uetite lupper extremity examplesnaoem, september 25, 2015 upper extremity sectionsupper extremity...
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U E t it E lUpper Extremity Examples
Paul S. Darby, MD, PhD, MPH, FACOEM with thanks toPaul S. Darby, MD, PhD, MPH, FACOEM with thanks to
Douglas W. Martin, MD, FAADEP, FACOEM, FAAFPg , , , ,
NAOEM, September 25, 2015
Upper Extremity SectionsUpper Extremity Sections
16.2 Amputation16 3 Sensory Loss16.3 Sensory Loss16.4 Range of Motion16.5 Peripheral Nerve Disorders16.6 Vascular Disorders16.7 Other Disorders16.8 Strength16.8 Strength
Case ACase A
Musculocutaneous N I jNerve Injury
A seventeen year old right A seventeen year old right handed meat packing planthanded meat packing planthanded meat packing plant handed meat packing plant worker sustained an worker sustained an accidental stab wound of his accidental stab wound of his left upper arm damaging hisleft upper arm damaging hisleft upper arm, damaging his left upper arm, damaging his musculomusculo--cutaneous nerve.cutaneous nerve.
Six months later, he has fullSix months later, he has fullSix months later, he has full Six months later, he has full elbow flexion with a 10 lb. weight elbow flexion with a 10 lb. weight in his hand but cannot flex fullyin his hand but cannot flex fullyin his hand, but cannot flex fully in his hand, but cannot flex fully with 15 lb. He can detect with 15 lb. He can detect pinprick on the radial side of his pinprick on the radial side of his forearm most of the time but itforearm most of the time but itforearm most of the time, but it forearm most of the time, but it doesn't "feel right" in this area. doesn't "feel right" in this area. He has no pain.He has no pain.
Determination of impairment Determination of impairment d i jd i jdue to nerve injurydue to nerve injury
Degree of sensory Degree of sensory ll
Degree of motor Degree of motor lllossloss lossloss
Maximum Maximum impairment due to impairment due to
Maximum Maximum impairment due to impairment due to impairment due to impairment due to
sensory loss of this sensory loss of this nervenerve
impairment due to impairment due to motor loss of this motor loss of this nervenerve
Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss
Upper extremity Upper extremity impairment due to impairment due to motor lossmotor losssensory losssensory loss motor lossmotor loss
Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit
Table 16Table 16--10, p. 482 10, p. 482 Determination of percent of sensory deficitDetermination of percent of sensory deficitDetermination of percent of sensory deficitDetermination of percent of sensory deficit
Determination of impairment Determination of impairment due to nerve injurydue to nerve injury
Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor lossg yg y gg
Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of hh
Maximum impairment Maximum impairment due to motor loss of due to motor loss of hhthis nervethis nerve this nervethis nerve
Upper extremity Upper extremity Upper extremity Upper extremity Uppe e t e tyUppe e t e tyimpairment due to impairment due to sensory losssensory loss
Uppe e t e tyUppe e t e tyimpairment due to impairment due to motor lossmotor loss
Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit
Excerpt from Table 16Excerpt from Table 16--15, p. 49215, p. 492Maximum percent impairments Maximum percent impairments of the upper extremity due toof the upper extremity due topp ypp y
injury of specific nervesinjury of specific nerves
Sensory MotorSensory Motor
Determination of impairment Determination of impairment due to nerve injurydue to nerve injury
Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor loss
Maximum impairment Maximum impairment d t l f d t l f
Maximum impairment Maximum impairment d t t l f thi d t t l f thi due to sensory loss of due to sensory loss of
this nervethis nerve5 %5 % due to motor loss of this due to motor loss of this
nervenerve
Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss
Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss
Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit
Determination of impairment Determination of impairment due to nerve injurydue to nerve injury
Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor lossg yg y gg
Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of thi thi
5 %5 %Maximum impairment Maximum impairment due to motor loss of this due to motor loss of this
this nervethis nerve nervenerve
Upper extremity Upper extremity Upper extremity Upper extremity pp ypp yimpairment due to impairment due to sensory losssensory loss
1 %1 %pp ypp y
impairment due to impairment due to motor lossmotor loss
Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit
Table 16Table 16--11, p. 484. 11, p. 484. D i i f f d fi iD i i f f d fi iDetermination of percent of motor deficitDetermination of percent of motor deficit
