33 tibial plateau

5 3-6

2-10 4
10 - 25
25 25% 5%
common peroneal (
3-37) 1.25%
(25% x 5%) 1% 2-11 3
26 - 50
50% 50%
42%
common peroneal ( 3-37) 21
1
21 (50% x
42% = 21%) 22

5 22
26
10 (26% x 0.4 = 10.4% 10%)

3.24

20

30 3.21
2

150 2 900 200 100

200 200

15

254

3.25

3-33 3-34
3-6
3 34

40

11
1
8

1
O
15
0
2
1

4 2
40+8+11+8+4+2+4+1+1+2 = 81
50 20 ( 3-33)
(Transmetatarsal Amputation)
25
50

5

(Transmetatrsal Amputation)



100
(Flexion Contracture 100) 250 (Os calcis)
150 150

(Valgus Deformity)
(Healed Transmetatarsal Amputation)
25
3-32
57 40

3-13 25
subtalar
3-11
15 ()

255

40 , 25 15
62
0.4 24.8 (62% x 0.4 =24.8%)
25






0.4
3-3

() 2

256
3-10
(Lower Extremity Impairment Evaluation Record and Worksheet)
_______________________________________________________________ ______________ ______ [ ] [ ] _ ______________
____________________________________________________________________________________

3-33
%

3-31
%

3-36
%

3-4
%

3-32
%

3-33/34
%

%
3-9 3-15 3-19

3-31
%

3-30
%

.
... .
..

3-4
%

.
... .
..

3-8
%

3-32
%
ROM
%

...

..

...

..

ROM
= . %
(

3-10 3-20 3-23

.
.

...

..

...

..

ROM
= . %
(
)

3-33/34
3-31
3-36
3-4
3-32
3-33/35
3-31
3-36
3-8
3-32

%
%
%
%
%
%
%
%
%
%

%
%
%
%
%
%
%
%
%
%

3-6
3-33
3-36
3-4
3-32

%
%
%
%
%

%
%
%
%
%

257

/ 3-11 3-13
3-24 3-28

...... ............ .......... ...................

............ .......... ...................

..........
............ ..........
........... ............ .......... ........
ROM
= %
3-14 3-30

............ .................. .
.......... .................. ......

. .......... ................... .
.......... ................... .

ROM
= %

( 2-14)

( 2-15)

3-29/33
3-31
3-36
3-8/9
3-32

%
%
%
%
%

ROM

%
%
%
%
%
%

3-33
3-31
3-36
3- 8/14
3-32

%
%
%
%
%

ROM

%
%
%
%
%
%

--------- =
---------------

.................

------ x

.................

------ x

--------- =

--------

--------

.................

------ x

--------- =

--------

--------

=.. %
( 3-38)
---------------- =... %
( 3.5)
( 3.5)
=... %

( )
=... %

258

(Recording Range of Motion Measurements)

(ROM)




(Warm
Up Exercises)

(Measruement Devices)

(Goniometers) / (Inclinometers)
2



( )

(Measurement Techniques)

()

, -

259

(00) frontal
plane

(O0) sagittal plane

(Recording System)

SFTR Method (Standard Figure Technique for Record Method)
SFTR Method

SFTR Method

260
SFTR Method
1. 0o .




2. 3 sagittal (S) frontal (F)
(Transverse) (T) (Rotation) (R)
4-7
. sagittal (S) sagittal

. frontal (F)
(Elevation) (Depression) radius ulnar

. (R)
(Horizontal) 90o
(Retraction) (Protraction)
(Hallux Valgus)
. (Rotation) (R)
(R)
-
3. 3

(Valgus) (Eversion) ()
00
00 ( 00)
(Varus) (Inversion)
4. 2
00 200 (S) 20-0
200 (S) 0-20
5. O0
0
300 ( 300) 900
(S) 0-30-90
1, 2 3
SFTR Method

261
1 *
(Recording ROM Measurements for the Upper Extremities)

sagittal

frontal

(Rotation)

sagittal

(Rotation)
sagittal

frontal

ROM 0 ROM ( )
- 0 -
(40)
- 0 - (180)

- 0 -
(180) - 0 - (30)
- 0 -
(90)
- 0 - (80)

- 0
(0) 0 (150)
0
(80) 0 (80)
0
(60) 0 (60)
Radius 0
Ulnar
(20)0 (30)

*
SFTR = Standard Figure Technique for Record

SFTR
(0)
400 1500
300 1100
1000 100
1500 300
900
800
800
400
00 1500
00 1100
600 800
800 800
2
200, 500
radius 200
ulnar 300
radius
100 ulnar 100

S : 40 - 0 - 150
S : 30 - 0 - 110
F : 100 - 0 - 10
F : 150 - 0 - 30
R : 90 - 0 - 80
R : 80 - 0 - 40
S : 0 - 0 - 150
S : 0 - 0 - 110
R : 60 - 0 - 80
R : 80 - 0 - 80
S : 20 0
S : 20 0 - 50
F : 20 0 30
F : 10 0 10

262
2 *
(Recording ROM Measurements for the The Spine)

Sagittal

Frontal

Rotation

Sagittal

Frontal

(Rotation)

Sagittal

Frontal

0
( )

0 -
(60)
0 (50)

0
(45)
0 (45)
0
(80)-0-(80)

SFTR
(0o)
300 , 450 S : 30 - 0 - 45
300
400
400
500
00,
450

F : 30 0 40
R : 40 0 50
S : 0 0 45

(0)
0 (45)

450 F : 45 0 -20
(45)
0 (45)
200
0 150 R : 15 0 20

(30-0-30)
200
0
250, 400 S: 25- 0 40
(25) 0 (600)
0 F : 20 0

20o
(25) 0 (25)
F : 0 20

20o
F : 30 20 - 0
200
300
**

*
** (00)

263
3
(Recording ROM Measurements for the Lower Extremities)

Sagittal

Frontal

(Rotation)

Sagittal

Sagittal
(Talocrural)

(Subtalar)

Fontal

SFTR
(0o)
-0-
300 800 S :
30 0 80
0
0
(30) 0 (100)
10 60 S :
10 0 60
0
0
-0-
30 10
F :
30 0 10
0
0
(40) 0 (20)
20 10
F :
20 0 10
0
0
30 R :
30 0 30
0
(50)-0-(40)
30
200 R : 20 0 15
150
-0-
00 1500 S :
0 0 150
0
(0) 0 (150)
10 S :
0 0 120
0
120
0
100 S :
10 0 10
0
10
(20) 0 (40)
20 0 40
200 S :
0
40
-0- F :
20 0 30
o
(20) 0 (30)
20
300
F : 10 0 20
10o
20o
0
()

 4
()

(The Spine)
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13

4.14
4.15

(Principles of Assessment)

(Determining the Appropriate Method for Assessment)

(Diagnosis Related Estimates Method or DRE)

(DRE : Lumbar Spine)

(DRE : Thoracic Spine)

(DRE : Cervical Spine)

corticospinal tract
(Rating Corticospinal Tract Damage)

(Range-of-Motion Method or ROM)

(ROM : Lumbar Spine)

(ROM : Thoracic Spine)

(ROM : Cervical Spine)

/
(Nerve Root and/or Spinal Cord)

(Criteria for Converting Whole Person Impairment to Regional Spine Impairment)

(Rating Impairment of the Pelvis)

(Spine Evaluation Summary)

266

4.1 (Principles of Assessment)

1.
( 4-0)
, CT Scan, MRI,
(EMG)
2.

4-0 (Activities of Daily
Living Scales or ADL)

4.1.1 (Interpretation of Symptoms and Signs)

4.1.1.1 (History)



CT, MRI,

267





(Paresthesia)

4.1.1.2 (Physical Examination)

, ,
, , , , Root Tension
Signs, ( 4-1)

(Motor) (Sensory)
Sciatic

4-1
4-1
1.

:
:

: / , / ,
:
:

:
(Straight Leg Raising)

268

:
Straight leg raising
:
: Sciatic
Femoral
: Spinous process

2.

:
:

3.

: (Cervical
Compression) (Foraminal
Compression or Spurling Test)
: biceps, triceps
,brachioradialis (HoffmanSign)

4.1.1.3 Sciatic (Evaluation of Sciatic Nerve

Tension Signs)
Sciatic


Sciatic
Straight Leg Raising Test (SLR) ( 4)
90 ( 4-,)
(Posterior of Thigh) / (Leg Pain)

269

4- SLR () () ()
Sciatic
Sciatic 20 -70
L4 , L5
S1
SLR

( SLR ) Hamstrings

Sciatic
(SLR) SLR
(Sensitivity Test) 72-97 (Non-specific)
11-45 SLR Sciatic
() Crossed SLR (Specificity)
100 (Sensitivity Test) 23-42
SLR ()

Sciatica
SLR
2

SLR (Reverse SLR)

Femoral (Femoral Stretch Test) L2 , L3
L4

270
4.1.1.4 (Neurologic Tests)
(Motor)
(Sensory) (Reflexs)
90 L3 4 , L4 5 , L5- S1 L4 , L5 S1
4-2
(Knee Reflex) L4
L3 - 4
L4 (L4 Dermatome) ( 4-1) Quadriceps L5
Extensor hallucis longus

S1 S1
(Foot Plantar Flexion)
Babinski sign Clonus ()
(Hypereflexia) Corticospinal tract
4-2

L3 - 4

L4 - 5

L4

L5

L5- S1

S1

Quadriceps

: Anterolateral
(Thigh)
:
: Medial
(Medial Leg and
Foot)
Extensor
:
hallucis longus
(Lateral Thigh)
: Anterolateral
(Leg)
:
(Mid-Dorsal Foot)
:
(Posterior Leg)

:
(Lateral Foot)

Medial Hamstrings

271

C4 - 5

C5 - 6

C5

C6

C6 - 7

C7- T1

T1 - T 2

T1

Deltoid anterolateral
Biceps
(Shoulder
and Arm)

Biceps

(Lateral Forearm and
Hand Thumb)

C7
Triceps

:
C8
,
(Hand Intrinsics)
(Medial Forearm and Hand,
Ring and Little Fingers)
(Medial
(Hand Intrinsics) Forearm)

Biceps

Brachio-radialis
Pronator teres

Triceps

(Myelopathy)

( 4-2)
(Extremity Sensory Dermatome) 4-2
Biceps ( C5
C6) Brachioradialis ( C6) Triceps ( C7)
Deltoid Biceps C5
C6
Triceps, ,
C7
() C8
(Intrinsics) C8 T1


(Vibrating Fork) Dermatome

272
4-1

(Autonomous Zones)

273

42
(Autonomous Zones)

4.1.2
4.1.2.1 (Clinical Investigation)

: (Electromyography)
: (Cystometry)
:
: CT Scan
: Magnetic Resonance Imaging (MRI)

274







MRI
30 () 50 (Bulging Discs)
(Herniations)
MRI
MRI
MRI DRE
(EMG)
(Radiculopathy)
(DRE) DRE 3
4.1.2.2 (Spinal Motions)
. (Motion Segment Integrity)
(A Motion Segment of the Spine)
2
(Apophyseal or Facet Joints) ( 4-3)
4-3 (A Motion Segment Integrity)

Occiput 2 (C2 ) (Flexion) (Extension)
C2 C3 10 C5 - C6 C6
- C7 20

275
(Flexion - Extension Movements) 4
6 12
L1 - L2 12 20 L5 - S1
(Lateral Bending) 5
6 6 8 9
L3 - L4
(Axial Rotation)
30 40 5 6

(Couple)

(Flexion and Extension)
.
(Alteration of Motion Segment Integrity)




1.
(Loss of Motion Segment Integrity)

(Increased Translation Motion)
(Increased Angular Motion)
(Spinal Instability)
(Decreased Motion)

2.

276
.
(Determining the Loss of Motion Segment
Integrity)
( 4-3
, , )

1. (Translation)
1.1 (Cervical Spine) 3.5 .
1.2 (Thoracic Spine) 2.5 .
1.3 (Lumbar Spine) 4.5 .
2. (Angular Motion)
2.1 (Cervical Spine) 11
( 4-3 )
2.2 (Lumbar Spine) L1L2, L2 L3, L3L4
15 L4L5 20 ( 4-3 )
2.3 (Lumbosacral Joint) L5-S1
25 ( 4-3 )
4-3 (Loss of Motion Segment Integrity,
Translation)

(Posterior Superior Corner)

(Posterior Inferior Corner)
A A
( 4-3 ) A
3.5 . 2.5 .
4.5 .

277

4-3
(Loss of Motion Segment Integrity, Angular Motion - Sagittal Rotation , Lumbar Spine)
2

(Lordosis) (Extension) (Kyphosis)
(Flexion)
15 L1L2, L2L3, L3 L4 L4L5 20
L5- S1 25

+8 18
=
L4 L5 = +8 - (-18)
= 26

278
4-3 (Loss of Motion Segment
Integrity, Cervical Spine)

2 2
2
2 A,B, C
11
( A B C )

4.2 (Determining the Appropriate

Method for Assessment)
2
1. (Diagnosis Related Estimate
Method) DRE 100%
2. (Range of
Motion Method) ROM 100%
1. (Diagnosis-Related
Estimate Method) (DRE)
DRE
1.1
1.2
DRE
1.3
DRE
1.4 Corticospinal tract.

279
2.
(Range of Motion Method) ROM
ROM
2.1
2.2 , ,
ROM
2.3 DRE
2.4
(Stenosis)
(Radiculopathy) 2 (Bilateral)
2.5
Corticospinal tract.
2.6 Radiculopathy

2.7
Radiculopathy 2

280
4-4

(MMI)

ROM

1.
2.

DRE

DRE

3.

1.
DRE ROM
2. 2
DRE ROM 2

281
3.
( ) 4.13
4.
4-4
4.2.1
4.2.1.1

(), ,

4.2.1.2
12

4.2.1.3

4.2.1.4
(Multilevel Involvement or Multiple Recurrences
/Occasions) ( )
ROM
. ()
. Radiculopathy
.
2
.
Radiculopathy
ROM
4.2.1.5 4.2.1.4
DRE 5 DRE 1 , 2 3
Corticospinal tract. 4.7
4.2.1.6

(ADL)

(Asymptomatic)

4.2.1.7
DRE

282
4.2.1.8


Bone scan
4.2.1.9 4.2.1.8




ROM
ROM DRE ROM
ROM DRE ROM
2 ()

4.2.1.10 Corticospinal tract
4-6

4.3 (Diagnosis-Related
Estimate Method or DRE)
4.3.1
DRE 5 3
DRE
1. , ,
12 4-1
2. /

DRE
DRE

DRE 5
3 (

) 4 5

()

ROM
DRE 4 1
1 , 2 3 DRE 1 , DRE 2
Radiculopathy , DRE 3
Radiculopathy
Radiculopathy

283

(MMI)

(MMI)

Radiculopathy

Radiculopathy DRE 2
Radiculopathy DRE 3
Radiculopathy
Radiculopathy
(Asymptomic) 3
DRE
( )

(Developmental Findings)
2.1 Spondylolysis 7
2.2 Spondylolisthesis 3
2.3 Radiculopathy
30
40
2.4 MRI 40
35 50 CT Scan MRI

( 2.1 2.2 )





(Aggravation)

4.3.2 DRE 4-1

284
4 1 DRE

1. (Muscle Spasm)
( Paravertebral Muscle
Spasm) (Acute Spinal Injury)

functional
scoliosis

2. (Muscle Guarding)
( ) () muscle spasm
(Loss of
Lumbar Lordosis)
3. (Asymmetry of Spinal Motion)

4. (Nonverifiable Radicular Pain)

MRI EMG
4-1 4-2
5. (Reflexes)


Babinskis signs Clonus
Corticospinal tract
6. (Weakness and Loss of Sensation)

(Dermatomal Pattern) 4-1 4-2

285
7. (Muscle Atrophy)
(Thigh) 2 .
(Leg) 1 .

8. (Radiculopathy)

/ paresthesia
dermatome (SLR)

(Imaging study)

9. (Electrodiagnostic Verification
of Radiculopathy)
2
Multiple positive sharp waves Fibrillation potentials
(Innervated)

(EMG)


MRI
10. (Alteration of Motion
Segment Integrity)

(Translation) (Angular Motion)

11. Cauda equina (Cauda Equina Syndrome)
/ (Saddle Anesthesia)



12. (Urodynamic Tests) Cystometrograms
Cauda equina syndrome

Urodynamic tests

286
4.3.3 (Application of Clinical
Findings to Determine DRE Category)

DRE 1, 2 3
1 (Category 1) (Subjective)
2 (Category 2) Radiculopathy

Lateral spinal stenosis ()

3 (Category 3) Radiculopathy
Radiculopathy Lateral spinal
stenosis
4 (Category 4)
5 ( Category 5) 3 4
(Radiculopathy + Loss of Spinal Integrity)
Cauda equina syndrome Corticospinal tract

4.4

(DRE : Lumbar spine)

5 ( 4-3)
2 5 (Range) 10% - 13%,
20% - 23%
(ADL) 13% 23%

287
4-3 (Criteria
for Rating Impairment due to Lumbar Spine Injury)

1
(DRE : Lumbar Category 1)
0

(Radiculopathy)

Imaging study

1. body
25
2. Posterior element
( Spondylolysis )

3. Spinous process Transverse process

body

2
(DRE : Lumbar Category 2)

5-8

288

3
(DRE : Lumbar Category 3)

1013

4
(DRE : Lumbar Category 4)

20-23

(Radiculopathy)

Dermatome
(
)
(EMG)

Radiculopathy
Radiculopathy
Radiculopathy

1. body
25-50
2. Posterior element

1. 4.5 .
2. L1L2 , L2L3 L3L4 15 0 ,
L4L5 20 0 L5S1 25 0

Body 50

289

5
(DRE : Lumbar category 5)

2528

3 4
Radiculopathy
(Loss of Motion Segment Integrity)

/
Dermatome EMG (
3)
( 4)

Body 50

4.1
0

28 25
6

(Muscle Spasm)
3

SLR

Acute Minor Lumbar Strain

(0%)

1 DRE : Lumbar Category 1)
4.2
5-8

32

(Paraspinal Muscle Spasm) SLR
60 0 , Crossed SLR 70 0 Ankle reflex

6

290

1

SLR Motor
Sensation
MRI L5S1
Right Posterolateral Disc Herniation L5S1 with Right S1 Radiculopathy Resolved
()
5
MRI
L5-S1

Radiculopathy
2 (DRE : Lumbar Category 2)

4.3
10-13

30

Paraspinal
muscle spasm SLR 50 0 Crossed SLR
60 0 Achilles tendon reflex
3

4

8
2

Achilles reflex
SLR

MRI
L5-S1

L5 S1 S1
Radiculopathy

10

MRI

3 (DRE :
Lumbar Category 3)

291
4.4
10-13 Radiculopathy

28
Paraspinal
muscles spasm SLR 30 0 Crossed SLR
40 0 Extensor hallucis longus (EHL) 34
Achilles reflex
2
4
9

EHL 4
(L5) Ankle reflex 2 SLR
60 0

MRI L5
( L4L5) MRI Gadolinium 9
(Fibrosis) L5
(Recurrent)

Radiculopathy ( Chronic Low Back Pain and

Radiculopathy)

13

MRI
Radiculopathy

3 (DRE : Lumbar Category 3)

13
()
4.5
20-23 50

48 3
Burst fracture L2 60

7

292

L2
SLR

65
Burst Fracture L2 50
20
L2 50
4 (DRE : Lumbar Category 4)

5 Corticospinal tract
( 4.7)
(ROM Method)

4.6
25-28 radiculopathy

40

Paraspinal muscle spasm SLR 50 Crossed
SLR
60 Extensor hallucis longus (EHL)
34 Ankle reflex
4
L4L5 9

SLR 60 L5
EHL 4

MRI L4L5
L5 MRI Gadolinium
1 L5

L4L5 L5
Radiculopathy
L4
L5

28

293

MRI



Radiculopathy 5
(DRE:Lumbar Category 5)
radiculopathy

4.5
(DRE: Thoracic Spine)
1. 5 ( 44)
2. Corticospinal
tract

( 1-5)
3.
Corticospinal tract 4.7 46
4.

,
2-4
5.

294
44
(Criteria for Rating Impairment Due to Thoracic Spine Injury)

1
(DRE : Thoracic Category 1)
0

2
(DRE : Thoracic Category 2)

5 - 8

3
(DRE : Thoracic Category 3)

15 - 18

(Asymmetry or Dysmetria)

1. body
25
2. Posterior element

3. Spinous process Transverse process

Body

(Motor Function) ,
(Sensory Function) ,


(EMG)

295

4
(DRE : Thoracic Category 4)

20 23

5
(DRE : Thoracic Category 5)

25 - 28

(Imaging study)

1. body 25-50
2. Posterior element

Bone
scan

()



(Translation) 2.5 .

3

Body 50%

3

4

Body
50 (Motor) 2
(Bilateral) Corticospinal tract
( Corticospinal tract
4-6)

296
4.7
0

40
2

2
3-4

Trapezius 2
2

(Upper Back Pain)

4.8
58

58

T 1 ,
T 2, T 3 (Dermatome)

Osteophyte T1 ,T2 MRI

T 1 T 2

T1T2 (Degenerative Disc Disease

T1 T2 )

2 (DRE : Thoracic
Category 2)
8
4.9
1518

30 2
T9

297

4/5

T9
30
T9 30
15
3 (DRE : Thoracic
Category 3)
25-50

4.10
20-23 T1

54

2 T1
(Intrinsic Hand Muscles) 2

T1 65

T1 65 Radiculopathy

20
0-14

Body T1 65 4 (DRE :
Thoracic Category 4)
20

4.11
25 28 Radiculopathy

32 2 T9
Anterior
decompression T8 T 10

298

4/5

T8 T10 MRI T9

T 9

25 (
)
5 (DRE : Thoracic
Category 5)
( 3)
( 4)
3 4
5
( 3 )
(ROM Method) 2

4.6
(DRE : Cervical Spine)
1. 5 ( 4-5)
2.

3. /
Corticospinal tract

( 15) 45
4. Corticospinal tract
Corticospinal tract ( 46)

299
4-5
(DRE : Cervical Spine)

1
(DRE:Cervical Category 1)

0
2
(DRE:Cervical Category 2)

58

(Asymmetry or Dysmetria)

()

1) Body
25
2) Posterior element

3) Spinous process Transverse process

300

3
(DRE:Cervical Category 3)

1518

4
(DRE:Cervical Category 4)

25 28

/ Dermatome



(EMG)

()

1) Body
25-50
2) Posterior element

Bone scan

()



(Translation) 3.5 . (Angular motion)
11
(Developmental
fusion), (Arthrodesis)


3

Body 50

301

5
(DRE:Cervical Category 5)

3538

(Motor) (Sensory)

4.12
(0%)

32

Trapezius (Spasm)

(Intermittent Cervical Neck Strain)

4.13
58

35

MRI C5 C6
12

MRI
C5 C6

C5 C6 C6
Radiculopathy

302

2
(DRE:Cervical Category 2)

4.14
1518 Radiculopathy

40

C8

MRI
C7T1

Radiculopathy
C7 T1

18

3
18

4.15
25-28

35


MRI C5C6
C5C6 C5C6

5

C5 C6

303

C5C6 C6 Radiculopathy
Radiculopathy C5C6

25
4

4.16
35-38

30

MRI
C5C6

C5C6

2 Biceps
Brachioradialis reflexes 2

C5C6

C5C6
C6 Radiculopathy

38

5
(DRE:Cervical Category 5)
3
Radiculopathy 4


38

304

4.7 Corticospinal tract

(Rating Corticospinal Tract Damage)
1.

2.
4-5
3. 5

Corticospinal tract ()
5
4.
46

46
5.
, /

6. 5
25 2-4
7. Corticospinal tract

8. 46

45

305
Corticospinal tract
(Rating Corticospinal Tract Impairmemt)
7
1. Corticospinal tract
(Criteria for Rating Impairment of One Upper Extremity due to Corticospinal Tract Impairment)
2. Corticospinal Tract
(Criteria for Rating Impairments of Two Upper Extremities)
3.
(Criteria for
Rating Impairments Due to Station and Gait Disorders)
4.
(Criteria for Rating Neurologic Impairment for the Bladder)
5.
(Criteria for Rating Neurologic Anorectal Impairment)
6.
(Criteria for Rating Neurologic Sexual Impairment)
7.
(Criteria for Rating Neurologic Impairment for Respiration)
4-6 Corticospinal tract
(Rating Corticospinal Tract Impairment)
1.
Corticospinal tract (Criteria for Rating Impairment of One Upper Extremity Due to Corticospinal Tract
Impairment) ( 5-14 )
1
2
1 9
10 24

(Self Care),
,
(Difficulty With
Digital Dexterity)
3
25 39

(Self Care) ,

(No Digital Dexterity)
4
40 60

(Self Care) (Self

Care)

306
2.
Corticospinal tract (Criteria for Rating Impairments of Two upper Extremities) (
5-15 )
1
2
1-19
20-39

(Self Care), (Self
Care), ,
(Difficulty With Digital Dexterity)
(No Digital
Dexterity)
3
4
40-79
80

(Self Care)

3. Corticospinal Tract
(Criteria for Rating Impairments Due to Station and Gait Disorders) ( 5-13
)
1
2
1-9
10-19
,
,

,

3
4
20-39
4060

,
, /

4.
(Criteria for Rating Neurologic Impairment for the Bladder) (5-17
)
1
2
19
1024
(Good Bladder
(Urgency) (Intermittent
Reflex Activity)
Incontinence)

(Voluntary Control)

307

3
4
25 39
4060


(No Voluntary Control)
(No Voluntary
Control)
5.
(Criteria for Rating Neurologic Anorectal Impairment) ( 5-18
)
1
2
3

119
2039
4050

(Limited Voluntary Control)

(No Voluntary Control)
6. (Criteria for
Rating Neurologic Sexual Impairment) ( 5-19 )
1
2
3

1-15
1629
30-35

7.
(Rating Neurologic Impairment of Respiration) ( 5-16 )
1
2
3
4

5-19
2049
50 89

90

,
,
,
,

(Ambulation)

(Exertion)

308

4.17
69 Corticospinal tract

25 4
C6 40
2 2
4 EMG
C7 Radiculopathy Positive sharp waves
3 C6 (Corpectomy)
C5 C7

(Orthoses)

C7
C6 C7

EMG
C5 C7

C6 40 Corticospinal tract

70

C6
Corticoscinal tract
( 4-6)
2 2
2 39 ( 4-6
2) 3

39 ( 46 3)
C6 40 DRE:Cervical 3
18
39 , 39 18
70
418
87 Burst fracture Cauda
equina syndrome

50
Burst fracture L2 35

309

Anterior decompression L1 L3
L2

2
2

L2
L2 S1 2
Knee reflex Ankle reflex
L1 L3
Burst Fracture L2 Cauda equina syndrome
87
2
2 3
39 ( 46 3)
4 60 ( 4 6 4)

2 39
L2 35 DRE:Lumbar 3
13 60, 39, 39, 13
87

4.8
(Range of Motion Method : ROM)
4
1.

2.
( 4-7)
3. (Spinal Nerve Deficits)
5 (Central and Peripheral Nervous System)

4. 3

1. (DRE)
2.
(DRE) (Multilevel DRE Category)
3. (Multilevel) /
()

310
4. Radiculopathy

5.
/ Radiculopathy

20 - 59
4.8.1 ROM





(Maxmimum Medical Improvement
:MMI)

(Neuromuscular Inhibition)
(Inconsistent)

(Precision)
3 3
(Mean)
50 5
50 10
6 3 6
(Invalid)

1.
2. (WarmUp Movements)

2 2
2

(Anatomical Landmarks)

311
,

4.8.2 (Principles of
Inclinometry and Spine Motion Measurement)
1.
(Inclinometer)
(Compound)
(Goniometer)

(Plumb Line) (Gravity) (00)
2 180
2
1.1 (Mechanical Inclinometer)

1.2 (Electronic Inclinometer)

1.1 0
(Pendulum) ( 46) () (Meniscus)

1.2 Gravity Sensors

2
0
0
0
46 (Inclinometer)

312
2. (Gravitational Plane)

4-7

3. (Sagittal Plane)
(Frontal or Coronal Plane)
( 4-7)
(Transverse or Axial Plane)

3 Sagittal (-) Frontal (

-) (Transverse or axice rotation) () ( 4-7)
2 2
()

313
4. (Stabilization)

( 4-17) 2

Micro processors 2
2 ( )




2

(ROM) ( 4-10,
4-14, 4-18)
4.8.3
(Rating of ankylosis and Motion with Ankylosis)
(Ankylosis)
(
)


0

2

3
ROM



(Estimating Whole
Person Impairment Using the ROM Method)

314
4.8.4
(Estmating Whole impairment Using the ROM Method)
1.


2.
2.

3. 4-7

ROM (ROM -Diagnosis

Based Method) 2


( 7 ,8,9 )
4. Sagittal, Frontal
(Transverse Plane) ( 4-7)

5. 3 3
4.8.2 3
50 10 3

6. 5 6
6

7. 3 4.8.2

4.8.3
300 600 0
( 30 ) 30 4-12
30
(
)

8.
(Radiculopathy)
. 4-15
. 4-16
. 4-17
. 4-18
(Lumbar and Sacral Nerve Roots)

315
. ()
()
9. ROM (ROM-Diagnosis Based
Method) ( 4-7) ROM

10.
1-9
11.

12.
()
13.
( 4-20)
4-7 (
)* (Criteria for Rating Whole
Person Impairment Percent Due to Specific Spine Disorders to Be Used as Part of the ROM Method *)

1.
. Body
0-25
4
2
5
26-50
6
3
7
50
10
5
12
4
2
5
. Posterior element Pedicle, Lamina,
Articular process, Transverse process
: Body Posterior element
2

5
3
6
. ()

5 ()

316

2. \
(Intervertebral Disc or Other Soft-Tissue Lesion)
.
.
(Rigidity)*

h MRI, CT Scan
.
* (Rigidity)

h MRI

.
(
)
.

.

.

1. 2
2. 3

0
4

0
2

0
5

10

2
1

317

3. Spondylolysis Spondylolisthesis
. Spondylolysis Spondylolisthesis grade 1 (
1-25) Grade 2 (
26-50)

. Spondylolisthesis grade 3 ( 5175) Grade 4 ( 76-100)

4. (Spinal Stenosis),
(Segmental Instability), Spondylolisthesis,

. Decompression

. Decompression

.
Decompression

.
Decompression

.
(Rigidity)
1. 2
2. 3

10

10

12

1
2
1

*


h Myelogram CT Scan MRI
Contrast Discogram CT Scan.

