AMA Guides® to the Evaluation of Permanent Impairment, Sixth Edition, 2023

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Summary of Updates to AMA Guides Sixth Edition 2023

  • Chapter 11: No Changes to Impairment Ratings 
  • Chapter 13: Changes to Impairment Ratings
  • Chapter 15: Minimal impact to Impairment Ratings; encourages use of the DBI method over ROM
  • AMA Guides Sixth 2023 Errata (link)   

Chapter 11: Ear, Nose, Throat, and Related Structures

  • 11.2g Equilibrium 
    • Inclusion of videonystagmography
    • Addition of Rotary Chair Testing 
  • 11.4b Mastication and Deglutition 
    • Text added: Dysphagia may be caused by structural, neuromuscular, neoplastic and other maladies. Oropharyngeal tumors must be ruled out and may occur even in young people, especially in association with human papilloma virus (HPV) infection
    • New dysphagia example

Chapter 13: The Nervous System

Content has been extensively re-written to better adhere to the principles of the AMA Guides, Sixth Edition by promoting the concept of Diagnosis Based Impairment. The structure of the chapter has changes and the way impairment ratings are performed has changed as well. 

Synopses of changes include, but are not limited to:

  • Change of chapter title from Central and Peripheral Nervous System to The Nervous System
  • Conformity of tables with all other Guides chapters
  • Identification of a Key Factor: Effect on ADLs consistent with known natural history of the diagnosis
  • Introduction of Grades within Classes along with Grade Modifiers
  • 3-Grade system with Grade A as the foundation
  • BOTC and adaptive measures can be used to Adjust Grade within Class
  • Update of the following Tables in conformity to the Guides Principle of Simplicity:
  • To maintain consistency with Chapter 14, The GAF has been incorporated into the MSCHIF as the MSCHIF-E; Aphasia has been incorporated into the Mental Status Examination within the MSCHIF-E; Modifies Episodic Disorders of Consciousness into Episodic Disorders; Consolidates 3 Tables on Pain into one (Neuropathic Pain); Defers Central Sleep Disorders to Chapter 14, consistent with the DSM-5
  • Creation of the QuickView Worksheet to improve Inter-Rater Reliability
  • Creation of a BOTC that is not burdensome on the evaluator

Chapter 15: The Upper Extremities

  • Tables 15-2, 15-3, 15-4 and 15-5
    • The words “with normal motion” be removed from all sections in which it appears; elimination of the footnote from the DBI tables that says: “*If motion loss is present, this impairment may alternatively be assessed using Section 15.7, Range of Motion Impairment. A range of motion impairment stands alone and is not combined with diagnosis impairment.”
  • Section 15-7 (and 15-3b) 
    • Edited to reinforce DBI as preferred method, but, when presented with decreased ROM, a rater can consider that as an alternative method when the impairment isn’t able to be rated with the DBI paradigm.

This page is designed to provide you with easy access to the AMA Guides to the Evaluation of Permanent Impairment 6th Edition, 2023 tables.

Jump to Chapter:

Chapter 1: Conceptual Foundations and Philosophy
Chapter 2: Practical Application of the Guides
Chapter 3: Pain-Related Impairment
Chapter 4: The Cardiovascular System
Chapter 5: The Pulmonary System
Chapter 6: The Digestive System
Chapter 7: The Urinary and Reproductive Systems
Chapter 8: The Skin
Chapter 9: The Hematopoietic System
Chapter 10: The Endocrine System
Chapter 11: Ear, Nose, Throat, and Related System
Chapter 12: The Visual System
Chapter 13: The Nervous System
Chapter 14: Mental and Behavioral Disorders
Chapter 15: The Upper Extremities
Chapter 16: The Lower Extremities
Chapter 17: The Spine and Pelvis
Appendix

