Many of the independent medical examinations (IMEs) are musculoskeletal and performed by orthopedic physicians.
What does an excellent orthopedic IME consist of? Dr. Ronald Zipper, DO, FAOAO explained some of the elements of an excellent orthopedic IME.
Pre IME Paperwork
You and your staff should, at all times be courteous.
Prior to, or at the time of your IME the examinee should complete all paperwork, including:
A copy of the claimant’s Driver’s License , or Photo ID.
Notice of Informed Consent.
History of injury, Review of Systems and Pain Assessment.
Diagrams: Pain, Katz-Hand.
Claim specific Questionnaires: DASH, Oswestry, Spinal Pain. See 6th Edition AMA “Guides”.
Prior Claim Histor(ies).
What makes up an IME?
Date of the Injur(ies).
Occupational vs. Personal
History of the Chief Complaint(s).
Review of Systems:
Past Medical History
Past Surgical History
Past Orthopedic History
Primary Physician(s) [Chiropractors? Psychiatrists?]
Physical Examination – including Vitals
Causality, Aggravation, Apportionment
Maximum Medical Improvement and Impairment Rating
Return to work
Opinions …to a reasonable degree of medical certainty…What does this mean?
Questions for the Examiner: Just answer the questions!
Who is currently providing the claimant’s treatment?
Has the claimant changed providers?
If so, find out why.
Is treatment helping?
Is further treatment scheduled?
Keys to Better History Taking
“Build” a history rather than “take” one.
Relaxed claimants will fully share their perspectives & have better outcomes.
Adopt a “narrative based medicine” approach to your interview.
Avoid vague questions.
Don’t accept vague answers.
Repeat your questions in different ways.
Avoid personal prejudices – remain neutral!
“Mistakes Available to be Made” is to blame the patient (victim) for being a patient.
“Poor historian” is not necessarily retarded, demented, or malingering.
Your roll is to reconstruct from both the patient’s current history and the medical records the best possible chronology of symptoms and medical events, in order to determine whether there is a good fit, or not.
You are an advocate for the entire medical record.
Avoid “Negative Affectivity” = over reporting (depression/anger/poor self-esteem).
What portions of his/her current and prior jobs can the claimant perform, or not perform?
How frequent did they change jobs?
If there’s a lag in their employment history, Why? Incarceration?
Information about prior occupations is relevant to long term disability determinations and in planning for vocational rehabilitation.
May also be of relevance in determining Apportionment.
The IME Physical Exam
Musculoskeletal examinations should include a description of:
• Gait, Toe/Heel Walking with/without assistive devices?
• Goniometry/Inclinometry Measured Ranges of Motion – Active & Passive (AROM/PROM)- Pain limited = *?
• Strength = Manual Muscle Testing (MMT).
• Jamar Grip, or Pinch strengths, three trials – Grip levels I-V. Rapid Grip Exchanges.
• Seated/Supine Straight leg raising (are there differences)?
• In hand injuries, trace the hand and note the abnormalities.
• Inequalities between right and left?
• Tinel’s, Phalen’s/Reverse Phalen’s signs and Dirkin’s tests.
• Congenital abnormalities?
• Scoliosis, Kyphosis, increased Lordosis, Café-au-lait Spots, Spinal Fistula, Hairy Patches?
• Measure and describe all scars.
• Document piercings and “Body art” [“If it isn’t documented, you didn’t do it!”]
• Are there inconsistencies – between: elements of the physical exam; the physical exam & the history; the history and the “usual” anatomy; and pathophysiology of the condition. Is there a good fit?
• Sensory abnormalities (light touch, 2-point discrimination (5-6mm) vibration, and/or proprioception?
• Are deficits non-dermatomal, i.e. “Stocking/Midline”?
• Measured atrophy (> than 2 cm.).
• Tandem Walking, Romberg’s Signs, Past-Pointing?
• Deep Tendon Reflexes (DTR’s).
• Clonus? Babinski?
• Ability to make a fist, claw, or have full opposition?
• Affect: Stoic/Flat?
IME vs. “Usual Exam”: Symptom Magnification
The IME differs from a “usual” examination.
It requires you to question & evaluate the validity of subjective complaints.
Differentiate between “symptom magnification” and malingering. There are a number of observations that can be used for this purpose.
Overall attitude, pleasant, hostile?
Posture, gait and use of ambulatory aids?
Is the claimant who states that she or he has difficulty with sitting, standing, or various positions consistent?
Do gait and mobility “problems” improve upon exiting the waiting room, or your building, and when getting into a car?
Dr. Zipper described some of the most common symptom magnification tests. He utilizes during these exams:
The examiner notes inconsistencies in location when the examinee is asked to point with one fingertip to the site of pain (a location that the examiner may mark) and repeated after the examinee has been distracted by other tests.
Strength Reflex Test
While the examinee resists a muscle test with supposedly “maximum effort,” the examiner carefully pulls quickly enough to evoke a stretch reflex.
In this way, true reserve strength can be determined.
Hip Adductor Test
Use when the claimant is alleging a paralyzed limb.
This test is positive when there is resisted hip adduction when the you ask the examinee to adduct the contralateral hip against resistance, which is inconsistent with an alleged paralyzed lower limb.
Axial Loading Test, aka Foraminal Compression Test (FCT)
You apply gentle downward pressure of approximately two (2) pounds to the top of a standing examinee’s head.
The wrong response is increased low back pain.
Two pounds of pressure will not transmit through thirty-three (33) levels to cause pain.
Some examiners have the examinee perform this test with his or her own hand, especially if there are cervical complaints
Gordon: Welberry Toe Test
You flex the supine examinee’s hip and knee 90 degrees.
You gently flex the ipsilateral lesser toes, while stabilizing the ankle.
Ask the examinee, “What does this do to the pain in your low back?”
This motion should not cause complaints of increased back pain.
A variant of this test involves dorsiflexing & plantar flexing the ankle with hip and knee flexed 90 degrees.
With the examinee standing, passively swivel their hips.
You are swiveling their hips.
You are not moving their spine.
An invalid response is that the examinee response that this maneuver elicits their subjective back complaints.
Flip, or Michelle Test
This test is conducted with the supine examinee’s hips and knees extended.
The examiner’s hands are cupped under each heel, and the examinee is asked to flex the involved hip, keeping the ipsilateral knee extended.
In essence, this is performing an active straight leg raise. An examinee attempting to raise the limb will push downward on the examiner’s palm with the uninvolved heel.
The absence of such pressure implies that minimal to no effort was exerted, which is a valid response.
Ability to perform an active straight leg raise on the uninvolved side, with concurrent downward pressure on the examiner’s palm from the involved heel, indicated the contralateral hip extension are functioning.
Grip Strength Test
Inconsistencies of grip strength may be demonstrated by lack of reproducibility of measurements, failure to achieve a bell shape curve in determining grip strength in five positions (if pain in the involved hand is not present, or significant differences between static measurements and those achieved during rapid alternating grips.
Tuning Fork Test
Vibration perception between different sides of the same bone (e.g., the skull) should be equal.
If they are not, this is nonorganic result.
Bowlus and Currier Test
The Bowlus and Currier Test is a distraction test used to evaluate the consistency of sensory findings of the forearm and hands.
Inconsistencies are noticed between initial assessment and when the examinee inverts and crosses the examinee’s arms and hands so that they are inside out.
The examinee may have difficulty in keeping his, or her left and right straight when are arms are inside out.
The excellent orthopedic IME is crucial as it is often relied upon by adjusters, attorneys, employers, insurers, self-insurers, and IME companies to determine value of and settle claims.