318
4-7
1. Spondylolysis , Spondylolisthesis Spinal Stenosis

2. (ROM
Method)
3.

4.
(ROM)

(Musculoskeletal), ,
5.

( 4-20)
6.

4.9
(ROM : Lumbar Spine)

1. (Flexion and Extension) (Ankylosis)

2. (Lateral Bending or Lateral Flexion) (Ankylosis)
1.
2 ( 4-8) (Two-Inclinometer Technique)
1.1
4-5
48 2

T12 S1

.
.
.
.

319
1.2
00
T12 S1 (Sacrum)
Sagittal plane T12 2
S1 Posterior superior iliac spines 2
2 ( 4-8 .)
1.3 2
T 12 ( 4-8 .)
1.4 2 S1
T12 ( 4-8 .)
00 2
1.5 3-6 3 ( 3
) 5 500
500 100 3

1.6 () (Accessory Validity Test)
(Lumbosacral Flexion and Extension)
S1 (Sacral Flexion Angle) S1 (Sacral Extension Angle)
65 55 (> 650
> 550 ) Straigth-legraising (SLR) 150 Hamstring Gluteus
65 55
SLR 150

(Accessory Validity Test)

(Straigth-leg-raising angle) (SLR)
(Tibial Crest)
( 4-8 ) SLR
SLR 150 150
(Invalid) SLR
(SLR) Radiculopathy
(Accessory Validity Test)
ROM
(Valid)
SLR ( + ) 150 ( 150)

320
24 100 600
100 200
= 200 + 100 = 300
Struigth-leg-raising angle (SLR) 700
SLR ( = 700 300 = 400
15 (Invalid)
Validity Test 300 550

(ROM:Lumbar Spine Method)
1.7
4-8
4-8


4-8 *
75%

()

0
0
45
60
0
0
45
2
0
30
4
0
15
7
0
0
10
0
0
0
30 45
40
4
0
20
7
0
0
10
0
0
0
0 - 29
30
5
0
15
8
0
0
11

0
(0 )

00
100
150
200
250

250
150
100
50
00

00
100
150
200
250

7
5
3
2
0

* () 150 (SLR )
SLR () 15O
R

321
(Ankylosis)
/
2 Sagittal plane.
2 (Stress)

4-8

2. (Lateral Bending or Lateral Flexion)

2 (Two-Inclinometer Technique)
2.1
2.2 (Horizontal) T12
(Sacrum) ( Frontal Plane) T12 2
(Sacrum)
00 ( 4-9 )
49 2

2.3 2
T 12
2.4 ( 4-9 ) 2
T 12

2.5 3 6 50
10
4-9 ()

322
2.6

4.19
1

50

T12 200 200 300 250

150 50 100 100
200 150 , 200 50 , 300 100 , 250 100
=
50, 150 , 200 , 150
150, 200 , 150 50 10%
(13.750 ) 200

(Chronic Low Back Pain)

1 4-9

2.1 (Ankylosis in Lateral Flexion)

(Scoliosis)
T12
Frontal (Coronal) plane.
2 (T12 S1) T12
( 00) 4-9

323
4-9 :
(Impairment Due to Abnormal Motion and Ankylosis of the Lumbar Region : Lateral Bending)
500
40

.
0

(0 )

00
100
150
200
250

(00)
00
100
150
200
250

00 ()
300
450
600
750 ()

250
150
100
50
00

00
100
150
200
250

5
3
2
1
0

250
150
100
50
00

00
100
150
200
250

5
3
2
1
0
10
20
30
40
50

324

4-10
4-10
*
[Lumbar Range of Motion (ROM)] *
......

T12

+ 10% 5o

T12

+ 10% 5o

SLR )

(Right SLR)

SLR
+ 10% 5o
SLR

( SLR

150
)

(Left SLR)

SLR
+ 10% 5o
SLR

( SLR

150
)

T12

+ 10% 5o

T12

+ 10% 5o

)


*

325

4.20
15

35
3 4

0 0
150 250 150
00 150

3,4

15
(Ankylosis) 15O ( 4-9), 2515 = 10O
2
15

( 4-7)
()
4.10
(ROM : Thoracic Spine)

1. (Flexion and Extension)

2. (Rotation)
3. (Ankylosis)
1. (Flexion and Extension)

(Kyphosis)
(Minimum Kyphosis)
4-10 (Ankylosis)

326
4-10
(Impairment Due to Abnormal Motion (Flexion) and Ankylosis of the Thoracic
Region)
500
60

() (00)

00
500
150
350
300
200
500
00

-300 : (Extension Thoracic Lordosis)

00 ()
600
800
1000

00
150
300
500

4
2
1
0

20
0
5
20
40

2 (Two-Inclinometer Technique)
1.

2. T1 T12
2 00
T1 T12 ( 4-11 ) (4-11 .) T 12
T1 ( 2 ) T12
T1 2
4-10

327
4-11 2 (Angles of Minimum
Kyphosis) (Thoracic Flexion)
2
T1 T12
.

.
.

3. 2 00
T12 T1 ( 4-11
4-11)
4. 6
3 50 10%
5. 00

6. 4-10

1.1 (Ankylosis)

328

(Thoracic Lordosis) 4-10
4.21
5 (Ankylosing Spondylitis)

35
(Ankylosing Spondylitis)

600
T1 350 , 450 550 T 12
250 , 300 400 T 12
T 1 100 , 150 , 150 3

(Ankylosing Spondylitis)

600 5
150 2


5

4-7 (
4-7) (Ankylosing Spondylitis)

2. (Rotation) 2
2.1 2 (Two-Inclinometer Technique)
2.1.1
2.1.2
(Horizontal Plane) ( 4-12 .) T 1 T 12
00
T 1 T 12
2.1.3 T1 T 12 ( 4-12 .) T 12
T1 ( 4-12
.)
2.1.4 T1 T12 T12
T 1

329

4 12 T1 T12
. 2

2.1.5 3 6 3
50 10%
2.1.6
4-11

330
4-11
(Impairment Due to Abnormal Motion and Ankylosis of the Thoracic Region : Rotation)
600 ( 30 )
40

(00)

0
0
0
0
30
0
3
0
0
0
10
20
10
2
0
0
0
20
10
20
1
0
0
0
30
0
30
0
.
(00)
00
300
00
3
0
0
0
10
20
10
2
0
0
0
20
10
20
1
0
0
0
30
0
30
0
.
00 ()
50
250
350 ()

6
10
20
30

T1 150 , 200 150

T 12 50, 100 50 150 50 ,
200-100 , 150 50 100 4-11
2
2.2 (Alternative Thoracic Rotation Technique)
2.2.1
() (Manubrium) (Sternal Notch)
00 ( 4 13 .)

331
4-13

2.2.2
50 ( )

2.2.3 ( 4-13 .)
50
2.2.4 3 6 3
3 50 10%
2.2.5 4-11

3. (Ankylosis)
(Rotational Ankylosis)


T12 T1

4-11 .
ROM 4-11 ,
4-12 4-13

332
4-14
(ROM : Thoracic Spine)
......

T1
T12

T1
T12

+ 10% 5o

T1
T12

+ 10% 5o

T1
T12

+ 10% 5o

xxxx
Xxxx
xxxx
Xxxx
xxxx
xxxx
Xxxx
xxxx
Xxxx
xxxx
xxxx
Xxxx
xxxx
Xxxx
xxxx
(
)

(

)

*
*

333

4.11
(ROM : Cervical Spine)
3
1. (Flexion and Extension) (Ankylosis)
2. (Lateral Bending) (Ankylosis)
3. (Cervical Rotation) (Ankylosis)
1. (Flexion and Extension)
2 (Two - Inclinometer Technique)
1.1
1.2 T1
T1 (Sagittal Plane)
2 ( 415 .) 00 2
(Calvarium) Sagittal Frontal
2 00 ( 4-15 .)
4-15 2
2 T1

1.3 2 T1
( 4-15 .) 00
1.4 2 T1
( 4-15 .) 00
1.5 3
0
5 10
1.6
4-12
1.7

334
( 4-7) /

4-12
(Cervical Region Impairments from Abnormal Flexion or Extension or
Ankylosis)
1100
40

0
(0 )

00
500
00
5
0
0
0
15
35
15
4
0
0
0
30
20
30
2
0
0
0
50
0
50
0
.
(00)
00
600
00
6
0
0
0
20
40
20
4
0
0
0
40
20
40
2
0
0
0
60
0
60
0

00 ()
12
0
15
20
0
30
30
0
50 ()
40

00 ()
200
400
600 ()

12
20
30
40

335
30 600 , 400 450
T 1 200 , 50 50
400 (600 200 = 400) , 350 (400 50 = 350) 400 (450 50 =
400) 400
1
( 4-12)
(Ankylosis)
1.
00
Sagittal plane
00
2. (Vertical)
0
0 ( 1.2)
Sagittal Frontal plane 00 ( 4-15 .)
3. 2 T1 T 1

4. 3 4-12
5. 4

50
150 00 T1 50 00

150 00
15 0 5 0 0 0

150 + 50 = 200
200
20 ( 4-12)
2. (Lateral Bending)
2 (Two-Inclinometer Technique)
2.1
2.2 T 1
Coronal plane
(Calvarium) ( 4-16 .) 00

336
4-16 2

00 -
T1
2.3 2 ( 4-16 .)
T 1

2.4 2 ( 4-16 .)
T1
2.5 3 3 50
10 3

2.6 2.5
4-13
2.7

337
4-13
(Impairment Due to Abnormal Motion and Ankylosis of Cervical Region : Lateral Bending)
900
25

0
(0 )
00
450
00
4
0
0
0
15
30
15
2
0
0
0
30
15
30
1
0
0
0
45
0
45
0
.

0
(0 )
00
450
00
4
0
0
0
15
30
15
2
0
0
0
30
15
30
1
0
0
0
45
0
45
0
.
00 ()
150
300
450 ()

8
20
30
40

38 200 , 350 , 350 400 T1

50 , 50 , 100 100
(200 50) , (350 50) , (350 100) , (400 100) 150 , 300 , 250 , 300
150 ( 50
10 ) 300
1
( 4-13)
(Ankylosis)

1. 00
2. Frontal plane T 1 2

338
3.

0 0
( 4-16 .)
4. (
4-13)
3. (Cervical Rotation)

2
3.1
00
3.2
(Thoraco-Lumbar) ( 4-17 .)
00
50 10

3.6
( 4-14)
3.7

4 17

339
4-14 (Impairments
Due to Abnormal Motion and Ankylosis of the Cervical Region : Rotation)
1600
35

(0 )

00
200
400
600
800

(00)
0

800
00
600
200
400
400
200
600
00
800

0
80
0
20
60 0
40 0
40 0
60 0
20 0
80 0
00

0 0 ()
20 0
40 0
60 0
80 0 ()

4.22

00
20 0
40 0
60 0
80 0

6
4
2
1
0

6
4
2
1
0
12
20
30
40
50

45 150 , 350 , 550 , 600 550

1
2 3

600
( 4-14)
1

(Ankylosis)

340

1.

( 4-17)
2.
3.
( 4-14)
34 250 50
250 50 200
20 ( 4 14)
418

341
4-18
[Cervical Range of Motion (ROM) ]*
.............................. ...................... ....... ........ ......................... ...............

T1

10% 5

T1

10% 5

T1

10% 5

342

T1

10% 5

10% 5

10% 5

)
-
* ...................
- (
/////
) = ..............
*
() ()

343

4.12 / (Rating
Impairment of Nerve Root and / or Spinal Cord)
ROM

Long tract signs
Long tract signs

L1 Cauda
equina

1.
(Dermatome Distribution Chart)
( 4-1) ( 4-2)
2.
( 4-15 4-16)
3. (Nerve
Dysfunction) ( 4-17) ( 4-18)
4.
( 4-15 )
( 4-17 4-18)
5.
( 4-16)
( 4-17 4-18)

2 (
)

6. 0.6
0.4 ROM


0.8 0.4 0.9
100% 100%
4.13

344
2 (Bilateral) ()

(Neurologist) / (Neurosurgeon)
5

345
4-15 (Determining
Impairment Due to Sensory Loss)
.

4
(Light touch)
1 25

3
(Light Touch) Two26 60
point discrimination

2

61 80

81 99
1

(Superficial Cutaneous Pain)

(Deep Cutaneous Pain)

0

100

.
1.
Dermatome 4-1, 4-2
2.
3.
4.
5.

1 2-12 , 2-12
2 -48
.

( 4-17 , 4-18) ( 2-14)

4

346
4-16 (Determining Impairment
Due to Loss of Power and Motor Deficts)
.

1 25

26 50

51 75

76 99

100

.
1
(, )
2

( 4-17 , 4-18 , 2-11 , 2-13 2-37)

4

347

2-48 2

348
2-12 (Origins and Functions of the Peripheral Nerves of the Upper
Extremity Emanation From the Brachial Plexus)

Muscular branches
Dorsal scapular (C5)
Long thoracic (C5, C6, C7)
Suprascapular (C5, C6)
Lateral pectoral (C5, C6, C7)
Medial pectoral (C8, T1)
Upper subscapular (C5, C6)
Lower subscapular (C5, C6)
Thoracodorsal (C6, C7, C8)
Medial brachial cutaneous (T1)
Intercostobrachial (T2)
Medial antebrachial cutaneous (C8, T1)

Musculocutaneous (C5, C6, C7)

Lateral antebrachial cutaneous

Teres minor branch
Anterior
Posterior
Muscular branches
Upper lateral
brachial cutaneous

Axillary (C5, C6)

ongus colli, Scalenes, and Subclavius

Rhomboideus major and minor, Levator scapulae
Serratus anterior
Supraspinatus and Infraspinatus
Pectoralis major
Pectoralis major and minor
Subscapularis
Teres major and Subscapularis
Latissimus dorsi
Anteromedial surface of arm (with intercostobrachial)
Posteromedial surface of arm (with medial brachial cutaneous)
Anteromedial surface of arm, Anteromedial half of forearm
, and
Posteromedial third of elbow, forearm, and wrist
Coracobrachialis, Biceps Brachii, Brachialis
Anterolateral half and posterolateral third of forearm
Teres minor
Deltoid ()
Deltoid ()
Deltoid

349
2-12 (Origins and Functions of the Peripheral Nerves of the Upper
Extremity Emanation From the Brachial Plexus) ()

Radial (C5, C6, C7, C8, + T1)

Ulnar collateral
Posterior brachial cutaneous
Inferior lateral brachial cutaneous
Posterior anterbrachial cutaneous
Dorsal Branches
Superficial terminal
Dorsal Digitals
(5 Branches)

Superficial Branch
Deep terminal
Deep Branch

Triceps brachii, Anconeous, Brachioradialis, Extensor

carpi radialis longus, Brachialis (lateral part)
Medial head of triceps Brachii
Distal posterocentral surface of arm as far as olecranon
Distal posterolateral surface of arm and elbow
Posterocentral surface of forearm
Posterolateral half of wrist and hand
Dorsum of thumb, Index, Middle, and Ring (radial half) fingers
up to middle
phalanx
Extensor carpi radialis brevis, supinator
Extensor digitorum communis, Extensor digiti minimi,
Extensor carpi
ulnaris
Extensor pollicis longus, Extensor pollicis brevis, Abductor
pollicis longus,
Extensor indicis proprius
Wrist joint capsule

350
2-12 (Origins and Functions of the Peripheral Nerves of the Upper
Extremity Emanation From the Brachial Plexus)

Median ( + C5, C6, C7, C8, T1 )

Cubital fossa and

forearm branches

1st Lumbrical branch

Pronator teres, Flexor carpi radialis, Palmaris longus,

Flexor digitorum superficialis
Radial half of flexor digitorum profundus of the index and
middle fingers, Flexor pollicis longus, Pronator quadratus
Raidal surface
Abductor pollicis brevis, Flexor pollicis brevis (superficial
head) and Opponens pollicis
First web space, Palmar and distal dorsal surfaces of thumb,
Index (radial side)
1st Lumbrical

Proper palmar digitals

(3 branches)
2nd Lumbrical branch

1st web space (palmar), Palmar and distal dorsal surfaces of

thumb (both sides) and index (radial side)
2nd Lumbrical

Proper palmar digital

(2 branches)
Proper palmar digital
(2 branches)

2nd web space (palmar), Palmar and distal dorsal surfaces of

contiguous sides of index and middle fingers
3rd web space (palmar), Palmar and distal dorsal surfaces of
contiguous sides of middle and ring fingers

Anterior interosseus
Palmar cutaneous
Thenar muscular

Common palmar radial

digital

Common palmar central

digital

Common palmar ulnar

digital

351
2-12 (Origins and Functions of the Peripheral Nerves of the Upper
Extremity Emanation From the Brachial Plexus) ()

Ulnar ( + C7, C8, T1)

Palmar cutaneous
Dorsal cutaneous

Superficial palmar

Deep palmar

Forearm branches

Dorsal branches
Dorsal digitals
(3 branches)
Palmaris brevis br.
Proper palmar digitals
(3 branches)

Flexor carpi ulnaris, Ulnar half of flexor digitorum

profundus (ring and little fingers)
Ulnar surface of palm and wrist
Ulnar dorsum of wrist and hand
Dorsum of ring finger (ulnar proximal half), little finger (up
to nail root) and 4th web space
Palmaris brevis
Palmar and distal dorsal surface of ring (ulnar half) and
little finger (both sides)
Adductor pollicis, Flexor pollicis brevis (deep head),
Abductor digiti minimi, Flexor digiti minimi brevis, Opponens digiti minimi, 3rd
and 4th Lumbricals, All interossei

 4-17
(Unilateral Spinal Nerve Root Upper Extremity Impairment)

C5

30
34
5

C6

35

40

C7

35

38

C8

45

48

T1

20

24

4-18 *
(Unilateral Spinal Nerve Root Lower Extremity Impairment)

L3
L4
L5
S1

5
20
24
5
34
37
5
37
40
5
20
24

4.12 ROM
4.23
20
(Radiculopathy)

50
Sciatic
4

15
MRI

2 2

353

SLR 300
Achilles reflex
S1 SLR
2 200
300 () 450 200
250 S1 4
4-15 S1 4 4-16
MRI 2
MRI
Gadolinium 2

L5 S1
Recurrent Herniated Disc with Radiculopathy
20
4-7 12

10
2 2
2 12

4-8 20 0
2 300
() 450 4 (
4-8)
2%+4% = 6%
49 25 0
200 1

6% + 1% = 7%
4-15 4
25 () S 1
25% S1
5% ( 4-18)
25% x 5% = 1.25% = 1% ()

354
4-16 4
25% () 20% 4-18

S1
S1 25% x 20% = 5% 1%
5%
S1 6%
6% x 0.4 = 2.4% = 2% ()

4 7 12
4- 8
7 2
20 (12% 7%
2%)

ROM
3 DRE Lumbar 10
20 2 10
4.24
7 Ankylosing Spondylitis

35 Ankylosing Spondylitis

600
T1 350 , 450 550 T12 25 0 , 300
400 T12 T1 350
250 , 450 300 , 550 400 100 , 150 150
T1 150 , 200 150 T 12 50 , 100 50
150 50 , 200 100 , 150 50 100 ,
100 100 100

Ankylosing Spondylitis

4-10 600
5 150 2
( 410)
5

355
4-11 10 0
1% + 1% = 2%
4-7

5% 2% 7
()

4.25
27

45 2
L2 (Burst Fracture L2) 55 L3
20
6

.
SLR 100 300
150 2
L2
50 L3 20

L2 L3

27

4-7
L2 55 12
L3 20 5
L2 L3 16 ( )
4-8
100 5

300 450
4
4-9
150 2

150 2

5% + 4% + 2% + 2% 13%
4-7 , 4-8 , 4-9 16%
13% 27

356

4.13
(Criteria for Converting Whole Person Impairment to
Regional Spine Impairment)

1. (DRE Method)

1.1 0.35
1.2 0.20
1.3 0.75
: (DRE Method)

1. 35
2. 20
3. 75
2. (ROM
Method) ( 4-19)
2.1 0.80
2.2 0.40
2.3 0.90
4-19

357

90% 40% 80%

4.26
25

(DRE Method) 20

= 20% 0.35
= 57.14%
= 57%
4.26
55
(ROM Method) 25

= 25% 0.90
= 27.7% 28%
100% 100%
17-37 (Impairments Due to Nerve
Deficits)
() []

Femoral

(Motor)
15 (37)

(Sensory)
1(2)

(Dysesthesia)
3 (7)

Obturator

3 (7)

Superior gluteal

25 (62)

Inferior gluteal

15 (37)

1 (2)

3 (7)

Sciatic

30 (75)

7 (17)

5 (12)

Common peroneal

15 (42)

2 (5)

2 (5)

Superficial peroneal

2 (5)

2 (5)

0
2 (5) [7]
2 (5) [7]

1 (2)
2 (5) [7]
2 (5) [7]

2 (5)
2 (5) [7]
2 (5) [7]

Lateral femoral cutaneous

Sural
Medial plantar
Lateral plantar

358

/ 100%
(Maximum Upper Extremity Impairments due to Unilateral Sensory or Motor Deficits of Brachial Plexus
or to Combined 100% Deficits.) 16 16-14

- (C5 C8 , T1)

100

100

100

- (Upper trunk, C5 , C6
Erb-Duchenne)
- (Middle trunk.C7)

25

75

81

35

38

- (Lower trunk, C8-T1

Djerine-Klumpke)

20

70

76

2
2-47

359

4.14 (Rating Impairment of the

Pelvis)
3 Ilium , Ischium Pubis 2
Ilium (Sacrum) Sacroiliac synchondrosis
4-20
Pelvis (Symphysis Pubis)

4-20 A

360
4-19 *
Impairment due to Selected Disorders of the Pelvis)

1.

2. (Malunion)

. (Single Ramus)
. (Bilateral Rami)
. (Ilium)
. (Ischium)
.
(Symphysis Pubis, Without Separation)
. (Sacrum)
. (Coccyx)
3.

.
.
.
. 2.5 .
.
(Symphysis Pubis, Displaced or Separated)
.
.
.
(Fracture into Acetabulum)
4.
(Hemipelvectomy) (17-32 )

(Whole Person

0
0
0
0
5
5
0

0
5
2
10
15
10
5

50

*

DRE ROM

361
4.28
5 (Pelvic Stress fracture)

25
20

2

Adductor Hamstrings
Inferior ischio-pubic junction.
Obturator foramen
Callus

(Stress Fracture) Ischiopubic junction

Callus (Delayed Union)

9
(Stress Fracture)
Inferior pubic rami

Callus (Malunion)

362
4.15 (Spine Evaluation Summary)
4-20
4-20 *

1.
(DRE Method) (
4-3 4-5)
2.
(ROM Method) (
4-8)
3.

3.1

3.2
4.
( 4.14)
5.
(
1 - 4 )
6. ( )
7.

7.1 ...............................................
7.2 ................................................
7.3 .................................................
7.4 .................................................
7.5 ................................................
8.
7


...............................................
* (DRE Method) (ROM
Method)

5.1
5.1.1
5.1.2

5.2
5.3
5.3.1
5.3.2
5.3.3
5.3.4
5.3.5
5.3.6

(Consciousness) (Awareness)
(Episodic Neurologic Impairment)

(Mental Status) (Cognition)

(Dysphasia and Aphasia)
(Emotion) (Behavior)

5.4
5.4.1
5.4.2
5.4.3
5.4.4
5.4.5
5.4.6
5.4.7
5.4.8
5.4.9

1 (Olfactory Nerve)
2 (Optic Nerve)
3 , 4 6 (Oculomotor, Trochlear &Abducens Nerves )
5 (Trigeminal Nerve)
7 (Facial Nerve)
8 (Vestibulocochlear Nerve)
9 10 (Glossopharyngeal Vagus Nerves)
11 (Spinal Accessory Nerve)
12 (Hypoglossal Nerve)

5.5
5.5.1
5.5.2

5.6

5.7
5.7.1
5.7.2
5.7.3
5.7.4

5.8

366

5.9 ,
Neuromuscular junction,
5.9.1
5.9.2
5.9.3
5.9.4

(Peripheral Nervous System)

Neuromuscular junction

367

5.1

(Maximum
Medical Improvement MMI)
(
1-1 1)






(Combined Values Chart : 19)
5.1.1







(Objective Findings)




(Spastic Paraparesis)

368
MRI Demyelinating Plaques


5.1.2

()
1. (Neuropsychologic Assessment)
2. (Spinal Puncture)
3. (Electroencephalography : EEG)
4. Evoke potential
5. Carotid duplex
6. Computerized Tomography (CT scan)
7. Magnetic Resonace Imaging (MRI)
8. Magnetic Resonace Angiography (MRA)
9. Positron Emission Tomography (PET)
10. Single Photon Emission Computed Tomography (SPECT)

1. Nerve Conduction and Electromyography (EMG)

2. Quantitative Sensory Tests
3. Autonomic Function Assessment
( )

5.2


4

(1)
(State of Consciousness and Level of Awareness, Permanent or Episodic)
(2)
(Mental Status and Intregrative Functioning)

369
(3)
(Use and Understanding of Language)
(4)
(Behavior and Mood)
4



1

1.1 5.2

1.2 5.3

1.3 5.4

2
5.6
3
5.7 Aphasia Dysphasia
4
5.8
5 5.1
1-4
(Combined Valued Chart)
5.1

, ,

( 5.2 5.4, 5.6
5.8 (Combined Values Chart )

370

5.3
5.3.1 (Consciousness) (Awareness)



C.T. Scan, MRI,

5.2

1


2

, , ,

3 4
2

5.2
(Consciousness) (Awareness)

1

0-14

2
15- 39

3
40-69

(Personal Self Care)

371

4
70-90

Semicoma

Irreversible Coma

5.1
0-14 Orthostatic Hypotension

50

3
Parkinsons disease 10

, , , , ,
, (Resting Tremor)

140/90 .. 100/70 ..
Parkinson syndrome
, ,

MRI:

Parkinson;syndrome

14

5.2
15-39 Uremic Encephalopathy

40

5 3 3
Uremic Uncephalopathy

372

140/90 .. , 2 3
, 7 ,
, 2 (Grade 4/5), Deep
tendon reflex , ,
,
(EEG) Alpha, 8-13 Hz Theta, 4-7
Hz , , BUN,
Creatinine Calcium Phosphorus
Uremic Encephalopathy (Episodic Confusion)
Uremic Neuropathy.
30

(Peripheral Neuropathy)
(Combined Values Chart)

(Dementia)

,

5.3
40-69 (Dementia)

55

,
, ,
, ,

,, , ,
,
(Hemisensory Loss) (Hemianopia)

Central-Parietal Area
(Slow Wave)

(Dementia) (Hemiplegia)

49
(Dementia
() (Combine
Values Chart)

373

5.4
70-90 Persistent vegetative state

40

,
, Sleep-Wake Cycle,
, , Dolls eye
movement, (Nystagmus) Cold caloric, DTR
,

, Delta

Persistent vegetative state

90

Persistent vegetative state

(SleepWake Cycle) Hypothalamus (Brain
Stem)
1
5.3.2 (Episodic Neurologic Impairment)
,

1


,

374

(MMI)
,
, ,
,

, ,
(1)
, (2) , (3)

(1) , (2)
, (3)
, (4)

(Orthostatic Hypotension), Reflex action,
(
5.3)
5-3
(Convulsion)
(Episodic Loss of Consciousness or Awareness)

1

0-14

15/10 ..
, 2
,

375

2
15- 29

25/15 ..
12

3
30-49

, ,

30/20 ..
12

4
50-70

30/20 ..

5.5
0-14 (Dizziness and Light-Headedness)

55

, ,
1 2
,

130/80 .., 110/70 ..