Chapter 1: Conceptual Foundations and Philosophy
Tables
Table 1-1: Self-Care
Table 1-2: Hierarchy of Study Types
Table 1-3: ICF Codes and Functional Levels
Table 1-4: Sample Impairment Function Classification
Table 1-5: Generic Template for Impairment Classification Grids
Table 1-6: General Principles for Calculating Impairment
Chapter 2: Practical Application of the Guides
Tables
Table 2-1: Fundamental Principles of the Guides
Chapter 3: Pain-Related Impairment
Tables
Table 3-1: Pain-Related Impairment and Whole Person Impairment Based on Pain Disability Questionnaire
Chapter 4: The Cardiovascular System
Tables
Table 4-1: NYHA Functional Classification of Cardiac Disease
Table 4-2: Relationship of METs and Functional Class According to 5 Treadmill Protocols
Table 4-3: Energy Expenditure in METs During Bicycle Ergometry
Table 4-4: Methodology for Determining the Grade in an Impairment Class
Table 4-5: Criteria for Rating Permanent Impairment due to Valvular Heart Disease
Table 4-6: Criteria for Rating Impairment due to Coronary Artery Disease
Table 4-7: Criteria for Rating Impairment due to Cardiomyopathies
Table 4-8: Criteria for Rating Impairment due to Pericardial Heart Disease
Table 4-9: Criteria for Rating Impairment due to Dysrhythmias
Table 4-10: Classification of Blood Pressure for Adults
Table 4-11: Criteria for Rating impairment due to Hypertensive Cardiovascular Disease
Table 4-12: Criteria for Rating Impairment due to Peripheral Vascular Disease – Lower Extremity
Table 4-13: Criteria for Rating Impairment due to Peripheral Vascular Disease – Upper Extremity
Table 4-14: Criteria for Rating Impairment due to Diseases of the Pulmonary Artery
Table 4-15: Cardiac Impairment Evaluation Summary
Chapter 5: The Pulmonary System
Tables
Table 5-1: Impairment Classification of Dyspnea (Adapted)
Table 5-2: Impairment Classification for Prolonged Physical Work Intensity by Oxygen Consumption
Table 5-3: Methodology for Determining the Grade in an Impairment Class
Table 5-4: Criteria for Rating Permanent Impairment due to Pulmonary Dysfunction
Table 5-5: Criteria for Rating Permanent Impairment due to Asthma
Table 5-6: Scale for Judging Capabilities of Subjects With Cancer
Table 5-7: Pulmonary Impairment Evaluation Summary
Chapter 6: The Digestive System
Tables
Table 6-1: Desirable Weights for Men by Height and Body Build
Table 6-2: Desirable Weights for Women by Height and Body Build
Table 6-3: Methodology for Determining the Grade in an Impairment Class
Table 6-4: Criteria for Rating Permanent Impairment due to Upper Digestive Tract (Esophagus, Stomach and Duodenum, Small Intestine, and Pancreas) Disease
Table 6-5: Criteria for Rating Permanent Impairment due to Colonic and Rectal Disorders
Table 6-6: Criteria for Rating Permanent Impairment due to Anal Disease
Table 6-7: Impairments From Surgically Created Stomas
Table 6-8: Criteria for Rating Permanent Impairment due to Liver Disease
Table 6-9: Criteria for Rating Permanent Impairment due to Biliary Tract Disease
Table 6-10: Criteria for Rating Permanent Impairment due to Herniation
Table 6-11: Digestive System Impairment Evaluation Summary
Chapter 7: The Urinary and Reproductive Systems
Tables
Table 7-1: Methodology for Determining the Grade in an Impairment Class
Table 7-2: Criteria for Rating Permanent Impairment due to Upper Urinary Tract Disease
Table 7-3: Criteria for Rating Permanent Impairment due to Urinary Diversion Disorders
Table 7-4: Criteria for Rating Permanent Impairment due to Bladder Disease
Table 7-5: Criteria for Rating Permanent Impairment due to Urethral Disease
Table 7-6: Criteria for Rating Permanent Impairment due to Penile Disease
Table 7-7: Criteria for Rating Permanent Impairment due to Scrotal Disease
Table 7-8: Criteria for Rating Impairment due to Testicular, Epididymal, and Spermatic Cord Disease