Determination of impairment Determination of impairment due to nerve injurydue to nerve injurydue to nerve injurydue to nerve injury
Degree of sensory lossDegree of sensory loss 25%25% Degree of motor lossDegree of motor loss 20 %20 %
Maximum impairment Maximum impairment d t l f d t l f
Maximum impairment Maximum impairment d t t l f thi d t t l f thi due to sensory loss of due to sensory loss of
this nervethis nerve5%5% due to motor loss of this due to motor loss of this
nervenerve
Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss
1%1%Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss
Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit
Excerpt from Table 16Excerpt from Table 16--15, p. 49215, p. 492Maximum percent impairmentsMaximum percent impairmentsMaximum percent impairments Maximum percent impairments
of the upper extremity of the upper extremity due to injury of specific nervesdue to injury of specific nervesj y pj y p
Sensory MotorSensory Motor
Determination of impairment Determination of impairment due to nerve injurydue to nerve injurydue to nerve injurydue to nerve injury
Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor loss 20 %20 %
Maximum impairment Maximum impairment Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of this nervethis nerve
5 %5 % due to motor loss of this due to motor loss of this nervenerve
25 %25 %
Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss
1 %1 %Upper extremity Upper extremity impairment due to impairment due to motor lossmotor lossyy
Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit
Determination of impairment Determination of impairment due to nerve injurydue to nerve injurydue to nerve injurydue to nerve injury
D f lD f l 25 %25 % D f lD f l 20 %20 %Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor loss 20 %20 %
Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of 5 %5 %
Maximum impairment Maximum impairment due to motor loss of this due to motor loss of this 25 %25 %due to sensory loss of due to sensory loss of
this nervethis nerve5 %5 % due to motor loss of this due to motor loss of this
nervenerve25 %25 %
Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss
1 %1 %Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss
5 %5 %
Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit
Determination of impairment Determination of impairment due to nerve injurydue to nerve injurydue to nerve injurydue to nerve injury
Degree of sensory lossDegree of sensory loss 25%25% Degree of motor lossDegree of motor loss 20 %20 %Degree of sensory lossDegree of sensory loss 25%25% Degree of motor lossDegree of motor loss 20 %20 %
Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of 5%5%
Maximum impairment Maximum impairment due to motor loss of this due to motor loss of this 25 %25 %due to sensory loss of due to sensory loss of
this nervethis nerve5%5% due to motor loss of this due to motor loss of this
nervenerve25 %25 %
Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss
1%1%Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss
5 %5 %
U t it i i t d t d fi itU t it i i t d t d fi it 6 %6 %Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit 6 %6 %
Case BCase B
Fractured HumerusFractured Humerus
A 48 year old file clerk fell down theA 48 year old file clerk fell down theA 48 year old file clerk fell down the A 48 year old file clerk fell down the stairs at work sustaining a fracture of stairs at work sustaining a fracture of her right distal humerus Openher right distal humerus Openher right distal humerus. Open her right distal humerus. Open reduction of the fracture was necessary. reduction of the fracture was necessary. Si h f i j h li f hSi h f i j h li f hSix months after injury, healing of the Six months after injury, healing of the fracture was complete and serial fracture was complete and serial measurements showed no further measurements showed no further improvement in range of motion.improvement in range of motion.p gp g
H lb fl d 120 d d l k dH lb fl d 120 d d l k dHer elbow flexed 120 degrees and lacked Her elbow flexed 120 degrees and lacked 40 degrees of full extension. She had 60 40 degrees of full extension. She had 60 degrees of pronation and 20 degrees of degrees of pronation and 20 degrees of supination. Her shoulder would flex 150 supination. Her shoulder would flex 150 ppdegrees and would extend 30 degrees. degrees and would extend 30 degrees. She had 40 degrees of adduction and 90She had 40 degrees of adduction and 90She had 40 degrees of adduction and 90 She had 40 degrees of adduction and 90 degrees of abduction. She had 30 degrees degrees of abduction. She had 30 degrees of internal rotation and 40 degrees ofof internal rotation and 40 degrees ofof internal rotation and 40 degrees of of internal rotation and 40 degrees of external rotation.external rotation.
