Socioeconomic factors influence all aspects of workers’ compensation, personal injury, and disability systems, but the best financial interest of certain stakeholders may not be aligned with the ultimate best interests of those who are injured or ill. The AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ), Fifth Edition, was introduced in California in 2005 to improve the reliability of permanent disability award ratings, which previously were based primarily on subjective factors. The result was a reduction in the dollar value of disability rewards, and, in response, certain stakeholders took steps to reduce this impact, including instructing physicians to ignore instructions in the AMA Guides . The AMA Guides, Sixth Edition, addresses many of the potential misapplications of the criteria in the fifth edition. Despite efforts to improve the validity and reliability of impairment assessment, some stakeholders continue to resist use of the more current edition. In California, impairment currently is rated by agreed medical evaluators; this should be changed to ensure that evaluations are performed by unbiased physicians who are educated with respect to evidence-based medicine and causation. Injured workers must be fairly and appropriately compensated for losses associated with an injury, but not at the cost of inappropriate inflation of impairment and disability ratings because the latter contribute to needless disability and impede living a productive and joyous life.

Pennsylvania adopted the impairment rating provisions described in the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ) in 1996 as an exposure cap for employers seeking predictability and cost control in workers’ compensation claims. In 2017, the Supreme Court of Pennsylvania handed down the Protz decision, which held that requiring physicians to apply the methodology set forth in the most recent edition of the AMA Guides reflected an unconstitutional delegation of legislative power to the American Medical Association. The decision eliminates the impairment-rating evaluation (IRE) mechanism under which claimants were assigned an impairment rating under the most recent edition of the AMA Guides . The AMA Guides periodically are revised to include the most recent scientific evidence regarding impairment ratings, and the AMA Guides, Sixth Edition, acknowledges that impairment is a complex concept that is not yet defined in a way that readily permits an evidence-based definition of assessment. The AMA Guides should not be considered standards frozen in time simply to withstand future scrutiny by the courts; instead, workers’ compensation acts could state that when a new edition of the AMA Guides is published, the legislature shall review and consider adopting the new edition. It appears unlikely that the Protz decision will be followed in other jurisdictions: Challenges to using the AMA Guides in assessing workers’ compensation claims have been attempted in three states, and all attempts failed.

Physicians frequently are asked to assess work ability in individuals with low back pain (LBP) who also require an impairment rating. Physicians may be tempted to base their decisions about the individual's work ability on spinal anatomy/diagnosis as established by imaging, because that may seem objective. However, a review of the current medical literature consistently demonstrates that anatomical abnormalities identified on imaging do not predict functional ability. Rather, recent studies have demonstrated a strong association between the number of symptoms and functional status, on the one hand, and the lack of correlation between findings on imaging and symptoms, on the other hand. For example, a systematic review by Mayo Clinic physicians of 33 published studies in which 3110 asymptomatic adults were imaged using magnetic resonance imaging (MRI) showed that, in middle age when most problematic back pain problems present, roughly half of asymptomatic adults had disc bulges, roughly one-third had disc protrusions, and roughly one-quarter had annular fissures. The authors of the present study also review related studies regarding low back pain and conclude that current scientific knowledge suggests that imaging alone is not useful in predicting function or in assessing future risk. Degenerative changes on imaging are not a sound basis for work restrictions because they do not correlate with risk or capacity.

The normal cervical spine is straight in the coronal plane and usually is lordotic (curved convex anteriorly) in the sagittal plane, and although cervical spine deformity occurs in the coronal plane (eg, scoliosis), sagittal plane deformities are more common. For example, cervical lordosis can be increased (hyperlordosis) within the normal range, decreased (hypolordosis), absent (a straight cervical spine with 0° of curvature on a lateral X ray), or reversed (kyphosis). Primary deformity of the cervical spine often is congenital (eg, wedge vertebra); secondary sagittal deformities may be due to disc degeneration accompanying aging, disease such as ankylosing spondylitis, or surgery (eg, for postlaminectomy kyphosis). Decreased, straightened, or reversed cervical lordosis (DSRCL) may be idiopathic and can be voluntary, and evaluators must differentiate DSRCL that does not change over time vs sagittal plane alignment that varies over time or with a change in posture or position. DSRCL usually is asymptomatic, but severe cervical kyphosis can cause neck pain, myelopathy, dysphagia, loss of horizontal gaze, and other symptoms that are sufficiently severe to result in disability and to require surgical correction. Reports of DSRCL due to spasm, particularly at times temporally remote to an injury, should be met with extreme skepticism. Kyphosis of sufficient severity to be symptomatic usually is a postoperative deformity, not an effect of whiplash.