Table 7-9: Criteria for Rating Impairment due to Prostate Disease
Table 7-10: Criteria for Rating Permanent Impairment due to Vulval and Vaginal Disease
Table 7-11: Criteria for Rating Permanent Impairment due to Cervical and Uterine Disease
Table 7-12: Criteria for Rating Permanent Impairment due to Fallopian Tube and Ovarian Disease
Table 7-13: Urinary and Reproductive Systems Impairment Evaluation Summary
Chapter 8: The Skin
Tables
Table 8-1: Structure, Functions, and Disorders of the Skin
Table 8-2: Criteria for Rating Permanent Impairment due to Skin Disorders
Table 8-3: Skin Impairment Evaluation Summary
Chapter 9: The Hematopoietic System
Tables
Table 9-1: Karnofsky Performance Status Scale Definitions Rating (%) Criteria
Table 9-2: Eastern Cooperative Oncology Group Performance Status Scale (ECOG-PSS)
Table 9-3: Burden of Treatment Compliance
Table 9-4: Methodology for Determining the Grade in an Impairment Class
Table 9-5: Criteria for Rating Permanent Impairment due to Anemia
Table 9-6: Criteria for Rating Permanent Impairment due to Neutropenia
Table 9-7: Criteria for Rating Permanent Impairment due to the Leukemias
Table 9-8: Criteria for Rating Permanent Impairment due to HIV Disease
Table 9-9: Criteria for Rating Impairment due to Platelet Disorders
Table 9-10: Criteria for Rating Impairment due to the Hemophilias
Table 9-11: Criteria for Rating Impairment due to Other Bleeding Disorders
Table 9-12: Criteria for Rating Impairment due to Thrombotic Disorders
Table 9-13: Criteria for Rating Impairment due to Lymphoma and Metastatic Disease
Table 9-14: Hematologic Impairment Evaluation Summary
Chapter 10: The Endocrine System
Tables
Table 10-1: Methodology for Determining the Grade in an Impairment Class
Table 10-2a: Enteral, Intranasal, and Topical Medications
Table 10-2b: Parenteral Medications
Table 10-3: Points Assigned for Dietary Modification
Table 10-4: Procedure-Based Points
Table 10-5: Criteria for Rating Impairment due to Disorders of the Hypothalamic-Pituitary Axis
Table 10-6: Criteria for Rating Impairment due to Thyroid Abnormalities
Table 10-7: Criteria for Rating Impairment due to Disorders of the Parathyroids
Table 10-8: Criteria for Rating Impairment due to Disorders of the Adrenal Cortex
Table 10-9: Criteria for Rating Impairment due to Disorders of the Adrenal Medulla
Table 10-10: Criteria for Rating Impairment due to Diabetes Mellitus
Table 10-11: Criteria for Rating Impairment due to Hypoglycemia
Table 10-12: Criteria for Rating Impairment due to Gonadal Disorders
Table 10-13: Criteria for Rating Impairment due to Mammary Disorders
Table 10-14: Criteria for Rating Impairment due to Metabolic Bone Disease
Table 10-15: Endocrine System Impairment Evaluation Summary
Chapter 11: Ear, Nose, Throat, and Related Structures
Tables
Table 11-1: Monaural Hearing Loss and Impairment
Table 11-2: Computation of Binaural Hearing Impairment
Table 11-3: Relationship of Binaural Hearing Impairment to Impairment of the Whole Person
Table 11-4: Criteria for Rating Impairments due to Vestibular Disorders
Table 11-5: Criteria for Rating Impairment due to Facial Disorders and/or Disfigurement
Table 11-6: Criteria for Rating Impairment due to Air Passage Deficits
Table 11-7: Impairments of Mastication and Deglutition: Relationship of Dietary Restrictions to Permanent Impairment
Table 11-8: Criteria for Rating Voice and Speech Impairment
Chapter 12: The Visual System
Tables
Table 12-1: Calculation Steps for the Visual System
Table 12-2: Impairment of Visual Acuity
Table 12-3: Calculation of the Acuity-Related Impairment Rating
Table 12-4: Classification of Impairment of Visual Acuity
Table 12-5: Impairment of Visual Field
Table 12-6: Conversion of Field Radius to Field Score