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion Shoulder flexionShoulder flexion
extensionextension extensionextension
pronationpronation abductionabduction
supinationsupination adductionadductionsupinationsupination adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
impairment due to impairment due to limited shoulder motionlimited shoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--34, p. 47234, p. 472120120°° Elbow flexionElbow flexion120120 Elbow flexionElbow flexion
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion
extensionextension extensionextension
pronationpronation abductionabduction
supinationsupination adductionadductionsupinationsupination adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
impairment due to impairment due to limited shoulder motionlimited shoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--34, p. 472. 34, p. 472. 4040°° Elbow extensionElbow extension
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion
extensionextension 44 extensionextension
pronationpronation abductionabduction
supinationsupination adductionadductionsupinationsupination adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
impairment due to limited impairment due to limited shoulder motionshoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--37, p. 47437, p. 4746060°° forearm pronationforearm pronation6060 forearm pronationforearm pronation
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion
extensionextension 44 extensionextension
pronationpronation 11 abductionabduction
supinationsupination adductionadductionsupinationsupination adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to limited impairment due to limited elbow motionelbow motion
impairment due to limited impairment due to limited shoulder motionshoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--37, p. 47437, p. 4742020°° f i tif i ti2020°° forearm supinationforearm supination
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion
extensionextension 44 extensionextension
pronationpronation 11 abductionabduction
supinationsupination 33 adductionadductionsupinationsupination 33 adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
impairment due to impairment due to limited shoulder motionlimited shoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion
extensionextension 44 extensionextension
pronationpronation 11 abductionabduction
supinationsupination 33 adductionadductionsupinationsupination 33 adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010 impairment due to limited impairment due to limited shoulder motionshoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--40, p 47640, p 476150150°° h ld fl ih ld fl i150150°° shoulder flexionshoulder flexion
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22
extensionextension 44 extensionextension
pronationpronation 11 abductionabduction
supinationsupination 33 adductionadductionsupinationsupination 33 adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010 impairment due to limited impairment due to limited shoulder motionshoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--40, p 47640, p 4763030°° h ld t ih ld t i3030°° shoulder extensionshoulder extension
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22extensionextension 44 extensionextension 11extensionextension 44 extensionextension 11pronationpronation 11 abductionabduction
supinationsupination 33 adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010Upper extremity Upper extremity impairment due to impairment due to limited shoulder motionlimited shoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--43, p. 47743, p. 4779090°° shouldershoulder abductionabduction9090 shoulder shoulder abductionabduction
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22
extensionextension 44 extensionextension 11
pronationpronation 11 abductionabduction 44
supinationsupination 33 adductionadductionsupinationsupination 33 adductionadduction
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010 impairment due to impairment due to limited shoulder motionlimited shoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--43, p. 47743, p. 4774040°° shouldershoulder adductionadduction4040 shoulder shoulder adductionadduction
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22
extensionextension 44 extensionextension 11
pronationpronation 11 abductionabduction 44
supinationsupination 33 adductionadduction 00supinationsupination 33 adductionadduction 00
internal rotation internal rotation
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010 impairment due to impairment due to limited shoulder motionlimited shoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--46, p. 47946, p. 4793030°° Internal rotationInternal rotation3030 Internal rotation Internal rotation
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22
extensionextension 44 extensionextension 11
pronationpronation 11 abductionabduction 44
supinationsupination 33 adductionadduction 00supinationsupination 33 adductionadduction 00
internal rotation internal rotation 44
external rotationexternal rotation
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010 impairment due to impairment due to limited shoulder motionlimited shoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Table 16Table 16--46, p. 47946, p. 4794040°° External rotationExternal rotation4040 External rotation External rotation
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22
extensionextension 44 extensionextension 11
pronationpronation 11 abductionabduction 44
supinationsupination 33 adductionadduction 00supinationsupination 33 adductionadduction 00
internal rotation internal rotation 44
external rotationexternal rotation 11
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010 impairment due to limited impairment due to limited shoulder motionshoulder motion
Combined upper extremity impairmentCombined upper extremity impairment
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22
extensionextension 44 extensionextension 11
pronationpronation 11 abductionabduction 44
supinationsupination 33 adductionadduction 00supinationsupination 33 adductionadduction 00
internal rotation internal rotation 44
external rotationexternal rotation 11
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to
limited elbow motionlimited elbow motion1010 impairment due to impairment due to
limited shoulder motionlimited shoulder motion1212
Combined upper extremity impairmentCombined upper extremity impairment
Impairment due to loss of:Impairment due to loss of:
Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22
extensionextension 44 extensionextension 11
pronationpronation 11 abductionabduction 44
supinationsupination 33 adductionadduction 00supinationsupination 33 adductionadduction 00
internal rotation internal rotation 44
external rotationexternal rotation 11
Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion
1010 impairment due to impairment due to limited shoulder motionlimited shoulder motion
1212
Combined upper extremity impairmentCombined upper extremity impairment 2121
Case CCase C
Rotator Cuff TearRotator Cuff Tear
A 47 year old carpenter sustained a major rotator cuff tear of his rightmajor rotator cuff tear of his right shoulder while at work. He had surgical repair and appropriate rehabilitation.
