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Jay Blaisdell
and
James B. Talmage

Abstract

Ratings for “non-specific chronic, or chronic reoccurring, back pain” are based on the diagnosis-based impairment method whereby an impairment class, usually representing a range of impairment values within a cell of a grid, is selected by diagnosis and “specific criteria” (key factors). Within the impairment class, the default impairment value then can be modified using non-key factors or “grade modifiers” such as functional history, physical examination, and clinical studies using the net adjustment formula. The diagnosis of “nonspecific chronic, or chronic reoccurring, back pain” can be rated in class 0 and 1; the former has a default value of 0%, and the latter has a default value of 2% before any modifications. The key concept here is that the physician believes that the patient is experiencing pain, yet there are no related objective findings, most notably radiculopathy as distinguished from “nonverifiable radicular complaints.” If the individual is found not to have radiculopathy and the medical record shows that the patient has never had clinically verifiable radiculopathy, then the diagnosis of “intervertebral disk herniation and/or AOMSI [alteration of motion segment integrity] cannot be used.” If the patient is asymptomatic at maximum medical improvement, then impairment Class 0 should be chosen, not Class 1; a final whole person impairment rating of 1% indicates incorrect use of the methodology.

in AMA Guides® Newsletter
Jay Blaisdell
and
James B. Talmage

Abstract

Examiners use range-of-motion (ROM) testing to help calculate the physical examination modifier when they use the diagnosis-based impairment (DBI) method in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. DBI is the preferred method for calculating upper and lower extremity ratings, but, in instances specified by the regional grid, the evaluator may choose to use the ROM method, typically because it yields a higher impairment rating relative to the DBI method. In rare lower-limb cases when the injury is not fully articulated by the regional grid (eg, severe crushes, burns, and scarring), ROM may be used instead of diagnosis. In cases of amputation, ROM may be used for the remaining portion of the limb and combined with amputation rating as explained in sections of Chapter 15. Note that, in the AMA Guides, the extended anatomic position is 0° rather than 180°, and evaluators can consult the detailed diagrams of the planes of the thumbs, fingers, wrists, elbows, and shoulders. Invalid results are declared if, after three consecutive efforts, the three measurements for a given plane of motion vary more than 10° from the mean (average) of these three measurements. The article also discusses adjustments for functional history when the ROM method does not adequately capture the full impairment.

in AMA Guides® Newsletter
James B. Talmage
and
Christopher Brigham

Abstract

Impairment evaluations not performed following processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) will result in erroneous ratings. Common errors in impairment rating (IR) for upper extremity are frequently seen in physician IR reports and independent medical examination reports. Recognizing these errors can result in the prevention and management of these ratings. Common errors include rating impairment using the diagnosis-based approach for more than one diagnosis within a region and making incorrect assessments of motion loss, nerve injuries, entrapment disorders, and complex regional pain syndrome.

in AMA Guides® Newsletter
James B. Talmage
and
Jay Blaisdell

Abstract

In many workers’ compensation systems, shoulder injuries are among the most common reasons for filing a claim, and greater familiarity with the significant differences in rating processes between the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions will help physicians avoid common pitfalls and improve the reliability of impairment ratings. One source of confusion associated with rating a shoulder is determining whether to use the range-of-motion (ROM) method or the diagnosis-based impairment (DBI) method. The AMA Guides, Sixth Edition, clearly states that DBI is the primary method of evaluation for the upper limb and that range of motion is used primarily as a physical examination adjustment factor and only when a grid permits its use as an option. An impairment rating that is calculated using ROM may not be combined with a DBI-based impairment rating; DBI is the primary method, and ROM should be used “only under specific circumstances.” When measuring ROM, evaluators should record all six measurements of shoulder motion for each arm and use the injured arm as a baseline. If two or more diagnoses are possible under the DBI method, evaluators should choose the highest causally related impairment rating from the shoulder grid and modify the clinical studies grade modifier.