(Dizziness and Light-headedness )

376

5.6
0-14 (Partial epilepsy)

30

(Tonic-clonic convulsion) 18


2-3 2-3

2-3

Spike Temporal Lobes

, MRI

Partial epilepsy

10

5.7
0-14 (Partial epilepsy)

24

, 1

, 5-10

6
3 2

, MRI
Partial epilepsy
14

377

5.8
15-29 (Partial epilepsy)

40

30
4 1

5 (Focal Seizure)
2

,
,
4/5, Deep tendon reflex Bicep , Co-ordination Test

Delta Tempero-parietal Lobe

MRI

Partial epilepsy

25


(Combine Values Chart)

MRI

5.9
15-29

55

378

160/90 138/75

Tilt Table Test 25/15

25


(Combined Vaules Chart)

5.10
15-29 (Partial epilepsy)

22

(Status Epilepticus)
Phenytoin

Phenytoin Auras
Auras 0-8
5-10

MRI Temproral Lobe

Spike

Partial epilepsy

29

Minor Seizure

(Status Epilepticus)
5.11
30-49

45

3
, ,
, 5

379

170/90 130/70

30
MRI Parietal Lobe

, (Transient Cerebral Ischemia),

45

(Combined Vaules Chart)

(
) Transient ischemic attack

5.12
30-49

45

Minor Complex Seizures

MRI. Frontal Temporal Lobe,

Polyspike Waves

Partial epilepsy (Intractable Epilepsy)

45

(Combined Vaules Chart)

380
5.13
30-49 (Generalized Convulsive Epilepsy)

55

Hypoxic Encephalopathy
1 (Mental Function)

(Generalized Tonic-Clonic Seizures)

2-6 Postictal State 1-2

Mini
Mental State Examination MMSE 23/30

Bitemporal Sharp Waves

(Hyperventilation test)

Generalized Convulsive Epilepsy

49

5.14
50-70

50

() ,
, Clonic Seizure
,
5 10

, (Hemianopia),

,
Delta Slowing

, ,
Partial Epilepsy (Status
Epilepticus)

65

()

381
5.15
50-70

45

Parkinson 5 ,
(Orthostatic Hypotension)
(Postprandial Hypotension),

,
,

110/80 .., 70/40 .. ,

(Resting Tremor), , ,
(Rigidity)

Tilt Table Test

Shy Drager

70 Shy-Drager

Parkinsonism

Parkinson

5.16
50-70

45

(Epidural Hematoma)

6 Partial Complex Seizure

,
5
3
1 2

Temporal Lobe Rare Spike Slow
Waves

Partial epilepsy

382

70

(Combined
Vaules Chart)
Epidual Hematoma

5.3.3
,
, (Excessive Somnolence), (Sleep
Induced Respiratory Impairment), (Sleep-Wake Schedules)
(1)
, , , (2)
, , , (3)
(Systemic and Pulmonary Hypertension), ,
, (Arrhythmias) (4)
(Excessive
Daytime Sleepiness) Central Sleep Apnea Syndrome, Narcolepsy, Idiopathic Hypersommia,
Depression, Brain Tumors, Post-traumatic Hypersomnolence, Multiple Sclerosis, Encephalitis,
Postencephalitis, Alzhermers Disease, Parkinsons Disease, Multiple System Atrophy, Periodic Limb
Movement Disorder, Restless Leg Syndrome, Neuromuscular Disorder with Sleep Apnea

Epworth Sleepiness Scale

(1) , (2) , (3)
, (4) , (5) , (6)
, (7) (8)

0 3
10/24 2
Epworth Sleepiness Scale Multiple Sleep Latency Test (MDLT)
Narcolepsy Idiopathic Hypersomnia. 5.4

383
5.4

(Daytime
1
Alertness)
1-9

2
10-29
3
30-69
4
70-90

(Daytime
Alertness)

(Daytime
Alertness)

(Daytime Alertness)
(Personal Self
Care)

5.17
1-9

40

20
(Daytime Somnolence)

, Polysomnogram
Obstructive sleep apnea

(Obstructive sleep apnea)

5.18
10-29

25

384

MRI , Polysomnogram
(Marked Hypersomnolence)
(Idiopathic Hypersomnolence)
19

(Reduced Daytime Alertness)

5.19
30-69

40

2
(Excessive
Daytime Somnolence)
15

MRI , Polysomnogram Multiple sleep

latency test (MSLT) (Narcolepsy)

Narcolepsy

39

5.20
70-90 (Brainstem Infarct)

60

MRI Basilar Artery, Midbrain

Basilar Artery

90

385

5.2 (
)

4 Semicoma 90

5.3.4 (Mental Status) (Cognition)

Organic Brain Syndrome, (Dementia)

(Mental Status Tests) ,

(Orientation), (Attention) (Immediate Recall),
, , ,

Short Blessd Test, Neurobehavioral Cognitive Status Examination

(NCSE) Mini-Mental State Examination (MMSE)
Neuropsychological Test
Neuropsychological Test
, , , , , ,
Neuropsychological Test
(Cognition)

Neuropsychological Test , (Dementia),
Parkinsons Disease, HIV, Encephalopathy, Multiple Sclerosis, ,

Clinical Dementia Rating (CDR) (1)

(Memory), (2) (Orientation), (3) (Judgement and
Problem Solving), (4) (Home and Hobbies), (5) (Community
Affairs), (6) (Personal Care)

5.5
5.6 ( NCSE MMSE CDR
)

386
CDR :
M=Memory, O=Orientation, JPS=Judgement and Problem Solving, CA=Community Affairs, HH=Home and
Hobbies, PC=Personal Care 5.5
(M) (Primary)
(Secondary)
(1) 3 M, CDR M
M=2, O=2, JPS=2, CA=1, HH=1, PC=1 : CDR=2
(2) 3 M, CDR

M=2, O=3, JPS=1, CA=1, HH=1, PC=0.5

M
JPS=1
M=2 O=3
CA=1
HH=1
PC=0.5
M =1 : CDR=1
(3) (M) 5 2
3 2 CDR M
M=1, O=1, JPS=0.5, CA=0.5, HH=2, PC=2
M
O=1 M=1
HH=2
JPS=0.5
PC=2
CA=0.5
CDR=M=1
(4) M=0.5 3 1 CDR 1
M=0.5, O=1, JPS=1, CA=0.5, HH=1, PC=1
4 1 CDR=1
( M=0.5, CDR 2 0.5 1)
M=0.5, O=0.5, JPS=1, CA=1, HH=0, PC=0 : CDR=0.5
(5) M=0, CDR 0 2 0.5
, CDR 0.5
M=0, O=0, JPS=0.5, CA=0, HH=0, PC=0 : CDR=0
M=0, O=0, JPS=0.5, CA=1, HH=1, PC=0 : CDR=0.5
5.6
CDR CDR=0.5 1,
CDR = 1 2,CDR=2 3, CDR=3 4

387
5.5 Clinical Dementia Rating (CDR)
CDR

(M)

,
,
(O)

0.5

1.0

(Recent
Memory)

2.0

3.0

,
,,

388
CDR

(PS)

(CA)

0.5

1.0

2.0

3.0

389
CDR

(HH)

(PC)

0.5

1.0

2.0

3.0

390
5.6 (Mental Status)

1

1-14

CDR = 0.5

2

15-29

CDR = 1.0

3
,
30-49

CDR = 2.0

4

50-70

CDR = 3.0
5.21
15-29 Alzheimers Disease

70

2-3

(Focal Neurological Symptoms

and Signs), Recent Memory,

, 3 ,
, ,
, ,
, ,

MRI
Absent rhythmic alpha activity without slowing
or paroxysm

Alzheimers Disease

29

CDR Score 1.0

391
5.22
30-49

25

1
4

, ,
,
, ,
, , ,
,

, , ,
Gait ataxia Romberg sign ,
, , , ,
3 , ,
Cerebellar sign

40

CDR Score 2.0,

3 , ,
, , ,


,

5.3.5 (Dysphasia and Aphasia)





Parietal Lobe Aphasia

,

392
Dysphasia Aphasia
(Sensory or Receptive
Dysphasia) (Motor or Expressive
Dysphasia)
Aphasia Dysphasia
(1) (Dysarthria) (2)
(Dysphonia)
Dysphasia
7

Dysphasia

(Receptive Dysphasia)
(Expressive Dysphasia)
(Speech Therapy) Aphasia
Dysphasia , ,

Aphasia
Dysphasia
(1)
(2)
(3)
(4)
(5) (

)
(6)

1 2 5.7
Aphasia Dysphasia
5.7 Aphasia Dysphasia

0-9
2
10-24

393
3
25-39

4
40-60

5.23
0 9 Dysphasia

35

Mild intermittent Brocas dysphasia

5.24
0 9 Expressive dysphasia

40

10

- (Neuropsychological tests)

Expressive dysphasia
9



6

394

5.25
10-24 Receptive dysphasia

30

MRI Temporal Parietal lobe

Receptive dysphasia

20 Dysphasia

Temporal Parietal lobe

Receptive
Dysphasia
5.26
25 39 Conductive Aphasia

55

(Spastic
Hemiplegia) (Hemianopia )

MRI
Middle cerebral artery

, Homonymous
hemianopia Conductive Aphasia
30 Aphasia

Hemianopia (Combined
Values Chart)

395

Middle cerebral artery

5.27
40 60

40

Slow activity Temporal lobe

MRI

(Hypoxic encephalopathy)

60 Aphasia

5.3.6 (Emotion) (Behavior)


, ,

(Depression), - (Manic State), (Emotional
Fluctuations), ,

(Right Hemispheric Infact) ,
(Dysphasia),
Temporalimbic

Temporalimbic
(Dementia)
(Apathy), (Delusion), (Agitation-Aggression),

396
(Hallucination), (Euphoria)
(Aberrant Motor Behavior)
Neuropsychiatry Inventory (NPI)

5.8
18 5.8

5.8

1
,
0-14

2
15-29
3
30-69
4
70-90

5.28
15 29

50

10

Neuropsychology, , 7
3 ,

397

MRI
Poor background alpha activity Focal
Generalized Slowing
Traumatic encephalopathy
17

5.29
30 69

40

,
, , ,

Two Point
Discrimination,

MRI Parietal lobe

3 ,
Moderate amplitude delta activity Parietal lobe

Low grade glioma Parietal lobe

45

( )

,
,

5.30
70 90 Huntingtons chorea

50

Recent memory

398

Chorea





Chorea

MRI Caudate nucleus
Relatively poor background activity Focal Lateral abnormalities
Huntingtons chorea
70
Huntingtons chorea
( )

5.4 5.9
5-1
5.3.1 5.3.6
5-1

(Combined
Values Chart)

5.4
5.4.1 1 (Olfactory Nerve)
1

7 9
(Anosmia), (Dysosmia)
(Parosmia)
1

3

399
5.31
3 1

20

(Ansomia)

, MRI,

5 (Trigeminal Nerve)
1
,
5.4.2 2 (Optic Nerve)
2
(Occipital Lobe)
2 2
(Visual Acuity Loss) (Visual Field Loss)
6
5.4.3 3 , 4 6 (Oculomotor, Trochlear &Abducens Nerves)

3
(Strabismus) 2 Comitant
Strabismus Paralytic Noncomitant Strabismus

Comitant strabismus

(Diplopia)
(Amblyopia)
6 (Visual Acuity Loss)
Paralytic Noncomitant strabismus

(Diplopia)

400
6
(Diplopia)
5.4.4 5 (Trigeminal Nerve)
5 , (Cornea),
,, , Supra-tentorial
5
(1) (2)
(3) Trigeminal neuralgia
5
, ,
(

)
3

Trigeminal Neuralgia
5
(Tics)


7
Trigeminal neuralgia Postherpetic neuralgia
5

5-9 Trigeminal neuralgia

Atypical
episodic facial pain
5-9 5 Trigeminal Neuralgia

0-14
2
15-24
3
25-35

401
5.32
15-24 Trigeminal neuralgia

45

Trigeminal neuralgia

15

Trigeminal neuralgia
Carbamazepine Lioresal
Stereotactic thermocoagulation of
Gasserian ganglion

5.33
25-35

55

5
1

(Postherpetic Neuralgia)

25

30

402

5.4.5 7 (Facial Nerve)

7 (Mixed Nerve) (1)
(Muscle of Facial Expression) , (2)

, (3)
7




5-10
7
5-10 7

0-4

5-19

75

3
75
20-45
5.34
5-19 (Bells palsy)

30

3 2 - 3

403

(EMG)

(Bells palsy)

19

Corticosteroids


EMG

5.4.6 8 (Vestibulocochlear Nerve)

8 (Brainstem)
(1) Cochlear portion (2)
Vestibular portion

(1)
1.1 (Hearing Loss)
7
1.2 Tinnitus
(Unilateral Hearing Loss) (Speech
Discrimination)
5
Tinnitus
(2)
Vestibular portion 8



(Kinesthetic Senses)

Vestibular portion
8 Vetigo

(Ataxia) (Nystagmus)


Vestibular portion 8 5-11
7

404
Vertigo
7
5-11 8 Vestibular portion

0-9

2
10-29

3
30-49

4
50-70

(Selfcare)

(Self-care)

(Ambulation),
(Self-care)

5.4.7 9 10 (Glossopharyngeal Vagus Nerves)

9 10 (Pharynx),
(Larynx), (Trachea)

5-12 9 10
9 Neuralgia 5


Trigeminal neuralgia 5
( 5-9)
5.4.8 11 (Spinal Accessory Nerve)

405
10
Sternocleidomastoid Trapezius

7
Sternocleidomastoid Trapezius
4
() 2 ()
5.4.9 12 (Hypoglossal Nerve)



5-12 7

5-12 9, 10
12 (Glossopharyngeal, Vagus , Hypoglossal Nerves)

(Dysarthria), (Dystonia)
1
(Dysphagia)
1-14

(Semisolid food)
(Dysarthria)
2
(Dysphagia)
15-39
(Regurgitation)

(Semisolid food)

3

40-60
(Suction)

5.35
15-39 Amyotrophic Lateral Sclerosis

40

,
10

406

3/5

fasciculation , Deep tendon reflex
Babinski sign
EMG Denervation
Fibrillations Positive sharp waves
Amyotrophic lateral sclerosis (ALS)
39
Amyotrophic lateral sclerosis

5.36
40-60

50

0/5



Left homonymous hemianopia
Babinski sign

Basal ganglia Thalamus

(Hemiplegia)
Hemianopia

60

(
)

407

5.5
5.5.1

Multiple
sclerosis (Muscle Tone)
(Spastic Paraparesis) Romberg sign
( )
(Peripheral Neuropathy)
Electrodiagnosis

5-13

5-13

,
1

1-9

2
10-19
3
20-39
4
40-60

,
,

, /

408
5.37
20-39

40

, Deep tendon reflex

, Babinski sign , ,

EMG Motor neuron disease

CT. Myelogram

Motor neuron disease, ALS.

39
Motor neuron disease
( )
(Combined Values Chart)

5.38
40- 60

50

(Spastic Hemiplegia), Deep

tendon reflex , Babinski sign ,
,
Walker

55


(Combined Values Chart)

( 5-14)

409
5.5.2

(Mild Tics)
Tremor (Resting, Postural, Intention), Chorea, Athetosis, Hemiballismus Dystonia

Basal ganglia Cerebellum

(Gait
Ataxia)


5-14 5-15
5-13

5.6

5-14 5-15
5-14
5-15

5-14 5-15
(Muscle Weakness), (Abnormal
Movement) ,
, Multiple sclerosis, Neurodegenerative disease Parkinsons
disease Progressive supranuclear palsy
5-14 5-15 ,
,

410
5-14

1
(Self Care),
1-9
,
(Difficulty With
Digital Dexterity)

2
(Self Care) ,
10-24

(No Digital Dexterity)

3
(Self Care)
25-39

4
(Self
40-60
Care)
15.38
39

45

, Deep tendon reflex

Babinski sign
Walker

Left cerebral infarction

39

55 39

73

411
5.39
60

50

(Hemiplegia) 0/5

(Hemianopia)

(Massive Intraventricular
Hemorrhage)

CVA with right hemiplegia, homonymous hemianopia, and dysphasia

60

(
5-13), Dysphasia ( 5-7), ()
60
5-15

1
(Self Care),
1-19

(Difficulty With Digital Dexterity)

2
(Self Care),
20-39
,
(No Digital Dexterity)

3
(Self Care)
40-79

80

412
5.40
80

50

,
1-2/5, Deep tendon reflex ,
Babinski sign , ,
, ,

EMG Motor neuron dieseae,

CT. Myelogram

Amyotrophic Lateral Sclerosis

80
Motor neuron disease

80
39
88

5.7
(Spinal cord) ,,



4
()
(1) , (2)
, (3) , (4) , (5) , (6) , (7)

, , , ,
(Paresthesias and Dysesthesias)
, ,


, , ,
,

413



, , , , ,


5.7.1

5-16
9
5-16

,
1

5-19
(Exertion)
,
2
(Ambulation)
20-49

,
3

50-89

,
4

90
5.7.2

Cystometry

5-17

13

414
5-17

1
(Urgency) (Intermittent
1-9
Incontinence)
(Good Bladder
2
Reflex Activity)
10-24

(Voluntary Control)

3

25-39
(No Voluntary
Control)

4
( No Voluntary Control)
40-60
5.7.3

5-18

5-18

1
(Limited Voluntary Control)
1-19
2
20-39
3
40-50

(No Voluntary Control)

5.7.4

(Orgasm)
5-19

415
5-19

1
,
1-15

2

16-29

3
30-35

5.8
(Intractable Pain)

Chronic pain syndrome

Thalamus

(1) Causalgia, (2) Post-traumatic neuralgia, (3) Reflex sympathetic dystrophy
Causalgia
, ,

Sympathetic block Posttraumatic neuralgia Causalgia

Reflex sympathetic dystrophy (RSD)


( 6 )
Sympathetic block
(Tremor)


, ,
,

(1) Three-phase
bone scan Uptake

416
(Sensitivity) 50 (2) (Plain X-ray) Patchy demineralization
(3) Laser Doppler
flowmetry (4) Sudomotor
reflex

Causalgia, Post-traumatic neuralgia, RSD

5-14 5-15 5-13

5.41
25-39 Post-traumatic neuralgia

30

Superficial radial nerve

2 Transcutaneous Electrical Nerve
Stimulation (TENS)

Superficial radial nerve
, , ,

Trophic changes Hyperesthesia

Superficial radial nerve

Post-traumatic neuralgia Superficial radial nerve

25

Superficial radial nerve

Tenosynovectomy de
Quervain

5.42
40-60 Reflex sympathetic dystrophy

25

Carpal tunnel syndrome 6

Stellate ganglion block

TENS

417

(Allodynia)

Three-phase bone scan,

Demineralization
Reflex sympathetic dystrophy
40
Reflex sympathetic dystrophy

5.9 ,
Neuromuscular junction,
5.9.1 (Peripheral Nervous System)
(Roots of Spinal Nerves), Brachial
Lumbosacral plexus,
, , , ,

, , (, Plexus, ),

Neuroimaging CT Scan, MRI, Plain
X-ray Physiologic Electromyography (EMG), Nerve conduction velocity (NCV),
Evoked potentials
2 ()
3 ()
5.9.2 Neuromuscular junction
Neuromuscular junction Myasthenia Gravis Myasthenic
Syndromes (Proximal Muscle Weakness)

5-13 ()
5-14 5-15 (
)
5.9.3
Muscular dystrophy,
Metabolic myopathy, Abnormal potassium metabolism, Endocrine myopathy Inflammatory muscle
disease

5-14
5-15
5-13 3-6 3-8 3 ()

418

5-13
5.9.4


Polyneuropathy, Familial dysautonomia, Landry-Guillain-Barre syndrome, Syringomyelia, Porphyria, Cord and
Brain Tumors, Myelopathy
, , -

Cardiopulmonary disorders, Orthostasis, Reflex action
5-2

-
, , Plexus

6.1
6.2
6.3
6.4
6.5
6.6

6.6.1
6.6.2

6.7
6.8
6.9
6.10

423

6.1
(visual system) 2 , Ocular adnexa Visual
pathway 4
1. Enucleation Evisceration

2.
2.1 (Loss of Central Visual Acuity) (Distance
Vision)
2.2 (Loss of Visual Field)
3. 2 (Loss of Binocular Vision)
2
4. Entropion, Ectropion,
Lagophthalmos, Epiphora, Symblepharon
2 3.

6.2
1. Snellen
E () Broken ring Landolt
2.
3. (Perimeter)

6.3

6.4
6 ( 20 )
5 Foot candles
25 1

(Contact Lens)

424

6.5
(Contact Lens)
6 - 1
(Near Vision) (Distance Vision)
1.5/60
20/800 Counting finger, Hand motion, Light perception (Loss of Central
Vision) 95
(Aphakia)
50
Accommodate Monocular pseudophakia
Monocular pseudophakia
Monocular aphakia (Contact Lens)
20/40 Central visual efficiency 85 50 85/2
43 Loss of central vision 100 43 57
( 6 - 1)
Monocular pseudophakia 6 1
20/40 (Loss of Central Vision) (15+57)/2 36
6-1 Central vision
Snellen

Metric English
system system
6/5
6/6
6/7.5
6/9
6/12
6/15
6/18
6/22
6/24
6/30
6/36
6/50
6/60
4/60
3/60
1.5/60

20/15
20/20
20/25
20/30
20/40
20/50
20/60
20/70
20/80
20/100
20/125
20/150
20/200
13/200
10/200
5/200

Percent central
visual efficiency

Central vision

Central vision in
monocular
aphakia

Central vision in
monocular
pseudophakia

100
100
95
90
85
75
65
60
55
50
40
30
20
15
10
5

0
0
5
10
15
25
35
40
45
50
60
70
80
85
90
95

50
50
52
55
57
62
67
70
72
75
80
85
90
92
95
97

25
25
29
33
36
44
51
55
58
63
70
78
85
89
93
96

425
2
2
= (3 X ) + ()
4

= (3 X % Impairment of Better Eye) + (% Impairment of Worse Eye)

4

30 60
2 = (3 X 30) + (60)
4
= 37.5

= 38 %
2 38

2
6 - 3
(% Impairment of Worse Eye)
(% Impairment of Better Eye)

2 60 30
38
6.6
6.6.1
Perimeter Goldmann perimeter ARC perimeter Automated
perimeter 6 - 2
6 - 2
(phakic)
(aphakic)
Goldmann (kinetic)
III 4e
IV 4e
ARC perimeter (kinetic)
3 mm white at radius 330 mm
6 mm white at radius 330 mm
Allergan Humphrey
10 dB
6 dB
(static, size 3)
Octopus (static, size 3)
7 dB
3 dB
:

426
6-1 Meridian

(Direction)
(Degree)
Temporally
85
Down temporally
85
Down
65
Down nasally
50
Nasally
60
Up nasally
55
Up
45
Up temporally
55
Total
500
6.6.2
10
Central 10 1 2
1 10 ( 60)

4 meridian (25, 65, 115, 155) 6 meridian (195, 225, 255,
285, 315, 345) 6-2

427
6 - 2 meridian

1 Meridian
Central 10
5 (1 2)
Peripheral 20 - 60
5 (1 10)
1 10 Meridian Visual field score 100
6-3
6-3
Central 10 Visual field score
Central 10 = 50
Central visual field 10 50% Primary
visual cortex
Visual field loss Central 10 Visual acuity
loss 20/200 Complete hemianopia
(Visual field score = 50)

428
Visual field score
6-4

85

6-4
Visual field score
Meridian
Visual field score
= Meridian ( = 100)
: 60 1 10
Scotoma Central 10 1
2 , Peripheral 20-60 1 10 6-5
6-5 Scotoma

429
Scotoma
= 18
Visual score
= 100 18 = 82
Automated static perimetry Goldman Pseudoisopter Area
10 dB 6-6 6-7

6-6
Automated perimetry

6-7 Pseudoisopter
Automated perimetry 6-6

Visual field score 6+6+7+6+0+0+0+3+0+0 28

100 - 28 72
2 = 3 x +
4
2
=
(3 x 0) + 72
4
=
18
(30 )
Full field 120 Point screening test
120

430
6 - 8
6 - 8

=
=

12
12 x 100
120
10

10
6.7 2
2
2
2
1. Perimeter 330
2. Tangent screen 1
360 20
Target Diplopia Tangent screen (Pen Light)

431
2

1) Diplopia 20 100
2) Diplopia 20 Diplopia
0O , 45 O , 90 O , 135 O , 180 O , 225 O , 270 O 315 O
100%

diplopia 180 O 20O 30 O dipopia

225 O 30 O 40 O

diplopia 180 O 20 O 30 O 20%

diplopia 225 O 30 O 40 O 10%
30%
3) Diplopia 30 40

Diplopia Subjective
Diplopia

6.8
1.
2.
3.
4.
5.

515
510
Entropion () 510
Entropion () 510
Ectropion () 510

432
6.
7.
8.
9.
10.

Ectropion () 510
Epiphora () 510
Lagophthalmos () 510
Symblepharon () 515
Blepharoptosis () 5 15

2 19

6.9



1. 3
2. 3
3. Extraocular muscle, Sympathetic ophthalmia, Traumatic cataract,
Traumatic vitreous hemorrhage Optic nerve atrophy
6 12

6.10
1.

Visual acuity 6/24 Visual

acuity 6/6
6-1 45

2. 1
19

Central vision 90 20
92 (90 20 92)
3. 2 2

433

Central vision 80 45

2
= (3 X % ) + (% )
4
= (3 X 45) + 80
4
= 53.75 54
2 54
4.
2

Visual acuity
6/60
Macular scar () Visual acuity 6/24
6-1 Central vision 80 Central vision
45
2
= (3 X % ) + (% )
4
= (3 X 45) + 80
4
= 53.75 54
2 54
90


Rupture cornea, Traumatic cataract, Hyphema

5.
( enucleation evisceration)

( 100 % )
7 (
15 )

434

100
( 2 ) = (3x0) + 100
= 25
4

24
15
( , ) 35 ()
6.
6 - 4

6 4

0
0
15
14
30
28
45
42
60
57
75
71
1
1
16
15
31
29
46
43
61
58
76
72
2
2
17
16
32
30
47
44
62
59
77
73
3
3
18
17
33
31
48
45
63
59
78
74
4
4
19
18
34
32
49
46
64
60
79
75
5
5
20
19
35
33
50
47
65
61
80
76
6
6
21
20
36
34
51
48
66
62
81
76
7
7
22
21
37
35
52
49
67
63
82
77
8
8
23
22
38
36
53
50
68
64
83
78
9
8
24
23
39
37
54
51
69
65
84
79
10
9
25
24
40
38
55
52
70
66
85
80
11
10
26
25
41
39
56
53
71
67
86
81
12
11
27
25
42
40
57
54
72
68
87
82
13
12
28
26
43
41
58
55
73
69
88
83
14
13
29
27
44
42
59
56
74
70
89
84
90-100
85

435

436

437

7.1
7.2
7.3
7.4
7.5

7.5.1

7.6
7.6.1 Vestibular system
7.6.1.1 (Complete Loss of Vestibular Function)
7.6.1.2 (Disturbances Of Vestibular Function)
7.6.1.3

7.7
7.7.1
7.7.2
7.7.3
7.7.4

(Respiration)
(Mastication and Deglutition)
(Olfaction and Taste)

7.7.4.1 /

7.7.5 (Speech)
7.7.5.1 (Voice)

7.8

441

7.1


1.
2.
3.
4. Temporo-mandibular joint
5.
6.
7.


( )

7.2

(Auditory Cortex)
2
1.
2.





(Tinnitus)

5

442

7.3
The American
Academy of Otolaryngology Head and Neck Surgery

1. (Permanent Hearing Impairment)

(Prosthetic Device)

2. (Permanent Binaural Hearing

Impairment)
3. (Intensity) (dB)
4. (Frequency) (Hertz , Hz)
5. (Hearing Threshold Level for Pure Tones)
(Standard Audiometric Zero)
( American National
Standard Institute (ANSI) S 3.6 1996)
6. (Estimate Hearing Level for Speech)
4 500, 1000, 2000, 3000

7. (Evaluation of Monaural Impairment)

500, 1000, 2000 3000 25
91.7
100

1.5 67 25
(67 91.7-25 = 67) 100 ( 100 1.5x67 =
100)
8. (Evaluation of Binaural Hearing
Impairment) (Pure Tone Audiogram)
= [5 x (%

) + (% )] 6
(Monaural Impairment)
2 (Binaural Impairment) %
0
7-2
7-3 2

443

7.4

1. (pure tone audiometry) 500,

1000, 2000 3000

. 100 100
. ( -5 dB) 0
2. 4
3. 2 1
(Monaural Hearing Impairment)

:
235 dB = 50.5
160 dB = 22.5
:
230 dB = 48.9
260 dB = 60
(dB)
(Hz)
500
1000
2000
3000
DSHL *

50
55
60
70
235

30
40
40
50
160

35
60
65
70
230

45
65
70
80
260

DSHL* = 500, 1000, 2000 3000 (decibel

sum of the hearing threshold levels at 500, 1000, 2000 and 3000 Hz)
4. 7-2 2 (Binaural Hearing
Impairment)
:
= 160, = 235 2
2 = 27.2
:
= 230, = 260 2
2 = 50.6
5. 7-3 (Iimpairment of The
Whole Person)
:
2 27.2
10
:
2 50.6
18

444

2 (Binaural Hearing Impairment)
7-1 (Monaural Hearing Loss and Impairment (%)*)
DSHL+
100

0.0

105
110
115
120

1.9
3.8
5.6
7.5

125
130
135
140

9.4
11.2
13.1
15.0

145
150
155
160

16.9
18.8
20.6
22.5

165
170
175
180

24.4
26.2
28.1
30.0

185

31.9

DSHL+
190
195
200

33.8
35.6
37.5

205
210
215
220

39.4
41.2
43.1
45.0

225
230
235
240

46.9
48.9
50.5
52.5

245
250
255
260

54.4
56.2
58.1
60.0

265
270
275
280

61.9
63.8
65.6
67.5

* ANSIS 3.6-1989
+
Decibel sum of the hearing threshold levels at 500, 1000, 2000, 3000 Hz.

DSHL+
285
290
295
300

69.3
71.2
73.1
75.0

305
310
315
320

76.9
78.8
80.6
82.5

325
330
335
340

84.4
86.2
88.1
90.0

345
350
355
360

90.9
93.8
95.6
97.5

365
99.4
368
100.0
368

 7 2 2 (computation of Binaural Hearing Impairment)

446
7-3
(Relationship of Binaural Hearing Impairment to Impairment of the Whole Person)

0 - 1.7
1.8 - 4.2
4.3 - 7.4
7.5 - 9.9
10.0 13.1

0
1
2
3
4

50.0 - 53.1
53.2 - 55.7
55.8 - 58.8
58.9 - 61.4
61.5 - 64.5

18
19
20
21
22

13.2 15.9
16.0 18.8
18.9 21.4
21.5 24.5
24.6 27.1

5
6
7
8
9

64.6 - 67.1
67.2 - 70.0
70.1 - 72.8
72.9 - 75.9
76.0 - 78.5

23
24
25
26
27

27.2 30.0
30.1 32.8
32.9 35.9
36.0 38.5
38.6 41.7

10
11
12
13
14

78.6 - 81.7
81.8 - 84.2
84.3 - 87.4
87.5 - 89.9
90.0 - 93.1

28
29
30
31
32

41.8 44.2
44.3 47.4
47.5 49.9

15
16
17

93.2 - 95.7
95.8 - 98.8
98.9 - 100.0

33
34
35

7.5

1.

2.
3. Audiometry
4. audiogram

447
. ( Air Conduction) 500, 1000, 2000 3000
2
. .
. . 7-2 (Binaural
Hearing Impairment)
. . 7-3
(Wholeman Impairment)

Hearing level in decibels

125
-10
0
10
20
30
40
50
60
70
80
90
100
110
120

250

500

1000 2000 4000 8000

750 1500 3000 6000

Frequency (Hz.)

. .

50
500 Hz
30 dB
55
1000 Hz
40 dB
60
2000 Hz
40 dB
70
3000 Hz
50 dB
Worse Ear = 235
160 = Better Ear
. . . 7-2 27.2
. 27.2 . 7-3 10
7.5.1

24 ..2547
1.
12 ..2537 (.....2
, ......)

448
2.