Six months later, he was back at work as a carpenter, although he p gneeded help on some parts of his job that he used to do by himself. Hethat he used to do by himself. He had some aching pain after work, and occasionally had pain at nightand occasionally had pain at night.
At the time of his evaluation, six months after surgical repair he hadmonths after surgical repair, he had motions as follows:
Flexion 120° Extension 20°Adduction 20° Abduction 90°External rotation 40° Internal rotation 60°
M l l t ti h dManual muscle testing showed a strength loss index of between 10% and 20% in all shoulder motions.
Table 16Table 16--40, p 47640, p 476120120°° h ld fl ih ld fl i120120°° shoulder flexionshoulder flexion
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extensionabduction
adduction
internal rotation
t l t tiexternal rotation
Upper extremity impairment due to limited shoulder motionUpper extremity impairment due to weakness
Impairment of upper extremity
Impairment of whole person
Table 16Table 16--40, p 47640, p 4762020°° h ld t ih ld t i2020°° shoulder extensionshoulder extension
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extension 2%abduction
adduction
internal rotation
t l t tiexternal rotation
Upper extremity impairment due to limited shoulder motionUpper extremity impairment due to weakness
Impairment of upper extremity
Impairment of whole person
Table 16-43, p. 47790° shoulder abduction90 shoulder abduction
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extension 2%abduction 4%
adduction
internal rotation
t l t tiexternal rotation
Upper extremity impairment due to limited shoulder motionUpper extremity impairment due to weakness
Impairment of upper extremity
Impairment of whole person
Table 16-43, p. 47740° shoulder adduction40 shoulder adduction
Upper extremity impairment due to limitation of:Shoulder flexion extension 4%
2%abduction 4%abduction 4%
adduction 1%
internal rotation internal rotation
external rotation
Upper extremity impairment due to limited shoulder pp y pmotionUpper extremity impairment due to weakness
Impai ment of ppe e t emitImpairment of upper extremity
Impairment of whole person
Table 16-46, p. 47960° Internal rotation60 Internal rotation
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extension 2%abduction 4%
adduction 1%
internal rotation 2%
t l t tiexternal rotation
Upper extremity impairment due to limited shoulder motionUpper extremity impairment due to weakness
Impairment of upper extremity
Impairment of whole person
Table 16-46, p. 47940° External rotation40 External rotation
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extension 2%abduction 4%
adduction 1%
internal rotation 2%
t l t ti 1%external rotation 1%
Upper extremity impairment due to limited shoulder motion
14%
Upper extremity impairment due to weakness
Impairment of upper extremity
Impairment of whole person
Table 16-35, p. 510Impairment of Upper Extremity due to
Weakness of Shoulder or Elbow
3%
1%
2%
1%
1%
1%
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extension 2%abduction 4%
adduction 1%
internal rotation 2%
t l t ti 1%external rotation 1%
Upper extremity impairment due to limited shoulder motion
14%
Upper extremity impairment due to weakness 9%
Impairment of upper extremity
Impairment of whole person
NOT SO FAST MY FRIEND !!NOT SO FAST, MY FRIEND !!
16.8: Strength Evaluation16.8a: Principles, p. 50816.8a: Principles, p. 508
“If the examiner judges that loss of strength If the examiner judges that loss of strength should be rated separately in an extremity that presents with other impairments, the i i t d t l f t th ld b impairment due to loss of strength could be combined with the other impairments, only if based on unrelated etiologic or pathomechanical causes. Otherwise, the impairment ratings based on objective anatomic findings take precedence Decreased strength cannot be rated precedence. Decreased strength cannot be rated in the presence of decreased motion, painful conditions, deformities or absence of parts (eg,
t ti ) ” …amputation)…”
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extension 2%abduction 4%
adduction 1%
internal rotation 2%
t l t ti 1%external rotation 1%
Upper extremity impairment due to limited shoulder motion
14%
Upper extremity impairment due to weakness 9%
Impairment of upper extremity
Impairment of whole person
Upper extremity impairment due to limitation of:Shoulder flexion 4%
extension 2%abduction 4%
adduction 1%
internal rotation 2%
t l t ti 1%external rotation 1%
Upper extremity impairment due to limited shoulder motion
14%
Upper extremity impairment due to weakness 9% NO!
Impairment of upper extremity 14%
Impairment of whole person BUT DON’T REPORT!!! 8%