Chapter 17, The Spine and Pelvis, of the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ), Sixth Edition, is used frequently when determining an individual's permanent impairment rating at maximum medical improvement (MMI). Frequently, ratings for diagnoses of “nonverifiable back pain,” herniated discs, nonverifiable radicular pain, and radiculopathy are requested. Definitions of terminology used in the AMA Guides may differ from those used by some physicians when they see patients, and evaluators should use terminology that is consistent with that of the AMA Guides . For example, for the purposes of the AMA Guides, radiculopathy is defined as “significant alteration in the function of a single or multiple nerve roots and is usually caused by mechanical or chemical irritation of one or several nerves.” This article presents fifteen cases, the whole person impairment associated with each case, and a discussion of the process whereby the rating was obtained. Accurate and fair ratings of common cases of injury-related back and leg pain require a thorough knowledge of the definitions outlined in the AMA Guides, Sixth Edition, as well as thorough knowledge of the peripheral nervous system. Also, an accurate and detailed subjective history of pain reports (including true “radicular” referral patterns) and objective physical examination, as well as a review of the medical records and previous documentations, are essential.

The sacroiliac joint (SIJ) is an accepted source of pain in patients with ankylosing spondylitis and other spondyloarthropathies, osteoarthritis, infections, and tumors, but the occurrence of isolated SIJ pain in the absence of such diseases is controversial. The term, sacroiliac joint dysfunction, which is used widely, describes pain from an SIJ that has no identifiable lesion but is presumed to have some mechanical etiology. Practitioners currently have no universally accepted gold standard for identifying a disc, facet joint, of SIJ as the pain generator. Treatment options for SIJ pain include medications, physical therapy, bracing, manual therapy, injections, radiofrequency neurotomy, and arthrodesis. Optimal management of patients with SIJ pain remains controversial. In the AMA Guides, Sixth Edition, a clinically established and causally related diagnosis of SIJ dysfunction is rated using the first row in Table 17-4. Surgery does not change the diagnosis or rating: The SIJ is not a motion segment of the lumbar spine, and SIJ fusion is not an alteration of motion segment integrity. Clinically, pain presumed to be from SIJ dysfunction is low back pain, so if this is the clinical diagnosis, the spine chapter in the AMA Guides, Fifth Edition, should be used. In such cases, the first step is to determine whether to use the diagnosis-related estimate or the range-of-motion method, and the article provides guidance about situations in which the use of each is appropriate.

Low back pain and disability are common and evaluating a patient with non-specific spinal pain may be challenging, including determining impairment. The AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ), Sixth Edition, provides ratable impairment for the diagnosis of “non-specific chronic, or chronic recurrent low back pain (also known as chronic sprain/strain, symptomatic degenerative disc disease, facet joint pain,” and others. The evaluator should consider the diagnosis of non-specific chronic back pain only when no category of specific diagnosis fits the case (eg, no fracture, no spinal stenosis) or when “no reliable physical examination or imaging findings” but the patient's history of pain is felt to be reliable. According to the AMA Guides, primary determinant between a class 0 and class 1 rating for non-specific chronic back pain is whether the evaluator gives credibility to the patient's subjective reports of pain and interference with activities of daily living (ADLs). An evaluator may choose to use the Pain Disability Questionnaire (reproduced in the article) and Table 17-6, Functional History Adjustment, Spine, to determine the Functional History Grade Modifier (GMFH). The diagnosis of non-specific chronic or chronic recurrent low back pain yields a positive impairment only when the evaluator feels the patient's pain, as quantified by the GMFH, is reliably reported. Because there are no diagnostic objective findings on physical examination or clinical studies, these modifiers are excluded.