1 2
10 = 10 x 2 = 20

2 ()

7.6



(1) (Vision), (2)
(Kinesthetic Sense) (3)
(Vestibular End-Organ)

Cerebrum
(Cerebellum)

(Subjective) (Objective) ,
,

1. (Vertigo) Vestibular system

Central nervous system components Cerebral cortex, Cerebellum, Brainstem,

2. (Giddiness Or Lightheadedness)
3.
7.6.1 Vestibular system
Vestibular
organ (Labyrinthine) [
(Cerebrum, Cerebellum, Brainstem)
5 )] Vestibular organ 2
1. (Complete Loss of Vestibular Function)
2. (Disturbances Of Vestibular Function)

449
7.6.1.1 (Complete Loss of Vestibular Function)

(Kinesthetic or
Proprioceptive Senses) (Vision)
Vestibular system
0-95

7.6.1.2 (Disturbances Of Vestibular Function)

(Vertigo or Vestibular
Dysequilibrium) (Giddiness or Lightheadedness)
Vestibular organ

(Nystagmus)
Vestibular organ (Labyrinthine) (Hearing
Loss) (Tinnitus)


5

7.6.1.3
1 0
1.
(Objective Finding)
2.
2 1-10
1.
(Objective Finding)
2.


3 11-30
1.
(Objective Finding)
2.
(Self-care), , ,

450
4 31 60
1.
(Objective Finding)
2.

5 61-95
1.
(objective finding)
2.
(Ambulation)
3.

7.7
(Nose) (Throat) (Related Structures)
1.
(Nasopharynx)
2. (Temporomandibular Joint)
(Palatine Tonsils) (Oropharynx)
3. (Neck) (Chest Region)
(Hypopharynx), (Larynx), (Trachea), (Bronchi) (Esophagus)

1. (respiration)
2. (mastication and deglutition)
3. (olfaction and taste)
4.
5.

7.7.1 (Respiration)


(
9 )
(Obstruction) (Stenosis)
(Occlusion) (Dyspnea)
(Sleep Apnea)

451

7-4
9
7- 4

(Dyspnea)
1

010
(Dyspnea)

,
, , *

(Partial Obstruction)
(Oropharynx),
(Laryngopharynx), , (
1-4), (bronchi)
(Complete Obstruction)
2 (Nasopharynx)
(Dyspnea)
2
1129

, ,
,

(Partial Obstruction)
(Oropharynx),
(Laryngopharynx), , (
1-4), (bronchi)
(Complete Obstruction)
2 (Nasopharynx)

452

3
3049

4
5089

5
90

(Dyspnea)

50
100 ,

, , ,

(Partial Obstruction)
(Oropharynx),
(Laryngopharynx), , (
1-4), (bronchi)
(Dyspnea)
(Bedridden)

(Partial obstruction)
(Oropharynx),
(Laryngopharynx), , (
1-4), /
(Bronchi)
(Dyspnea)

(Partial Obstruction)
(Oropharynx),
(Laryngopharynx), , (
1-4), / (Bronchi)

* 1
(Permanent Tracheostomy) 25

453
7.1
0-10

25 4 Right anterior cervical

fusion

(Fiber optic laryngoscopy)

Paramedian position 2-3

5-10

7.2
11-29
(Permanent Tracheostomy)

40

10
Arnold-Chiari syndrome
Decompression

20

(Fiber optic laryngoscopy)

(midline position) (abduction)

29

454
7.7.2 (Mastication and Deglutition)


(Temporomandibular Joint)





7-5
7-5

(Semi-Solid Foods)
1 5-19
(Soft Foods)
(Liquid Foods)
2 20-39

3 40-60
(Tube Feeding)
(Gastrostomy)
7.3
5-19 (Temporomandibular joint)

55 Oroantral fistula
(Upper left third molar)
Maxillary sinus
Fistula

1 6 Fistula
Naso-antral window Inferior meatus

Coronoid process
Steroid
(Stent)

60
Fistula

10

455

7.7.3 (Olfaction and Taste)

5


7.7.4

( )



( 8 )
2

456
7.7.4.1 /

(Facial Disfigurement)

(1) 1
(2) 8

(3)
16-50
7-6
7-7

7-6
(Disfigurement)

(Unilateral Facial Paralysis)

14
(Mild)
5 19
(Severe)

(Bilateral Facial Paralysis)

(Mild)
(Severe)

* 8

5 19
20 45
15
15 30
15

457
7 - 7

1
0-5

2
6-10

3
11-15

4
16-50

( 8 )

( ,
)

,

(

- 6

7.4
0-5

25 1 2 .


:

1.5 .

458
7.5
1-5

35 1

3-4 .

7.6
6-10

35 6

3 . 3-4 .

459
7.7
6-10

35 12

(Malar)

1-2 .
1
(Enophthalmos)

10

7.8
11-15

35 9

4 . 2 .
(Nasolabial fold )

15

460
7.9
11-15

55 1

15

6
7.10
16-50

25 2
3

25

7.11
16-50

40 2

461

40

6

7.7.5 (Speech)

3
1. (Audibility)
2. (Intelligibility)
3. (Functional Efficiency)

1.
1.1 (Speech Pathologist)
1.2 (Otolaryngologist)
(Neurologist)
1.3
2. 1
2.1
2.2

3.

4.
4.1 1
4.2
4.3
4.3.1 10 10

462
4.3.2 1
75 100
4.3.3 1 100 100 2
4.3.4 3 7-9


Audibility 10 Intelligibility 60 Functional
Efficiency 15 60

60
4.3.5 7-8

7 - 8

0
0
5
2
10
4
15
5
20
7
25
9
30
10
35
12
40
14
45
16
50
18
55
19
60
21
65
23
70
24
75
26
80
28
85
30
90
32
95
33
100
35

463
7.7.5.1 (Voice)

(Phonation)


,
, /

Objective
(Laryngoscopy) (Acoustic Analysis of Voice)
(Strobovideolaryngoscopy) (Analysis of Phonatory Function)
(Laryngeal Electromyography)

7-9 7
1
2
3
4

0-14
15-34
35-59
60-84

(Audibility)

2-3

85-100

464
1

0-14

(intelligibility)

(functional

efficiency of
speech)

15-34

35-59

60-84

85-100

/ 7-8 7-9

465
7.12
/ 0-14

55 2

2 CT
Scan 1 Dislocated arytenoids cartilage

Dislocated arytenoids cartilage

0-14
0-5

Dislocated arytenoids cartilage

7.13
/ 15-34

28 1

3
1
(Laryngopharyngeal Reflux)

/ 15-34
5-12

466
7.14

45
4
3
30 2





CT scan MRI


/ 15-34
5-12

7.15
/ 35-59

45 10
10





1

467

/ 35-59
12-21

(Audibility) 3

7.16
/ 35-59

40 2


14

/ 35-59
12-21

7.17
/ 60-84

40 20

8 3

468

1 8

2

2
/ 60 84
21-30
2

7.18
/ 60-84

40 7
1
4
2
6

2
S/Z

Papilloma

469

/ 60 84
21-30
2

7.19
/ 85-100

38 20
Vinyl chloride
1
2 6
1

2 2

/ 85-100
30-35

5

3
5

470
7.20
/ 85-100

50 1
2
4.5 . 2 40-50

/ 85-100
30-35

7.8 :
1. Speak at a level sufficient to be heard
by normal hearing person
2. Correct articulation,
voice quality and language (As a function of meaning)

3.

4. (Speech Pathologist) Speech pathology

5. (Otolaryngologist)
6. (Neurologist)

7.

8.

. 10
. 10
. 1-100 2

471
. 3
Audibility
= 10
Intelligibility
= 60
Functional efficiency = 15
/ 60
. 7-8 60 /
21

8.1
8.1.1
8.1.2
8.1.3
8.1.4

8.2
8.2.1
8.2.2
8.2.3
8.2.4

(Scars) (Skin Grafts)

(Contact Dermatitis)
(Natural Rubber Latex Allergy)

8.3

475

8.1
8.1.1
1.
2.
3.
4.
5.
6.

8.1.2
8-1
8-1

( Epidermis)
Stratum corneum
Squamous and basal cells
Melanocytes

Langerhans cells

(Dermis)
Blood vessels and mast cell

, ,

Lymphatics

Nerve tissue

Connective tissue
,
(Eccrine sweat gland)
Sebaceous gland

, , ,
,
, ,
melanoma
(Allergic contact
dermatitis)
, , heat stroke

, , ,
,
(heat intolerance)
,
, ,

476
8.1.3
. (Chemical condition)
1. (Contact Dermatitis)
2. , , (Acnegenic agents)
3. (Pigmentary change)
4. (Carcinogens)
. (Mechanical condition)
1. , , ,
2. ,
. (Physical condition)
1.
2. ,
. (Biologic condition)
1.
:
/, ,
2.
:
,
3.
:
, ,
4.
:
, ,
8.1.4


: patch, open, prick, intracutaneous, serologic allergy tests
: Woods light
:
: ,
.

,

. (Patch test)
(allergic contact dermatitis)

8.2
8.2.1 (Scars) (Skin Grafts)
.

477

1) ( )
2)
3)
4) (atrophic) (hypertrophic)
5)
6)

.










8.2.2 (Contact Dermatitis)

,
2 (irritant
contact dermatitis) 80
(allergic contact dermatitis) 20
delay-type hypersensitivity



chromate, nickel salt, epoxy
resins
paraphenylenediamine
benzocaine cross sensitivity

478
2

patch test

8.2.3 (Natural Rubber Latex Allergy)

hypersensitivity type 1 (IgE mediated immediate hypersensitivity)

atopic dermatitis
(angioedema) anaphylaxis
Delayed type hypersensitivity

8.2.4
3
(1) Basal cell carcinoma
(2) Squamous cell carcinoma
(3) Malignant melanoma
(1) Basal cell carcinoma (BCC)
, ,
,
basal cell nevus Gorlin syndrome
basal cell carcinoma

(2) Squamous cell carcinoma (SCC)

actinic keratosis
, polycyclic aromatic hydrocarbon; infrared,


anaplastic Basal cell carcinoma

479
(3) Malignant melanoma (MM)


(insitu early invasive)

8.3
2
1.
,
8-2
2.




8-3



(Combine Values Charts)

480
8-2

1.
2.
3.
4.
5. 1
6.
7.
8.
9. 1
10. 1
11.
12. 1
13.
14. 1

1-10
1-5
1-5
1-10 ( 6)
1-2
1-10
1-15
1-5
1-5
1-5
1-5
1-5 ()
1-15 ( 14,15)
1-5

:
15

481
8-3

1
0-9

2
10-24

3
25-54

4
55-84

5
85-95

-
-

-
-

-
-
-

-
-

482

8.1
0-9

27

1

Patch test nonmercurial preservative, 2 n 4 - isothiazolin

8.2
0-9

38 (the second degree burn)

7x12

(Depigmentation caused by thermal burn)

2 9
8-3
0-9

52 13

paratertiary butyl phenol (TBP)

10 methoxalen
(PUVA therapy)

Patch test 2+ TBP 1%

483

8-4

8-5

8.6

0-9
35 10

10 (body surface area)

eosinophil 12%
(chronic urticaria)
5
sedative
antihistamine

20
0-9
32
prednisolone 2



severe dermatitis
Patch test
(Allergic contact dermatitis due to chromate
from occupational cement exposure)
9

10
43 second degree burn
1


5 10

484

8.7

8.8

, ()
10

38 18
,




, ,
Hypoallergenic



Red, swollen, crusted, fissured palms, fingers and wrists
Patch test thiuram mix (
), glutaraldehyde () quaternium 15 ()
Latex RAST: positive (class3) Prick test: allergy latex protein avocado

(1) Latex allergy
(2) Allergic contact dermatitis
(3) Irritant contact dermatitis
15

10-24
25
infantile eczema

7-10

485

(Atopic dermatitis)
15
atopic dermatitis

8.9

10-24
40
methyl methacrylate monomer methyl mathacrylate
polymer

Exposed and keratinized nail beds; paronychial areas swollen and tender
Patch test 2% methyl methachylate monomer
(Chemically induced nail dystrophy and anonychia
20

8.10

10-24
30 Zirconium chloride
,
22

10 15
1 2




,
16x11
, ,
.

(Zirconium chloride burn and leukoderma with residual skin dysfunction)

486

20

8.11

25-54
45

6






patch test
staphylococcus
aureas,coagulase positive
(Persistent neurodermatitis
secondary to occupational contact dermatitis)
30





(Combined Value Chart)

8.12

25 - 54

44

(Scaring due to thermal burn)

30

487
8.13

8.14

55 84
40 basal cell
carcinoma 15
fibroma




basal
cell
carcinoma

- (macrocephaly)
- (hypertelorism)
- (frontal bossing)
- keratocysts
- calcification falx cerebri
- bifid ribs
Basal cell nevus syndrome basal cell carcinoma
55
- Basal cell nevus Gorlin syndrome
1 : 56,000 basal cell carcinomas

-
18
55-84%
25 85%






atrophic scar 85%

2

(Extensive scarring
due to thermal burns and dyspnea)

488

60


60

2


(Combined Value Chart)

8.15

85 95 Xeroderma Pigmentosum
18 13 5

(basal and
squamous cell epitheliomas)

1

porphyrin

Xeroderma pigmentosum
85
Xeroderma pigmentosum

8.16

85 95 Epidermolysis Bullosa
Dystrophica
19


40
esophageal stricture
Epidermolysis Bullosa Dystrophica
95
esophageal stricture
- autosomal recessive

- squamous cell carcinoma
-

9.1

9.2 (Occupational lung diseases)

9.2.1
9.2.2
9.2.3
9.2.4
9.2.5
9.2.6
9.2.7

(Silicosis)
(Asbestosis)
(Byssinosis)
(Hypersensitivity pneumonitis)
(Bagassosis)
(Occupational asthma)
(Obstructive Sleep Apnea syndrome, OSA)

9.3
9.3.1
9.3.2
9.3.3
9.3.4
9.3.5
9.3.6
9.3.7

(Silicosis)
(Asbestosis)
(Bussinosis)
(Occupational asthma)
(Pleural mesothelioma)
(Lung cancer)
(Chronic bronchitis)

9.4
9.4.1
diffusing capacity
9.4.2

9.4.3

9.4.4

9.4.5

491

pleural plaque

0%

( 1-2 9-1)

wheeze
(CT chest)

subjective objective

492

objective

(CXR, CT chest
MRI) exercise test

objective data

metabolic, neurologic, anxiety physical deconditioning ()

( 9-1)

9 1 (Dyspnea)

?

?
90
?

?

493






(chronic bronchitis)
ATS 3 2
(bronchitis) (pneumonia)
pulmonary
embolism, bronchiectasis , aspergilloma AVM

Wheezing
( )
glottis bronchioles inspiratory wheezing
stridor larynx expiratory wheezing
(bronchospasm) bronchus
wheeze
(occupational asthma) exercise-induced asthma wheeze
asthmatic bronchitis

kyphoscoliosis
(scoliosis) (kyphosis) Cobb
(lateral)
(posteroanterior) 100 kyphoscoliosis

severe kyphoscoliosis
(restricted lung volume)
hypoxia hypercapnia
respiratory failure

494

(
/) pack-years



10-15

acute lung injury (high irritative
gas, fume, mist, vapor) non cardiogenic pulmonary edema acute respiratory distress
syndrome acute process diffuse
pulmonary fibrosis obliterative bronchiolitis

(hypersensitivity pneumonitis)
pneumoconiosis

9.1

(accessory muscles)
(body habitus)
(pursed lip breathing) COPD
-
(barrel shape) (hyperinflation)

495
hyperresonance, consolidation
, crackles, wheezes rhonchi
inspiratory crackles
2/3 chronic interstitial lung diseases
restrictive respiratory impairment wheezing rhonchi
obstructive airway diseases
wheez diffuse bilateral expiratory wheezing
generalized bronchospasm unilateral localized wheezing
tumor mucous pluging early inspiratory
crackles opening snaps airflow obstruction bronchiolitis obliterans.
Cyanosis cyanosis
anemia
pulse oximeter blood gas
Digital clubbing ()
pulmonary fibrosis,
bronchiectasis, bronchogenic carcinoma, pleural tumor, lung abscess, empyema cyanotic heart diseases.
( Chest roentgenograms)
postero-anterior lateral films

airflow limitation asthma emphysema
parenchyma, bronchovascular, cardiovascular, pleura
trachea mediastinal
hyperinflation, fibrosis, cavitary cystic. Hyperinflation
airway obstruction volume restriction fibrosis, chest wall compliance severe
neuromuscular weakness
anteroposterior diameter retrosternal airspace
hyperinflation .
Diffuse fibrotic (linear/streak) (nodule)
diffuse
localized silicosis nodular (linear)
asbestosis linear pleural plaques
International Labor Organization (ILO)
pneumoconiosis National Institute for Occupational
Safety and Health (NIOSH)

pulmonary hypertension / cor pulmonale pulmonary hypertension

pulmonary artery hilar
cor pulmonale pulmonary hypertension

496
(Computerized Tomography, CT)
CT chest (HRCT)

asbestosis
CT chest 10 .
nodule HRCT 1-2 .
linear interstial lung diseases
HRCT local emphysema regional air trapping
small airway disease bronchiolitis obliterance large airway disease bronchiectasis
prone supine position

(Simple spirometry)
spirometer
(ATS 1994 Statement on Standardization of
Spirometry) calibrate

24 spirometry
methacholine challenge test. (forced expiratory maneuvers)
3 5
spirometry force vital capacity (FVC), force expiratory volume 1
(FEV1) (FEV1/FVC) FVC FEV1
FEV1/FVC 0.70
wheeze
spirometry FEV1 FVC

FEV1, FVC DLco (,

) FEV1 FEV1
(predicted value) FEV1/FVC

Diffusing Capacity for Carbon Monoxide (DLco)

single-breath DLco
ATS 1995 DLco
alveolar-capillary membrane

hemoglobin alveolar-capillary membrane
hemoglobin

497
Dlco

carbon monoxide
DLco 8
DLco
Cardiopulmonary Exercise testing
(dyspnea)

CO2 , minute ventilation
,

oxygen consumption/ (Vo2) ml [kg.min] metabolic equivalents
(METS) 3.5 ml/[kg. min] (
METS 10) 40%
8 . 9 2 ,

9 2 ,
70 kg

7 ml/kg; 0.5 L/min

8-15 ml/kg; 0.6-1.0 L/min
16-20 ml/kg; 1.1-1.5 L/min
21-30 ml/kg; 1.6-2.0 L/min
> 30 ml/kg; >2.0 L/min

( METS )
<2
2-4
9-6
7-8
>8

invasive

invasive

FEV1 (PaO2)

(hypoxemia) 2 4

55 mmHg 60
mmHg pulmonary hypertension, cor pulmonale, erythrocytosis

498

(pulse oximetry)

9.2 (Occupational lung diseases)

allergic responses

(pneumoconioses)

Coal workers pneumoconioses silica asbestos


1.
inert nonreactive
kaolin diatomaceous earth ()
silica asbestos
2. farmers lung hypersensitivity
pneumonitis (mouldy hay)
3. (occupational asthma)
4.
5.

9.2.1 (Silicosis)

silica silica

(chronic form) silica

15 (accelerated form) 5 15
(acute form)
silica

499






cor-pulmonale, congestive cardiac failure

silica



autoimmune disease

cellular reaction hyaline
nodule polarized light double refractile particle silica

silica
silica
9.2.2 (Asbestosis)

asbestos
asbestos 30-40
asbestos


asbestos body


restrictive ventilatory defect compliance
obstructive ventilatory defect chronic obstructive airway



pleural plaque

500

(clubbing finger)

asbestos

9.2.3 (Byssinosis)

2

2 3

Schilling 4
grade 1/2 -

grade 1 -

grade 2 -

grade 3 - grade 2

1. /
2
2.
3.
4. spirometry

501
4.1 grade 1/2 2

2
6-8 2
FEV1 10
4.2 grade 3 5
FEV1 FEV1/FVC 80 75

9.2.4 (Hypersensitivity pneumonitis)
Hypersensitivity pneumonitis extrinsic allergic alveolitis farmers lung
organic dusts
(mouldy hay) low-molecular
weight

4-8
restriction diffusing capacity (DLco) hypoxemia
diffuse micronodular
1-4
sub acute chronic

restriction obstruction
restriction

precipitin FLH antigen
honey comb lung,
sarcoidosis pulmonary aspergillosis

502

9.2.5 (Bagassosis)

granulomatous pneumonia
farmers lung fibrosis
precipitin mouldy bagasse 80 - 100
thermoactinomycetes T. vulgaris
bagassosis
9.2.6 (Occupational asthma)

toluene diisocyanates 2

2 - 3

latent interval latent interval
(potency)
(atopy)
platinum 3 isocyanates
2

latent interval reactive airway dysfunction syndrome (RADS).

metal salt, wood, vegetable, industrial chemical,

pharmaceutical agent, biologic enzyme
2 high low molecular weight

503

2 3 immediate asthma
bronchospasm
10 - 30 late asthma 3 - 8
bronchospasm immediate asthma
12-36 immediate
late asthma dual asthma

bronchial hyperreactivity
(reversible airflow obstruction)

PEFR
(serial PEFR at and away from work) 9.1 PEFR
PEFR 20 PEFR
PEFR 20
bronchial provocative challenge

9-1 PEFR

504

bronchospasm


9.2.7 (Obstructive Sleep Apnea syndrome, OSA)

pharynx

pharynx

(obstructive hypopnea)


60-90%
erythrocytosis, pulmonary hypertension
corpulmonale
OSA obesity hypoventilation syndrome

OSA OSA obesity
hypoventilation syndrome
OSA
,
(motor coordination)

OSA polysomnography
continuous positive
airway pressure (CPAP)
OSA apnea/hypopnea
polysomnography OSA
OSA

505

9.3

9.3.1 (Silicosis)
1. 5
acute silicosis :
-
-
-
-
-
-
-
2.
ILO (International Labour Organization Classification of Radiographs of
Pneumoconiosis 1980) 1/1 small round nodular lesion /
fibrosis hilar node
3. /

2 3
9.3.2 (Asbestosis)
1.


2.
ILO (International Classification of Radiographs of Pneumoconiosis
1980) 1/1 pleural thickening, pleural plague interstitial
fibrosis
3.
2 3

9.3.3 (Bussinosis)
1.
2
2. grade grade
3
grade 1/2 -
grade 1 -
grade 2 -

506
grade 3 - grade 2
3. spirometry
3.1 grade1/2 2

2
6-8
2 FEV1
10
3.2 grade 3 5
FEV1 FEV1/FVC 80 75

3
9.3.4 (Occupational asthma)
1. high molecular
weight grain dusts low molecular weight acid anhydrides, diisocyanates, antibiotic
powder metallic salt
2. 2
reactive airway dysfunction syndrome (RADS)

3.
4. (4.1) spirometry
reversible airflow obstruction (4.2) bronchial hyperreactivity
methacholine histamine / (4.3) PEFR
PEFR 20 20 (4.4) bronchial
provocative test
4
9.3.5 (Pleural mesothelioma)
1.
20

2. pleural mesothelioma
2
9.3.6 (Lung cancer)
1. , nickel, arsenic,
chromates, 20
2

2

507
9.3.7 (Chronic bronchitis)
1.
2. 3 2
3.
4.
5.
6.
6

9.4

spirometer


1.
2.

3. spirometry spirometer
2
3.1 (forced vital capacity ,FVC)
3.2 1 (forced expiratory volume in one second ,
FEV1)
(1)
4. , arterial blood gases
analysis , diffusing capacity , 6 minutes exercise test Vo2 max

spirometry DLco
9-3
DLco Vo2 max
(predicted values) .






9-3 9-4

508

spirometry
9 - 4

Reference spirometric values for healthy lifetime nonsmokers in Thailand. 2543; 83: 457 466.

9.4.1
disffusing capacity
9-3
disffusing capacity
3
2
1
4

0-9 51
26-50 100
10-25

FVC
FVC
80 %
60 79 %
51%
50 %
predicted
predicted
predicted
59%

predicted
FEV1
FEV1
60 79 %
41
40 %
80%
predicted
predicted
predicted
59%

predicted
FEV1/FVC
FEV1/FVC
FEV1/FVC
FEV1/FVC 75% FEV1/FVC
75%
75%
75%

DLco
DLco >
80%
41 59% 40 %
60 79 %
predicted
predicted predicted
predicted

Vo2 max
Vo2 max
14 ml/( kg. min )
25 ml/( kg. 20 < 24 ml/( 15 < 19
kg. min ) 5.7 ml/( kg. min )
min ) > 7.1
7.1 METS
4.3 < 5.7
METS
< 4.3 METS
METS

509
9.4.2

9 4

1
0 - 9

1.
2. FVC FEV1 80 %
2
10 - 25

1.
2. FVC FEV1 60-79 %
3
26 - 50

1.

2. FVC 51-59 % FEV1 41-59%

4
51 - 100

1. 90
2. FVC 50 % FEV1 40%

9 5

510
9.4.3

9 - 5
1

0-9
1.
2. FEV1 >80
3. FEV1 base line 10-19
4.
10-25
1.
2. FEV1 60-79
3. FEV1 base line 10-30
4. 400-800 g (
beclomethasone )
26-50
1.
2. FEV1 50-59
3. FEV1 base line 10 - 30
4. 800-1000 g (
beclomethasone )

51-100
1.

2. FEV1 50
3. FEV1 base line 10-30
4. 1000 g
(beclomethasone ) /

511
9.4.4

50 1

9-3 9 4
50 ( 4)
Karnofsky scale ( 9-6)

9-6 Karnofsky scale

0
1
2
3
4

0

1-9

10 - 25

26 - 50

(waking hours)
51 - 100

9.4.5

9-3
9 4
restrictive disorders
9 - 7

512
9-7

restrictive

( )

x-ray, CT
chest

9-3 9-4

, ,

, ,

, wheeze,

P2, jugular
venous
distension , right
heart
prominence

: spirometry,
lung volumes,
diffusing capacity,
methacholine
challenge test,
radiographs

cardiac
function,
cor pulmonale

9-3 9-4

9-5

restrictive

, ,
, ,

Chest wall
excursion,
crackles,
clubbing

: spirometry,
lung volumes,
diffusing capacity,
imaging studies

9-3 9-4

,
, ,
, ,

Chest wall
excursion,
crackles,
clubbing,
adenopathy

Bronchoscopy,
pulmonary function
tests, biopsy

-
Idiopathic
cardiac function pulmonary
fibrosis,
asbestosis,
pneumoconiosis
chest wall
disorders
-
Squamous,

adeno, small cell

9-3, 9-4 9-6

 10
:

10.1 (Principles of assessment)

10.1.1 (Interpretation of symptoms and signs)
10.1.2 ( Exercise testing)
10.1.3 (Function capacity)

10.2 (Determination of impairment)

10.3 (Valvular heart disease)
10.3.1

10.4 (Coronary heart disease)

10.4.1

10.5 (Congenital Heart Disease)

10.5.1

10.6 (Cardiomyopathy)
10.6.1 cardiomyopathy

10.7 (Pericardial heart disease)

10.7.1

10.8 (Arrhythmias)
10.8.1
(Criteria for rating permanent impairment due to arrhythmia)

515

10
:

10
(coronary)

10.1 (Principles of assessment)

10.1.1 (Interpretation of symptoms and signs)

(objective)

New York Heart Association (NYHA) functional classification 10 -1
10-1 NYHA functional classification of cardiac disease*

*
I


II

III


IV



*

Criteria Committee of the New York Heart Association. Disease of the Heart and Blood Vessels: Nomenclature and Criteria for
Disease. 6th ed. Boston, Mass: Little Brown & Co; 1964. 7th edition

10.1.2 ( Exercise testing)

MET
(resting metabolic energy) 1
MET 3.5 ml/kg/min. 70 .
1.2 kcal/min 3 METS 4 / .

516
10-2 METS functional class
protocol 2-3
METS
10-2

METS functional class

5 *
1.6 2 3 4 5
6 7
8
9 10
11 12
13 14 15

METS
Treadmill
tests
Ellestad
Miles per hour
% grade
Bruce
Miles per hour
% grade
Balke
Miles per hour
% grade
Balke
Miles per hour
3.0
% grade
0
Naughton
Miles per hour 1.0 2.0 2.0
% grade
0 0 3.5
Clinical
status
Symptomatic
patients
Disease,
recovered
Sedentary
healthy
Physical active
Functinal
IV
III
class
*

3.0
10

1.7
10
1.7
10

5.0
10

4.0
10
4.2
16

3.4
14

2.5
12

3.4
2

3.4
4

3.4
6

3.4
8

3.4
10

3.0
2.5

3.0
5

3.0
7.5

3.0
10

3.0 3.0 3.0 3.0 3.0

12.5 15 17.5 20 22.5

3.4
12

3.4
14

3.4
16

3.4
18

3.4 3.4 3.4 3.4

20 22 24 26

2.0 2.0 2.0 2.0

7 10.5 14 17.5

II

16

I and Normal

Fox SM III, Naughton JP, Haskell WL. Physical activity and the prevention of coronary heart disease. Ann Clin Res. 1971; 3: 404-432.

517
10-3

METS *

, kgm-1 min-1 (Watts)

kg (Ib) 75 150 300 450 600 750 900 1050 1200 1350 1500 1650 1800
(12) (25) (50) (75) (100) (125) (150) (175) (200) (225) (250) (275) (300)
20 (44) 4.0 6.0 10.0 14.0 18.0 22.0
30 (66) 3.4 4.7 7.3 10.0 12.7 15.3 17.9 20.7 23.3
8.0 10.0 12.0 14.0 16.0 18.0 20.0 22.0
40 (88) 3.0 4.0 6.0
6.8
8.4 10.0 11.5 13.2 14.8 16.3 18.0 19.6 21.1
50 (110) 2.8 3.6 5.2
6.0
7.3
8.7 10.0 11.3 12.7 14.0 15.3 16.7 18.0
60 (132) 2.7 3.3 4.7
5.4
6.6
7.7
8.8 10.0 11.1 12.2 13.4 14.0 15.7
70 (154) 2.6 3.1 4.3
5.0
6.0
7.0
8.0
9.0 10.0 11.0 12.0 13.0 14.0
80 (176) 2.5 3.0 4.0
4.7
5.6
6.4
7.3
8.2
9.1 10.0 10.9 11.8 12.6
90 (198) 2.4 2.9 3.8
4.4
5.2
6.0
6.8
7.6
8.4
9.2 10.0 10.8 11.6
100 (220) 2.4 2.8 3.6
4.2
4.9
5.6
6.3
7.1
7.8
8.5
9.3 10.0 10.7
110 (242) 2.4 2.7 3.4
4.0
4.7
5.3
6.0
6.7
7.3
8.0
8.7
9.3 10.0
120 (264) 2.3 2.7 3.3
* : American College of Sports Medicine. Guidelines for Graded Exercise Testing and Exercise Prescription. Philadelphia, Pa: Lea and
Febiger; 1975:17.

