Permanent Partial Impairment (PPI) Ratings – Definitions and Physician Involvement

Posted on Monday, November 16th, 2020 at 12:13 pm    

This article defines when impairment ratings are required and how the rating is determined. The proper impairment rating may help to maximize the total amount of weekly benefits you’re entitled to after medical treatments can no longer improve your medical condition.

In the context of a workers’ compensation case, a permanent partial impairment rating  will typically be a measure of any permanent damage or restriction that is objectively measured in a specific body part, such as the upper extremities, lower extremities, hands, or feet. In North Carolina (not in Virginia) this can also include permanent impairment to the spine.  These partial impairment ratings are expressed in terms of a percentage of permanent impairment. 

AMA definition of maximum medical improvement (MMI)

 The Department of Labor’s AMA guidelines (North Carolina’s is comparable) states that MMI is the medical condition/time at which the worker’s health is not likely to improve – with our without- any further medical treatment. The AMA has an exception for a terminal employee who is undergoing medical treatment for an “illness that has not reached MMI.” 

A permanent partial impairment rating cannot be made until the worker reaches MMI.

The claim becomes more complicated if a worker has multiple illnesses or conditions – one of which has reached MMI and the others haven’t reached MMI. An experienced North Carolina workers’ compensation lawyer can then explain what happens.

The impairment rating is typically measured via a Functional Capacity Exam (FCE), which will usually include narrative text – to state and support the opinion of the therapist as to the percentage of impairment. Then the treating doctor will review that opinion and either sign off on it, or add his or her own modifications, often with a descriptive rationale to support any such modifications. 

Which physician conducts the impairment rating?

Your treating physician should also be the doctor who “signs off” on the percentage impairment and assigns a percentage rating to the impairment. As noted previously, that is usually done via a Functional Capacity Examination that your physician will have to review. The insurance carrier for the employer has the right to review this assessment. If the insurance company agrees with the assessment, then, depending on whether you are still receiving TTD benefits, they may forward an Award Agreement which you will sign, indicating how much you will receive for your PPI benefits. 

Alternatively, the rating money may be incorporated into a full and final settlement as negotiated between your work injury lawyer and the insurance company, obviously, in consultation with you.  The settlement can:

  • Award the payments for your permanent disability to be paid over time – for example, 35 weeks.
  • Alternatively, your lawyer and the insurance company can also discuss a lump-sum payment.  Here, you receive one check to cover the amount you would receive over time (for example, 35 weeks). 
  • If your attorney and the insurance carrier, in consultation with you, opt to engage in negotiations for a full and final settlement, where the PPI money is incorporated into that settlement, then there  are some considerations  and issues that will need to be resolved such as:
    • Ensuring that the settlement will cover any outstanding past and potential future medical expenses which are related to your work injuries. Even though an impairment rating means you’ve reached maximum medical improvement, workers often need extensive physical therapy, additional treatment such as injections or even possible future surgery to address any worsening of their injuries over time.  This is often addressed by your attorney asking your treating doctor for an opinion letter where the doctor may provide information as to your potential future care. 
    • Adjusting the amount because you’re getting all of it now instead of having to wait for it. This is called reducing the future projections to present value
    • Addressing any issues involving Medicare or Social Security.’
    • Addressing future potential medical transportations costs. In some cases, depending on the likely frequency of care and the location of your residence, these can be significant. 

If the insurance company does not agree with the impairment rating, they have the right to ask for an independent medical examination. In North Carolina, if you are unsatisfied with your doctor’s impairment rating, you can also request an independent  ratings examination with a doctor of your choice at the expense of the defense. (This option is not available in Virginia). The Workers Compensation Commission or Industrial Commission can then choose to accept:

  • The impairment rating of the treating physician
  • The impairment rating of the doctor who provides the independent medical examination
  • The average of the two different ratings

What tests and evaluation methods does the physician use to make the impairment rating?

The tests and evaluation methods vary depending on the nature of your injury. Treating doctors and independent medical examination doctors can perform these tests and methods – using the AMA guidelines or state guidelines – depending on the state. 

Today, as mentioned previously, most physicians send the patient to another healthcare analyst who specializes in functional capacity examinations (FCEs). These are usually physical therapy facilities with qualified personnel to perform the examination. There are two types or phases of an FCE exam. 

One part of the FCE exam focuses on the worker’s ability to do his/her job. This portion of the exam will typically rate the injured worker’s ability to perform work on a scale or continuum of ability as defined by the U.S. Department of Labor as Physical Demand Characteristics.  It ranges from no ability to work, on to sedentary, all the way up to very heavy work. 

Those parameters for the physical demand characteristics of workers are defined as follows: 

          Occasional Frequent       Constant 

          (0-33% of    (34-66% of                       (67-100% of 

          Workday)   Workday)                         Workday)

Sedentary        10 lbs. negligible negligible 

Light             20 lbs 10 lbs negligible 

Medium            20-50 lbs 10-25 lbs 10 lbs

Heavy             50-100 lbs 25-50 lbs 10-20 lbs. 

Very Heavy       over 100lbs 50 lbs 20 lbs  

 Another portion of the FCE is focused on the relevant injured body parts and is used to determine the permanent partial impairment in that body part and assign an impairment rating to that body part. 

Insofar as the portion that assesses whether the worker can perform his or her job, the FCE can also address what rehabilitation steps and what work modifications steps might help the worker who has a disability or medical condition – that otherwise prevents him/her from working.