Myelopathy literally indicates any pathology of the spinal cord, but the term most commonly is used when the cord pathology results from degenerative disease. Specific names usually are used if the disorder is traumatic (spinal cord injury), infectious (myelitis), or neoplastic (the name of the tumor is used). Cervical myelopathy (CM) may result in symptoms such as clumsiness, loss of dexterity, imbalance or poor coordination; muscle weakness; pain; and, in severe cases, bowel, bladder, or sexual dysfunction. When impairment is rated, if the evaluator finds objective evidence of myelopathy when the individual is at maximum medical improvement, neurological impairment is combined with that for the spine. A detailed and thorough neurologic examination is the current standard for the diagnosis of CM, but diagnosis is challenging in the early stages. Correlation of patient symptoms and imaging studies, both plain radiographs and magnetic resonance imaging scans, is essential for correct diagnosis. When imaging studies are equivocal or insensitive, other studies such as electrodiagnostic testing and cerebrospinal fluid analysis may be considered. When CM is defined as the presence of more than one long-tract sign, spinal cord compression in isolation did not cause myelopathy, and up to 20% of those with cord compression did not exhibit CM.

Although back pain is the most common and expensive cause of work disability in the United States, our understanding of low back pain (LBP) is limited despite the advantages of advanced imaging technologies. Diagnostic studies often are requested for fear of missing serious or occult pathology or to reassure patients but have a low likelihood of identifying a specific cause for the reported symptoms in patients who present with nonspecific LBP. From a clinical perspective, the information provided in lumbar imaging, whether plain X rays or magnetic resonance imaging (MRI), has not been found either to influence treatment recommendations or improve outcomes. Further, routine advanced imaging is not associated with improved outcomes and identifies many radiographic findings that correlate poorly with symptoms; imaging is recommended when severe or progressive neurologic deficit is present or if serious underlying disease is suspected. Surgery rates are highest where imaging rates are highest, and a significant proportion of the variation in rates of spine surgery can be explained by differences in the rates of advanced spinal imaging. Because imaging has no role in the impairment rating of nonspecific LBP, an individual's having a work injury that requires an impairment rating is not a reason to order spinal imaging. To answer the question in this article's title, the answer usually is not to order a spinal image.

The AMA Guides to the Evaluation of Permanent Impairment, ( AMA Guides ), Sixth Edition, is the recognized international standard for assessing impairment. The National Council on Compensation Insurance (NCCI) conducted a comparative study to examine the effects on impairment ratings in three states that have switched from the fifth to the sixth edition. The purpose and objectives of this article are as follows: 1) to provide a brief review of the conceptual framework and terminology of disablement and of the current model of disability in the AMA Guides and also to underscore the importance of the construct of medical impairment to compensation schemes within workers' compensation and other disability systems; 2) to examine the AMA Guides in terms of its origin, purpose, distribution, applications, and misapplications; 3) to examine the changes in the sixth edition in terms of efforts to direct change and improve upon the AMA Guides ; 4) to examine the merits and shortcomings of the NCCI study and its conclusions within a broader context of inherent sources of variance in impairment ratings, as well as the content validity, reliability, and reproducibility of the ratings themselves; 5) to provide recommendations regarding the implications of this study for the use of the sixth and earlier editions of the AMA Guides, and to suggest new directions for much needed critical research.

