Understanding the AMA Guides to Impairment, 6th Edition

1. Understanding the AMA Guides to Impairment, 6th Edition PRESENTER:Richard Radnovich, D.O., Medical Director,Injury Care Medical Center

2. Impairment Ratings • Objectives • Understand changes in 5th and 6th editions of the Guides • Understand how impairments are rated using the 6th edition of the Guides • Be able to calculate simple ratings • How to critically read and evaluate an impairment rating • Identify common errors in ratings • Accurately and thoroughly represent the Guides, not my opinions

3. Impairment Ratings • OUTLINE • Define impairment • Brief history • Differences in content • Differences in application • Changes/clarifications/corrections • Present a case • 5th v 6th editions • Disc terminology, bulge v herniation • Treatment of disc herniations • Physical examination • ROM • Waddel’s signs • Rate an impairment

5. Impairment Ratings • Impairment evaluation: • Medical evaluation performed by a physician using the Guides to determine impairment • Treating or non-treating • Assessment of individual medical condition and its effect on function

6. Impairment Ratings • Impairment • A loss or loss of use or derangement of a body part, organ system, or organ function from its preexisting level. • Impairment rating: • Estimate of the degree to which the impairment decreases the individuals ability to perform ADL’s –NOT WORK ACIVITIES. • Assess functional limitation/loss – NOT DISABILITY • “Consensus-derived percentage estimate of loss of activity reflecting severity for a given health condition, and the degree of associated limitations in terms of ADLs”

7. “I read somewhere that 77 per cent of all the mentally ill live in poverty. Actually, I'm more intrigued by the 23 per cent who are apparently doing quite well for themselves.”

8. Impairment Ratings • 6th edition released late 2007 • 5th edition released 2001 • First published in book form in 1971 • Studies v Expert Consensus Opinion • NOT ALL conditions/problems are addressed in the Guides

9. Impairment Ratings • Cardiovascular- Heart and Aorta • Cardiovascular- Arteries • Respiratory system • Digestive system • Urinary and reproductive systems • Skin • Blood/Hematological • Endocrine system • ENT • Vision • Central and Peripheral nervous system • Mental and Behavioral • Spine • Upper extremities • Lower extremities • Pain

10. Impairment Ratings • Pain • Cardiovascular • Pulmonary system • Digestive system • Urinary and reproductive systems • Skin • Blood/Hematological • Endocrine system • Ear, nose and throat • Visual system • Central and Peripheral nervous system • Mental and Behavioral • Upper extremities • Lower extremities • Spine and pelvis

11. Impairment Ratings • Reasons to update the Guides 5th edition • New medical data • Function and Impairment • World Health Organization’s International Classification of Functioning (ICF) • Reduce ambiguity • Increase consistency between chapters • Increase consistency between raters • Statement of principals

12. Impairment Ratings • Differences in content • Causation • Apportionment • Cultural differences • Pain chapter • Mental and Behavioral • “Constitution” of the Guides

13. TABLE 2-1, Fundamental Principals of the Guides • The concepts in this chapter are the fundamental principals of the Guides; they shall preempt anything in subsequent chapters that conflicts with or compromises these principals. • No impairment may exceed 100% whole person impairment. No impairment of arising from a member or organ may exceed the amputation value of that member. • All regional impairments in the same organ or body system shall be combined at the same level first and then combined by regions then whole person. • Impairments must be rated in accordance with the chapter relevant to the organ or system where the injury primarily arose or where the greatest dysfunction consistent with then objectively documented pathology remains. • Only permanent impairment may be rated according to the Guides, and only after Maximum Medical Improvement is certified • A licensed physician must perform impairment evaluations. Chiropractic doctors, if authorized by the appropriate jusridictional authority to perform rating under the Guides, should restrict rating to the spine. • A valid impairment evaluation report based on the Guides must contain the 3 step approach described in section 2.7 • The evaluating physician must use knowledge, skill and ability generally accepted by the medical scientific community when evaluating an individual, to arrive at the correct impairment rating according to the Guides. • The Guides is based on objective criteria. The physician must use all clinical knowledge, skill and abilities in determining whether measurements, test results, or written historical information are consistent and concordant with the pathology being evaluated. If such findings, or an impairment estimate based on these findings, conflict with established medical principals, they cannot be used to justify an impairment rating. • Range of motion, and strength measurement techniques should be assessed carefully in the presence of apparent self-inhibition secondary to pain and fear. • The Guides do not permit the rating of future impairment. • If the Guides provides more than one method to rate a particular impairment or condition, the method producing the higher rating must be used. • Subjective complaints alone are generally no ratable under the Guides (see chapter 3 for potential exceptions). • Round all fractional impairment ratings, whether intermediate or final, to the nearest whole number.