The FCE examiner will evaluate the worker’s physical abilities. The evaluations provide data for the physician to make an impairment rating determination. The FCE examiner will typically assign an impairment rating and it is the treating doctor’s job to either “sign off” on that rating, or make modifications. 

Some of the tasks an FCE examiner may review include the worker’s:

  • Ability to lift
  • Ability to push or pull
  • How long the worker can sit or stand without discomfort
  • Ability to reach
  • Flexibility range
  • Ability to grasp and hold an object
  • The ability to bend
  • The worker’s balance
  • The ability to follow directions
  • The ability to communicate and organize
  • Walking on a treadmill
  • Crouching and kneeling

The FCE examiner will:

  • Conduct an intake examination
  • Review your medical records
  • Take an oral history
  • Conduct a physical examination

The tests are often done over a four to six-hour time frame. Some examinations are conducted over a two-day period – if stamina and tolerance to pain need to be examined. Many workers who are on workers’ compensation may be trying these exercises/routines for the first time since they stopped working. 

FCE exams are usually conducted by occupational therapists and physical therapists – in their own facility.  Both professionals require training, education, and certification.

If at all possible, our office tries to exercise some control over your doctor’s referral to the specific FCE facility where you will be evaluated. Sometimes, as in where your physician will make a direct referral to a facility, there is little we can do. But in other cases, the doctor will simply make a general FCE referral, in which case we try to convince the workers’ compensation insurance company to allow the evaluation to be performed at certain facilities that, in our experience, will conduct a fair examination. 

Unfortunately, as is the case across the medical treatment and evaluation landscape, there are certain providers and facilities whom we have come to know as being  very biased in favor of the insurance companies. These facilities will almost always come back with very low ratings on their FCE evaluations, and either find that the injured worker is 100% capable of returning to work, or that the injured worker is malingering, or faking his or her disabilities and that therefore, the results of the FCE are not reliable. 

How does the impairment rating work?

The impairment is generally assessed according to the loss of unction of a body part – such as limbs, muscles, joints, the brain, the spinal cord, and nerve damage.

In North Carolina, the state essentially uses a two part determination method:

  • Part one is categorizing the type of disability. For each type body part,  North Carolina law and Virginia Law sets forth the maximum  compensation (at the workers’ compensation rate, which is  2/3rd’s of the injured worker’s average weekly wage ) the worker would receive if he/she had a 100% permanent impairment in that particular body part.


For example, the maximum permanent loss of use of an arm is payable for 240 weeks in North Carolina.

  • Part two is assigning a percentage. The percentage is essentially a multiplier of the maximum figure that is presented in the statute. So, for example, if as in the above example, a worker has an arm injury, then we know the maximum is 240 weeks in North Carolina. 


 If the impairment rating is 20%, then the injured worker is entitled to 48 weeks of payments. That is 240 x 20%=48 weeks. So then you would take the TTD or compensation rate (let’s assume it’s $500.00) and multiply it times the weeks. In our example 48 weeks x $500.00=$24,000.00 in PPI money that the injured worker would be entitled to.  

Attorney Joe Miller, Esq. is a respected North Carolina and Virginia workers’ compensation lawyer. He’s been helping injured employees obtain just recoveries for more than 30 years. He’ll work with your doctors to ensure your impairment rating is judged correctly. He’ll explain which tests the doctor or an FCE examiner is likely to perform. He’ll fight to make sure you aren’t forced back to work if you can’t work. He’ll also work to ensure your medical bills are aid. To talk with an experienced work injury lawyer, call North Carolina and Virginia attorney Joe Miller, Esq., at 888-667-8295 or fill out my online contact form  or our new online case evaluation tool

The American Medical Association Guidelines and State Workers’ Compensation Guidelines – for Determining a Worker’s Permanent Impairment Rating

Posted on Thursday, November 12th, 2020 at 12:10 pm    

Different federal agencies and different states use the AMA guidelines (either directly or indirectly) to assess a worker’s permanent partial impairment. In the context of a workers’ compensation case, a permanent partial impairment rating  will typically be a measure of any permanent damage or restriction that is objectively measured in a specific body part, such as the upper extremities, lower extremities, hands, or feet. In North Carolina (not in Virginia) this can also include permanent impairment to the spine.  These partial impairment ratings are expressed in terms of a percentage of permanent impairment. 

The United States  Department of Labor has guidelines for evaluating medical evidence necessary to show a “ratable permanent impairment” for certain federal workers. Generally, workers who have a ratable permanent impairment are entitled to additional pay after they have reached the point of maximum medical improvement. 

States, such as North Carolina and Virginia, generally use comparable guidelines in determining how much, if any, additional compensation injured or ill workers should receive due to a workplace injury or disease. In Virginia, the guidelines are not specifically mentioned by statute, but are often utilized by doctors and rehabilitation professionals to assign permanent impairment ratings to the injured body parts of claimants.  Others use their own guidelines. For example, North Carolina has its own rating guide for impairment

Before we go further, one important note about impairment ratings generally: If we have an accepted claim or a claimant who is under an Award in Virginia, and the injured worker is injured to the extent that he or she cannot return to job he/she held prior to their injury, and the employer is unable to accommodate the employee’s physical restrictions, then really, except in  rare circumstances,  the impairment rating is not a very important item to consider.