The incidence of cervical and lumbar fusion surgery has increased in the past twenty years, and during follow-up some of these patients develop changes at the adjacent segment. Recognizing that adjacent segment degeneration and disease may occur in the future does not alter the rating for a cervical or lumbar fusion at the time the patient's condition is determined to be at maximum medical improvement (MMI). The term adjacent segment degeneration refers to the presence of radiographic findings of degenerative disc disease, including disc space narrowing, instability, and so on at the motion segment above or below a cervical or lumbar fusion. Adjacent segment disease refers to the development of new clinical symptoms that correspond to these changes on imaging. The biomechanics of adjacent segment degeneration have been studied, and, although the exact mechanism is uncertain, genetics may play a role. Findings associated with adjacent segment degeneration include degeneration of the facet joints with hypertrophy and thickening of the ligamentum flavum, disc space collapse, and translation—but the clinical significance of these radiographic degenerative changes remains unclear, particularly in light of the known presence of abnormal findings in asymptomatic patients. Evaluators should not rate an individual in anticipation of the development of changes at the level above a fusion, although such a development is a recognized possibility.

Accurate, unbiased impairment ratings must follow the procedures and processes defined in the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ). This Case Example from California in 2010 illustrates some problems that result from rating a lumbar injury as if it were an inguinal hernia. At critical issue in this case is whether sufficient clinical findings were available to support a rating for lumbar radiculopathy; the evaluating (and also, treating) physician gave the patient the benefit of doubt with a rating of “nonverifiable radicular (nerve root) pain” but did not address the patient's ability to perform activities of daily living (ADLs). The State of California Workers’ Compensation Appeals Board (WCAB) affirmed on August 20, 2010, that the State relies on the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ), Fifth Edition, to determine impairment. WCAB noted that “medical opinion that departs unreasonably from a strict application of the [ AMA ] Guides can be challenged, and it would not be acceptable as substantial evidence.” In the present case, the rating provided by the evaluating physician was based on an obviously inapplicable section of the AMA Guides and is not appropriate. Evaluators must use the procedures defined in the AMA Guides, perform evaluations according to the standards in the AMA Guides, and do so without bias.

This Case Example illustrates common questions associated with the use of the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ), Fifth Edition, including the selection of appropriate methodology and the issue of whether spinal injections are considered to be ratable events. A 32-year-old male worker in California sustained a work-related low back injury and was examined by a chiropractic Qualified Medical Examiner (QME). The patient was referred for magnetic resonance imaging, which showed multiple lumbar disk protrusions and an L4-5 annular fissure. An epidural steroid injection at L5-S1 was of limited benefit, but bilateral L4-5 and L5-S1 facet injections, followed by chiropractic care, precluded any need for medial branch blocks or a facet rhizotomy. On presentation to the QME, the individual reported experiencing low back pain 10% of the time; this was rated 3/10 and was localized around the lumbar and lumbosacral region and was exacerbated with prolonged sitting or playing sports. The evaluator provided a rating of the lumbar spine using the range of motion (ROM) method, but the AMA Guides, Fifth Edition, states that the Diagnosis-related estimate (DRE) must be used because the impairment is due to an injury. The article demonstrates in detail how the DRE method would be applied in this case. The performance of epidural and facet injections does not constitute a ratable surgical event because these are not intradiscal injections intended to produce permanent anatomic changes in the disk.

Spinal stenosis refers to narrowing of the spinal canal that may result in compression of the spinal cord, or cauda equina. The most common type of spinal stenosis is degenerative stenosis associated with the natural process of aging. In the lumbar spine, the narrowing may result in compression of spinal nerve roots, causing a constellation of symptoms that may include lower pack pain, neurogenic claudication, and lower extremity pain. This case illustrates the AMA Guides to the Evaluation of Permanent Impairment ( AMA Guides ), Sixth Edition process of assessing impairment for spinal stenosis. The case involves a 54-year-old male truck driver whose lumbar spine was injured when he unloaded and lifted a tire; he underwent lumbar decompression at L3-4 and L4-5, and fourteen months after surgery was evaluated as being at maximum medical improvement, was able to walk, and could void spontaneously. In a one-page final medical report, the patient's physician hand wrote a note assigning 29% whole person impairment without a medical rationale to support the rating. The author of this case example first notes that the medical reporting does not support placing this patient in class 4, and the examinee's condition is most consistent with a class 1 rating for spinal stenosis. Using Section 17.3, Adjustment Grids and Grade Modifiers: Non-Key Factors, an evaluator would conclude a grade B, 6% whole person impairment for the lumbar spine.