Table 12-7: Calculation of the Visual Field–Related Impairment Rating
Table 12-8: Classification of Impairment of Visual Field
Table 12-9: Correction for Central Scotomata
Table 12-10: Classification of Impairment of the Visual System and of the Whole Person
Table 12-11: Determination of Reading Acuity and Impairment Rating, Using Letter Size and Viewing Distance
Chapter 13: The Nervous System
Tables
Table 13-1A: Summary of Chapters Used to Rate Various Neurologic Disorders
Table 13-1B: Activities of Daily Living
Table 13-1C: Summary of Impairment Rating Tables
Table 13-1D: Burden of Treatment Compliance
Table 13-2A: Nervous System Rating Tables
Table 13-2B: Rating the Effects of a Neurologic Disease
Table 13-2C: Methods for Rating Neurologic-Based Impairment 
Table 13-2D: Framework for Rating Tables Within This Chapter
Table 13-3A: Method Specific to Rating Cognitive Cerebral Impairments
Table 13-3B: Progression of the MSCHIF-E Into Disorders of Consciousness
Table 13-4 QuickView Worksheet (Master): Summary of Rating Impairment Table
Table 13-5A: Disorders of Consciousness
Table 13-5B: Episodic Disorders (Epilepsy and Autonomic Disorders)
Table 13-5C: Mental Status, Cognition, Highest Integrative Function, and Emotion (MSCHIF-E)
Table 13-5D Upper Extremity CNS Dysfunction
Table 13-5E Station and Gait Disorders
Table 13-5F Neurogenic Respiratory Dysfunction
Table 13-5G Neurogenic Bowel
Table 13-5H Neurogenic Bladder
Table 13-5I Neurogenic Sexual Dysfunction
Table 13-5J Neuropathic Pain (Peripheral Neuropathy and Craniofacial)
Table 13-5K Migraine
Chapter 14: Mental and Behavioral Disorders
Tables
Table 14-1: Mental Status Examination
Table 14-2: Selected Psychological Assessment Tools in Adults
Table 14-3: Suggestions for the Mental and Behavioral Disorders Independent Medical Examination
Table 14-4: Functional Impairment Scales for Patients With Mental and Behavioral Disorders (M&BDs)
Table 14-5: Factors That May Affect Motivation
Table 14-6: Characteristics Suggestive of the Need to Evaluate for Malingering
Table 14-7: Brief Psychiatric Rating Scale Form
Table 14-8: Impairment Score of Brief Psychiatric Rating Scale
Table 14-9: Self-Care, Personal Hygiene, and Activities of Daily Living
Table 14-10: Role Functioning, Social and Recreational Activities
Table 14-11: Travel
Table 14-12: Interpersonal Relationships
Table 14-13: Concentration, Persistence, and Pace
Table 14-14: Resilience and Employability
Table 14-15: Impairment Score of Psychiatric Impairment Rating Scale
Chapter 15: The Upper Extremities
Tables
Table 15-1: Definition of Impairment Classes
Table 15-2: Digit Regional Grid: Digit Impairments
Table 15-3: Wrist Regional Grid: Upper Extremity Impairments
Table 15-4: Elbow Regional Grid: Upper Extremity Impairments
Table 15-5: Shoulder Regional Grid: Upper Extremity Impairments
Table 15-6: Adjustment Grid: Summary
Table 15-7: Functional History Adjustment: Upper Extremities
Table 15-8: Physical Examination Adjustment: Upper Extremities
Table 15-9: Clinical Studies Adjustment: Upper Extremities
Table 15-10: Methodology for Determining the Grade in an Impairment Class
Table 15-11: Impairment Values Calculated From Upper Extremity Impairment
Table 15-12: Impairment Values Calculated From Digit Impairment
Table 15-13: Monofilament Test Criteria
Table 15-14: Sensory and Motor Severity
Table 15-15: Sensory Quality Impairment Classification
Table 15-16: Digit Impairment for Transverse and Longitudinal Sensory Losses in Thumb and Little Finger Based on Percent of Digital Length Involved
Table 15-17: Digit Impairment for Transverse and Longitudinal Sensory Losses in Index, Middle, and Ring Fingers Based on Percent of Digital Length Involved
Table 15-18: Impairment for Sensory Only Peripheral Nerve Injury