(effort) (ability)

10.1.3 (Function capacity)

10-2 10-3

20 70 percentage functional aerobic capacity

percentage functional aerobic capacity

(Left ventricular function)

1. Systolic function

2. Diastolic function

518
(Ejection fraction)
Ejection fraction (EF) 1
EF (echocardiography)
(radionuclide angiography) (left
ventriculography) EF 0.5 EF 0.4-0.5
(mild systolic dysfunction) EF 0.3-0.4 < 0.3
(moderate systolic dysfunction) (severe systolic dysfunction)
(Diastolic dysfunction)
Diastolic dysfunction (heart failure, HF)
diastolic dysfunction diastolic dysfunction
filling pressure HF systolic dysfunction
diastolic dysfunction Doppler echocardiography
10.2 (Determination of impairment)
10-5 10-11
NYHA functional classification ( 10-1)
(anatomy) (physiology)
(functional abnormality) I NYHA functional classification
10-1 1 10-5 10-11
10-5 10-11 NYHA functional
classification

1.

2. reserve capacity

3. LV ejection fraction
80% functional aerobic capacity

519

10.3 (Valvular heart disease)

(congenital) (rheumatic)
(infection) (traumatic factor)
1) (LV) (RV) (pressure
hypertrophy) ( filling pressure)
(myocardial ischemia) LV dysfunction
2) (LV) (RV)
(volume hypertrophy) ventricle (dilatation)
(irreversible myocardium dysfunction) (congestive heart failure)
3) (organ congestion) (inflow obstruction)

4) (cardiac output)

Doppler echocardiography (cardiac catheterization)
(valve gradient)
valve gradient cardiac output
pressure gradient cardiac output 10-4

10-4

Severity of Stenosis
Aortic valve
Mild
Moderate
Severe
Mitral valve
Mild
Moderate
Severe

Mean Valve Gradient

(mmHg)

Valve area (cm2)

<25
25-50
>50

>1.5
1.0-1.5
<1.0

<5
5-10
>10

>1.5
1.0-1.5
<1.0

Doppler echocardiography Doppler echocardiography

aortic root

520
(catheter based)

10.3.1
10-5
10-5

1 0-9

(functional class I; 5 METS;

3-2) (7-10 METS)

(CHF)

ventricular dysfunction dilation stenosis

regurgitation mild METS>7; TMET [Bruce
protocol] > 6

521

2 10-29

3 30-49

4 50-100

(functional
class II)

CHF syncope,
chest pain emboli

cardiac dysfunction /
dilation
METS 5-7, TMET [Bruce protocol] >
3

functional class II

(function class III)

CHF

chamber dysfunction
dilation
METS > 2 < 5, TMET
[Bruce protocol] > 1 < 3

functional
class III

(functional class IV)

CHF

chamber dysfunction
dilation
METS <2, TMET [Bruce
protocol] < 1

functional
class IV

522
10.1

10.2

10.3

0-9
22 mid systolic click late systolic murmur

(pectus excavatum)

(mitral valve prolapse) (LA) (LV)

(mitral valve prolapse syndrome, PMV)

0
T-wave abnormality LA LV
1-9
CHF
LV
ECHO
0-9
38 systolic
murmur

52 / mid-peaking systolic ejection murmur
echocardiogram bicuspid aortic valve radient 22 mmHg valve
area 1.5 . ECG R wave 25 mm ST
depression V5-6
bicuspid aortic valve
ECG
1 - 9
bacterial endocarditis

10-29
66 3


St. Judes bileaflet
3
anticoagulants prothrombin time 3

523

10.4

slightly sustained
apical impulse early systolic murmur grade 1/6 first right intercostals
space closing click
low T waves I, aVL, V5-6 ECG
(apex) valve prosthesis
pulmonary congestion
LV
10 . LVEF = 0.45
calcific aortic stenosis congenital bicuspid aortic valve

20
1) diastolic decrescendo murmur 2)
systole
prosthesis 3)

10-29
63
5

160/50 . 70 / bounding peripheral pulses

mid clavicular line
harsh aortic ejection murmur decrescendo diastolic murmur
grade 3/6 murmur
ECG borderline voltage criteria LVH
pulmonary congestion aortic root
3 leaflet fluttering anterior leaflet
Doppler


20-29




4-2

524
10.5

10.6

30-49
71 thrombocytopenia
2
digoxin
(shortness of breath) 2
2 1

110/80 . 84 /
harsh breath sound
(apical impulse) hyperdynamic anterior axillary line
parasternal heave S1 S2 holosystolic murmur grade
4/6 sternum axilla S3
(atrial fibrillation)
ventricle 80 / T waves LA
upper lobe flail mitral leaflet
Doppler
(peak systolic pulmonary arterial pressure) 50 . LV
LA LV hyperdynamic
flail leaflet
ventricle
40-90

30-49
60 1
anticoagulants digoxin

1 (nocturnal
dyspnea) 6.8 .
110/70 . 80 /

sustained systole anterior axillary line parasternal
heave early systolic murmur grade 1/6
1 sternum

525

10.7

(atrial fibrillation)
ventricle 80 / stage II Bruce protocol
(5 METS)
LA LV upper lobe
LV LA LV systolic function

40-49
50-100
50 2
CHF
digoxin
prerenal azotemia

1
110/70 . 80 /

parasternal heave click holosystolic murmur grade 1/6 apex
(atrial fibrillation)
ventricle 80 / T wave LA, RV LV
Kerly B line
LA LV systolic function
LVEF 0.30
5 .

110/18 . LA = 20 .
45/18 . LV angiogram

70-79

526
10.8

50-100
45 10
digoxin
3

22 /
110/70 . 80 /
v wave
2 parasternal heave harsh systolic
murmur grade 3/6 systole
decrescendo diastolic murmur blowing holosystolic murmur
mid diastolic rumble apex S1
S2 12 . pulsatile
ascites
(atrial fibrillation)
ventricle 80 / QRS T wave
Kerley B line
2 LVEF 0.20
Doppler

70 .

90-99

10.4 (Coronary heart disease)

(spasm)

(ostium)




( 10.6)

527

10.4.1

10-6
10-6

1
0-9

2
10-29

0-9%

50%
METS

(functional class I)

(CHF)
90%
predicted maximum HR, PMHR 3-6
ST segment VT
(
) > 7METs

7 METS

528

3
30-49

(radioisotope)
(fixed)
(dynamic) 50%

(CHF)
(functional class II); METS>5 <7

4

50-100

(fixed) (dynamic) 50%

(CHF)
(functional class III or IV); METS<5

10-6 90%
Heart Rate (beats/min) by Age (y)
30
35
40
45
50
55
60
65
Men
Maximal
193
191
189
187
184
182
180
178
90%Maximal
173
172
170
168
166
164
162
160
Women Maximal
190
185
181
177
172
168
163
159
90%Maximal
171
167
163
159
155
151
147
143
:

Sheffield LH. Exercise stress testing. In: Braunwald E, ed. Heart Disease: A textbook of Cardiovascular Medicine. 3 rd ed. Philadejphia, Pa: WB
Saunders Co: 1988:227

529
10.9

10.10

0-9
55
(total cholesterol 215mg/dL; LDL 135mg/dL; HDL 45 mg/dL) CT
scan calcium score 99th percentile

(heart attack) 62

9 Bruce protocol up-sloping ST depression 1.5 . V5

(echocardiography)
left circumflex (LCx) right coronary (RCA)
diffuse 40% left anterior descending (LAD) 30%, LVEF 0.68
(asymptomatic coronary artery disease)
1-5
(mild atherosclerotic CAD)
CT scan
false positive
(aggressive
secondary prevention program)

0-9
55
exercise thallium stress test



2


(total cholesterol: 365 mg/dl; HDL: 45 mg/dl; triglycerides: 225
mg/dl; LDL: 275 mg/dl) exercise thallium: 9
Bruce protocol 180 /
170 / (1.5 mm ST depression)
thallium scan
50 LAD
RCA LCx 20 30 LVEF
0.65

530

(silent
ischemia)
5 - 9
exercise thallium stress test

10 - 2
90% 3-7
10-7 90%
Heart Rate (beats/min) by Age (y)
30
35
40
45
50
55
60
65
Maximal
193
191
189
187
184
182
180
178
Men
90%Maximal
173
172
170
168
166
164
162
160
190
185
181
177
172
168
163
159
Women Maximal
90%Maximal
171
167
163
159
155
151
147
143
:

Sheffield LH. Exercise stress testing. In: Braunwald E, ed. Heart Disease: A textbook of Cardiovascular Medicine. 3 rd ed. Philadelphia, Pa: WB
Saunders Co: 1988:227

10.11

10-29
50 8
10
(inferior wall MI)
LVEF 0.55
72 .
( 11 .)
Q flat T waves II, III, aVF
152

(recent inferior wall MI)

10 - 19

(anterior wall MI)

531
10.12

10.13

10-29
52
6 (vein
graft) (LAD) (RCA)

(left circumflex artery)
14
300 .

Bruce protocol 10 144 ST segment
10
T wave I, aVL, V4, V5, V6 Q wave

10-19
10-29
48 2
(cholesterol: 245 mg/dl)
66

140/90 76 / ectopic beat

14 172 /

RCA 40
LVEF 0.6
6 24 .
(Holter monitoring) ST segment elevation
(spasm)
ergonovine RCA
(vasospastic angina pectoris)

10-19

(psychological therapy)

532
10.14

10.15

30-49
58 6
(multivessel PCI)

1.5 2
beta-blocker nitrate

ECG: ST segment depression T wave inversion lateral precordial leads;

exercise thallium stress test apex
6.8 METs
80 LAD
LVEF 0.40

30-35

30-49
62 4 13



beta-blocker nitrates
110/70
62 / apical impulse murmurs gallops
ECG low T wave lead 6
118 / 1-2
ST segment depression 1.5 . V4-V6
(native coronary arteries) 90 3
(grafts) RCA, LCx, LAD
diagonal branch LAD LVEF: 0.50

30-39

533
10.16

10.17

30-49
55 6
ECG ST segment elevation
V1-V6, cardiac enzymes (thrombolytic)
2 (phase II cardiac rehabilitation)

20-30
6 ECG
105 / ST elevation <1 . V3-V6
stress echocardiogram Bruce
protocol 5.5 ECG ST segment elevation 4 .
20

98/60 68 / large
sustained impulse lateral nipple
5 anterior axillary line S4 gallops

(anteroapical aneurysm) LVEF 0.35 0.25
LAD LCx RCA
ACE inhibitor, nitrates, furosemide, coumadin
4 beta-blocker ECG ST segment elevation
1 . V2-V6

45-49


aneurysm
50-100
42 (inferior wall MI) 2
anteroseptal wall MI 15
1-10 6
beta-blocker nitrate calciumchannel blocker
120/80 . 54 /
apical impulse sustained
5 anterior axillary line S1 S4 holosystolic murmur
grade 2/6 apex

534

10.18

ECG Q wave II, III, aVF; QS V1-V3; QR V4 low T wave lead

vascular prominent
ST depression I, aVL, V5-V6 2 EF
0.3 0.25 ( multigated blood pool scan)

75-90

50-100
46 4 11

3
(calcium
channel blocker)
110/70 . 92 /
45o apical impulse
sustained anterior axillary line parasternal
heave, S1 S3 holosystolic murmur grade 2/6 apex rales
2
ECG QS V1-V4; Q wave V5-V6; R wave T wave
I, aVL V1-V5 low T wave lead
increased vascular markings
LAD RCA LCx 90
RCA LCx LAD
LCx (ventriculogram)
EF 0.20

90-100

10.5 (Congenital Heart Disease)

(impaired)

(functional impairment)
(radioisotope)
hemodynamic
functional classification 3-1

535
10.5.1
10-8
10-8

1 0-9

(bacterial endocarditis)
(surgical procedures)

right-to-left shunt
left-to-right shunt Qp/Qs < 1.5:1.0

(corrective heart surgery)

2 10-29

(functional class II)

(emboli)
(cyanosis)

right-to-left shunt
left-to-right shunt Qp/Qs < 2.0:1.0
pulmonary vascular resistance
systemic vascular resistance

536

3 30-49

4 50-100

10.19

(functional class III)

right-to-left shunt left-to-right shunt pulmonary flow 2
systemic flow pulmonary vascular resistance
systemic vascular resistance

functional class III cyanosis

leftto-right right-to-left shunt pulmonary vascular resistance

(functional class IV)

pulmonary
vascular resistance systemic vascular resistance
left-to-right shunt
pulmonary flow 2 systemic flow left-to-right shunt
pulmonary vascular resistance systemic
vascular resistance
right-to-left shunt

0-9
25 (atrial septal defect)
10

sternum precordial pulsations

S1 S2 widely split
murmur

537

10.20

10.21

ECG incomplete right bundle branch block

shunt color Doppler flow pulmonary
artery pressure (PAP)

5
left-to-right PAP
6-9

0-9
22 systolic murmur left sternal border
2 18
pulmonary artery 20 . PAP cardiac output
shunt
cyanosis precordial heaves,
thrills, taps S2 systolic
murmur grade 3/6 S2 2 early
systolic click diastolic murmurs gallops
ECG

9
Doppler ECHO > 40
. ECG
(ventricular septal defect)
1 (bacterial
endocarditis)
anomalous venous return
1
10-29
42 tetralogy of Fallot 15
pericardial patch right ventricular outflow tract
(RVOT) VSD

110/70 . 70 /
precordium S1 S2 mid-diastolic
scratchy murmur ejection systolic murmur grade 2/6 2
3

538

10.22

ECG: right bundle branch block apical prominence

RVOT (
8 .) right ventricular systolic pressure 30 . Doppler study
shunt
Tetralogy of Follot VSD
15-20
shunt conduit
prosthesis pulmonary outflow tract

10-29
35 systolic murmur



cyanosis
cyanosis 15 . large v wave
12 . precordial thrills, taps heaves
sharp sound early systole left sternal border
S2 early diastolic sound midprecordium holosystolic
murmur left sternal border
ECG right bundle branch block, R wave V1 broad notched P
wave III, aVF T waves V1-V2 premature atrial beat
sternum, pulmonary
vasculature Ebsteins
anomaly
Doppler study right-to-left
shunt 7 . V wave 15 .
RVP PAP shunt
Ebsteins anomaly
25
right-to-left shunt


(exercise testing)
functional class

539
10.23

10.24

30-49
52 Ebsteins anomaly
2-3


(ascites)

14 . pulsatile
precordial: active parasternal area heaves
early systole sound left sternal border widely
split early diastolic sound holosystolic murmur
sternum diastolic murmur
left sternal border
ECG right bundle branch block, R wave V1, prominent P wave
sternum pulmonary
vasculature
Ebsteins anomaly Doppler study right-to-left shunt

Ebsteins anomaly
40-49
30-49
20 Blalock-Hanlon Mustard
transposition of the great vessels 10


cyanosis prominent a wave
precordium parasternal apical
heaves holosystolic murmur left sternal border S4
ECG R wave precordial leads lead
intra-atrial baffle
2
12 . a wave 20 . systolic RVP PAP 30-35 .

Transposition of the great vessels Mustard procedure

40-49

540
10.25

10.26

50-100
35 Tetralogy of Fallot
Blalock-Taussig systemic pulmonary artery ligate
2 RVOT
VSD 2


v wave 14 . parasternal cardiac activity
sustained heave holosystolic murmur grade 3/6 left sternal border
mid-diastolic murmur 2

ECG right bundle branch block

RVOT obstruction residual VSD
Tetralogy of Follot VSD

80-90
50-100
23 Eisenmengers complex 10
VSD pulmonary vascular resistance
systemic vascular resistance

cyanosis prominent a wave

45o forceful, sustained
parasternal heave S2 narrowly split component 2
early systolic ejection murmur left sternal border
ECG: peak P wave II, III, aVF
(prominent)
pulmonary vascular markings peripheral
Eisenmengers complex VSD pulmonary vascular resistance
95-100

541

10.6 (cardiomyopathy)

(ventricle) 3
1) (systolic dysfunction)
2) (diastolic dysfunction)
3)


(hypertrophic cardiomyopathy)
(left ventricular outflow tract obstruction) (mitral regurgitation)
(angina)
cardiomyopathy


cardiomyopathy
3
1. (dilated congestive cardiomyopathy)
2. (hypertrophic cardiomyopathy)
3. (restrictive cardiomyopathy)
cardiomyopathy

(echocardiography)
10.6.1 cardiomyopathy
10-9
10- 9 cardiomyopathy

1 0-9

(congestive heart failure)

2 10-29

542

3 30-49

4 50-100

10.27

(functional class II)

(functional class III IV)

0-9 cardiomyopathy
31
(detoxification center)





(left ventricular ejection fraction, LVEF) 40

(alcoholic cardiomyopathy)
5-9

543

10.28

0-9 cardiomyopathy
26
3
(sinus tachycardia)
LVEF 0.3
digitalis
6


110/70 .
70 / ventricular heave


LVEF 0.55 95%
LVEF 0.5
(postpartum cardiomyopathy)
9

LVEF
9

10-29

10-29 cardiomyopathy
28
(septal myectomy)
2

130/70 .
70 / carotid (brisk carotid
pulse) sustained apical impulse soft mid systolic murmur grade 1/6
sternum S4 gallop
prominent Q waves, high voltage
(ventricular
septum) (posterior ventricular wall)
Doppler

544

10.30

10.31

(LVOT) 10 .
24 . (Holter monitor)
(ventricular tachycardia)
(hypertrophic cardiomyopathy)
septal myectomy
20
septal myectomy

Holter monitor (antiarrhythmic agent)

10-29 cardiomyopathy
59

digitalis ACE inhibitor

ACE inhibitor

120/80 . 70 / precordial impulse
sustained anterior axillary line parasternal heave
S1 S2 S3
small R waves, low T waves lateral chest leads


40 75
functional aerobic capacity

25
30-49 cardiomyopathy
38 3 HIV
5 ACE inhibitor (functional
class II)

545

10.32

10.33

2

130/80 . 88 /
(jugular venous pressure)
murmur gallops
congestion (stress
testing) 3.8 ST depression 1 .

30 (grade 1/4) (cardiac catheterization)

infiltration (infiltrative cardiomyopathy)
HIV (HIV cardiomyopathy)
40 - 49
HIV
30-49 cardiomyopathy
54
3

end-diastolic pressure 28 . LVEF0.3
ACE inhibitor


110/70 . 70 / JVP
apical impulse sustained anterior
axillary line early diastolic impulse S1 S2
T wave lead QS pattern lead V1, V2


LVEF 0.3
(idiopathic cardiomyopathy)
49

50-100 cardiomyopathy
62 2

(hypertrophic cardiomyopathy)
murmur

546

10.34

dual
chamber 6
150/90 . 50 /
carotid 2 (brisk and bifid)
sustained triple impulse
(septal
hypertrophy) LVEF.70
aorta 70 .
anterior leaflet
sinus bradycardia

(severe hypertrophic cardiomyopathy)

70 - 79

(dilated cardiomyopathy)
(septal myectomy)

50-100 cardiomyopathy
47 3

1 25 ACE inhibitor

rale 2 apical
impulse sustained holosystolic
murmur 2/6
sinus rhythm 90 / QRS complex
lead QS pattern lead II,III,aVF
(pulmonary venous hypertension)

32 amyloidosis
amyloidosis (cardiac amyloidosis)
80 - 89
amyloidosis

547

( )
non-sustained

10.7 (Pericardial heart disease)

(1) (systemic illness) lupus
erythematosus (2) (mechanical forces)
(3) (idiopathic pericarditis) (4) (5)
(post-pericardiotomy syndrome)
(recurrent pericarditis)
(pleuritic chest pain)

ESR (Erythrocyte Sedimentation Rate)
constrictive pericarditis



tamponade
(recurrent pericarditis) tamponade
acute
illness

pericardial friction rub

early diastolic pericardial knock
(Computerized
Tomography-CT) (Magnetic Resonance Imaging-MRI)

548
10.7.1
10-10
10-10

1
0-9

2
10-29

3
30-49

4
50-100

(pericardial window)

(functional class II)

constrictive physiology

hemodynamics

(functional class III-IV)

549
10.35

10.36

10.37

0-9
28 15
pericardial friction rub

0
(constrictive pericarditis)

0-9
64

0

10-29
32 pleuritic
1
ESR

autoimmune
1
4-6 10
murmur
pericardial rub
T wave

(recurrent idiopathic pericarditis)

15

550

salicylates,
NSAID, colchicines

10.38

10-29
60 (pericardectomy)
(constrictive pericarditis) 1

pulsus paradoxus

LVEF 0.5 mitral inflow amplitude
early diastolic filling (constrictive physiology)

20 - 29

10.39

30-49
45
10 furosemide

12 .
ventricular heaves thrill, S1 S2
rub
QRS T wave lead


LVEF 0.4 early diastolic filling
wave amplitude mitral inflow 50

30 - 39

551

30-39

10.40

30-39
48
2-3 1

(constrictive physiology)
(effusive-constrictive physiology)

30 - 39

10.41

50-100
62


1

20 . 2+
ventricular heaves, thrill
tap precordium murmur
QRS T wave
(distention)
LVEF 0.55 Doppler

80 - 89

552
95-100

10.42

50-100
47
2
furosemide 160 . 2 digitalis
nitrate (compression stocking)

114/80 . 85/45 .


2+
LVEF 0.30


(congestive hepatomegaly)

2
90 - 100
4

10.8 (Arrhythmias)

sinus node 1
(conduction defect arrhythmia)
(structure
and function)

553
10.8.1
(Criteria for rating permanent impairment due to arrhythmia) 10- 11
10-11

1
0-9

2
10-29

3
30-49

(atrium) (ventricle)
50-100 / ectopic beats
3 asystole 1.5

(organic heart disease)

(Implantable Cardiovertor -Defibrillator-ICD)

/
presyncope (low cardiac
output)

ICD

554

4

50-100 (functional class III /IV)

ICD

10.43

0-9
56 frequent premature beat

premature beats
atrial premature complexes
0

10.44

0-9
21
3
110 / 110/65 .
85/40 .
3

orthostatic hypotension vasovagal syncope

0

555
10.45

10.46

10.47

10-29
62 (atrial fibrillation) 1
75 /

75 /

(atrial fibrillation)
(controlled ventricular response)
15

10-29
52 8
(complete heart
block)

120/80 . 72 /
murmur

72 / (premature
ventricular beats)

Adams-Stroke attack

20
30-49
44 5-15
vagal maneuver

verapamil 240 ./ verapamil 360
./ 13

86 /

556

10.48

10.49

Holter supraventricular tachycardia

155 / reentry
AV node atroventricular nodal reentry tachycardia (AVNRT)
reentry AV node

30

49
30-49
58
3
(ICD)
5 45

80 /

(sustained ventricular tachycardia)
40 - 49

()
1 / ()
()
50-100
38 10

(CPR) 30
5
quinidine 300 . 6 procainamide 350 . 4
propranolol 160 . 2
verapamil

557

10.50

systemic lupus erythematosus (SLE)

200-250 /
(electrophysiologic study)
(ventricular tachycardia)

(recurrent ventricular tachycardia)

70 - 90

50-100
42
8

75 - 90

558
10-12

(

)

( )
-
(cardiac
output)

(rhythm)

(
)

10-5

559
10-12

(

)

hemodynamics

(

)

10-6

10-8

tetralogy of Fallot ,
Ebsteins

Eisenmengers

10-9

(
restrictive
cardiomyopathy
)

560
10-12

-
-
ESR

(pericardial rub, early

diastolic pericardial
knock)

(

)

(

)

tamponade

(VT)
(AF)

(premature
complexes)

10-10

10-11

561

11
:

11.1
11.1.1

11.2
11.2.1

11.3
11.3.1

11.4

563

11
:

10 10-1

11.1
JNC-6 (The sixth report of the Joint National Committee on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure: JNC-6)
(systolic blood pressure) 140 .
(diastolic blood pressure) 89 ( 11-1:
JNC-6)
11-1

1
2
3

<120
<130
130-139 140-159
160-179
> 180

<80
<85
85-89
90-99
100-109
> 110
*
6 (JNC 6)

29

564
11.1.1



11-2

11.2

1 0-9

1 2

2 10-29 1 2

:
(1)
blood urea
nitrogen (BUN) serum creatinine
(2)
copper silver wiring

exudates

565

3 30-49 3

:
(1)
blood urea
nitrogen (BUN) serum creatinine creatinine
clearance 20-50%
(2) (LV hypertrophy)
echocardiography

4 50-100
1-3

(1)
blood urea
nitrogen (BUN) serum creatinine creatinine
clearance <20%
(2)
(encephalopathy)

(3)
/

11.1

0-9

55 5
angiotensin II

105/78 .

0 3

566

11.2

0 - 9

26 18

1
160/95 . 160/95 .
1


(BUN, serum creatinine)

1 3

11.3

10-29

44 (obstructive sleep apnea)

ACE

145/90 . silver wire

1
10 15

(obstructive sleep apnea)

echocardiogram

567
11.4

11.5

10-29

40 32
3 12
150/100 160/105 .

electrolyte, BUN creatinine

2+ 2
high power field 24
1,400

15

30-49

48


170/95 . 64 /
(light reflex)

exudates (disk) sustained impulse

(S4 gallops)
R wave T wave lateral
chest lead

30-39

568
11.6

11.7

30-49

55 ACE

(S4) sustained apical impulse

II/IV

30-39

() ()
()

50-100

48 2 8
260/160
.

(papilledema)

120 .
3
T wave lateral chest leads
BUN 111.3 / (40 ./.), creatinine 203 / (2.3 ./.)
3+

(hypertensive encephalopathy)
55

569
11.8

50-100

62 10
2

6

180/100 .

exudates
anterior axillary line
(S3, S4) crepitation

S wave lead V2 , R wave lead V5-V6 , T wave

lead I, aVL V4-V6
BUN, creatinine

LVEF 0.3

80


10
4

10
4

11.2

(atherosclerotic dilatation)
diffuse atherosclerosis

advanced imaging (MRI)

570
(CT scan) (transesophageal echocardiography)

(atheromatous emboli)

11.2.1

11-3
11-3

1 0-9

2 10-29

3 30-49

4 50-100

(functional
class 3-4)

571
11.9

11.10

11.11

0-9
60

45 .

(Ectasia of the ascending aorta)
0
(aortic ectasia)
(aortic aneurysm)

0-9
55

(abdominal aortic aneurysm)

3.9 .

0-5

10-29
60
5

graft

10-15
graft
graft

572
11.12

11.13

10-29
50 mixed connective tissue disease

88 / 130/50 . diastolic murmur grade 1/6

proximal ascending
aorta 50 .
proximal ascending
10-20
aortic aneurysm

30-49
48
atherosclerosis 2
(blue toe)

(deep vein thrombosis, DVT)

shaggy atheromatous descending thoracic aorta mobile

atheromatous plaque 0.5x1.5 .
ascending sinotubular junction 54 .

ascending aorta
descending

30-40

573
11.14

11.15

30-49
54 ascending aorta
48 .
descending aorta

1.5
(PND)
140/45 . 92
diastolic murmur 3/6
apical impulse heave

3
58 . (LVEF) 0.62
ascending
aorta 54 .
5.2 Bruce protocol 144

ascending aorta
30-49

50-100
62
(dissecting proximal aortic aneurysm) 2 valved
conduit
ACE

1

150/85 . 96 diastolic murmur
4/6
graft

574

60-70
valved conduit
( 3)

11.16

50-100
52 atherosclerosis
2
8
( 1 )
(intermittent claudication)

livedo reticularis
(embolectomy)

(atheroemboli)
atherosclerosis

60 80

atherosclerosis aorta

11.3
(peripheral vascular disease, PVD)

(1) :
(intermittent claudication)
(gangrene)
(Raynauds phenomenon)
(2) :
(stasis dermatitis)
(3) (lymphedema)

575

thromboangiitis obliterans varicose vein

noninvasive

1
( 2 10% 5
)
(blanching)
(cyanosis) (erythema)

(objective testing)
(finger/brachial index) 0.8

(Doppler flowmetry)
microcirculation (real time)

11-4

2-4 (Combined Value Chart)
11.3.1

11-4
11-5

0.6 2-3

0.4 3-3

576
11-4

1
0-9

2
10-39

(claudication) (rest pain)

(Raynauds symptom)
( finger brachial indices 0.8
laser
Doppler signal )
/

( finger
brachial indices 0.8
laser Doppler signal
)
/

577

3
40-69

4
70-89

5
90-100

11.17

0 - 9
25 Raynauds phenomenon 1

0
(32 ) prazosin 1

Finger/brachial index 0.6

Raynauds phenomenon

5-9

578
11.18

11.19

10 - 39
58
(arteriovenous fistula, AV fistular)
gangrene

gangrene

gangrene
gangrene
35-39

40 - 69
45 Raynaud scleroderma 9

conservative prazosin

finger / brachial 0.6 laser Doppler

(microcirculation)
scleroderma Raynaud

55 25
(5% ) (2% )
2 7%
( 16.2)
(55% 7%) 58
35
2 25 15

49

579

Raynaud
3
2

11.20

90 - 100
48
2

100

11-5 (lower extremitry)

1
0-9

2
10-39

580

3
40-69

4
70-89

5
90-100

11.21

25-100

25

2
2

> 2

> 2

0 9
48 (CABG)

1

(venous plethysmography)

0-9

() () ()

581
11.22

11.23

11.24

10-39
36 8

(dermatophytosis) 4-8

(
)

20

10-39
48 gangrene 1

gangrene
20-30

40-69
54
gangrene

6 gangrene

582

60-69

11.25

70-89
24 3
1 skin graft

80

11.26

70-89
62

(transcutaneous oximetry)

80-89

11.27

90-100
56 3
arteriosclerosis obliterans 9
25

creatinine
407 (11.6 /)

583

ankle brachial index (ABI) < 0.3

arteriosclerosis obliterans

95

11.4
(primary pulmonary hypertension)


( )

right ventricular lift

(ECG strain)
(pulmonary arterial
pressure, PAP)

11.4.1

584
11-6
()

1 0-9

2 10-29
3 30-49

4 50-100

11.28

(PAP 40-50 .)
Doppler 3-3.5 /

(PAP 51-75 .)
(PAP >75 .)

( 2)

(PAP > 75 .)

