Cover AMA Guides® to the Evaluation of Permanent Impairment, Sixth Edition, 2024

AMA Guides® to the Evaluation of Permanent Impairment, Sixth Edition, 2024

Publisher:
American Medical Association
DOI:
https://doi.org/10.1001/978-1-64016-320-1
ISBN:
9781640163201
Publication Date:
12 Sep 2024
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What's New for 2024

Evaluators familiar with the 2008 Guides will notice significant changes in the latest update. The grade modifiers have been replaced to address the feedback from multiple stakeholders, who found that these modifiers introduced an undesirable bias, reducing the fairness and equity of impairment values across various jurisdictions. Specifically, the grade modifiers, which used terms like "mild," "moderate," or "severe," lacked specificity and resulted in wide ranges of impairment values for similar functional losses. This led to reduced interrater and intrarater reliability, and a decline in accuracy, consistency, and reproducibility.

In place of the grade modifiers, the 2024 edition introduces specific individual elements (SIEs) of the clinical history, physical examination, and relevant clinical studies. Additionally, key elements have been replaced with specific diagnostic rows in the diagnosis-based impairment (DBI) tables, leading to more fair and equitable impairment values.

Evaluators are already familiar with the criteria in the diagnostic row, which are based on the traditional three components: clinical history, physical examination, and relevant clinical studies. As a result, all evaluators possess the skills necessary to match the objectively verified anatomical findings to the criteria in each diagnostic row.

The SIEs for clinical history include current clinical presentation; mechanism of injury; reported functional loss; functional outcome surveys; the impact of no treatment, appropriate treatment, or inappropriate treatment; and any preexisting impairments, diseases, conditions, illnesses, comorbidities, psychosocial factors, and considerations for the natural history of the diagnosis.

For physical examination, the SIEs cover traditional assessments such as appearance, sensory function, motor strength, and vascular supply.

The SIEs for relevant clinical studies include radiographs, MRI, CT scans, nerve studies, vascular studies, and laboratory tests.

By using specific individual elements (SIEs), evaluators can apply objectively verifiable criteria to confirm appropriate impairment values based on the International Classification of Functioning, Disability, and Health classes defined in the diagnostic rows. This approach ensures that impairment values are fair and equitable, accurately reflecting the individual's condition at the time of maximum medical improvement and the improvements provided by treatments.

The diagnostic rows list the necessary SIEs to determine the impairment value, enhancing the quality of impairment rating reports. Evaluators can now document the diagnosis and the SIEs present at maximum medical improvement (MMI) to determine the impairment rating. This method allows for easier review by both professional and nonprofessional evaluators, ensuring consistency and fairness across multiple jurisdictions.

What's New for Diagnoses

The diagnosis-based impairment (DBI) tables have been expanded to encompass a wider range of diagnoses, including new conditions, treatments, and medical advancements that were unavailable in 2008. This update ensures that the DBI tables are more comprehensive and up-to-date, allowing evaluators to consider a wider range of conditions and their respective treatments. As a result, impairment ratings are more accurate and reflective of current medical practices, improving the overall fairness and reliability of impairment evaluations.

Consistency

All three musculoskeletal chapters follow the same format and approach in the DBI tables. Sections and tables are specifically numbered to facilitate easy identification of the diagnostic row in the evaluator's report, establishing the specific individual elements of the clinical history (CH), physical examination (PE), and relevant clinical studies (CS) used to match the diagnostic row criteria.

The DBI tables include specific instructions to minimize the need to reference multiple sections or tables, eliminating the need to use grade modifier tables and reducing the need to "flip back and forth in the book” during an impairment evaluation. This streamlines the process, reduces errors, and improves the accuracy of impairment ratings. Clear guidance for adding or combining impairment values at different level is often incorporated into the DBI tables.

Vignettes

The 2008 vignettes have been updated to align with the 2024 method, reducing the need for additional training and enhancing reliability and consistency. Furthermore, new vignettes featuring complex clinical presentations (real-world examples) have been added to illustrate the 2024 method.

Getting Started

While the evaluator is encouraged to thoroughly read the entire chapter, valuable insights and detailed explanations are provided to support the instructions in the DBI tables. This comprehensive review ensures a deep understanding of the methodology and the rationale behind the updated approach, facilitating a more accurate and consistent application of the impairment evaluation process. Familiarity with the entire chapter will enhance the evaluator's ability to effectively use the DBI tables and apply the 2024 method to a wide range of clinical scenarios.

On behalf of the Guides Panel, we would like to thank the panel members, the five musculoskeletal subcommittees, contributors and reviewers, those who provided public comments, web access attendees, and the AMA Guides staff for their support in this update as listed in the Acknowledgments Section.