in AMA Guides® Newsletter
Blaisdell Jay
and
James Talmage

Abstract

Of the many types of abdominal wall hernias, inguinal hernias are, by far, the most common type and typically present in males in workers’ compensation cases who report the cause as heavy lifting. The AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, indicates that genetics (family history) is the strongest risk factor. Conditions that chronically increase intra-abdominal pressure (eg, obesity, ascites, or pregnancy) and smoking are statistically associated with abdominal wall hernias, but no good studies show an increased risk of hernia formation in laborers. Abdominal hernias with palpable defects or protrusions usually are corrected with surgery, and the outcome typically warrants an impairment of 0%. In the AMA Guides, Sixth Edition, Section 6.6, Hernias, and Table 6-10, Criteria for Rating Permanent Impairment Due to Hernias, are used for ratings. The rating scheme in the internal medicine chapters differs from that found in the musculoskeletal chapters because the rater uses a key factor of two of three potential variables—history, physical findings, and objective findings—to select the impairment class. Like the grade modifiers in the musculoskeletal chapters, the other variables (other than the key factors) then are used to modify the impairment rating within the impairment class. Most hernias are not due to injury and result in 0% whole person permanent impairment after repair.

in AMA Guides® Newsletter
James B. Talmage
and
Jay Blaisdell

Abstract

To assess medical impairments, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) divides cardiovascular diseases into the following eight groups, each of which has its own grid: valvular heart disease; coronary artery disease; cardiomyopathies, pericardial heart disease, dysrhythmias, hypertensive cardiovascular disease, vascular diseases affecting the extremities, and diseases of the pulmonary artery. An accompanying table shows the criteria for rating permanent impairment due to valvular heart disease. Within the grids, the rows are divided into three main impairment variables: history, physical findings, and objective test results. The latter are essential in assigning cardiovascular impairment ratings. The AMA Guides names the objective test results variable as the key factor to underscore its role in assigning the impairment class in the cardiovascular chapter. For cardiovascular impairments, objective test results are always used to place the injury in its impairment class; therefore, objective test results are never used to modify the rating once the evaluator chooses the impairment class. Not all internal medicine chapters designate objective test results as the key factor, but all use one key factor that is clearly indicated in a footnote and one or two non-key factors. This rating scheme emphasizes objective test results, history, and physical findings and avoids incorporating variables twice.

in AMA Guides® Newsletter
James B. Talmage
and
Jay Blaisdell

Abstract

Injuries that affect the central nervous system (CNS) can be catastrophic because they involve the brain or spinal cord, and determining the underlying clinical cause of impairment is essential in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), in part because the AMA Guides addresses neurological impairment in several chapters. Unlike the musculoskeletal chapters, Chapter 13, The Central and Peripheral Nervous System, does not use grades, grade modifiers, and a net adjustment formula; rather the chapter uses an approach that is similar to that in prior editions of the AMA Guides. The following steps can be used to perform a CNS rating: 1) evaluate all four major categories of cerebral impairment, and choose the one that is most severe; 2) rate the single most severe cerebral impairment of the four major categories; 3) rate all other impairments that are due to neurogenic problems; and 4) combine the rating of the single most severe category of cerebral impairment with the ratings of all other impairments. Because some neurological dysfunctions are rated elsewhere in the AMA Guides, Sixth Edition, the evaluator may consult Table 13-1 to verify the appropriate chapter to use.

in AMA Guides® Newsletter
Restricted access
Jay Blaisdell
and
James Talmage

Abstract

Workers who kneel for major portions of their workday (eg, floor and roof installers) may be prone to inflammation of the knee bursae and patellofemoral pain. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), range-of-motion (ROM) and diagnosis-based impairment (DBI) are the two possible stand-alone methods for rating knee impairment. The ROM method was widely used in previous editions of the AMA Guides, but at present DBI is the method of choice for calculating impairment. To rate knee impairment using the DBI method, the physician first chooses the appropriate diagnosis from the Knee Regional Grid in the AMA Guides, Sixth Edition. Next, the physician chooses the appropriate impairment class for the diagnosis and then selects the appropriate grade modifiers. The physician applies the net adjustment formula to determine lower extremity impairment and finally converts the final lower extremity impairment to whole person impairment. Two or more conditions often are found in the knees and require causation analysis in which the physician should choose the single causally related diagnosis that will yield the highest impairment rating. Modifiers should be chosen based on reliable findings that have not been used previously to assign either the diagnosis or impairment class. The ROM method can be used to select the physical examination grade modifier or as a stand-alone rating if the physician offers a rationale that is supported by the AMA Guides.

in AMA Guides® Newsletter