(class 3 4)

0-9
43 ( 29)

45 .

0-5

585
11.29

11.30

11.31

0-9
48 35




45 .
120
FEV1 55

10-29
58 5

1/6

55
.

10-15

10-29

38
24.6 55

586

11.32

11.33

60 . 110

15-20

30-49
38 2 2

heave
70 .
120


( 2)
30-40

30-49
58 5

heave
55 .
140 .

3

587

40-49

11.34

50-100
42 80 .
120 .

RV heave P2
70 .

50-70

11.35

50-100
37 scleroderma CREST


scleroderma

58 .

3.5
115
scleroderma

70-90

588
11.7

11-7

. )

589

11-2

11-3

(dissection)

(atherosclerosis)
(
)

silver wire

(arterio-venous
crossing)

590
11-7
()

/Doppler

591

11-4 11-5

Raynaud

gangrene
thromboangitis obliterans

11-6

593

12

12.1
12.1.1
12.1.2

12.2
12.2.1
()
12.2.2 (colon, rectum and anus)
12.2.3
12.2.4

595

12

12.1
3
1.




2.
/
3.

1)
Helicobacter pylori

2)

3)

4)
metallic stent

596

12.1.1

portal hypertension
(esophageal varices)
(hepatic encephalopathy) (hepatorenal syndrome)

incarceration strangulation Omentum

inguinal femoral incarceration strangulation

597
12.1.2



1) fluoroscope

2) cytology
3) pH , manometric
study
4)

1) Imaging fluoroscopy

2)
cytology 3)
4)
5)
6) urea breath test

1) Fluoroscopy
2) video capsule enteroscope
3)
4) stool fat , D xylose test, C14 breath test
5)

1)
2) CT scan
3) fine needle aspiration
4) glucose tolerance test
5)
6) secretin test

1) colonoscopy
2)
3)
4) fluoroscopy
5)

598

1)
2) ERCP
3) CT scan , MRI MRCP
4) scan
5) angiography
6) biopsy fine needle aspiration
7)
8)
12.1.3


1.

2.
1 2

12.2

12-1
(.)
15-24
(.)
155 156
49
157 159
50
160 161
51
162 164
52
165 166
53
167 169
54

25-65
(.)
51
53
54
56
58
59

599
(.)
170 171
172 174
175 176
177 179
180 181
:

15-24
(.)
55
56
58
60
62

25-65
(.)
60
63
65
66
68

Bunnag S, Piampitis. Average weights by height of Thai adult. JMAT 1979. 62:579-588

12- 2
(.)
145 146
147 149
150 151
152 154
155 156
157 159
160 161
162 164
165 166
167 169
170 171

15-24
(.)
42
43
44
45
46
47
48
50
51
52
53

25-65
(.)
46
47
49
50
51
52
53
55
57
59
61

Bunnag S, Piampitis. Average weights by height of Thai adult. JMAT 1979. 62:579-588

12.2.1
()
12 - 3

600
12- 3

1
0-9

2
10-24

3
25-49

4
50-75

-
-

- 10

-

- 10-20

- 20

601
12.1

0 9
44 9

65 .. 168 .
UGI study hiatal hernia
Hiatal hernia, Uncomplicated
0

12.2

0 - 9
28 5

2
175 . 65 ..



endoscopy duodenum 1 .
H. pylori triple therapy urea
breath test 8
Resolved peptic ulcer disease associated with H. pylori infection
0
H. pylori duodenal ulcer 95-100 70-80
gastric ulcer

12.3

0 - 9
25
1
1

160 . 59 ..
albumin cholesterol
Small bowel resection with no malabsorption
0

602
12.4

12.5

12.6

0 - 9
40 serum
amylase 1 2 3 2

Recurrent acute pancreatitis

5


10 - 24
59
5

8
7.5

corkscrew configuration diffuse spasm
manometry
Diffuse spasm of the esophagus
15
10
calcium channel blocking
agent 70-80
Gastroesophageal reflux disease 10 - 24
43 2

omeprazole

3 squamous
epithelium
Moderately severe gastroesophageal reflux disease without stricture
15

603

12.7

10 - 24
40
10 3 2

7

3 .
Recurrent duodenal ulcer with bulb deformity
15

12.8

10 24
46 2

60

bile salt diarrhea

Tuberculosis of the terminal ileum with chronic diarrhea

15

5

604
12.9

12.10

12.11

10 - 24
35 2-3

expanding cyst subtotal pancreatectomy
pancreatic enzyme 15
glucose
tolerance test
49 .. 168 .

Status post subtotal pancreatectomy consequent to trauma, residual exocrine
pancreatic insufficiency
20
exocrine pancreatic function
20
25 - 49
49
5


13.5 vital signs
widening mediastinum.
constriction

bougie balloon
2
Achalasia of the esophagus
30


10 esophagomyotomy
25 - 49
50

15

605

12.12

12.13

160 . 45.5 .
15
70

Postgastrectomy dumping syndrome

30

25 - 49
28 4
3
regional enteritis terminal ileum


10

Recurrent regional enteritis, with intestinal malabsorption and recurring obstruction
after ileal resection
40
parenteral nutritional therapy

25 - 49
45 cholecystectomy subtotal pancreatectomy
chroni pancreatitis


pancreatic enzyme
15


CT scan pancreatic calcification ERCP

Chronic pancreatitis with intractable pain and both endocrine and exocrine
insufficiency
40

606

total pancreatectomy

12.14

50 - 75
58 complete esophageal obstruction
tumour recurrence
stenosing esophagitis
gastrostomy
170 . 46 ..

Stenosing esophagitis
65 stenosing esophagitis 15
gastrostomy combined values chart
70

20

12.15

50 - 75
62

175 . 52.7 .

Postoperative absence of the stomach with esophagojejunal anastomosis; secondary
nutritional deficiency
60

20

607
12.16

12.17

50 - 75
69
5 Intestinal
infarction 20
malabsorption syndrome

163 . 40 .. 25
malabsorption
Intestinal malabsorption due to extensive small bowel resection
75

malapsorption 25

50 - 75
47 13

cystic adenoma pancreas total pancreatectomy
duodenectomy (whipple operation)
malabsorption syndrome steatorrhea
pancreatic enzyme
insulin
25
25
malabsorption DM
Pancreatic insufficiency consequent to total pancreatectomy
70 total pancreatic insufficiency

608
12.2.2 (colon, rectum and anus)

12-4
12-4 (Colon, rectum)

1
0-9

2
10-24

3
25-49

-
-

-
-

-

-

609

4
50-75

12.18

12.19

0 9
50 part time

(proctosigmoidoscopy)

diverticulosis sigmoid colon

diverticulitis
Irritable bowel syndrome with diverticulosis coli
0

10 - 24
22 ulcerative colitis 5

rectosigmoid

granularity punctuate friability rectosigmoid

Idiopathic ulcerative colitis, mild, limited to the rectosigmoid segment
15

610

12.20

25 - 49
32 Crohns disease 19

20
Crohns disease

Chronic, recurrent enterocolitis (Crohns disease)

45 enterocolitis

12.21

50 - 75
45 chronic ulcerative colitis 15







20

sclerosing cholangitis
cirrhosis
Chronic ulcerative colitis, severe; sclerosing cholangitis with cirrhosis
60 ulcerative colitis

611
)
12-5
12-5

1
0-9

2
10-19

3
20-35

12.22

-
-

-
-

0 9
45 5

Proctosigmoidoscopy
Healed anal fistula
0

612
12.23

12.24

10 19
32 Crohns colotis 14
pararectal anal fistula
rectovaginal fistula

Inactive perianal disease

colonoscopy Crohns colitis rectum colon
Chronic anal fistula with moderate impairment of anal function, associated with
Crohns disease of the colon
10

rectovaginal
fistula


20-35
56 pararectal abscess 10 3
4

Anal incontinence due to complete loss of sphincter function

25

enterocutaneous fistula ()
enterocutaneous fistula
enterocutaneous fistula GI tract, biliary tract
(stoma)

6

613
12-6 enterocutaneous fistula

enterocutaneous fistula
Esophagostomy
10-15
gastrostomy
10-15
Jejunostomy
15-20
Ileostomy
15-20
Colostomy
5-10
ileal pouch anal anastomosis
15-20
12.2.3

12-7 12-8
.
12- 7

1
-
0 14
ascites esophageal varices
3

- bilirubin metabolism
2
-
15 29
ascites esophageal varices
3

-
3
-
30 49
ascites esophageal varices 1

- hepatic encephalopathy

614

4
50 95

-
esophageal gastric varices
hepatic encephalopathy

.
12 - 8

1
-
0 14
2
-

15- 29
3
-
30 -49
(cholangitis)
4
-
(common bile duct)
50 -95
12.25

0 - 9
30
5 delirium

penportal fibrosis

2

AST
History of acute alcoholic hepatitis and steatonecrosis, with residual slight
hepatomegaly, probably due to fatty metamorphosis and portal fibrosis
0

615
12.26

12.27

15 29
35 10




telangiectasia 4
firm 1
2.1 mg/dL 40 g/L AST 160 U/L HBsAg Anti
HBe chronic active hepatitis cirrhosis
Chronic active hepatitis
15
chronic active hepatitis
6
3 4
C

30 - 49
46
2
alkaline phosphatase
antimitochondrial antibody

xanthomata
alkaline phosphatase 4 bilirubin
5 mg% antimitochondial antibody
fibrosis Primary biliary cirrhosis
Primary biliary cirrhosis
40
Primary biliary cirrhosis
4

616
12.28

50 - 95
55 5






Biliary cirrhosis, secondary to recurrent and progressive obstruction of bile ducts
85

12.2.4

12-9
12- 9

1
-
0-9

2
-
10-19

3
-
20-30

617
12.29

12.30

12.31

0 9
56 3

Uncomplicated incisional hernia

0
incisional hernia

10 - 19
49 inguinal



inguinal area

Reducible right indirect inguinal hernia

10

inguinal hernia

20 - 30
65 inguinal hernia 2
3 2 1

Recurrent bilateral inguinal hernia after unsuccessful herniorrhaphy

30
inguinal hernia

619

13

13.1
13.1.1
13.1.2

13.2
13.2.1

13.3 (urinary diversion)

13.3.1

13.4 (urinary bladder)

13.4.1

621

13

pons bladder
hyperreflexia pons
hyperreflexic bladder detrusor sphincter dyssynnergia
vesicoureteral reflux hydronephrosis
lumbosacral injury
T10

13.1
(ureter)
(urethra)
renal calices, pelves, ureters

voluntary sphincter
voluntary sphincter propulsive muscles seminal ejaculations

622
(urinary diversions)
diversion



13.1.1

, (ectopic urinary opening),
(periurethral mass)
13.1.2
(serum creatinine)
creatinine clearance

1.5 ./. (133 /)
(glomerular filtration rate)
24
creatinine clearance 90 139 / (130 200 /24 .) 80 125 /
(115150 /.)
isotope
renograms , urine
osmolalities, x-ray computed tomographic (CT) scan

endoscopy 1 2 arteriography
CT scan magnetic resonance imaging (MRI)
cystoscopy, cystography, voiding
cystourethrography, cystometry, uroflometry,
urethroscopy, urethrography, cystourethrography,
endoscopy cystometrography

623

13.2
13.2.1

13-1 creatinine clearance

13-1

0-14

creatinine
clearance 52-62.5
./ (75-90 /24
.)

15-34

creatinine
clearance 42-52 ./
(60-75 /24 .)

35-59

creatinine
clearance 28-42 ./
(40-60 /24 .)

60-95

creatinine
clearance 28
./ (40 /24 .)

creatinine clearance
52 ./ (75
/24 .)

creatinine clearance
42-52 ./(60-75
/24 .)

creatinine
clearance 28-42 ./
(40-60 /24 .)

peritoneal dialysis
hemodialysis

624


2
10%
( Combined Values Chart 604)
(dialysis)
(peritoneal dialysis) (hemodialysis)
60-95% 4 7-1

15-34% 2

( 1-2) 0-5%
1

Cushing osteoporosis steroids
Combined Values Chart 604

13.3 (urinary diversion)

13.3.1

13-2
13-2

ureterointestinal
cutaneous ureterostomy
nephrostomy

10%
10%
15%

625

13.4 (urinary bladder)

13.4.1
13-3
13-3
1
2

0-15%
16-40%

*
*

41-70%

(poor reflex
activity
,
)
/

urodynamics (reflex or areflex

bladder on urodynamics)

* ( 2 ),
(severe nocturia; 3 )

13.5 (urethra)
13.5.1
13.4
13-4
1

0-10%

2
3

11-20%
21-40%

627

14

14.1 (Penis)
14.1.1
14.1.2

14.2 (Scrotum)
14.3 (Testis, epididymis and spermatic cords)
14.4 (Prostate & seminal vesicles)

629

14

(Male reproductive organs)

1. (penis)
2. (scrotum)
3. (testis and epididymis)
4. (spermatic cord)
5. (prostate glands)
6. (seminal vesicles)
40 50% 65
50%
20 35
20% + 0.5 (20%) = 30%

14.1 (Penis)


14.1.1
(erection) (sensation) (ejaculation)

14.1.2
(penile tumescence studies, Doppler ultrasound penile blood flow evaluations, dynamic cavernosometry
cavernosography, and angiography)
14-1

1


0 15
2

16 - 29

3

30 - 35

630

14.2 (Scrotum)


-
-
-
-
-
14-2

1
0 - 10
2
11 - 20

3
21 - 35

14.3 (Testis, epididymis and spermatic cords)

epididymis spermatic cord

631

vasography, lymphangiography, ultrasonography, biopsy, semen analysis

hormone follicular stimulating hormone, luteinizing hormone testosterone
14-3

0 15

16 - 29

3
2
30 - 35

14.4 (Prostate & seminal vesicles)

(oligospermia)

632
(hemospermia)

urethrography, cystourethroscopy, prostatic ultrasonography, vasography, biopsy, prostatic fluid

examination, PSA (prostatic specific antigen)
14-4

1
0-15

2
16-29

3
30-35

/
/

/
(ablation or extirpative surgery)
:

633

15

15.1
15.1.1

15.2
15.2.1

15.3
15.3.1

15.4

635

15

(Female reproductive organs)
1.
2.
3.

15.1




15.1.1
1.
2.
3. /
4. /
5. (colposcope)
15- 1

1


0 - 15

2

16-25

636

3
26-35

15.1

15.2

15.3

0-15
35 3
active dermatitis


dermatitis

dermatitis of vulva; intertrigo
5
16-25
32 rectovaginal fistula 2
(severe vaginal stenosis)
3

severe postoperative vaginal stenosis

25
26-35
30 2
vesicovaginal fistula, rectovaginal fistula, severe vaginal stenosis

2 5

Vesicovaginal fistula, rectovaginal fistula and severe vaginal stenosis

637

35

15.2




15.2.1
1.
2.
3. /
4.
- /
- (Ultrasonography)
5.
- (colposcope)
- (hysteroscope)
-
-
-
15-2

1
0-15

2
16-25

638

3
26-35

15.4

15-5

15.6

0-15
42 14 3
1
38

Asymptomatic subserous uterine leiomyoma

0-15
60 adenomyosis 20

vaginal vault prolapse, cystocele rectocele

Posthysterectomy vaginal vault prolapse

15

pessary 2
16-25
32 partial cervical stenosis
2-4
2 38

639

Incomplete cervical stenosis

16

15.7

26-35
34

3 12-16

Large, prolapsed uterus
(Pap smear)
Partial cervical absence and incompetence; uterine prolapse
30

15.8

26-35
28 I B

status post hysterectomy secondary to treatment of invasive cervical squamous cell

carcinoma
30

15.3

15.3.1
1.
2.
3. /
4.

640
5.
- (laparoscope)
-
-
- /
15- 3

1
0-15

2
16-25

3
26-35

15.9

0-15
28 6
40-60 12
2

Irregular ovulation secondary to hypothalamic-pituitary dysfunction
5

641
15-10

15.11

15.12

16-25
27 2 severe pelvic
endometriosis

recurrent endometriosis

Recurrent pelvic endometriosis

20
26-35
32 2

2
2
2
status post bilateral salpingectomy
30
26-35
27 Wilms tumor radical nephrectomy

5
nephrectomy

primary ovarian failure
Infertility due to primary ovarian failure
30

15.4
2
1. (carcinogenic substance)

642
2. (teratogenic substance)

15.5

Maslow
5
1.
2.

3.

4.
5.

643

16

16.1
16.1.1

16.2 Polycythemia ()
16.2.1 Polycythemia vera (P. vera)
16.2.2 Polycythemia ()

16.3
16.3.1
16.3.2
16.3..3
16.3.4

HIV

16.4 myelofibrosis
16.4.1 myelofibrosis
16.4.2 myelofibrosis

16.5 (Hemorrhagic disorders)

16.5.1

16.6
(thrombotic disorders)
16.6.1 Inherited Thrombotic Disorders
16.6.2 Acquired Thrombotic Disorders
16.6.3

645

16

(hematopoietic system) (bone marrow)

, , (lymphoid tissue)

16

16.
complete blood count, (aspiration/biopsy), hemoglobin electrophoresis, immunochemistry,
cytogenetics, Coombs test, flow cytometry hemostasis studies

16-1
16-1

1.

2.

3.

4.

646

16.1

3
(1)
(2)

(3) (compensatory mechanism)

, 12

demyelinization 12
extramedullary hematopoiesis 2
osteopenia


() erythropoietin


16.1.1
16-2

647
16-2

1
0-10
2
11-30
3
31-70
4
71-100

10 12 /*

# 8 10 /*

# 58 /
* 1 2
# 58 /
* 1 1

*
#
1

16.1

0 - 10
18

Hemoglobin 12 gm/dl., MCV 65 fl., Hemoglobin typing: A2A, A2 = 4%

Beta thalassemia trait
0

16.2

0 -10 rheumatoid arthritis

48 rheumatoid arthritis 10
aspirin NSAID prednisolone

2 rheumatoid arthritis
Hemoglobin 10.2 gm/dl., hematocrit 31%, MCV 79 fl. Serum ferritin 110 ng/ml,
Rheumatoid factor positive

Anemia with rheumatoid arthritis

648

16.3

16.4

5-10
rheumatoid arthritis
rheumatoid arthritis
rheumatoid arthritis chronic inflammation
serum ferritin
anemia of chronic
disease
11 - 30 autoimmune hemolytic anemia
59 2



Hemoglobin 9.5 gm/dl., hematocrit 29%, MCV 110 fl. Cold agglutinin
autoagglutination Blood smear
Autoimmune hemolytic anemia cold antibody
20


malignant lymphoma large cell type

11 - 30 hemoglobin H disease
22 hemoglobin H disease acute
hemolytic crisis hemoglobin 8.5 9.5 gm/dl
hemolytic crisis
1
2
Hemoglobin 8.2 gm/dl., hematocrit 29%, MCV 65 fl. Hypochromic microcytic red cell
hemoglobin typing hemoglobin H disease
Hemoglobin H disease
25

hemolytic crisis

649
16.5

16.6

16.7

31 70 myelodysplastic
syndrome
48 1
erythropoietin (packed red Cell) 1
3 4 5

7 10

myelodysplasia with excess blasts Hemoglobin 7.0 gm/dl
Chronic anemia with myelodysplastic anemia
65

alloantibody acute leukemia
hemochromatosis
31 70 aplastic anemia
32 severe aplastic anemia 4
immunosuppression stem cell transplant
3 4

5 10

Hemoglobin 7.0 gm/dl.

Aplastic anemia
60-69

hemochromatosis
71 - 100
36 2 cerebrovascular accident
hemolysis iron defieiency 4 Budd-Chiari
syndrome

100
Hemoglobin 6.5 gm/dl., WBC 2500 / microlitre, platelet 80000 / microlitre

650

Severe hemolytic anemia , paroxysmal nocturnal hemoglobinuria and Budd-Chiari

syndrome
90
Budd-Chiari syndrome

16.2 Polycythemia ( )
(Polycythemia)
(Polycythemia vera)
,
16.2.1 Polycythemia vera (P. vera)
18
red cell mass P. vera
(blood viscosity)
(vascular overdistention)
,
16 polycythemia
vera



16.2.2 Polycythemia ()
Polycythemia () 16-3
16-3

1
0 - 20

2
21 - 50

3
51 - 90

2
18
2 6

18
2
6

651
16.8

16.9

16.3

50 polycythemia vera (phlebotomy)

2 15-17

Polycythemia vera
20

55 polycythemia vera (phlebotomy)

3-4 18


Polycythemia vera
40

50 polycythemia vera
2-3 18


Polycythemia vera
80

16.3

3 granulocytes, lymphocytes monocytes-macrophages 3

652
16.3.1
. Granulocytes
(phagocytosis)

6
granulocytes
furunculosis


(granulocytopenia)
500 ..
2 2 acute granulocytic leukemia chronic
granulocytic leukemia /

. Lymphocytes

humoral cellular
lymphocytes 2 T thymus-derived lymphocytes
cellular delayed transplant rejection
2 B bursa-derived lymphocytes humoral immunoglobulins
kinins
lymphocytes
Hodgkin
lymphocytes

immunoglobulins
delayed lymphocytes
1. leukemias chronic lymphocytic leukemia, chronic myeloid leukemia, acute lymphoid
leukemia hairy cell leukemia
2. lymphomas Hodgkin, Non Hodgkin lymphomas, mycosis fungoides
3. multiple myeloma macroglobulinemia
chronic lymphocytic leukemia, hairy cell leukemia low-grade lymphoma
multiple myeloma
macroglobulinemia

multiple myeloma

653
. Monocytes-macrophages

Lipid storage disease
macrophages ,

enzyme replacement Gaucher

disease lipid storage disease

acute monocytic leukemia leukemic

reticuloendotheliosis
16.3.2

1 4 macrphoage
pneumococcus 2% 2
polyvalent pneumococcal vaccine
nonencapsulated
bacteria



5 ( 24 2550 )
16.3.3 HIV
CD4 T lymphocytes
CD4
HIV HIV
, , , ,

Acute retroviral syndrome HIV
HIV RNA 3
1. CD4 500 ..

2. 2 CD4 200-500 ..

654
3. 3 CD4 200 ..
Pneumocystis carinii
, Toxoplasma gondii , , cryptosporidiosis ,
salmonellosis , Candida Kaposis sarcoma,
, mononeuritis multiplex, peripheral neuropathies,
cranial nerve palsies myelitis CD4 100 .. HIV-associated dementia,
wasting syndrome, progressive multifocal leukoencephalopathy , CMV retinitis , disseminated Mycobacterium avium
complex , cryptococcal meningitis , disseminated coccidiomycosis , histoplasmosis invasive aspergillosis
CD4
HIV reverse transcriptase inhibitor, viral protease enzyme inhibitor


16.3.4
16-4
16-4

1

0-15

16-30

3

31-55

4

56-100

16.10

0-15
21
2 8

655

10,000-18,000 ..

16.11

0-15 HIV
30 HIV

HIV enzyme immunoassay Western blot HIV RNA:

5,000 copies . CD4: 700 ..
HIV
5-15
HIV

16.12

16-30 chronic granulocytic leukemia

40 150,000 ..
6
3.6 . 12 .
4 .
150,000 .. myelocyte
promyelocytes
Chronic granulocytic leukemia
15

16.13

16-30 HIV
30 HIV

CD4. 350 . . HIV RNA 45,000 copies .

HIV moderately advanced
16-30
CD4

656
16.14

31-55
55 6


7 /. 21% 82,000 . . 96%
reticulocytes 13% direct antiglobulin test
Chronic lymphocytic leukemia with autoimmine hemolytic anemia
40
steroid

16.15

31-55 Hodgkin
28

diaphragm
Hodgkins disease
Recurrent, active Hodgkins disease
50 Hodgkins disease

16.16

31-55
30 HIV


CD4. 110 . . HIV RNA 146,000 copies .

31-50
Pneumocystis carinii

16.17

56-100 acute leukemia

55 10
6
4 .
4 /. 12,000 . . 80% blasts
18,000 . .

657

Acute leukemia
90
partial

16.18

56-100
30 4

10%
CD4. 20 . . HIV RNA 1,200,000 copies .
90

16.4 myelofibrosis
16.4.1 myelofibrosis
anemia, leukoerythroblastic blood picture,
tear drop red blood cell fibrosis fibrosis
16.4.2 myelofibrosis
( 16-2)

myelofibrosis with myeloid metaplasia hemoglobin 8 g/dL
50-60
16.19

16.20

55 Myelofibrosis 16-9.5


15

50 myelofibrosis 6-7
1
1 6

40

658
16.21

40 Myelofibrosis 1 2
7-7.5

1
70

16.5 (Hemorrhagic disorders)

(coagulation disorder)
(platelet disorder) (thrombocytopenia) (platelet
dysfunction) (vascular disorder)

hemophilia

(home treatment)



(aplastic anemia)
myelodysplastic syndrome (MDS) , ,
MDS 50 (acute
leukemia)

autoimmune thrombocytopenia


warfarin

0-10

659
16.5.1

16-5
16-5

1
0-15

2
16-30

3
31-55

4
56- 100

16.22

0-15
49 Idiopathic Thrombocytopenia Purpura (ITP) 5
, 4


platelet 38 x 109 /L severe osteoporosis T.12
L.1 compression fracture
Idiopathic Thrombocytopenic purpura
0

660
16.23

16.24

16.25

16-30
18 1-2 /

ecchymosis radius 2
platelet 8 x 109 /L
Thrombocytopenia with Absent Radii (TAR) syndrome
30

(platelet refractoriness)
31-55
21 Hemophillia A
factor VIII 2 , 2


, 2

Hemoglobin 12 g/dL, factor VIII 0.001, inhibitor Anti HIV

Hemorphilia A
21 40

factor VIII

56-100
58 38 hemorrhagic
telangiectasia (packed red blood cell) 2-6

2-3 /
telangiectasia , ,
Hemoglobin 8 g/dL , serum iron 12 ug/dL, Iron- binding capacity 420
ug/dL, Ferritin 5 ug/mL
Hereditaing hemorrhagic telangiectasia (Oster- Water-Rendu syndrome)

661

75

16.6

(thrombotic disorders)
2


16.6.1 Inherited Thrombotic Disorders
protein C, protein S
antithrombin III. factor V prothrombin
factor V Leiden prothrombin 20210A homocystein
cystathionine B-synthase homocysteine (atheroselerosis)

70 factor V Leiden mutation
protein S, protein C
antithrombin prothrombin 20210A

(family history) (early age) (recurrence)
mesenteric, portal, splenic, renal, cerebral retinal vein.
16.6.2 Acquired Thrombotic Disorders
antiphospholipid antibody
syndrome (stroke)
(malignancy) (oral pill) (immobilization) (postoperative
state) (multiple trauma) (pregnancy)
heparin ,
warfarin 3-6

(temporary) (post surgery) (life long)
(inherited thrombotic disorders) (recurrent thrombosis)
homocystein (hyperhomocysteinemia)
folic acid

662
,
(intermittent claudication)

post thrombosis syndrome


16.6.3

, ,

(stroke)
warfarin low
molecular weight heparin
10
16.26

49 40 5
pulmonary embolism) 2
warfarin
5 warfarin 2
hematoma hematoma international
normalized ratio (INR) 5 7 large hemorrhagic skin necrosis
2 INR 4.0
postthrombotic syndrome 30

(ecchymosis)

aPTT , INR = 2.8, Protein C antigen 62

Protein C deficiency with recurrent venous thrombosis postthrombotic syndrome

( C
)
30
20
2

663

Hemoglobin 9.5 gm/dl., hematocrit 29%, MCV 110 fl. Cold agglutinin
autoagglutination Blood smear
Autoimmune hemolytic anemia cold antibody
20

665

17

17.1 (hypothalamic-pituitary axis)
17.1.1
17.1.2
17.1.3

17.2
17.2.1
17.2.2
17.2.3

17.3
17.3.1
17.3.2
17.3.3

17.4 cortex
17.4.1 cortex
17.4.2 cortex
17.4.3 cortex

17.5 Medulla
17.5.1 medulla

17.6
17.6.1 ()
17.6.2 ()

17.7
17.7.1 Gonads
17.7.2 Gonads
17.7.3

17.8
17.8.1
17.8.2

17.9. ( Metabolic bone disease)

17.9.1

667

17



1.
2.
3.
4. cortex
5. medulla
6.
7.
8.
9.

1.

2.


3
1.




( stress)

2.

3.

668
17.1 (hypothalamic-pituitary axis)

ADH (vasopressin) oxytocin

(thyrotropin-TSH)
(corticotrophin-ACTH) (lutenizing hormone-LH follicle stimulating hormone-FSH)
growth hormone (GH) prolactin (PRL)
Growth hormone prolactin

Growth hormone epiphyseal plate

growth hormone
prolactin
prolactin
ADH
(vasopressin) oxytocin prohormone ADH
oxytocin
17.1.1

obstructive
hydrocephalus

1. Prolactin (prolactinoma) 1 (microadenoma) 1 .
(macroadenoma)
2. Growth hormone
3. ACTH
prolactin hypogonadism
estrogen

prolactin gonadotropin ovarian failure testicular failure

Growth hormone epiphyseal plate gigantism

acromegaly ,
acromegaly , peripheral neuropathy,
insulin resistance, glucose intolerance
hypopituitarism
(
) infiltrative disease

669
hypopituitarism hypogonadism growth hormone
hypogonadism
growth hormone


hypopituitarism

syndrome of inappropriate ADH secretion
(SIADH) SIADH


ADH
pituitary stalk
niopharyngioma histiocytosis X



17.1.2
computed tomography (CT) scan magnetic
resonance imaging (MRI) (visual field)
stimulation suppression test growth hormone
growth hormone levodopa
arginine ACTH cortisol ACTH
ACTH
secondary hypothyroidism (pituitary hypothalamic hypothyroidism)
TSH CT scan MRI

secondary gonadal insufficiency (hypogonadotropic hypogonadism)

testosterone estrogen
LH FSH
ADH osmolality
ADH osmolality
prolactin
metoclopamide
Growth hormone growth hormone glucose load
prolactin
SIADH osmolality

670
17.1.3
Hypothalamic-Pituitary Axis

a. (primary abnormalities) growth hormone, prolactin ADH

b. (secondary abnormalities)
gonads
c.