 Why? Because first, if it is an accepted or awarded claim, and one cannot return to his or her pre-injury job, and the employer is not able to accommodate, then the employee will continue to receive TTD for potentially up to 500 weeks. So long as an injured worker is receiving TTD, then the law says he or she cannot simultaneously receive payments for permanent partial impairment (PPI) and TTD.  In other words, one cannot ADD to the 500- week maximum with PPI payments. 

Those PPI payments would only be available if, and when the injured worker returned to work at any job.   

In addition, in the scenario of an accepted claim, we are often looking at a potential settlement of the claim. The value of the indemnity or “weekly TTD checks” portion of the claim in a case where one cannot return to the pre-injury job is usually far higher than any payment that one would be entitled to for PPI. 

Accordingly, the only time PPI usually becomes more important is the scenario where the injured worker has returned to work in some capacity. Once that happens, we are going to factor those available payments into any potential settlement. In the above scenario, where the injured worker continues to receive TTD, and we are looking at a potential 500-weeks maximum of payout, we do not care as much about the ratings in any settlement scenario. 

North Carolina rating guide

North Carolina distinguishes between an evaluation of permanent physical impairment and permanent disability. It references the AMA guidelines as follows:

The Disability Committee of the American Medical Association (AMA) has pointed out that the evaluation of permanent disability is twofold:

  • The medical evaluation of the permanent physical impairment.
  • The rating of the disability according to the administrative bodies.


Physical impairment is a purely medical condition. Permanent physical impairment is any anatomical or functional abnormality or loss after maximum medical rehabilitation has been achieved and which abnormality or loss the physician considers stable or non-progressive at the time the evaluation is made.”

  • Permanent disability is not a purely medical condition. A patient is ‘permanently disabled’ if ‘under a permanent disability’ when his actual or presumed ability to engage in gainful activity is reduced or absent because of ‘impairment’ and no fundamental or marked change in the future can be expected.
  • Medically, disability is physical impairment and inability to perform physical functions normally.
  • Legally, disability is permanent injury to the body for which the person should or should not be compensated.

In workers’ compensation cases in North Carolina there are four types of disability:

  • Temporary partial disability. (TPD) The worker can return to work – but with restrictions. The worker receives treatments to try to improve his/her condition during this period. This is also available in Virginia, and in such circumstances, if the injured worker is working under reduced pay because of the physical restrictions, then he or she is entitled to 2/3rds of the difference between the pre-injury wages and the wages in the new, light duty job. 
  • Temporary total disability. (TTD) The period of time when the worker can’t do any work at all per the treating physician and is receiving medical treatment. TTD payments are 2/3’s of the injured worker’s average weekly wage.  To obtain an accurate number for TTD,  we multiply the average weekly wage x .66667
  • Permanent partial disability or impairment. (PPI) This term applies to a worker who has some permanent physical damage or some loss of use of a body part – after he/she has reached maximum medical improvement. Again, these impairments are expressed in terms of a percentage. Using the percentage, one would reference the law that sets forth the maximum permitted recovery for the body part in question. That recovery is expressed in terms of weeks of TTD. Then one uses the percentage to determine the available payment for one’s impairment rating. A quick example: In North Carolina, the maximum payment for the back or spine is 300 weeks. (no such impairment for the spine is available in Virginia). The treating doctor rates the injured worker as having a 20% permanent partial impairment to the spine. 20% of 300 is 60 weeks. If the injured worker’s TTD rate is $500.00, then $500 x 60 weeks= $30,000.00. The injured worker would be entitled to a payment of $30,000.00. Some discounts to that amount typically apply if the injured worker wants to receive the amount in lump sum vs. over 60 weeks. 

North Carolina’s rating guide for impairment is just meant to be a guide for physicians in their rating exams – since many injuries involve intangible factors such as “pain, weakness, and dexterity.” The doctor’s job is to assign a percentage to the impairment. The doctor should use hie/her independent judgement based on experience, a clinical examination, test results, and other factors to set the percentage. The North Carolina industrial Commission then uses this percentage, among other factors, to determine what award, if any, should be paid to the worker.

That being said, usually, ratings are determined within the context of rigorous testing of the injured worker at a physical therapy facility by a qualified professional known as a functional capacity examination (FCE). The doctor will usually rely on the results of the FCE to determine permanent partial impairment. 

American Medical Association definition of impairment

The Department of Labor guidelines reference the 5th edition of the AMA impairment guidelines. The 5th edition defines an impairment as “a loss, loss of use or derangement of any body part, organ system or organ function.” In addition, the 5th edition states: 

“Impairment percentages or ratings developed by medical specialists are consensus-derived estimates that reflect the severity of the medical condition and the degree to which the impairment decreases an individual’s ability to perform common Activities of Daily Living (ADL)excluding work. (Emphasis in original).

The AMA guidelines rate various organs and bodily functions by category – such as respiratory, cardiac, nervous system, endocrine, etc.

According to Insurance Journals, the AMA guidelines for the 5th edition (2000) were updated by a 6th edition (2007). Research from McMaster University in Ontario and the Netherlands showed that the 6th edition “resulted in significantly lower impairment ratings than the 5th edition,” according to research from McMaster University in Ontario and the Netherlands. Their findings, which were published in the Journal of Occupational and Environmental Medicine, stated that the difference in the impairment ratings is that the focus on impairment ratings shifted from pain and range of motion – to direct measures of function. “For example, in an earlier guide they may have measured whether a person could lift their arm above their head without discomfort, but now they look at whether the person could put a box on a shelf.”