15. Impairment Ratings • Changes/clarifications/corrections • Sample report • Pain disability questionnaire • Cardiovascular • Pulmonary • Urology • Visual • Psyche • Upper extremity • Lower extremity • Spine

16. Impairment Ratings • http://www.ama-assn.org/go/amaguidessixthedition-errata • Guides6@ama-assn.org • Print request: Guides 6th edition Clarifications and Corrections • Name, Mailing address

18. Impairment Ratings • Differences in application • Utilization of ‘Uniform Template’ • “Key Factors” • ‘Class’ of injury • Default ratings • “Non-key Factors” • Objective tests, clinical studies/labs • Physical exam findings • Functional assessments

23. Name • Date of Injury • Date of Birth • Determine KEY FACTORS to be rated • Is the examinee at MMI for this KEY FACTOR • Determine CLASS of Key Factor (0, 1, 2, 3, or 4) _______ • Determine GRADE of within Class ________ • (NOTE: the default Grade is always ‘C’, • the percentage impairment that ‘C’ represents will vary depending on Class) • Determine GRADE MODIFIERS • Grade Modifiers for FUNCTION (0, 1, 2, 3, or 4) _______ • Grade Modifiers for EXAMINATION (0, 1, 2, 3, or 4) ________ • Grade Modifiers for CLINICAL STUDIES (0, 1, 2, 3, or 4) _______ • ADJUST GRADE to the left or right the number of columns based on the formula: • REMEMBER: the numbers for this problem will be 0, 1, 2, 3, or 4 as determined above. • (Grade modifier for FUNCTION # -- CLASS #)

24. Ernesto from Bolivia US 7 years, married to US citizen Fell off forklift from ~12 feet • Low back – L4-5 disc herniation, persistent R foot weakness, pain in Right lower extremity • Shoulder – Full thickness rotator cuff and labral tear, surgically repaired, pain with certain movements. • Previous low back injury 18 months ago. • Treated with PT, released to full duty, occasional lumbar and radiating pain

27. WHAT ARE THE KEY FACTORS?

28. Impairment Ratings • Determine “KEY FACTOR” • Review medical records • Interview examinee • Physical exam • Diagnoses

29. Impairment Ratings • Is there a category for each KEY FACTOR? • Is there more than one way to rate that KEY FACTOR?

36. “Herniated disc, herniated nucleus pulposus, ruptured disc, prolapsed disc (used nonspecifically), protruded disc (used nonspecifically), and bulging disc (used nonspecifically) have all been used in the literature in various ways to denote imprecisely defined displacement of disc material beyond the interspace. The absence of clear understanding of the meaning of these terms and lack of definition of limits that should be placed on an ideal general term have created a great deal of confusion in clinical practice and in attempts to make meaningful comparisons of research studies.” Fardon: Spine, Volume 26(5).March 1, 2001.E93-E113

37. Herniation = Bulge? Herniation ≠ Bulge? • Herniation has both specific and general meanings • The Guides do not indicate nomenclature they use • Radiologists do not necessarily follow standards

38. Fardon: Spine, Volume 26(5).March 1, 2001.E93-E113

41. Impairment Ratings Are there any other “Key Factors”?

42. Impairment Ratings Maximum Medical Improvement

44. Impairment Ratings • How severe is the KEY FACTOR? • Identify the CLASS for each KEY FACTOR • 0 - no symptoms • 1 - mild or intermittent symptoms, controlled with medications • 2 – constant mild symptoms, intermittent moderate symptoms despite ongoing treatment • 3 – constant moderate symptoms, intermittent severe symptoms, despite ongoing treatment • 4 – constant severe symptoms, intermittent extreme symptoms, despite ongoing treatment

46. Impairment Ratings • Adjustments for non-key factors • Functional history • Pain during activity • Medications • Disability questionnaire • Physical examination • ROM • Atrophy • Alignment • Strength • Palpatory findings • Clinical studies • Imaging • Electrodiagnostic studies