Combined value chart
17-1

1 0 15

2 16 25

3 26 50

17.1

19 15
4 7
3 6

desmopressin (DDAVP)

serum osmolality : 292 mOsm/kgH2O

serum sodium concentration : 142 mEq/L
urine osmolality : 120 mOsm/kgH2O
specific gravity : 1.003 glycosuria

671

17.2

17.3

serum osmolality 302

mOsm/kgH2O urine osmolality 150 mOsm/kgH2O ADH urine
osmolality 450 mOsm/kgH2O
DDAVP 0.1 .(10 g) 2

traumatic diabetes insipidus

5 (diabetes insipidus)
(
Combined value chart)

57 growth hormone
,
growth hormone 100 ng/mL (
0-10) bromocriptine
testosterone
testosterone 2 carpal tunnel
syndrome

carpal tunnel syndrome
sella turcica suprasellar
visual field growth hormone 575 ng/mL
Moderately severe acromegaly
16 acromegaly 5 testosterone deficiency
19% ( Combined value
chart)
carpal
tunnel syndrome 2
26

90/60 . 100
Achillestendon reflexes (visual fields)

672

17.4

prolactin metoclopamide (
Prolactin TSH TSH 500 g
) estradiol, FSH LH insulininduced hypoglycemia
cortisol growth hormone free thyroxine
0.6 ( 0.8-1.8 ng/dl) TSH : 0.2 IU/L ( 0.3-4)
Postpartum pituitary apoplexy (Sheehans syndrome) panhypopituitarism
20 panhypopituitarism 10

panhypopituitarism
levothyroxine, hydrocortisone dehydroepiandrosterone
hydrocortisone
stress

55 45 sella turcica
testosterone deficiency suprasellar

transsphenoidal pituitary
decompression glucocorticoid

bromocriptine testosterone
visual field
temporal field defect macular
visual acuity finger counting temporal field defect

film skull sella turcica CT scan

suprasellar prolactin 1,000
ng/mL ( 5 -25) prolactin 660 ng/mL
sella turcica prolactin
280 ng/mL testosterone cortisol
hypoglycemia
Prolactin-secreting pituitary adenoma pituitary apoplexy, secondary
panhypopituitarism vision loss
26
secondary adrenal dysfunction secondary testosterone deficiency
( Combined value
chart )

673

17.2


17.2.1
.

.
pericardial effusion, myxedema coma

17.2.2
1.
2. TSH
3. fine needle aspiration thyroid nodule
4. radioactive iodine uptake / thyroid scan

5. Thyroid antibodies
17.2.3
.
ophthalmopathy
atrial fibrillation

.

17-2

1

0-15

674

2
16-25

17.5

17.6

45 hypothyroidism Hashimotos thyroiditis

levothyroxine 200 g
5

65

levothyroxine 50 g
FT4 0.6 ng/dl ( 0.5-1.8) TSH 50 IU/L
( 0.3-4)
20
levothyroxine
angioplasty
levothyroxine

17.3

675
17.3.1
. adenoma hyperplasia


.
(chronic fatigue)
(paresthesia) (tetany and seizures) (candida)
hypogonadism
pernicious anemia, chronic active hepatitis polyglandular failure syndrome
17.3.2
serum calcium, phosphate, albumin parathyroid hormone
metabolic bone survey MIBI scan
17.3.3




17-3

0-14

2

15-29

3

30-90

676
17.7

17.8

76 chronic obstructive pulmonary disease (COPD)

serum calcium 12.2 / ( 8.5-10.5) PTH 165 pg/ml (
15-80)
parathyroid scan retropharyngeal parathyroid adenoma
COPD

25

72 1 parathyroid carcinoma
3
3x5
serum calcium 17.0 / ( 8.5-10.5) phosphate
0.52 / ( 1.0-4.5) recurrent parathyroid carcinoma
50

17-4

1
0-9
2
10-20

17.9

42 parathyroid adenoma 1
Chovsteks sign serum calcium 7.6 /
( 8.5-10.5) 1

677

17.10

17.11

0 hypocalcemia

62 parathyroid hyperplasia
serum calcium calcium carbonate 1000 .
calcium

58 parathyroid 3 3
hypocalcaemia calcium
20
3 permanent

17.4 cortex
Cortex adrenocortical hormone
cell membrane
permeability secondary sex characteristics

Combined value chart

17.4.1 cortex
adrenocortical hormone hyperplasia adrenal
cortex benign malignant
(1) Glucocorticoids
(2) Mineralocorticoids
(3) Androgens
(4) Estrogens

adrenal hormone iatrogenic Cushings syndrome supraphysiologic
doses glucocorticoids
adrenocortical hormone Cushings syndrome, adrenogenital syndrome
primary aldosteronism hyperplasia adrenal cortex
ectopic ACTH

678
primary
Addisons secondary ACTH
tertiary CRH
hypoaldosteronism

17.4.2 cortex
(1) adrenocortical hormone free cortisol
cortisol aldosterone
(2) ACTH, serum electrolytes, creatinine
(3) (suppression) (stimulation)

(4) , CT scan, MRI, venous sinus sampling

17.4.3 cortex
hypoadrenalism glucocorticoids / mineralocorticoids

stress , ,
stress
17-5 hypoadrenalism

1

0 14

2

15 29

adrenal
3
crisis *
30 90
*

679
17.12

17.13

28 subacute
painful thyroiditis prednisone 20 . 2
prednisolone 2

120/80 . 72
100/65 . 92
Serum sodium 128 mmol/L potassium 5.6 mmol/L plasma cortisol 8.00 . 8 g/dL
cortrosyn (ACTH) prednisone
6
Adrenal insufficiency exogenous glucocorticoids
0
relative adrenal insufficiency
prednisone

32 autoimmune thyroiditis 10
pernicious anemia
6.75 .

49.5 . vitiligo skin
creases , , 120/80 .
100/65 .

Serum sodium 122 mmol/L potassium 6 mmol/L BUN 30 ./ plasma ACTH
8.00 . 200 pg/mL ( 30-120) plasma cortisol 8.00 .
8 g/dL ( 8 - 25) 10g/dL cortrosyn
(ACTH) dehydroepiandrosterone sulfate (DHEA-S) free testosterone

Addisons disease
10
hypoadrenalism glucocorticoids
mineralocorticoids

680

17.14

17.15

68 Addisons disease 20 diverticulitiis 5

diverticulitis glucocorticoids
relative adrenal insufficiency
3 38.4

rebound tenderness 110/70 .
86 95/55 .
108
Serum sodium 126 mmol/L potassium 5.2 mmol/L BUN 30 / ESR 64 ./.
15,000/cumm neutrophil
adrenal insufficiency
fludrocortisone 0.1 .
prednisolone 20 . diverticulitis

Addisons disease recurrent febrile illness

25

febrile illness
adrenal insufficiency

72 Addisons disease 20
2 digoxin, ACE inhibitor
glucocorticoids
mineralocorticoids

105/70 . 104
90/55 . 120
basilar rales 2 vitiligo
appendectomy skin creases ,,
Serum sodium 122 mmol/L potassium 3.6 mmol/L BUN 42 . /
Addisons disease
60 Addisons disease
( Combined value chart
)

681

17.16

adrenal insufficiency

46 1 40
proliferative retinopathy, nephropathy, neuropathy neurogenic
bladder Addisons disease 10 physiologic
dose prednisolune fludrocortisone acetate
pyelonephritis hydrocortisone
pyelonephritis Candida albicans sepsis

38.9 110/80 . 76
80/65 . 76
skin creases
Serum sodium 123 mmol/L potassium 5.8 mmol/L Candida
albicans 3
Addisons disease, type1diabetes mellitus, Candida sepsis pyelonephritis
70 Addisons disease
Candida sepsis

prednisolone 10 .
adrenal
insufficiency Candida
sepsis

hyperadrenocorticism glucocorticoids supraphysiologic

iatrogenic Cushings syndrome osteoporosis
catabolic effect cataracts, aseptic necrosis, myopathy, striae
0%-100%
steroids

682
17-6 hyperadrenocorticism

hyperadrenocorticism
1

0 14

hyperadrenocorticism glucocorticoids

hyperadrenocorticism
2
bilateral hyperplasia
15 39

adrenalectomyhyperadrenocorticism
glucocorticoids
hyperadrenocorticism
3

40


adrenal steroid myopathy,

osteoporosis

17.17

30 2
6 4
2

160/80 . 68 central obesity
red striae
2 vellous hair
dark terminal hair
diurnal variation cortisol cortisol 8.00 .
22.00 . 25 g/dL 22 g/dL free cortisol 350
g/24 . ACTH cortisol free cortisol
dexamethasone suppression test dexamethasone 2 8
. CT scan abdomen 3 .

hyperadrenalism glucocorticoid 6

683

17.18

17.19

Cushings syndrome adrenocortical tumor

0

adrenal
adenoma 100%

21
13

120/80 . 80 167.6 .
72 . dark terminal hairs
dark vellous hairs striae
purpura
DHEA-S 4,000 g/mL free testosterone 12.2 pg/mL estradiol,
LH cortisol dexamethasone 1 .
17 - hydroxyprogesterone (120 g/dL)
cosyntropin (ACTH)
dexamethasone 0.5 .

Adult-onset 21-hydroxylase deficiency

14

56 10
prednisone 15 20 .
6.75 .

Cushingoid
L4 vertebra paralumbra 2

Candida albicans
osteoporosis compression fracture L2 vertebra
Iatrogenic Cushings syndrome

684

17.20

17.21

20 Cushings syndrome
vertebral collapse

hypercortisolism
glucocorticoid

54 Cushings disease transsphenoidal

microadrenomectomy 2
9.0 .
6
150/100 . 84 central obesity
red striae
Serum sodium 148 mmol/L potassium 2.8 mmol/L BUN 14 mg/dL ACTH
150 pg/mL free cortisol : 300 g/24 . cortisol
8.00 . 20ug/dL 22.00 . 22 g/dL cortisol
free cortisol low-dose dexamethasone
suppression test high-dose dexamethasone MRI pituitary
CTscan abdomen adrenal hyperplasia
4,500 rads conventional megavoltage
ketoconazole
Recurrent Cushings disease
25
mitotane
glucocorticoids
18 mitotane

74 18 adrenal carcinoma

160/100 . 80
central obesity 2 pleural effusion
free cortisol 300 g/24 . 17-ketosteroid (17-KS) 70 ./24
. Serum sodium 148 mmol/L, potassium 2.6 mmol/L

685

pleural effusion MRI abdomen adrenal mass

adrenal carcinoma
Recurrent adrenal carcinoma
95
mitotane hyperadrenalism
6

17.5 Medulla
Medulla catecholamine
(cardiac output)

medulla

pheochromocytoma pheochromocytoma
10 multiple endocrine neoplasia
17.5.1 medulla
catecholamine

medulla
1. VMA (vanillyl mandelic acid), metanephrine catecholamine
2. CT, MRI, metaiodobenzyl guanidine (MIBG) scan
17-7

pheochromocytoma

1
0-14

2
15-29
3
30-90

pheochromocytoma

pheochromocytoma

pheochromocytoma

686
17.22

17.23

42 1


130/80 . 76/ () 170/110
. 120/ ()
24-hour urine: vanillylmandelic acid (VMA) 20 ./24 . ( 0-10) CT scan:
3 .

Intra-adrenal Pheochromocytoma
0

64 1


3
180/120 . 112/ () 150/100 .
120/ ()
24-hour urine: vanillylmandelic acid (VMA) 30 ./24 .( 0-10) CT scan:
retroperitoneum
prazosin 4 . 3 metoprolol 50 . 2

Malignant Pheochromocytoma
20

687
17.24

17.25

62 2

200/130 . 110/ ()
24-hour urine: vanillylmandelic acid (VMA) 40 ./24 . ( 0-10 )
CT scan: peritoneal extension of left adrenal gland tumor (
peritoneum)
I-MIBG scan: skeletal metastases
prazosine 6 . 2 metoprolol 100 . 2
160/100 .
malignant pheochromocytoma
90

20 1


120/80 . 72/ () 180/110
. 120/ ()
24-hour urine: vanillylmandelic acid (VMA) 18 ./24 .
CT scan: 3 . 2
adrenal insufficiency
hyponatremia, hyperkalemia
prednisolone fudrocorticostreone

Bilateral Pheochromocytoma
14
adrenal insufficiency
prednisolone fudrocorticostreone
14

688
17.6
islets of Langerhans 2

17.6.1 ()
.
2 1
2
1
diabetic ketoacidosis
2 40

1. microvascular retinopathy nephropathy
2. macrovascular atherosclerosis
peripheral vascular disease
3. neuropathy
.
1. plasma glucose(fasting and postprandial plasma glucose)
2. HbA1c
3. (triglyceride, LDL HDL)
4.
5. (fundoscopy)
6. serum creatinineurine microalbuminuria
7. Doppler peripheral vascular disease
8.

689
17-8

2
1
diabetic microangiopathy
0-5
retinopathy albuminuria 30 /

2
2

6-10
diabetic microangiopathy
1 pancreatic diabetes
3

11-20
diabetic microangiopathy
1 pancreatic diabetes
4

21-40

17.26

17.27

40
3 . 6
130/80 . 76/ diabetic
retinopathy
Fasting plasma glucose (FPG) 2 160 / 172 /
Urine glucose 1+, albumin negative
3 FPG 110
/
2 microangiopathy
0

45 (candida albicans)
1
1
130/80 . 76/ retinal
microaneurysms dot and blot hemorrhage
Fasting plasma glucose(FPG) 2 180 / 200 /, Urine glucose
4+, albumin negative

690

3 FPG
110 /

Type 2 diabetes mellitus with early diabetic retinopathy

: 5
:

17.28

17.29

55 3


130/80 . 76/ retinal
nicroaneurysms dot and blot hemorrhages
Fasting plasma glucose (FPG) 2 130 140 / HbA1C 6.5%, urine
glucose negative, albumin negative

Type 2 diabetes mellitus

8

50 2 7
2 (BK amputation) severe peripheral disease
gangrene 4
NPH insulin 20 U

right knee amputation 150/85 . retinal

microaneurysms, dot and blot hemorrhages cotton-wool spot decreased
sensation in stocking glove distribution
Fasting plasma glucose (FPG) 170 / HbA1C 8.9%
3 FPG 110
/
Type 2 diabetes mellitus with complications

691

17.30

17.31

17.32

10
BK amputation nonproliferative diabetic retinopathy

33 1 5
plasma glucose 400 / ketonuria

fundi
Fasting plasma glucose (FPG) 150 / HbA1C 7.5%
Type 1 diabetes mellitus
12
2

40 1 20

130/80 . 76/ background
diabetic retinopathy
Fasting plasma glucose (FPG) 160 / HbA1C 10.5%
Type 1 diabetes mellitus with diabetic retinopathy
20
2 background diabetic retinopathy

45 1 25
4

Proliferative diabetic retinopathy
Serum creatinine 2.0 / FPG 120 / HbA1C 5.5%

692

17.33

17.34

Type 1 diabetes mellitus with proliferative diabetic retinopathy and nephropathy

20 proliferative diabetic retinopathy nephropathy

24 1 10
4
(self monitoring of blood glucose)
(severe hypoglycemia)

130/80 . 76/ background
diabetic retinopathy
Fasting plasma glucose (FPG) 180 / HbA1C 14%
Type 1 diabetes mellitus with poor control
35 1

35 1 15


100/80 . 76/ proliferative
diabetic retinopathy vibratory sensation deep tendon reflex
knees ankles
Fasting plasma glucose (FPG) 240 / HbA1C 15%
Type 1 diabetes mellitus with diabetic retinopathy and peripheral neuropathy, not
adequately controlled by diet and insulin
40

17.6.2 ()
.

693
.


1.
2.
3.
4.
17-9

0-5

2

6-50
(



)
17.35

45

5 . 2 2

prolonged fasting test 14 .
plasma glucose 20 / plasma insulin C-peptide hypoglycemia
Serum cortisol 30 / CT-abdomen: A small adenoma at the
head of the pancreas

Benign functioning islet cell adenoma (insulinoma)

0

694
17.36

55 insulinoma
hypoglycemia

hypoglycemia

Central obesity, mild facial acne, mild bipedal edema, palpable right upper quadrant
mass
lapararotomy : a large islet cell adenocarcinoma
in the tail of the pancreas with metastases in the liver

Metastatic islet cell adenocarcinoma with incomplete control of symptoms

50 hypoglycemia

17.7
(spermatozoa) (testosterone)

(ova) (estrogen progesterone)

(autoimmune disease)

17.7.1 Gonads
. Gonads
Gonads secondary
sexual characteristics puberty
epiphysis
Gonads
(osteoporosis) puberty secondary sexual
characteristics
. Gonads precocious puberty, hirsutism virilism
epiphysis

17.7.2 Gonads
1. testosterone, estradiol, progesterone, FSH, LH DHEA-S
2. bone age
3. CT scan MRI

695
4.
5. (biopsy)
6. (sperm analysis)
7. (cytology)
8. (laparoscopy)
9. (endometrial biopsy)
10. pelvis
17.7.3

0-35


17.37

17.38

31 sexual development high-pitched voice

testosterone
penis

penis was tiny: scrotum and testes were small
Bone age: 18 years. Plasma testosterone level: plasma gonadotropin level:
Hypogonadotropic hypogonadism
10

19

Height 128 cm. sparse pubic and axillary hair: Tanner 1 breast development; bilateral
short fourth metacarpals; webbed neck
Follicle-stimulating hormone (FSH): 45 XO karyotype, renal ultrasound,
echocardiogram TSH:
estrogen progesterone (replacement dose) sexual development

Gonadal dysgenesis (Turners syndrome)

696

30 gonadal dysgenesis
sexual development estrogen progesterone

17.8
17.8.1
(gynecomastia)
prolactinoma prolactin
17.8.2
0-5

(Galactorrhea)


17.39

32 prolactin-producing pituitary microadenoma

(microprolactinoma) 1
galactorrhea
bromocriptine
Expressible milky breast discharge; thyroid normal to palpation
Serum prolactin 120 g/L; BUN 16 / alkaline phosphatase: 35 /
Prolactin-producing pituitary microadenoma (microprolactinoma)
5
galactorrhea

17.9. ( Metabolic bone disease)

(osteoporosis), osteomalacia, renal osteodystrophy
osteogenesis imperfecta

osteomalesia

(bone mineral
density) (X-ray)
17.9.1

697
17-10

1
0 5
2
6 15

: (spinal collapse),

17.40

17.41

62 20 hormone replacement therapy

Bone mineral density (BMD): lumbar T-score -2.34, hip: T-score -2.65 at femoral neck,
TSH, parathyroid hormone (PTH), CBC,.BUN, Ca and P: normal
alendronate 70 mg
Postmenopausal osteoporosis
10
BMD

68 1
anti-resorptive drug
Scoliosis; stooped posture and slow gait
Film T-L spine: partial collapse of T 10-T 12
alendronate 70 mg
Severe osteoporosis
15

699

18

18.1
18.2

18.2.1 (Organic Mental Disorders)

18.2.1.1
18.2.2. (Schizophrenia, Schizotypal and Delusional Disorders)
18.2.2.1 (Schizophrenia)
18.2.2.2 Schizotypal Personality Disorder
18.2.2.3 (Persistent Delusional Disorders)
18.2.2.4 (Acute and Transient Psychotic Disorders)
18.2.2.5 (Induced Delusional Disorder)
18.2.2.6 Schizoaffective Disorder
18.2.3 (Mood or Affective Disorders)
18.2.3.1 Manic episode
18.2.3.2 Bipolar affective disorder
18.2.3.3 Depressive episode
18.2.3.4 Recurrent depressive disorder
18.2.3.5 Persistent mood (affective) disorder
18.2.4. (Neurotic, Stress-Related and Somatoform Disorders)
18.2.4.1 Phobic anxiety disorders
18.2.4.2 Other anxiety disorders
18.2.4.3 Obsessive-compulsive disorders
18.2.4.4 Acute stress reaction
18.2.4.5 Post - traumatic stress disorder
18.2.4.6 Adjustment disorders
18.2.4.7 Dissociative (Conversion) disorders
18.2.4.8 Somatoform disorders
18.2.5. (Disorders of Adult Personality and
Behavior)
18.2.6. (Mental Retardation)
18.2.6.1 (Mild Mental Retardation)
18.2.6.2 (Moderate Mental Retardation)
18.2.6.3 (Severe Mental Retardation)
18.2.6.4 (Profound Mental Retardation)

700
18.3

18.4

18.5

18.6

18.7
18.8

18.3.1
18.3.2 Somatoform pain disorder (SPD)
18.3.3 (Malingering)

18.4.1
18.4.1.1
18.4.1.2
18.4.2
18.4.3
18.4.3.1
18.4.3.2
18.4.3.3

18.5.1
18.5.2
18.5.3
18.5.4

18.6.1
18.6.2
18.6.3 (
)
18.6.4

701

18

18.1
3
1.
1.1
1.2
2.
3.
18.2

The International Classification of Diseases, Tenth Edition (ICD-10)
18.2.1 (Organic Mental Disorders)

Primary
Secondary
Organic mental disorders
18.2.1.1
(Organic, Including Symptomatic, Mental Disorders)
. (Dementia)

Cortex

(Cognitive)
.
(Organic Amnetic Syndrome, Not Induced by Alcohol and Other Psychoactive
Substances) Immediate recall
(Confabulation) (Disorientation)

702
. (Other Mental Disorders Due to
Brain Damage and Dysfunction and to Physical Disease)

. (Personality
and Behavioral Disorders Due to Brain Disease, Damage and Dysfunction)

, Cerebral lesions Temporal Frontal lobe
Euphoria Apathy Frontal lobe
Frontal lobe syndrome Prominent indifference, Apathy ()
Temper outbursts

18.2.2. (Schizophrenia, Schizotypal and Delusional Disorders)

18.2.2.1 (Schizophrenia)

(Inappropiate) (Blunted)
Thought echo,
Thought insertion or withdrawal, Thought broadcasting, Delusional perception and delusion of control, Influence
or passivity, Hallucinatory voices commenting or discussing in the third person, Thought disorders and negative
symptoms
(Course) Continuous Episodic with progressive
Stable deficit Complete or incomplete remission
Schizophrenia Depressive Manic Schizophrenia
Drug intoxication Withdrawal
Epilepsy

18.2.2.2 Schizotypal Personality Disorder

(Delusion)
Onset Personality disorder, Latent schizophrenic
reaction
18.2.2.3 (Persistent Delusional Disorder)

Organic, Schizophrenia Affective

703
18.2.2.4 (Acute and Transient Psychotic Disorders)
(Heterogenous)

2 (Perplexity and
Puzzlement) Delirium
2-3
Stress
18.2.2.5 (Induced Delusional Disorder)
Delusional Disorder 2
(Genuine Psychotic Disorder)

18.2.2.6 Schizoaffective Disorder
Episodic Disorder Schizophrenia Affective

18.2.3 (Mood or Affective Disorders)


Onset

18.2.3.1 Manic Episode

(Single Episode), Hypomanic
Manic episodes Affective episodes (Depressive, Hypomanic, Manic, or Mixed)
Bipolar affective disorder.
. Hypomania

. Mania without Psychotic Symptoms

. Mania with Psychotic Symptoms
Grandiose Flight of ideas

704
18.2.3.2 Bipolar Affective Disorder
2
Hypomania Mania Depression Hypomania Mania
Bipolar
18.2.3.3 Depressive Episode
Typical mild, moderate, or severe depressive episodes


Mild form
Somatic symptoms
(Agitation)
Mild, moderate severe depressive episode

18.2.3.4 Recurrent Depressive Disorder
Episodes of depression Mania
Hypomania Recurrent depressive disorder
Manic depressive disorder, Melancholia, Endogenous Depression
Onset
Episode Mania Bipolar
affective disorder
18.2.3.5 Persistent Mood (Affective) Disorder
Episode
Hypomanic Mild depressive episode
Manic Depressive episode Persistent mood disorder
18.2.4. (Neurotic, Stress-Related and Somatoform Disorders)
18.2.4.1 Phobic Anxiety Disorders




18.2.4.2 Other Anxiety Disorders

18.2.4.3 Obsessive-Compulsive Disorders

705




18.2.4.4 Acute Stress Reaction






2-3
18.2.4.5 Post - Traumatic Stress Disorder


2 - 3




18.2.4.6 Adjustment Disorders

(Conduct Disorder)

18.2.4.7 Dissociative (Conversion) Disorders

Dissociative Disorder 2-3
18.2.4.8 Somatoform Disorders

706
18.2.5. (Disorders of Adult Personality and
Behavior)

18.2.6. (Mental Retardation)

18.2.6.1 (Mild Mental Retardation)

(I.Q.) 50 - 69 (
9 - 12 )

18.2.6.2 (Moderate Mental Retardation)
(I.Q.) 35 - 49
( 6 - 9 )

18.2.6.3 (Severe Mental Retardation)

(I.Q.) 20 - 34
( 3 - 6 )
18.2.6.4 (Profound Mental Retardation)
(I.Q.) 20 (
3 )

707
18.3
18.3.1

1.
2.
3.

4. 3 /
2
18.3.2 Somatoform Pain Disorder (SPD)

Somatic delusion
Conversion
disorder


Somatoform SPD DSM-IV




1.

2.

3. Conversion
Non-conversion Delusional pain

18.3.3 (Malingering)

708

18.4
3
1.

2.

3.

18.4.1
The Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) The International Classification of Diseases, Tenth Edition (ICD-10)


DSM-IV ICD-10





18.4.1.1

709



,
, , ,



, ,

18.4.1.2

WAIS (Mental retardation)


,
,
IQ

18.4.2


Secondary gain


, (
)
,

18.4.3
18.4.3.1
,
, ,

710




18.4.3.2

1.
2.
3.
4.
5.
6.

18.4.3.3

100%

711

18.5

18.5.1

18.5.2

712
18.5.3



(Remission) (Cure)

Adjustment disorder with depressed mood



18.5.4
(
)

18.6





4
1.
2.
3. ( )
4.
, 4
18.1

18.6.1

713

18-2 1 () 5-1
5 4 3 2
1
18.6.2

18-2 2 (
) 5-1 5
4 3 2 1

18.6.3 ( )

100 7

714
18-2
3 () 5-1
5 4 3 2
1
18.6.4

18-2 4 ()
5-1 5 4 3
2 1
18-1

1
2
3

18-1 4 5

1.
2.
3.

4.

715
5.
Catatonic
, ,



Panic attack


4

18-2

1.
:

:

:

716
2.
:

:


:


:

18.2

3. ( )
5
:

4
:

3
:

2
:

1
:
4.
5
:

4
:
3
:
2
:
1
:

717

1. 4 18.2
2. 4
3.
18.3
18.3

1
5.00 4.51
09
2
4.50 3.51
10 24
3
3.50 2.51
25 54
4
2.50 1.51
55 75
5
1.50 1.00
75
18.7
18.1
29 2
1
(Schizophrenia)





18.2

(4+4+3+2) / 4 = 3.25
4
1.
4
2.
3
3.
2
4.
= 3.25
3 35

718
18. 2
25

2
(Major Depressive Disorder) 6

18.2

(5+5+4+3) / 4 = 4.25
5
1.
5
2.
4
3.
3
4.

= 4.25
2 10
18.3
20

4
(Obsessive compulsive disorder) 8



18.2

1.
2.
3.
4.

3
3
4
4

(3+3+4+4) / 4 = 3.50

= 3.50
3 25

719
18.8

1.
1.1
1.2 ()
1.3
1.4
2.
2.1
2.2

2.3

2.4

3.
3.1

3.2

3.3

1.

2.

3.

I. :
()

1. :
2. :

720
:
1)
2)
3) ,
:
1)
2)
3)
:
:
:
3. : ()
4. :

:
:
:
:
: /
1)
2)
3) (, )
4)
: :
1)
2)
3)
:
1)
2)
3)
4)
5. :
:

: ( )
/

721
:
6.
:
:
:
:
:
:
:
:

7.
:
:
8. :

: ,
: ( )
: ( )
: ( )
: ( , )
: ( , ,, ,
)
:
9. :
10. (psychological test) :

11. :
12. : ICD-10 ICD-10
13. : ,
( , GP)


.
.

