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Spinal Range Of Motion 2278 - Oregon
| Spinal Range Of Motion Form. This is a Oregon form and can be used in Medical Workers Comp . |
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Spinal Range of Motion Workers name: Date of injury: In describing range of motion of the spine, this form may be used as an alternative to a narrative format. Indicate the active range of motion of the injured part measured in degrees with an inclinometer. The use of the inclinometer as endorsed by the AMA in the Guides to the Evaluation of Permanent Impairment, 3rd edition (revised), copyright 1990, is the method of choice for measuring spinal range of motion. Bulletin No. 239 describes the criteria for measuring spinal range of motion using a single fluid-filled inclinometer. A video tape illustrating the use of a single fluid-filled inclinometer is available from the Department of Consumer & Business Services. The values in parentheses under each movement are the norms established by the AMA Guides and adopted by the Department of Consumer & Business Services. CERVICAL RANGE OF MOTION N/A Movement Description Measurements (minimum of three) a. Degrees of cranial flexion. Cervical b. Degrees of T1 flexion... c. Cervical flexion angle (a minus b).... 1 Flexion d. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No (60) e. Maximum cervical flexion angle .. a. Degrees of cranial extension. Cervical b. Degrees of T1 extension... c. Cervical extension angle (a minus b).... 2 extension d. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No (75) e. Maximum cervical extension angle... a. Degrees of cranial right lateral flexion.. Cervical right b. Degrees of T1 right lateral flexion.... c. Lateral flexion angle (a minus b).. 3 lateral flexion d. Are measurements within +/- 10% or 5 (whichever is greater)?..... Yes No (45) e. Maximum cervical right lateral flexion angle. ..... a. Degrees of cranial left lateral flexion.... Cervical left b. Degrees of T1 left lateral flexion.. c. Lateral flexion angle (a minus b).. 4 lateral flexion d. Are measurements within +/- 10% or 5 (whichever is greater)?.... Yes No (45) e. Maximum cervical left lateral flexion angle. ... a. Degrees of right cervical rotation. Cervical right 5 b. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No rotation (80) c. Maximum right cervical rotation angle..... a. Degrees of left cervical rotation Cervical left 6 b. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No rotation (80) c. Maximum left cervical rotation angle........... (Thoracic and lumbar on reverse) Examining physician name & title (print or type): Signature: Date of examination: 440-2278(3/00/DCBS/WCD/WEB) <<<<<<<<<********>>>>>>>>>>>>> 2 THORACIC RANGE OF MOTION N/A Movement Description Measurements (minimum of three) a. T12 angle compared to T1 (flexed)... Thoracic b. T12 angle compared to T1 (erect) (angle of minimum kyphosis). 1 Flexion c. Angle of thoracic flexion (a minus b)... (50) d. Are measurements within +/- 10% or 5 (whichever is greater)? Yes No e. Maximum thoracic flexion angle.. a. Degrees of right rotation at T1.. Thoracic right b. Degrees of right rotation at T12 2 rotation c. Thoracic right rotation angle (a minus b).. (30) d. Are measurements within +/- 10% or 5 (whichever is greater)? Yes No e. Maximum thoracic right rotation angle. a. Degrees of right rotation at T1.. Thoracic left b. Degrees of left rotation at T12.. 3 rotation c. Thoracic left rotation angle (a minus b) (30) d. Are measurements within +/- 10% or 5 (whichever is greater)? Yes No e. Maximum thoracic left rotation angle... LUMBAR RANGE OF MOTION N/A Movement Description Measurements (minimum of three) a. Degrees of flexion at T12.. Lumbar b. Degrees of flexion at midsacrum... 1 flexion c. True lumbar flexion angle (a minus b ). (60) d. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No e. Maximum true lumbar flexion angle. a. Degrees of extension at T12.. Lumbar b. Degrees of extension at midsacrum... 2 Extension c. True lumbar extension angle (a minus b ). (25) d. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No e. Maximum true lumbar extension angle. a. Right straight leg raising (SLR) angle... Passive straight b. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No leg raising right c. Maximum straight leg raising right... d. Left straight leg raising (SLR) angle. Passive straight e. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No 3 leg raising left f. Maximum straight leg raising left.. g. Total motion at midsacrum (1b + 2b) Straight leg h. Maximum midsacral motion. Raising validity i. Tightest SLR equal to or within 10 of maximum midsacral motion (3h)?.. Yes No check j. Therefore, lumbar flexion is valid Yes No a. Degrees of right lateral flexion at T12.. Lumbar right b. Degrees of right lateral midsacral flexion... 4 lateral flexion c. Right lateral flexion angle (a minus b).. (25) d. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No e. Maximum lumbar right lateral flexion angle.... a. Degrees of left lateral flexion at T12. Lumbar left b. Degrees of left lateral midsacral flexion. 5 lateral flexion c. Left lateral flexion angle (a minus b) (25) d. Are measurements within +/- 10% or 5 (whichever is greater)?. Yes No e. Maximum lumbar left lateral flexion angle... 440-2278 (3/00/DCBS/WCD/WEB)
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