“The results showed the median whole person impairment rating was seven per cent for 131 claimants assessed with the fifth edition of the AMA guides, and four per cent for 118 claimants assessed with the sixth edition.”

The study made another startling finding- that the state workers’ compensation boards throughout North America are not consistent with which AMA guides they use. 

According to Lexis, as of July 1, 2019, the count of  States Utilizing various guidelines broke out as follows: 

AMA Guides, 6th Edition 14 states 

AMA Guides, 5th Edition 10 states 

AMA Guides, 4th Edition 6 states 

AMA Guides, 3rd Edition Revised, 2 states 

State-specific guide used instead 16 states (although 15 states say AMA Guides may be consulted)

Comparison of the 5th and 6th AMA editions

Disability is defined as follows:

  • The 5th edition defines disability as – “Alteration of an individual’s capacity to meet personal, social or occupational demands or statutory or regulatory requirements because of impairment.”
  • The 6th edition defines disability as – “Activity limitations and/or participation restrictions in an individual with a health condition disorder or disease.” 

Impairment is defined as follows:

  • The 5th edition defines impairment as “a loss, loss of use or derangement of any body part, organ system or organ function.”  
  • The 6th edition adds the word “significant” to the definition. 

North Carolina and Virginia workers’ compensation lawyer Joe Miller Esq. is a premier workers’ compensation lawyer. He’s helped thousands of injured employees obtain strong recoveries. He works with your doctors and independent doctors to properly assess your disability and your impairment rating. He’ll fight to ensure you are required to work only if you are physically able to work. To speak with an experienced North Carolina and Virginia workers’ compensation attorney, call attorney Joe Miller, Esq., at 888-667-8295. or fill out my online contact form , or utilize our new online case evaluation form.

Carpal Tunnel Syndrome and Workers Compensation – Part Two

Posted on Friday, October 30th, 2020 at 8:52 am    

Carpal tunnel syndrome is painful and is likely to cause workers to lose time from their job. If your median nerve isn’t working you’ll have a lot of complications such as:

  • Not being able to use your thumb effectively
  • Not having the right feeling in your fingers
  • Not being able to hold objects well
  • Not being able to distinguish between hot and cold – on touch

How does your doctor diagnose carpal tunnel syndrome? 

According to the Mayo Clinic, your physician will conduct a series of tests and questions to determine if you have carpal tunnel syndrome. These tests and questions include:

  • Asking you about your symptoms. The doctor will take an oral history of the problems you’re having such as asking when the pain occurs and under what conditions it occurs.
  • Physically examining you.  The doctor will examine how well you feel with your fingers and how strong your hand muscles are. He/she will bend the wrist, touch on the median nerve, and/or press on the nerve to see if these efforts trigger pain.
  • Taking X-rays. Generally, X-Rays can’t diagnose carpal tunnel syndrome. X-rays can rule out other problems such as fractures.
  • Giving you an electromyography. This test measures the tiny electrical discharges produced in muscles. During this test, your doctor inserts a thin-needle electrode into specific muscles to evaluate the electrical activity when muscles contract and rest. This test can identify damage to the muscles controlled by the median nerve, and also may rule out other conditions.”
  • Taking a nerve conduction study. Here, two electrodes are taped to your skin. Then a small shock is directed through the median nerve – “to see if electrical impulses are slowed in the carpal tunnel.” The test can help diagnose carpal tunnel syndrome and also helps rule out other medical conditions.
  • Giving you a Tinel test. This test is a physical test to see if you develop a tingling sensation or if you are numb in certain areas of the wrist and hand. 

Imaging tests may also eliminate other problems such as diabetes.

What are the initial treatments for carpal tunnel syndrome?

It’s best to start treatments of carpal tunnel syndrome as quickly as possible. Early self-help treatments include:

  • Taking more frequent rest breaks
  • Avoiding any actions that make your symptoms worse
  • Using cold packs to help reduce any swelling

In milder cases, where your condition is less than 10 months old, splinting may help. If, however, your hands feel numb, you should treat with a doctor as soon as possible. As a general rule, you should see a doctor, even if you have a mild case, so he/she can diagnose the condition and recommend initial therapy.

Splinting the wrist helps keep the wrist still while you sleep. Patients use the wrist splint at night though it can help with daytime aches and pains.

Some stretching exercises may help. Some patients seek chiropractic care and/or acupuncture

What nonsurgical treatments may help?

Some nonsurgical therapy treatments include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications may help reduce carpal tunnel syndrome pain. NSAIDs include Advil, Motrin IB, and other medications. Generally, NSAIDs don’t improve your disorder. The aim of these drugs is to hopefully reduce the level of pain.
  • Corticosteroids. These are injections designed to help reduce pain. Sometimes your doctor uses an ultrasound to guide these injections.” “Corticosteroids decrease inflammation and swelling, which relieves pressure on the median nerve. Oral corticosteroids aren’t considered as effective as corticosteroid injections for treating carpal tunnel syndrome.”

What types of surgery are used for treating carpal tunnel syndrome?

The Mayo Clinic indicates that there are two types of carpal tunnel syndrome surgery:

  • Endoscopic surgery. “Your surgeon uses a telescope-like device with a tiny camera attached to it (endoscope) to see inside your carpal tunnel. Your surgeon cuts the ligament through one or two small incisions in your hand or wrist. Some surgeons may use ultrasound instead of a telescope to guide the tool that cuts the ligament.” This type of surgery, during the first few recovery weeks, may be less painful than open surgery.
  • Open surgery. “Your surgeon makes an incision in the palm of your hand over the carpal tunnel and cuts through the ligament to free the nerve.”