722
II.
1. Schizophrenia, Delusional (Paranoid) Disorders, Schizoaffective Disorders

:
:
:
2. Organic Mental Disorder :
: ,
1.
2.
3.
:
:
: ( EEG, CT) ,
3. Mental Retardation :
: IQ , ,
100 15
perceptual-motor ( Wechsler scales)
: Verbal performance full-scale IQ scores
:
, ,

723

19

% % = % + % (100% %)

40% 28%
(1) 40 28
(2) 40 28 57
(3) 40% 28% 57%
2 3 2
4
()
2
%

724

725

726

727

194
232,233,234
235
456
456
(CRPS)* 14,16,34,35,121,142,143,187-192,242,246,249,189-190
139
16
619
276-7,283
275
16, 18-21, 26,34,50,54-55,69,75,77,79-81,84,90,100,114,151 161,169,179-185,25,6258,276,278,280,287-8,314-5,322,324-7,331,333,335,338,340,343,365,369,371,407,409-10
36
SLR 270,290-3,354
696
696
335,337
637
274
491-2496,500,506-8,512
411,191
513,515-6,538
454
267368370374385399402409414418455456653
187-9293224256
189265279281-3287294-5299-300313316319332363
224-5
442
13-17,27,34,116,145,148,150,164,166,168,
171-3,179,238,306-7,410
365,368
365,370
237,473,476-7,486-7

728
619,622-624
624
631
279,309
419,422
7
225,236
191,223-6,231,236-7,248-9,252-4,315-6,319,335
391-2
373-4
414
415
385
385
385
395
413
416
433,456-60-70,72
651
202
208,251
208
209

651
16-21,47-8,50-2,55-7,59-6,163-4,66-70,72,74-8,86-7,91-2,94,96,99,102,106,
109-10,113,187,190,192,211-3,215,218-9,221,256-7,260
211-4
214-6
216-220
220,222
150,158,187,190-1,222-3,251,256

729

461
461
377,382,407,453,523,529,545,561,563-69,571,58-9,591,622,681,685-687
382-3
407
187,194-5
258,312-4,319-20,322,327-330,332,334,336-338,354
49,56,86-7,91,95,102,106,110,204-7,220,258,312,319-20
17,318

461

269-80,282,284

665,667-72,677-8,682,684,693-4
668
665,667-75,679
665,667-8
cortex 665,667-8
medulla 665,667
593,595-7,599-600,602,604-5,607,612,665,667

189,190-1,216-22

216

730

598
599
498,500

489,494,501
442
1 365,399

361
473,476-7,486
477
477
473,478
452

272,367,413

658
318
650
489,504

473,475-6,478-9,487-8
652,656
632
220

731

442
665,667
381,413,416,418,625
665,696-7
658
658
561,583
561,569-70
489,498,505
489,502
489,500,505-6
669,671
513,519-26,543,558,573
323
561,564
513,526-7,529-34,545,559,583,673-4
429,498,502-3,506
483,492,498

276,314-5,329,331
476,506,641-2
423,433-4,457,460-1
5 339-401,405
11 365,405
12 365,405
2 365,399
3 , 4 6 365
7 365,399,402-3
8 365,403-4
9 10 365,405
593,616

732

431
431-2
282,284,286,288,295-6,300-1,311

588,622
492
142-3,187-8,190-1,242,268

646
646-7,650-1,656-8

733

INDEX
A
A Motion Segment Integrity 275
A Motion Segment of the Spine 275
Acquired Thrombotic Disorders 643,661
Acromegaly 668,671
Activities of Daily Living or ADL 6
Acute granulocytic leukemia 652
Acute lymphoid leukemia 652
ADH 668-71
Adrenogenital syndrome 677
Aldosterone 678
Allergic contact dermatitis 475-77,483-84
Allodynia 121,242,417
Alteration of Motion Segment Integrity 276,286
Androgens 677
Ankylosing Spondylitis 329,355
Aphakia 424
Aphasia 365,369-95
Aplastic anemia 649,658
ARC perimeter 425
Arrhythmias 382,513,552
Arthrodesis 161,301
Asbestosis 489495-6499505512
Aspiration/biopsy 645
Audibility 461-3,467,471
Awareness 365,368,370,374
Atraumatic 158
Anterior Apprehension test 159,160
Anterior relocation test (jobes test) 159,160
Anterior instability 159
Anterior Glenoid labrum 161
Amputation 4131626-729-3439-4080147
Ankylosis 187,190,211-21,314,319,322-4,326-7,329,331-2,334-6,338,340-1
Adoing 13,26,69
Adouction 55,64-67,106-7,109,171,194,202,205,213,233

734
Abduction 55,62-64106-7,109,171,205,208,213,453
Autonomic fibers 116
Axillary negve 118
Ankle Foot orthosis AFO 197
Arthroplasty 148,150,153,157,161,163,227
Aesthesiometer 36
Active Motion 49
Assisted Active motion 49
Adsons test 139
Axonotmetic Lesion 140
Ankle 188

B
Babinski sign 271,406,-9,411-2
Bagassosis 489,502
Behavior 369
Bells palsy 403
Bilateral Facial Paralysis 456
Bladder hyperreflexia 621
Blepharoptosis 432
Bone marrow 638
Bone mineral density 696-7
Brachial Plexus 116,120,124-7,129,134-6,158,439-52,359
Bunnell (Bunnell Test) 49
Bursitis 189,191,227
Byssinosis 489,500
Bennetts fracture 169
Bone scan 143,198,242,283,296,301,416-7

C
Capal Tunnel Syndrome 139
Cardiomyopathy 513,541-46,559
Catecholamine 685
Cauda Equina Syndrome 286-7,309-10
Cavernosography 629
Cervical Compression 269
Chronic granulocytic leukemia 652,655
Chronic lymphocytic leukemia 652,656

735
Chronic myeloid leukemia 652
Clinical Dementia Rating (CDR) 383
Clonus 271,285
Coagulation disorder 658
Colostomy 613
Colposcope 635,631
Compartment Syndrome 201,203
Complete blood count 645
Complex Regional Pain Syndromes 14,121,143
Congenital Heart Disease 513,534
Consciousness 365,368,379,374
Contact Dermatitis 473,475-77,483-6,468
Convulsion (Episodic Loss of Consciousness or Awareness) 372
Coombs test 645
Coronary heart disease 513,516,526
Corticospinal tract 265,271,279-80,282-7,285,287,293-4,296,299,305-7,309
CRPS = Complex Regional Pain Syndrome 190
Cushings syndrome 677,681,683-84
Cutaneous ureterostomy 624
Cross usage chart 192
Claudication 146,244,574,576,662
Calculation 14,50,52,132
Constrictive tenosynovitis 165
Chuck 167
Carpal instability 16,155,157
Causalgia 14,121,140,142-44,187-8,190-1,242,416
Cyanosis 495,535-40,575
Callus 37,362
Compression Neuropathy 14,139
Chronic osteomyelitis 237
Combining 13,23,79-80
Contracture 48,49,149,204,208-9,222,234,236,254

D
Dementia 372,385,387,396,654,701
Detrusor sphincter dyssynnergia 621
Difficulty With Digital Dexterity 305-306,408,410
Distance Vision 420-421

736
Doppler ultrasound penile blood flow evaluations 629
Dysphasia 365,369,391-94,396,411-12
Diagnosis Based estimates 225
Digital Rotational Deformity 152
Demyelination 140
Dejering Klumpke 129,136
Discrimination 36-38,45-47,122,131,141-42,175,346,397,404
Dead arm syndrome 158
Dynamometer 167
Degroot 167
Dislocation 54,150,153,158,203
Dynamic 155,286,524

E
Ectropion 423,431-32
Ehlers-Danlos syndrome 158
Enterocutaneous fistula 612-13
Entropion 423,431
Enucleation 433
Epiphora 423,432
Esophagostomy 613
Estimate Hearing Level for Speech 422
Estrogens 677
Evisceration 423,33
Extramedullary hematopoiesis 646
External Rotation 110-13,159,171,205,212
Epicondylitis 166
Extension 47,48,57,60,83-85,92-94,104-05,164,236,276,320,320,335,687
Efferent Fibers 116
Erb-Duchenne 129,135,359
Entrapment 14,16,139
Erythema 145,547,575
Elbow Motion 91,100

737

F
Facial Disfigurement 456
Femoral Stretch Test 270
Flow cytometry 645
Free cortisol 678,682,684
Function capacity 513,517
Functional Efficiency 461-2,484,417
Foot 4,188,191,197,203,206,209,219,221,224,230-31,271,423
Finger Brachial index 146,147
Fasciitis 166
Factitious Disorder 143
Flexion 47-48,55-59,64-5,70-1,76,83-6,91-4,102-5,119,194,204,206,208-10,212,215-16,2212,234,236,254,271,275-6,278,319-20,322-23,326-28,334-35
Functional position of a joint 48
Functional unit 51

G
Gastrostomy 454,606,613
Gigantism 668
Glucocorticoids 677-82,684
Goldmann perimeter 425
Goniometer 204,258,312
Granulocytes 651-52
Growth hormone 658-72
Glenoid 158159161
Glenoid labrum 158,161
Glenohumeral translation 159, 160,161
Grip strength 166,167
Gait deoangement 191
Grade of musle fuction 201

H
hairy cell leukemia 652
Hearing Threshold Level for Pure Tones 442
Hematopoietic system 645
Hemipelvectomy 224,361
Hemodialysis 623-24

738
Hemoglobin electrophoresis 645
Hemophilia 658
Hemospermia 632
Hirsutism 694
HoffmanSign 269
Hyronephrosis 621
Hypereflexia 271
Hyperhomocysteinemia 661
Hypersensitivity pneumonitis 489,494,498,501
Hypogonadism 668-69,675,695
Hypomania 703-4
Hypopituitarism 668-69,672
Hysteroscope 637
Humeral Head 158-9,161
Humeral Head subluxation 158
Hyperlaxity 54,158
Hyperextension 47,48,70,164
Horner syndrome 136
Hind foot 188,209
Hip 4,188,191,194,202,204-5,208,211-13,224,232-34,446,697

I
Ieal pouch anal anastomosis 613
Ileostomy 604
Inclinometer 240,258,312,319,322,327,329,336
Inclinometry 312
Inherited Thrombotic Disorders 643,661
Intelligibility 461-2.464,471
Iodine Starch Sweat Test 36
Irreversible Coma 371
Irritant contact dermatitis 477,484
Involuntary 158
Implant replacement 161
Intrinsic Tightness 49,164
Intrinsic Muscle 136,164
Internal Rotation 112,171,212

739

J
Jejunostomy 613
Jamar Dynamometer 167
Joint Passive Mediolateral Tnstability 153
Joint Replacement Keypinch 167

K
Karnofsky scale 511
Key pinch 167
Knee-ankle foot orthosis kafo 197
Krukenberg 28

L
Lagophthalmos 423,432
Leukemias 652
Limb Length Discrepancy 187,190,194-5
Loss of Binocular Vision 423
Loss of Visual Field 420
Loss of Central Visual Acuity 423
Lymphangiography 631
Lymphocytes 651-53
Lymphomas 652
Loading posterior/anterior drawer test 159
Lunate 155-56
Longitudinal sensory loss 38,41-42,44,45
Laser Doppler flowmeter 145,146,147

M
Macroglobulinemia 652
Macrophages 651,653
Maximal Medical Improvement (MMI) 5,9
Meniscectomies 191
Metabolic bone disease 667,696
Metabolic bone survey 666
Mineralocorticoids 668,620
Monocular aphakia 424
Monocular pseudophakia 424

740
Monocytes-macrophages 651,653
Mood 369,699,703-4,712
Moving Two Point Discrimination 36
Multiple myeloma 652
Mycosis fungoides 652
Myelodysplastic syndrome 649,658
Myelopathy 272,418
Meniscectomies 191
Motor Deficit calculation 132
Mate 167
Malingering 143,700,707
Median nerve 118
Musculo cutaneous nerve 118
Mixeo Nerve 138
Musculotendinous disorder 150
Musculotendinous 15,148,150,158,164
Monofilament 36-37
Muscli Atrophy 187,190,198-9,286
Manual muscle testing 151,661,169,171,187,201

N
Natural Rubber Latex Allergy 473,477
Near Vision 424
Nephropathy 681,688,692
Nephrostomy 624
Nerve Entrapment Syndrome 16
Neuromas 13,34,45
Neuromuscular junction 366
Ninhydrin Sweat Test 36
Non Hodgkin lymphomas 652
Non Dissociate 155
Neutral Position 49,56,59,71,74,205,207,211,216,218-19
Neuropraxic Lesion 140

741

O
Obstructive Sleep Apnea syndrome, OSA 489,504
Occupational asthma 489,493,498,502,506
Oligospermia 631
Osteogenesis imperfecta 696
Osteomalacia 696
Osteoporosis 143,242,624,659,681-83,,694,696-97
Oxytocin 659
Occult shoulder instability 159
Opposition strengty 142
Oppostion 69,142

P
Parathyroid hormone 675,697
Pelvic Obliquity 194
Penile tumescence studies 629
Pericardial heart disease 513,547
Perimeter 423,425,430
Peripheral Nervous System 310,366,418
Peripheral vascular disease 146,244,574,688
Peritoneal dialysis 623-24
Permanent Impairment 5,513,553
Permanent Tracheostomy 452-53
Phantom Pain 34,225
Pheochromocytoma 685-87
Platelet disorder 658
Platelet dysfunction 658
Pneumoconioses 498
Polycythemia 643,650-51
Polycythemia vera 650-51
Precocious puberty 683
Primary aldosteronism 694
Primary pulmonary hypertension 583
Progesterone 659
Prostatic ultrasonography 632
PSA (prostatic specific antigen) 632
Pseudophakia 424
Pelvis 188

742
Periphegal vascular disease 146224574688
Peripheral Nerve 14116118122-27130138187190239-52
Provocative test 158506
Proximal row carpectomy 163
Pinch strength 167,169
Pinch Gauge 167
Pin prick test 36
Passive motion 49
Pronation 91,95
Phalens test 139
Peripheral nerves in juries 238

R
Radiculopathy 275,280,282-84,286-94,298-99,302-04,309,311,315,420,353-54
Range of Motion Method (ROM) 279-8,310
Raynauds phenomenon 145-47,574,557
Renal osteodystrophy 696
Retinopathy 688-92
Root Tension Signs 268
Radial nerve 45,417
Radiographic signs 143
Resection arthroplasty 161
Radiolunate angle 150
Rotational deformity 152
Reflex sympathetic dystrophy 14,121,142-43,190-91,242,416-17

S
Sciatic Nerve Tension Signs 269
Scoliosis 285,323,493,697
Segmental Instability 318
Semen analysis 631
Semicoma 371,385
Serum creatinine 564-66,622,688,691
Silicosis 495,505
Spinal Stenosis 287,318-19
Spondylolisthesis 284,318-19
Spondylolysis 284,288,318-19

743
Spurling Test 269
Static Two Point Discrimination 36
Stenosis 287,319,520,523,636,638
Straight Leg Raising 268-69
Symblepharon 423,432
Syndrome of inappropriate ADH secretion 669
Sudomotor 142,143,416
Sulcus sign 158
Shoulder instability 158-161
Shoulder motion 14,101,114
Subluxation 150
Scapholunate angle 155
Skin loss 187,190,237
Scaphoid 155-56
Somatoform pain disorder 143,700,707
Somatoform conversion disorder 143
Short leg brace 197
Strength loss index 177
Spinal nerve injury 134
Sensory fibers 116
Styloid 163
Strength evaluation 15,166
Swanson 16,167
Synovial hypertrophy 150
Sensation 35,285,291,629,690,692
Sensibility 35,131,139
Supination 26,91,95,97-99,171
Summagy 171

T
Temporomandibular Join 450,454
Testosterone 631,669,671-72,679,683,694-95
Thrombocytopenia 524,568,659-60
Thrombotic disorders 643,661
Trendelenberg Sign 197
Trigeminal neuralgia 400-1,405
Transverse sensory loss 38-40,44-45
Trophic changes 143,417

744
Two-point discrimination 122,131,141-42,175,346
Triquetrolunate step off 156-57
Translo cation 150
Traumatic 158,382,397,416-17,432-33,519,671,699,705
Trigger finger 165
Trigger thumb 165
Tendinitis 148,166
Three digit pinch 167
Tip pinch 167
Teleroentgenography 194,195,251

U
Unilateral Facial Paralysis 456
Urinary diversions 622
Urodynamics 625
Ulnar head 163
Ulnar translation 156-57
Ulnar nerve 118

V
Valvular heart disease 513,519
Vanillyl mandelic acid 685
Vasography 624-625
Vesicoureteral reflux 621
Virilism 694
Voluntary 158307-8414-15621
Vasomotor 142,143
Vascular disorders 15,145,243

W
Wrinkle test 36
Wrist motion 14,82,90


1.
2.
3.
4.
5.

6.

7.
8.
9.
10.
11.

12.
13.
14.
15.

16.
17.

2541.
:
2525

, . 2525.

, . 2525.
:
2
2544

: 2
2544
2
. 2546
. Reference spirometric values for healthy lifetime nonsmokers
in Thailand. 2543 ; 83 : 457 466.
Adams RM. Occupational Skin Disease. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1999.
Agner T, Flyvholm MA, Menne T. Formaldehyde allergy: a follow up study. Am J Contact
Dermatitis.1999 ;10:12 17
American Academy of Otolaryngology Committee on Hearing and Equilibrium, and American
Council of Otolaryngology Committee on the Medical Aspects of Noise. Guide for the
evaluation of hearing handicap. JAMA. 1979; 241:2055-2059.
American Medical Association , Guides to the evaluation of permanent impairment, 4th ed.
Chicago : Illinois, 1993.
American Medical Association , Guides to the evaluation of permanent impairment, 5th ed.
Chicago : Illinois, 2002.
American National Standards Institute. Specifications for Audiometers: ANSI Standards
S3.6 - 1989.
American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and
Statistical Manual of Mental Disorder, Revised Third Edition. Washington, DC: American
Psychiatric Association; 1987. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition. Washington,DC: American Psychiatric Association;1994.
Anaissie EJ, et al. Chronic myelogenous leukemia: biology and therapy. Ann Intern Med.
Arch Otolaryngol Head Neck Surg. 1989; 115:469-477.

746
18.
19.
20.
21.
22.
23.
24.

25.

26.
27.
28.
29.

30.
31.
32.
33.
34.
35.
36.
37.

Banks PA, et al. The spectrum of chronic pancreatitis. Parenteral Care. 1989;23(9):163-196.
Bengtsson H, Bergqvist D, Sternby NH. Increasing prevalence of abdominal aortic
aneurysms: necroscopy study. Eur J Surg. 1992;158:19-23.
Bickerstaff LK, Hollier LH, Van Peenen HJ, Melton LJ III, Pairolero PC, Cherry KJ. Abdominal
aortic aneurysms: the changing natural history. J Vasc Surg. 1984;1:6-12.
Bravereman LE, Utiger RD (eds). Werner & Ingbars. The THYROID. A Fundamental and
Clinical Text. Ninth edition,. Lippincott Williams & Wilkins. Philadelphia, 2005
Bunnag S, Piampitis. Average weights by height of Thai adult. JMAT 1979. 62:579-588
Burow B, Kettel LJ, Niden AH, Rabinowitz M, Diener CF. Patterns of cardiovascular
dysfunction in chronic obstructive lung disease . N Engl J Med. 1972;286:912-918.
Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment, and
control of hypertension in the adult US population. Data from the health examination
surveys. 1960 to 1991 [published erratum appears in Hypertension, 1996;27:1192].
Hypertension. 1995:26:60-69.
Cangemi JR, Wiesner RH, Beaver SJ, et al. Effect of proctocolectomy for chronic ulcerative
colitis on the natural history of primary sclerosing cholangitis. Gastroenterology. 1989; 96:790794.
Coffman JD. Intermittent claudication-be conservative. N Engl J med. 1991;325:577-578.
Colman RW, Hirsh J, Marder VJ, Salzman EW. Hemostasis and Thrombosis: Basic
DAlonzo GE, Barst RJ, Ayres SM, et al. Survival in patients with primary pulmonary
hypertension: results from a national prospective registry. Ann Intern Med. 1991;115:343-349.
DeGroot H , Dejong N ,Duijoter E, VanWyk RG, et al. Prevalence of natural rubber
latex allergy (Type I and Type IV ) in laboratory workers in the Netherlands. Contact
Dermatitis 1993; 38:159 163.
DeGroot LJ, Jameson JL (eds) Endocrinology. Fifth edition. Elsevier Saunders, Philadelphia
2006
Drake L, Dorner W, Goltz RW, et al. Guidelines of care for contact dermatitis. J Amer Acad
Dermatol. 1995;32:109-113
Duarte I, Nakano JT, Lazzarini R. Hand eczema: evaluation of 250 patients. Am J Contact
Dermatitis. 1998; 9:216-223.
Engrav LH, Covey MH, Dutcher KD, et al. Impairment, time out of school, and time off
from work after burns. Plast Reconstr Surg. 1987 ;79:927-934
Feldman M, Scharschmidt BF, Sleisenger MH,eds. Gastrointestinal diseases. 7th ed.
Fink JN, ed. Latex allergy. Immunol Allergy Clin North Am. 1995;15:1-179
Finlay AY, Khru GK, Luscombe DK, Salek MS. Validation of sickness impact profile and
psoriasis disability index in psoriasis. Br J Dermatol. 1990 ;123:751-756
Fisher AA. Permanent loss of fingernails from sensitization and reaction to acrylics in
a preparation designed to make artificial nails. J Dermatol Surg Oncol. 1980; 6:70-71.

747
38.

39.
40.
41.

42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.

Fishman AP, McGoon MD, Chazova IE, Fedullo PF, Kneussl M, Peacock AJ, et al.
Diagnosis and assessment of pulmonary hypertension. In: Rich S, ed. Primary Pulmonary
Hypertension: executive Summary from the World Symposium: Primary Pulmonary
Hypertension 1998.
Flexner C. Acute human immunodeficiency virus type 1 infection. N Eng J Med.
Freedberg IM, Eisen AZ, Wolff K, et al, eds. Dermatology in general Medicine. Vol 1, New
York, NY: McGraw Hill; 1999:840-864, 1080-1116
Frohlich ED. Pathophysiology of systemic arterial hypertension. In: Schlant RC, Alexander
RW, ORourke RA, Roberts R, Sonnenblick EH, eds. Hursts The Heart. 8th ed. New York,
NY: McGRAW-Hill ; 1993:1391-1401.
George JN, et al. Chronic idiopathic thrombocytopenic purpura. N Engl J Med.
Gerhardt JJ. Documentation of Joint Motion. Rev 3rd ed. Portland, Ore: Oregon Medical
Association; 1992.
Glynn RJ, Brock DB, Harris T, et al. Use of antihypertensive drugs and trends in blood
pressure in the elderly. Arch Intern Med. 1995;155:185-1860.
Goodnough LT, et al. The pathophysiology of acquired aplastic anemia. N Engl J Med.
Hall WD, Ferrario CM, Moore MA, et al. Hypertension related morbidity and mortality in the
southeastern United States. Am J Med Sci. 1997;313:195-206.
Haubrich Ws, Schaffer F, Berk JE, eds. Bockus Gastroenterology. 5th ed. Philadelphia, Pa:
WB Saunders Co; 1995.
Heinemann M, Laas J, Karck M, Borst HG. Thoracic aortic aneurysms after acute type Aortic
dissection: necessity for follow-up. Ann Thorac Surg. 1990;49:580-5811.
Hoffmann R, Benz EJ Jr, Shattil SJ, Furie B, Cohen HJ, Silberstein LF. Hematology:
1994;331:1207-1211. 1997;336:1365-1372. 1998;339:33-39. 1999;131:207-219
Hogan DJ, Dannaker CJ, Maibach HI. The prognosis of contact dermatitis. J Am Acad
Dermatol. 1990;23:300-307
Hoyer LW. Hemophilia A. N Engl J Med. 1994;330:37-47
Isselbacher EM, Eagle KA, DeSanctis RW. Diseases of the aorta. In: Hart Disease by
Braunwald. 5th ed. Philadelphia, Pa: WB Saunders: 1997:1546.
Kaplan AS, Assael LA,eds. Temporomandibular Disorders: Diagnosis and Treatment.
Karalis DG, Chandrasekaran K, Victor MF, Ross JJ Jr, Mintz GS, Recognition and embolic
potential of intraaortic atherosclerotic debris. J Am Coll Cardiol. 1991;17:73-78.
Key MM. Confusing compensation cases. Cutis. 1967; 3:965 969.
Khan CR, Weir GC, King GL, Jacobson AM, Moses AC, Smith RJ. Joslins Diabetes Mellitus.
Fourteenth edition. Lippincott Williams & Wilkins. Philadelphia, 2005
Lagergren J, Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a
risk factor for gastroesophageal adenocarcinoma. N Engl J Med. 1999;340:825-831.
Larsen PR, Kronenberg HM, Melmed S, Polonsky KS (eds). Williams Textbook of
Endocrinology. Tenth edition. Saunders, Philadelphia 2003

748
59.
60.
61.

62.
63.

64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.

Lau JYW, et al. Endoscopic retreatment or surgery after initial endoscopic control of bleeding
ulcers. N Engl J Med. 1999;340:751-756.
Lea RD, Gerhardt JJ. Current concepts review range of motion measurement. Bone Joint
Surg. 1995;77:784-798.
Levi M, et al. Disseminated intravascular coagulation. N Engl J Med. 1999;341:586-592. Basic
Principles and Practice. 2nd ed. New York, NY: Churchill Livingstone; 1995. HIV infection.
Ann Intern Med. 1999;131:136-143. Med. 1997;126:307-314. Principles and Clinical Practice.
3rd ed. Philadelphia, Pa: JB Lippincott; 1994.
Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK. The progression from hypertension to
congestive heart failure. JAMA. 1996;275:1557-1562.
Levy D, Salomon M, D Agostino RB, Belanger AJ, Kannel WB. Prognostic implications of
baseline electrocardiographic features and their serial changes in subjects with left ventricular
hypertrophy. Circulation. 1994;90:1786-1793.
Mackey SA, Marks JG. Dermatitis in machinists: a retrospective study. Am J Contact Derm.
1993; 4:22 26.
Mathias CGT. The skin. In Zenz C, ed. Occupational Medicine. 2nd ed. Chicago , III : Year
Book Medical Publishers ; 1988.
Mayer T, Kondraske G, Beals S, Gatchel R. Spinal range of motion : accuracy and sources of
error with inclinometric measurement. Spine. 1997;22:1976-1984.
McCord GS, Staiano A, Clouse RE. Achalasia, diffuse spasm and non-specific disorders.
Baillieres Clin Gastroenterol. 1991; 5:307-335.
McGoon MD, et al. Pulmonary hypertension. In: Giuliani ER, Gersh, BL, McGoon MD, Hayes
DL Schaff HV, eds, Mayo Clinic Practice of Cardiology. 3rd ed, St Louis, Mo:Mosby; 1996.
McNeil C,Rugh JD. Temporomandibular disorders; diagnosis, management, education, and
research. A Am Dent Assoc. 1990;120:253-263.
Meyerson A . Malingering. In: Kaplan H, Sadock B, eds. Textbook of Psychiatry. 5th ed. New
York, NY: Williams & Wilkins; 1989.
Meyerson A, Fine T.Psychiatric Disability: Clinical, Legal, and Administrative Dimensions.
Washington, DC: American Psychiatric Press; 1987.
Miura S, Shikata J, Hasebe M, Kobayashi K, et al Long-term outcome of massive small
Bowel resection. Am J Gastroenterol. 1991;86:454-459
Nethercott JR, Gallant C. Disability due to occupational contact dermatitis. Occup Med. 1986;
1:199-204.
Noble WG. Assessment of Hearing Loss and Handicap in Adults. New York, NY: Academic
Press, 1978.
Philadelphia, Pa: WB Saunders Co; 1991.
Philadelphia, Pa: WB Saunders Co; 2003
Pope CE II. Acid reflux disorders. N Engl J Med. 1994;331:656-660

749
78.
79.
80.
81.
82.
83.
84.
85.

86.

87.
88.
89.

90.

91.
92.
93.
94.
95.

96.

Preventing Allergic Reaction to Natural Rubber Latex in the Workplace. Cincinnati, Ohio:
National Institute for Occupational Safety and Health; 1997. Publication 97 135
Rich S, et al. The hypercoagulable states. Ann Intern Med. 1985;102:814-828.
Rockey DC. The beta-thalassemias. N Engl J Med. 1999;341:916-109.
Rogers R, ed. Clinical Assessment of Malingering and Deception. 2nd ed. New York, NY:
Guilford Publications; 1997.
Rubin LJ . Primary pulmonary hypertension. Chest. 1993;104236-250.
Satalof RT, Satalof J. Occupational Hearing Loss. 2nded. NY: Marcell Dekker, Inc., 1993.
Schabauer AMA, Rooke TW. Cutaneous laser Doppler flowmetry: applications and findings.
Mayo Clinic Proc. 1994;69:564-5711.
Scolapio JS, Fleming CR, Kelly DG, Wick DM, Zinsmeister AR. Survival of home parenteral
nutrition(HPN)-treatment patients: 20 years of experience at the Mayo Clinic. Mayo Clin Proc.
1999;74:217-222.
Sherertz EF, Storrs FJ. Occupational contact dermatitis. In: Rosenstock L, Cullen M, eds.
Textbook of Clinical Occupational and Environmental Medicine. Philadelphia, Pa: WB
Saunders Co; 1994.
Sherlock S, Dooley J, eds. Diseases of the liver and biliary system. 10th ed. Oxford, England:
Blackwell Scientific Publications; 1997.
Social Security Administration. Consultative Ecaminations Guide for Physicians. Baltimore,
Md: Social Security Administration; 1985, Publication No, 64-025.
Social Security Administration. Federal Old-Age, Survivors and Disability Insurance. Listing of
Impairments, Mental Disorders in Adults: Proposed Rules. Federal Register, July 18, 1991, vol
56, No. 138.
Social Securiyt Asministration. Federal Old-Age, Survivors and Disability Insurance. Listing of
Impairments, Mental Disorders: Final Rule (Listing). 20 CFR Part 404 (Reg No.4) 50(167),
Federal Register 1985 :35038-35070. The Listing and other guidance appear also in:
Disability Evaluation Under Social Security. Baltimore, Md: Social Security Administration;
February 1986. Publication No. 64-039.
Society of General Internal Medicine AIDS Task Force. Optimizing care for persons with
Steinberg MH, et al. Management of sickle cell disease. N Engl J Med. 1999;340:1021-1030.
Tarlo SM, Sussman GL, Holness DL. Latex sensitivity in dental students and staff: a crosssectional study. J Allergy Clin Immunol. 1997;99:396-401
Taylor JS, ed. Occupational dermatoses. Dermatol Clin North Am. 1994; 12:461 600.
Taylor JS, Wattanakrai P, Charous BL, Ownby DR. Year Book focus: latex allergy. In: Thiers
BH, Lang PG, eds. 1999 Year Book of Dermatology and Dermatologic Surgery. St Louis, Mo:
Mosby, St Louis University Press; 1999:1-44.
The Cosmetic Benefit Study. Washington, DC: The Cosmetic, Toiletry and Fragrance
Association; 1978.

750
97.

98.
99.

100.
101.
102.
103.
104.

105.

The sixth report of the Joint National Committee on prevention, detection evaluation, and
treatment of high blood pressure [published erratum appears in Arch Intern Med. 1998;
158:573]. Arch Intern Med. 1997:157:2413-2446.
Therapy for adults with refractory chronic immune thrombocytopenic purpura. Ann Intern
Tytgat GNJ, et al. The role of infectious agents in peptic ulcer disease. Gastroenterol Int.
1993;6:76-89. Yamada T. Textbook of Gastroenterology. 4th edi. Lippincott Williams&Wilkins.
Philaelphia 2003
Widlus DM, Osterman FA Jr. Evaluation and percutaneous management of atherosclerotic
peripheral vascular disease. JAMA. 1989;261:3148-31511.
WiggerAlberti W, Elsner P. Preventive measures in contact dermatitis. Clin Dermatol. 1997;
15:661 665.
Wilkes CH. Internal derangements of the temporomandibular joint: pathological variations.
World Health Organization. International Classification of Impairments, Disabilities, and
Handicaps. Geneva, 1980.
World Health Organization. Manual of the International Statistical Classification of Diseases,
Injuries, and Causes of Death: International Classification of Diseases (ICD). Geneva,
Switzerland: World Health Organization; 1978.
World Health Organization. WHO/Psychiatric Disability Assessement Schedule. Geneva, 1988.