Table 15-19: Origins and Functions of Peripheral Nerves of Upper Extremity Emanating From Brachial Plexus
Table 15-20: Brachial Plexus Impairment: Upper Extremity Impairments
Table 15-21: Peripheral Nerve Impairment: Upper Extremity Impairments
Table 15-22: Activities of Daily Living (ADLs)
Table 15-23: Entrapment/Compression Neuropathy Impairment
Table 15-24: Diagnostic Criteria for Complex Regional Pain Syndrome
Table 15-25: Objective Diagnostic Criteria Points for Complex Regional Pain Syndrome
Table 15-26: Complex Regional Pain Syndrome (Type I): Upper Extremity Impairments
Table 15-27: Level of Amputation
Table 15-28: Impairment for Upper Limb Amputation at Various Levels
Table 15-29: Amputation Impairment
Table 15-30: Thumb Range of Motion
Table 15-31: Finger Range of Motion
Table 15-32: Wrist Range of Motion
Table 15-33: Elbow/Forearm Range of Motion
Table 15-34: Shoulder Range of Motion
Table 15-35: Range of Motion Grade Modifiers
Table 15-36: Functional History Grade Adjustment: Range of Motion
Table 15-37: Activities of Daily Living Questionnaire
Table 15-38: ADLs Questionnaire Evaluation
Table 15-39: Comparison Between QuickDASH and ADL Questionnaires
Table 15-40: Self-Report Functional Assessment Measures
Chapter 16: The Lower Extremities
Tables
Table 16-1: Definition of Impairment Classes
Table 16-2: Foot and Ankle Regional Grid – Lower Extremity Impairments
Table 16-3: Knee Regional Grid – Lower Extremity Impairments
Table 16-4: Hip Regional Grid – Lower Extremity Impairments
Table 16-5: Adjustment Grid: Summary
Table 16-6: Functional History Adjustment – Lower Extremities
Table 16-7: Physical Examination Adjustment – Lower Extremities
Table 16-8: Clinical Studies Adjustment – Lower Extremities
Table 16-9: Methodology for Determining the Grade in an Impairment Class
Table 16-10: Impairment Values Calculated From Lower Extremity Impairment
Table 16-11: Sensory and Motor Severity
Table 16-12: Peripheral Nerve Impairment – Lower Extremity Impairments
Table 16-13: Diagnostic Criteria for Complex Regional Pain Syndrome
Table 16-14: Objective Diagnostic Criteria Points for Complex Regional Pain Syndrome
Table 16-15: Complex Regional Pain Syndrome (Type I) – Lower Extremity Impairments
Table 16-16: Amputation Impairment
Table 16-17: Functional History Net Modifier
Table 16-18: Lesser Toe Impairments
Table 16-19: Greater Toe Impairments
Table 16-20: Hindfoot Motion Impairments
Table 16-21: Ankle or Hindfoot Deformity Impairments
Table 16-22: Ankle Motion Impairments
Table 16-23: Knee Motion Impairments
Table 16-24: Hip Motion Impairments – Lower Extremity Impairment
Table 16-25: Range of Motion ICF Classification
Chapter 17: The Spine and Pelvis
Tables
Table 17-1: Definition of Impairment Classes and Impairment Ranges
Table 17-2: Cervical Spine Regional Grid: Spine Impairments
Table 17-3: Thoracic Spine Regional Grid: Spine Impairments
Table 17-4: Lumbar Spine Regional Grid: Spine Impairments
Table 17-5: Adjustment Grid: Summary
Table 17-6: Functional History Adjustment: Spine
Table 17-7: Physical Examination Adjustment: Spine
Table 17-8: Common Radicular Syndromes
Table 17-9: Clinical Studies Adjustment: Spine
Table 17-10: Methodology for Determining the Grade in an Impairment Class
Table 17-11: Diagnosis-Based Impairment Grid: Pelvis
Table 17-12: Functional History Adjustment: Pelvis
Table 17-13: Physical Examination Adjustment: Pelvis
Table 17-14: Clinical Studies Adjustment: Pelvis
Table 17-A: PDQ Scoring

 

Appendix
Combined Values Table
Burden of Treatment Compliance
B-1: Burden of Treatment Compliance
B-2a: Oral, Intranasal, Ocular, Skin
B-2b: Inhaled, Rectal
B-2c: Points for Subcutaneous, IM, Intradermal, IV, and Intracavitary Medication
B-3: Points Assigned For Dietary Modification
B-4: Points Assigned for Procedures

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