There are risks to surgery that your surgeon should explain to you before any operation. These risks include:

  • “Incomplete release of the ligament
  • Wound infections
  • Scar formation
  • Injuries to the nerves or blood vessels”

The healing process, after surgery usually takes a few months. During this time, “the ligament tissues gradually grow back together while allowing more room for the nerve.” Employees, who are entitled workers’ compensation, should receive temporary disability during the healing process. The employer’s insurance carrier should pay for the surgery.

In some cases, your symptoms may not completely disappear after surgery.

Are you entitled to workers’ compensation if you have carpal tunnel syndrome?

Often, employees can show that they developed carpal tunnel syndrome due to their work. Still, that doesn’t mean you’re automatically qualified for workers’ compensation in either North Carolina or Virginia. Generally, injuries must either be due to a workplace accident or an occupational illness or disease.

In Virginia, Carpal Tunnel Syndrome is specifically not recognized as a statutory occupational disease the same way as something like asbestosis; however, it is probably the most commonly claimed “ordinary disease of life” that injured workers claim is due to have occurred due to exposure to specific work conditions. 

It is definitely not a given that a claim for carpal tunnel will be found compensable. In Virginia, any “ordinary disease of life” much meet the higher standard of “clear and convincing” evidence. This means that there must be very clear proof that the unique work conditions are such that they have caused the CTS, and also that the CTS is not due to factors outside of work. It must be “characteristic of the employment and was caused by conditions peculiar to such employment.”

Employers will typically argue that your carpal tunnel syndrome is due to other conditions – such as a second job or activities you do at home. They’ll also argue that you had a pre-existing carpal tunnel condition caused by other activities or conditions that pre-dated your work history with the employer.

North Carolina is similar in its proof requirements. CTS would fall under the “catch all” occupational disease claim found at N.C.G.S. 97-53(13)  which does generally allow a carpal tunnel syndrome claim to be filed if it is due to a repetitive stress injury – if it can be shown that the CTS is proven “to be due to causes and conditions which are characteristic of and peculiar to a particular trade, occupation or employment, but excluding all ordinary diseases of life to which the general public is equally exposed outside of the employment.”

If you are able to prove your claim, while you’re out of work due to the CTS, you should be entitled to temporary disability benefits at 2/3rds of your average weekly wage and of course coverage for any and all treatment related to your CTS. If your hand doesn’t completely recover, and you end up with some kind of permanent impairment, you may be entitled to permanent partial disability (PPD) benefits.

North Carolina and Virginia workers’ compensation lawyer Joe Miller Esq has helped thousands of injured workers obtain just recoveries. He understands the unique coverage and treatment issues involved with carpal tunnel syndrome claims. To talk with a seasoned work injury lawyer, call North Carolina and Virginia attorney Joe Miller, Esq., at 888-667-8295. or use my online contact form or our new online case evaluation form to find out if you may have a claim. 

Carpal Tunnel Syndrome and Workers Compensation – Part One

Posted on Wednesday, October 28th, 2020 at 8:50 am    

Carpal tunnel syndrome is an injury due to stress. It happens when pressure on the median nerve and tendons that travel through the carpal tunnel (a passage in your arm). You feel the injury as you flex your fingers. The carpal tunnel can cause pain, numbness and tingling,  even with minor swelling.

What are the symptoms of carpal tunnel syndrome?

According to the Mayo Clinic, symptoms include:

  • Tingling or numbness. If you have carpal tunnel syndrome, you may notice numbness and tingling in your hand or fingers. The most affected fingers are the thumb and index, the ring fingers, and the middle fingers- but not your little finger. The sensation may even feel like an electric shock.

The feeling may extend from your wrist up your arm. The symptoms can appear while you’re driving or just reading a publication. They may cause you to wake from your sleep. Many people try to shake out the feelings. The numbness feeling may last a long time.

  • Weakness. You may not be able to grasp or hold onto objects – due to numbness or weakness. The inability to hold objects may also be due to the pinching muscles of the thumb.

What causes carpal tunnel syndrome?

Pressure on the median nerve causes carpal tunnel syndrome. The median nerve “provides sensation to the palm side of your thumb and fingers, except the little finger. It also provides nerve signals to move the muscles around the base of your thumb (motor function).”

Carpal tunnel syndrome can be due to anything that irritates or squeezes the median nerve. A fractured wrist can also cause the carpal tunnel to narrow. Rheumatoid arthritis is another cause of carpal tunnel syndrome. Often, there is no one singular cause. A combination of factors may cause he disorder.

What are the risk factors for carpal tunnel syndrome?

Many factors increase the risk of carpal tunnel syndrome though they may not cause the disorder. These risk factors include:

  • Anatomical factors. Examples include a fractured wrist, a dislocation of the wrist, or arthritis. These conditions can change the space within the carpal tunnel or place pressure on the median nerve.
  • If you have a smaller carpal tunnel than others, you’re more likely to have carpal tunnel syndrome.
  • Gender. Women are more likely to develop carpal tunnel syndrome than men. 
  • Nerve-damaging conditions. “Some chronic illnesses, such as diabetes, increase your risk of nerve damage, including damage to your median nerve.”
  • Inflammation. Inflammation, due to rheumatoid arthritis or other causes can place pressure on the median nerve and affect the tendon linings around the wrist
  • Medications. “Some studies have shown a link between carpal tunnel syndrome and the use of anastrozole (Arimidex), a drug used to treat breast cancer.”
  • Obesity. Being overweight is a risk factor
  • Changes in bodily fluids. Fluid retention can irritate the median nerve and “increase the pressure within your carpal tunnel.” Bodily fluid changes often occur during menopause and pregnancy. The good news is that once the delivery is complete, the mother usually feels better.
  • Other medical disorders. Examples include kidney failure, lymphedema, thyroid disorders, and menopause. Some diseases such as a tumor or diabetes can also increase the risk of carpal tunnel syndrome.