This page is designed to provide you with easy access to the AMA Guides to the Evaluation of Permanent Impairment 6th Edition, 2024 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 15-01: The Seventeen Periscapular Muscles of the Shoulder
Table 15-01g: Upper Limb Impairment Evaluation Record Template
Table 15-01n: Activities of Daily Living (ADLs)
Table 15-03c: Definition of DBI Impairment Classes and Ranges
Table 15-05c: Selected Biases Examples
Table 15-05g11: Nonorganic Findings or Yellow Flags of Physical Examination
Table 15-07k: Self-Reported Functional Loss and Comparison Ranges
Table 15-07l: Commonly Used PROMs
Table 15-11: Specific Individual Elements (SIEs) Grade Criteria
Table 15-16: Impairment Values Calculated From Digit Impairments
Table 15-16a: Relationship of Impairment of the Digits to Hand
Table 15-16b: Relationship of Impairment of the Hand to Upper Limb
Table 15-16c: Relationship of Impairment of the Upper Limb to Whole Person
Table 15-19: DBI Table Digit/Hand Impairment
Table 15-20: DBI Table Wrist Impairment
Table 15-21: DBI Table Elbow Impairment
Table 15-22: DBI Table Shoulder Impairment
Table 15-23c: Comparison of Motor Loss Patterns
Table 15-23d: Sensory and Motor Assessment
Table 15-23e1: Sensory Quality Impairment Classification for Thumb and Fingers
Table 15-23e2: Monofilament Test Criteria
Table 15-23e3: Monofilament Test Details
Table 15-23f: DBI Table Digital Nerve Sensory Impairment
Table 15-23h: DBI Table Sensory-Only Peripheral Nerve Impairment
Table 15-23i: DBI Table Peripheral Nerve Impairment
Table 15-23j: DBI Table Brachial Plexus Impairment
Table 15-23k: DBI Table Entrapment Neuropathy Impairment
Table 15-23r: DBI Table Thoracic Outlet Syndrome Impairment
Table 15-24e: Severity of Range of Motion Loss
Table 15-25: DBI Table Amputation Impairment Upper Limb
Table 15-26k: Clinical Studies for Vascular Impairment
Table 15-26l: Clinical Presentation of Vascular Conditions
Table 15-26m: Physican Examination of Vascular Conditions
Table 15-26: DBI Table Vascular Impairment Upper Limb
Table 15-27e1: Diagnostic Criteria for Complex Regional Pain Syndrome
Table 15-27e2: Diagnostic Criteria for Complex Regional Pain Syndrome
Table 15-27: DBI Table Complex Regional Pain Syndrome (CRPS) Impairment
Table 15-31c1: Comparison Between QuickDASH and ADL Questionnaires
Table 15-31d1: Concepts Related to Psychometric Measures
Chapter 16: The Lower Extremities
Tables
Table 16-01g: Lower Limb Impairment Evaluation Record Template
Table 16-01n: Activities of Daily Living (ADLs)
Table 16-03c: Definition of DBI Impairment Classes and Ranges
Table 16-05c: Selected Bias Examples
Table 16-05f11: Nonorganic Findings or Yellow Flags of Physical Examination
Table 16-07k: Self-Reported Functional Loss and Comparison Ranges
Table 16-07l: Commonly Used PROMs
Table 16-11: Specific Individual Elements (SIEs) Grade Criteria
Table 16-16a: MImpairment Values Conversion for Toe(s)/Foot, Lower Limb, and Whole Person
Table 16-16d: Combined Values Chart
Table 16-19: DBI Table Toe(s)/Foot/Ankle Impairment
Table 16-20: DBI Table Knee Impairment
Table 16-21: DBI Table Hip Impairment
Table 16-23c: Comparison of Motor Loss Patterns
Table 16-23d: Sensory and Motor Assessment
Table 16-23e2: Monofilament Test Criteria
Table 16-23e3: Monofilament Test Details
Table 16-23f: DBI Table Toe(s) Digital Nerve Sensory Impairment
Table 16-23h: DBI Table Sensory-Only Peripheral Nerve Impairment
Table 16-23i: DBI Table Peripheral Nerve and Entrapment Neuropathy Impairment
Table 16-23j: DBI Table 16-23j Lumbosacral Plexus Impairment
Table 16-24e: Severity of Range of Motion Loss
Table 16-25: Amputation Impairment Lower Limb
Table 16-26k: Clinical Studies for Vascular Impairment
Table 16-26l: Clinical Presentation of Vascular Conditions
Table 16-26m: Physical Examination of Vascular Conditions
Table 16-26: DBI Table Vascular Impairment
Table 16-27: DBI Table CRPS Impairment
Table 16-27e1: Diagnostic Criteria for Complex Regional Pain Syndrome
Table 16-27e2: Objective Diagnostic Criteria Points for Complex Regional Pain Syndrome
Chapter 17: The Spine and Pelvis
Tables
Table 17-01g: Spine and Pelvis Impairment Evaluation Template
Table 17-01n: Activities of Daily Living (ADLs)
Table 17-03a2m: AOMSI Upper Limits of Stable Motion
Table 17-03c: Definition of DBI Classes and Ranges
Table 17-05c: Selected Biases Examples
Table 17-05g11: Nonorganic Findings or Yellow Flags of Physical Examination
Table 17-05g13: Specific Individual Elements of Radiculopathy on the Physical Examination
Table 17-07k: Self-Reported Functional Loss and Comparison Ranges
Table 17-07L: Commonly Used PROMs
Table 17-11: Specific Individual Elements (SIEs) Grade Criteria
Table 17-19: DBI Table Cervical Spine Impairment
Table 17-20: DBI Table Thoracic Spine Impairment
Table 17-21: DBI Table Lumbar Spine Impairment
Table 17-22: DBI Table Pelvis Impairment
Table 17-23c: Comparison of Motor Loss Patterns

 

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

Publication Date: September 12, 2024

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