2008 Preface

The American Medical Association's Guides to the Evaluation of Permanent Impairment, Sixth Edition defines an innovative new international standard for impairment assessment. A consistent, well-designed methodology was adopted and applied to each chapter to enhance the relevancy of impairment ratings, improve internal consistency, promote greater precision, and standardize the rating process. The goal is to provide an impairment rating guide that is authoritative, fair, and equitable to all parties. The editorial process used an evidence-based foundation when possible and a modified Delphi panel approach to consensus building.

The AMA Guides is a treatise on evaluating impairment. Clinical discussions among physician colleagues regarding potential severity of an illness or injury typically involve four basic points of consideration: (1) what is the problem (diagnosis); (2) what symptoms and resulting functional difficulty does the patient report; (3) what are the physical findings pertaining to the problem; and (4) what are the results of clinical studies. These same basic considerations are used by physicians to evaluate and communicate about impairment and, therefore, are used as a guiding construct for this edition of the AMA Guides. The emphasis of this edition is on expanding the spectrum of diagnoses recognized in impairment rating. It is designed to encourage attention to and documentation of functional consequences of the impairment as a part of each physician's detailed history, to clarify and delineate key physical findings, and to underscore essential clinical test results where applicable.

The new methodology applies terminology and adopts an analytical framework based on the World Health Organization's International Classification of Functioning, Disability and Health (ICF); five impairment classes permit the rating of the patient from no impairment to most severe. Diagnosis-based grids were developed for each organ system. These grids arrange diagnoses into five classes of impairment severity, according to the consensus-based dominant criterion. The functionally based history, physical findings, and broadly accepted clinical test results, where applicable, are then integrated to determine severity grade and provide a corresponding impairment value. Ratings are transparent, clearly stated, and reproducible. The basic template of the diagnosis-based grid is common to each organ system and chapter; thus, there is greater internal consistency, facilitating the application of this new method.

Features of the new edition include the following:

• A standardized approach across organ systems and chapters.

• The most contemporary, evidence-based concepts and terminology of disablement from the ICF.

• The latest scientific research and evolving medical opinions provided by nationally and internationally recognized experts.

• Unified methodology that helps physicians calculate impairment ratings through a grid construct and promotes consistent scoring of impairment ratings.

• A more comprehensive and expanded diagnostic approach.

• Precise documentation of functional outcomes, physical findings, and clinical test results, as modifiers of impairment severity.

• Increased transparency and precision of the impairment ratings.

• Improved physician interrater reliability.

These features provide benefit to all stakeholders by minimizing conflict and improving decision-making. The process of defining impairment or the complexities of human function is not perfect; however, the Sixth Edition standardizes the rating process, improves accuracy, and provides a solid basis for future editions of the AMA Guides. p. vii

The AMA implemented a broader process for the Sixth Edition to ensure collective input, a more comprehensive review before publication, and an opportunity for comments from stakeholders on an ongoing basis for this and future editions. The process was guided by the Editorial Panel and features an open, well-defined, and tiered peer review process. State medical associations and national medical specialty societies were invited to participate by nominating a disability or impairment physician expert to serve as an Editorial Panel or Advisory Committee member, possible author, content contributor, and/or reviewer to the new edition. Those nominating members include the:

• American Academy of Dermatology

• American Academy of Disability Evaluating Physicians

• American Academy of Neurology

• American Academy of Ophthalmology

• American Academy of Orthopaedic Surgeons

• American Academy of Otolaryngology–Head & Neck Surgery

• American Academy of Pain Medicine

• American Academy of Physical Medicine and Rehabilitation

• American Academy of Psychiatry and the Law

• American Association for Hand Surgery

• American Association of Neurological Surgeons

• American College of Chest Physicians

• American College of Occupational and Environmental Medicine

• American Gastroenterological Association

• American Orthopaedic Foot and Ankle Society

• American Psychiatric Association

• American Society for Surgery of the Hand

• American Thoracic Society

• California Medical Association

• Congress of Neurological Surgeons

• International Spinal Intervention Society

• Medical Society of the State of New York

• North American Spine Society

• Texas Medical Association

• Wisconsin Medical Society

Members were chosen based on their contributions to evidence-based medicine research, reputation in their field, and their expertise in the application of scientific methods to problems of impairment evaluation.

The AMA Guides Editorial Panel was established to include a medical editor, five section editors, and five core physician experts. The Editorial Panel's responsibilities were to:

• Act as an expert resource in spearheading the development process of the Sixth Edition.

• Maintain the current knowledge base and provide historical perspective for the purpose of continuity for future editions of the AMA Guides.

• Advise on revising, updating, and modifying the AMA Guides.

The section editors relied on their experience and expertise in impairment rating to collectively define the contextual background for the individual chapters. The Editorial Panel developed five strategies to establish the framework and context for the Sixth Edition:

1. 1) Adopt the terminology, definitions, and conceptual framework of disablement of the 2001 ICF in place of the current and antiquated terminology of the International Classification of Impairments, Disabilities and Handicaps (ICIDH);
2. 2) Become more diagnosis based, with these diagnoses being evidence based.
3. 3) Give priority to simplicity and ease of application, and following precedent when applicable, with the goal of optimizing interrater and intrarater reliability.
4. 4) Stress conceptual and methodological congruity within and between organ system ratings.
5. 5) Provide rating percentages that consider the patient's clinical and functional history, careful physical examination, and thoughtful review and synthesis of objective clinical test results.

The section editors led a group of specialty-specific, expert contributors in developing relevant chapters within the scope of this established framework. Specific procedures were developed for addressing suggestions for Guides' revisions and changes on an ongoing basis.

In addition to the AMA Guides Editorial Panel, an advisory committee was assembled and is composed of numerous representatives from medical specialty societies that are members of the American Medical Association's House of Delegates and other experts from certification organizations, teaching organizations, and workers' compensation systems.

The AMA Guides Advisory Committee is ongoing and meets annually to discuss items of mutual concern and current issues in impairment and disability. The Advisory Committee's primary objectives are to:

• Serve as a resource to the AMA Guides Editorial Panel by giving advice on impairment rating as relevant to the member's specialty.

• Provide documentation to staff and the Editorial Panel regarding the medical appropriateness of p. viii changes under consideration for inclusion in the AMA Guides.

• Assist in the review and further development of relevant impairment issues and in the preparation of technical education material and articles pertaining to the AMA Guides.

• Promote and educate its membership on the use and benefits of the AMA Guides.

As recommendations are received, they will be forwarded to members of the AMA Guides Advisory Committee representing the relevant specialty organization or organizations. Based on current scientific and clinical evidence, the Advisory Committee members will determine the merit of each recommendation. If the Advisory Committee reaches consensus on accepting a recommendation, it is forwarded to the Editorial Panel for final decision and inclusion in the AMA Guides. The goals of the new approach are to obtain broad input from the stake-holders and to develop a process for defining impairment that is supportable, high-quality, efficient, and effective.

Robert D. Rondinelli, MD, PhD Guides Medical Editor