Of particular note, is that workplace conditions are a known risk factor. Examples include:

  • Working with tools that vibrate
  • Working on an assembly line which requires repetitive wrist flexing or prolonged wrist flexing – which can place pressure on the median nerve or affect existing nerve damage.
  • Age. Older people are more likely to develop carpal tunnel syndrome than younger people
  • Trauma. An injury increases the risk of carpal tunnel syndrome.

“Several studies have evaluated whether there is an association between computer use and carpal tunnel syndrome. Some evidence suggests that it is mouse use, and not the use of a keyboard, that may be the problem. However, there has not been enough quality and consistent evidence to support extensive computer use as a risk factor for carpal tunnel syndrome, although it may cause a different form of hand pain.”

Are there ways to prevent or reduce the risk of carpal tunnel syndrome?

Some of the ways to reduce stress on your wrists and hands include:

  • Use a relaxed grip. Reduce your force. If, for example, you use a computer or a cash register – try to hit the keys or numbers a little softer. If you write with a pen,, try using a large pen that has a large soft grip adapter – and ink that flows freely.
  • Take more breaks. During breaks – stretch and bend your hands and wrists. Try to alternate tasks – especially if you use equipment that vibrates like a jackhammer. A few minutes’ break every hour can make a large difference.
  • Watch your form. Try not to bend your wrist – all the way up or down. Use a relaxed position where possible. “Keep your keyboard at elbow height or slightly lower.”
  • Improve your posture. “Incorrect posture rolls shoulders forward, shortening your neck and shoulder muscles and compressing nerves in your neck. This can affect your wrists, fingers and hands, and can cause neck pain.”
  • Make sure you have a comfortable computer mouse.

You should also avoid working where it’s cold. If you can’t control the cold/heat, try using fingerless gloves. They may help.

What types of jobs are most at risk for carpal tunnel syndrome?

Some that we’ve mentioned include computer work or keyboard work, assembly line work, and using a cash register. Other risky jobs include:

North Carolina and Virginia workers’ compensation lawyer Joe Miller Esq. has helped thousands of injured workers obtain their full work injury benefits. He’ll fight to show your carpal tunnel syndrome is compensable under state workers’ compensation laws. He’ll work to show how much medical care and time off you need.To speak with an experienced work injury attorney, call North Carolina and Virginia lawyer Joe Miller, Esq., at 888-667-8295. or fill out my online contact form to make an appointment or feel free to utilize our new online case evaluation form.

Pre-Existing Medical Conditions and Workers’ Compensation Claims

Posted on Thursday, October 22nd, 2020 at 1:28 pm    

Workers’ compensation claimants have the right to demand that their employer pay for all medical bills for injuries related to a workplace accident or an occupational illness. The insurance carrier for the employer is also required to pay temporary benefits (2/3rds of your average weekly wages – with some adjustments) until you can return to work or alternate, light duty work is found for you. Once you’ve reached maximum medical improvement (MMI), you may be evaluated to determine if you have a permanent impairment as well as permanent work restrictions due to your workplace injury. This evaluation includes a permanency rating which details the type of disability you have in your injured body part(s) and the severity of the disability as it relates to the types of work you will be able to do, and not do, going forward. Additional work loss payments are paid depending on the impairment rating and whether you are capable of returning to your pre-injury job.

Insurance companies for the employers are always looking for a way to limit how much they have to pay. One classic strategy that employers use is to argue that your injuries and inability to work are due to a pre-existing condition. If the employer can show you have a pre-existing condition:

  • Your right to benefits could be denied;
  • Your right to medical treatments (and payment for those treatments) could be reduced or denied;
  • Your right to temporary wage loss benefits could be reduced or denied;
  • Your right to permanent disability benefits could be reduced or denied.

Whether these rights are denied or reduced depends on the relationship between any prior condition and your current medical condition.

If the pre-existing condition dose not relate to your current medication condition (for example, your knee now hurts when the pre-existing condition was a broken arm), then your right to new benefits should not be affected. Likewise, if he pre-existing condition fully healed before your current accident, then your right to benefits should not be denied.

What is a pre-existing condition?

A pre-existing condition in the context of an injury case is a form of injury for which a worker has previously received medical treatment or for which a diagnosis of an injury has been made in his or her current work injury case. It used to be the case that if you had a pre-existing medical condition, your own health insurance wouldn’t pay for treatment for that condition – unless a sufficient length of time had passed since the last treatment. Due to the Affordable Care Act, insurance companies are now prohibited from denying payment for any necessary treatments – even if you have a pre-existing condition.

While the ACA helps with medical bills, it doesn’t pay any wage compensation. In addition, if you use your own health insurance, you have to pay the deductible and copays. Workers compensation doesn’t require deductibles or copays. If your claim is accepted or ruled compensable, the workers compensation insurance company must pay all reasonable and related costs in connection with your work injury. 

Pre-existing conditions vary from worker to worker and patient to patient. They include conditions due to injury such as broken bones and arthritis due to surgeries. Pre-existing conditions also include diseases such as heart disease and cancer. Whether your pre-existing condition will negatively affect your workers comp claim depends on a variety of factors, not the least of which is where your case is pending. 

Is your current medical condition related to your pre-existing condition?

In most cases, your physicians will make the initial determination about whether you have a pre-existing condition. This determination is based on a number of factors including:

  • A thorough review of your prior medical records. Previous doctor reports should document any treatments you had. They’ll document any diagnostic tests, such as x-rays, MRI’s or CT scans– if you had diagnostics. If you never received any treatment for your prior injury, then your current doctor is less likely to be aware of you pre-existing condition.
  • A physical examination. A scar from a prior surgery, for example, is an immediate clue that you had a prior injury. On the other hand, if your prior injury has completely healed, then a physical exam is less likely to show the prior injury.
  • An oral examination. Your physician will likely ask you about any pre-existing conditions. You need to be as candid and forthcoming as possible. Never, never try to lie or hide any pre-existing condition. The Insurance companies have a vast network of computer surveillance and of course, the power to subpoena records. If your doctor and your attorney know about any relevant pre-existing conditions, they can be dealt with. A surprise piece of information that is dug up by the defense and thrust into your doctor’s face is less likely to be effectively dealt with and may cause your doctor to be hostile towards you. 

It is important that you speak with your North Carolina or Virginia workers’ compensation lawyer as soon as possible. Often, your employer will go on a fishing expedition to try to show you have a pre-existing condition. There are limits to what employers and even physicians can ask about your prior medical history. Your lawyer can explain these limits. But we will say this repeatedly—the worst thing you can do is try to hide a pre-existing condition. This will destroy your credibility, not only with the Workers Compensation Commission, but with your doctors as well. 

Is the pre-existing condition related to your current injury or illness?

Whether the injury is “related” to a pre-existing condition is a legal question. The main issue is one of determining how much the new accident caused your injury and how much the prior condition is contributing to your need for medical benefits and work loss payments. Factors that need to be considered include:

  • Were you still treating for prior medical condition?
  • Did the current injury worsen your prior medical condition?
  • Is the current injury different than the new one? For example, if your prior injury was a torn meniscus and your new injury is a torn ligament, then the injuries (even though both may be to the same knee) are fairly different.
  • Was the pre-existing condition due to another workplace accident, to a personal injury accident, to old age, or to some other cause?
  • The type of injury. Some injuries like a broken arm should fully heal within a few months. Other injuries, like a bad back can be chronic and last for a lifetime.
  • The severity and trauma of the current injury. If you had a pre-existing, active condition, and the trauma associated with the new injury was very slight, it may be harder to prove that you have a new injury. 

Jurisdiction Matters. A lot really depends on what jurisdiction you are proceeding under. In Virginia, believe it or not, the law relating to medical causation is actually fairly liberal. First, as with any work injury, you just show that you suffered an injury by accident, which means that you suffered a sudden mechanical change in your body as a result of a trauma. 

Then, once you can prove that, if ANY part of your current disability or need for treatment comes from the new injury by accident—even if it’s only 1%— then the entirety of the claim is compensable.  So yes, the law on this is very helpful for injured workers in Virginia. 

Let’s take an example. Say you had a pre-existing herniated disc in your back. You may have even had surgery, but the surgery was about a year before the current accident, and you’ve done fairly well. In fact, you’ve resumed your full duties at work for the last three months. 

But then your co-worker drops his end of a heavy object which pulls you down and causes you to have a “pop” and then horrific pain in your back. Your left leg goes, and stays completely numb with shooting pins and needles down your left thigh and leg. Your Neurosurgeon says it’s a re-aggravation of your previous injury, takes you 100% out of work, and also says you will now require a more extensive fusion surgery on your lumbar spine. 

In Virginia, unless your Neurosurgeon or Orthopedic can say that the new accident had NOTHING to do with your current inability to work, then you should have no problem moving forward with a new claim on your back. 

How is this determined? In Virginia, we typically will write your doctor and ask him to answer a few questions in the form of an Opinion Letter which sets forth

  1. Whether you suffered a sudden mechanical change as a result of the new injury; and 
  2. Whether the new injury contributes—even in the slightest degree—to your current disability and need for treatment. 

So long as the answer to both of those questions is “yes,” from your authorized treating doctor, you should be fine and the entirety of your new claim should be compensable. 

North Carolina Workers Compensation Pre-Existing Injury Law—Not Quite as Liberal

Unfortunately, North Carolina Workers Compensation Law is not quite as liberal as Virginia in relation to the law on pre-existing injuries. 

First of all, except with respect to back injuries, North Carolina requires that you show some type of actual “slip, trip, or fall,” when attempting to prove that you suffered an “injury by accident.”  Accordingly, a “leg giving way” or a twisting of the knee, without a fall to the ground or slip, would not be considered an “accident” under North Carolina Law, where it might in Virginia. That being said, North Carolina has carved out an exception for back injuries. All that need be shown is a “sudden traumatic event” if you’ve suffered a back injury.  This could be something as simple as feeling a sudden “pop” in one’s back as one is lifting something heavy at work. 

But of course, as in Virginia, once you have established that you have suffered an accident, what happens if you have a pre-existing condition in a North Carolina Workers Compensation Case? Unfortunately, things are not quite as easy as in Virginia. 

Let’s use the example we used in Virginia—you suffered a pre-existing back injury and surgery, and you’ve done fairly well and returned to full duty.  

Now you’ve re-injured the same back in a new North Carolina Workers’ Comp Case, and your doctor pulls you 100% out of work and says that you will require a more extensive back surgery. What will you have to prove to show that this is separate from the old injury? 

 North Carolina Law is similar, but not quite as liberal, as Virginia on this issue. The law in North Carolina is that where a nondisabling condition is aggravated or accelerated by an accidental injury from employment, so that the worker is now disabled, then the employer must compensate the employer for the entire resulting disability. In other words, just because the injured worker had some underlying condition that made the current injury worse, there is no “apportioning” done as between what was there before and what is wrong with the employee now. The entirety of the current disability is compensable. 

That being said, North Carolina has the extra requirement that the employee prove that the work-related accident “contributed in some reasonable degree” to the plaintiff’s disability.  The injured worker must prove that it is more likely than not that the accident was a “causal factor resulting in the disability.” 

So that standard is a little higher than Virginia’s causation standard, which sets forth that ANY contribution by the new injury to disability is enough to make the entire claim compensable. North Carolina requires a little more than that—a “reasonable degree” of contribution. 

How does one prove this? Again, as in Virginia, an opinion as to whether an aggravation of a pre-existing condition rests entirely with the authorized treating physician. If the physician is able to state that more likely than not, the new injury contributes in some reasonable degree to the current disability, then the entire claim is compensable. 

Unfortunately, unlike Virginia, the North Carolina Industrial Commission does not accept medical opinion letters as testimony or evidence, without sworn testimony. Accordingly, if a matter is proceeding to Hearing in North Carolina, the deposition of the doctor must be scheduled to elicit his or her testimony for hearing. 

That being said, oftentimes the production of a favorable opinion letter well in advance of any deposition of the doctor will give a clear indication of the way the physician intends to testify and may result in an agreement by the defense to accept the claim. 

North Carolina and Virginia workers’ compensation lawyer Joe Miller Esq. is a seasoned workers’ compensation attorney. He’s helped thousands of injured workers, including many with pre-existing conditions, obtain a just recovery. He’ll fight to show the prior condition isn’t related to your new medical condition. To speak with an experienced work injury lawyer, call North Carolina and Virginia attorney Joe Miller, Esq., at 888-667-8295. or fill out our online contact form  or our new online case evaluation form to streamline the process of having Mr. Miller review your case. 

COVID-19 Can Kill Your VA Workers Comp Case

Posted on Thursday, September 17th, 2020 at 2:27 pm    

In this video Workers Compensation Lawyer Joe Miller explains how your contraction of COVID-19 illness could completely “kill” or derail a perfectly good workers compensation case in Virginia, even if you are under an Award. As a matter of fact, if you become unable to work as a result of ANY condition that is not related to your work injury, and your workers comp doctor has you on light duty, you can expect your benefits to be immediately cut off.

Why? Because you have been removed from the labor market for an unrelated condition, and therefore, your inability to work has nothing to do with your work injury, but with an unrelated condition. Yes, it is very, very unfair and no, it was not your fault that you got sick. But the workers compensation insurance company does not care about that, nor does the Virginia Workers Compensation Commission. The bottom line is if you are under an Award, and you’re on light duty, you had better avoid getting COVID-at all costs. Even if you only test positive and have no symptoms, we know that positive result would prevent you from working anywhere and therefore, you can expect your benefits to be cut off.

Brain Injury and Workers’ Compensation

Posted on Wednesday, September 16th, 2020 at 11:23 am    

Many workers suffer traumatic brain injuries due to falls, violence, being struck by objects, and other reasons. According to the Centers for Disease Control and Prevention, over 150 people in the United States die each day from a traumatic brain injury. In 2014, 2.87 million people sought emergency department treatment for a TBI. (more…)

Potential Great News For Virginia Health Care Providers and others who Got Sick from COVID-19

Posted on Friday, September 4th, 2020 at 9:41 am    

Workers Compensation Attorney Joe Miller talks about Virginia Senate Bill 5066, which proposes to create a legal presumption for all police, firefighters, first Responders and healthcare providers in the Commonwealth that if he or she contracted COVID-19, then it is presumed to have been contracted on the job, and accordingly, is compensable as an occupational disease. Most importantly, the bill, as proposed, would be retroactive to provide this presumption to any worker in one of these occupations who became ill from COVID-19 at any time after January 1, 2020. Although some folks who have already taken their COVID cases to hearing in Virginia have prevailed, the majority have not. (more…)

Custodial Workers and Workers’ Compensation

Posted on Wednesday, August 26th, 2020 at 10:13 am    

As the start of the school year gets nearer, much of the focus has been on when and how the schools should open in light of the COVID-19 pandemic. One of the related issues will be the rights of teachers and custodial workers in these schools. We’ve written previously about teachers and workers’ compensation and also on the general rights of all workers to claim benefits if they contract COVID-19. (more…)

North Carolina Guidelines for People Attending Workers’ Compensation Hearings During the COVID-19 PANDEMIC

Posted on Thursday, August 20th, 2020 at 10:11 am    

The guidelines for North Carolina Industrial Commission hearings, as of July 2020, are the following:

You have COVID-19 symptoms

If you have any COVID-19 symptoms, you should not attend a hearing. You should not enter a courthouse or hearing room. You should contact the deputy commissioner by email or telephone to receive further instructions. (more…)

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