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Christopher R. Brigham
and
James B. Talmage

Abstract

Workers’ compensation in Canada is a legislated system of social insurance that is funded by assessments levied on employers. Thirteen established Workers’ Compensation Board (WCB) systems have regional jurisdiction and responsibility for administering and adjudicating compensation for the injured worker. Disability awards for certain injuries are determined by statute; others are determined using an acceptable reference or impairment schedule such as the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). On August 22, 1960, Dr D. E. Bell presented to the Association of Workers’ Compensation Boards of Canada an impairment rating schedule to represent the loss of earning capacity and fulfill the spirit of workers’ compensation. Dr Bell's schedule has served as the basis for many Canadian WCB Primary Rating Schedules. Most jurisdictions refer to the AMA Guides in instances when the primary schedule is inadequate. A table in this article lists the current primary and secondary schedules for assessment of impairment in Canada; another table shows the differences in the ratings between Dr Bell's schedule and the AMA Guides. The AMA Guides is used principally only in Yukon and Prince Edward Island and is used for impairment estimations of more complicated injuries in all regions but Quebec.

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

Abstract

Lesions of the peripheral nervous system (PNS), whether due to injury or illness, commonly result in residual symptoms and signs and, hence, permanent impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) describes procedures for rating upper extremity neural deficits in Chapter 3, The Musculoskeletal System, section 3.1k; Chapter 4, The Nervous System, section 4.4 provides additional information and an example. The AMA Guides also divides PNS deficits into sensory and motor and includes pain within the former. The impairment estimates take into account typical manifestations such as limited motion, atrophy, and reflex, trophic, and vasomotor deficits. Lesions of the peripheral nervous system may result in diminished sensation (anesthesia or hypesthesia), abnormal sensation (dysesthesia or paresthesia), or increased sensation (hyperesthesia). Lesions of motor nerves can result in weakness or paralysis of the muscles innervated. Spinal nerve deficits are identified by sensory loss or pain in the dermatome or weakness in the myotome supplied. The steps in estimating brachial plexus impairment are similar to those for spinal and peripheral nerves. Evaluators should take care not to rate the same impairment twice, eg, rating weakness resulting from a peripheral nerve injury and the joss of joint motion due to that weakness.

in AMA Guides® Newsletter
James B. Talmage
and
Leon H. Ensalada

Abstract

Evaluators must understand the complex overall process that makes up an independent medical evaluation (IME), whether the purpose of the evaluation is to assess impairment or other care issues. Part 1 of this article provides an overview of the process, and Part 2 [in this issue] reviews the pre-evaluation process in detail. The IME process comprises three phases: pre-evaluation, evaluation, and postevaluation. Pre-evaluation begins when a client requests an IME and provides the physician with medical records and other information. The following steps occur at the time of an evaluation: 1) patient is greeted; arrival time is noted; 2) identity of the examinee is verified; 3) the evaluation process is explained and written informed consent is obtained; 4) questions or inventories are completed; 5) physician reviews radiographs or diagnostic studies; 6) physician records start time and interviews examinee; 7) physician may dictate the history in the presence of the examinee; 8) physician examines examinee with staff member in attendance, documenting negative, physical, and nonphysiologic findings; 9) physician concludes evaluation, records end time, and provides a satisfaction survey to examinee; 10) examinee returns satisfaction survey before departure. Postevaluation work includes preparing the IME report, which is best done immediately after the evaluation. To perfect the IME process, examiners can assess their current approach to IMEs, identify strengths and weaknesses, and consider what can be done to improve efficiency and quality.

in AMA Guides® Newsletter
Charles N. Brooks
and
James B. Talmage

Abstract

Like all multi-authored texts, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) presents some challenges and inconsistencies, and in March 2002 AMA published an errata. The latter has only one correction for Chapter 17, The Lower Extremities, and this article reviews some additional problems and inconsistencies in Chapter 17. For example, the AMA Guides, Fifth Edition, gives inconsistent instructions about measurements of muscle atrophy, and this article recommends simple, unambiguous directions such as measuring thigh and leg circumferences 15 cm superior and inferior to the medial joint line of the knee, respectively. One could argue that no goniometer should be included in Figure 17-1a, Using a Goniometer to Measure Flexion of the Right Hip; in Figure 17-1b, the goniometer should be placed with its axis at the center of rotation of the right hip. In Figure 17-1c, the limb of the goniometer overlying the left femur should instead be parallel to the tabletop. Additional sections of the article discuss joint ankylosis; peripheral nerve injuries; causalgia, complex regional pain syndrome, and reflex sympathetic dystrophy. A careful reading of Chapter 17 uncovers some problems, none of which is critical, but all should be noted by frequent users of the AMA Guides.

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

Abstract

Before the publication of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, each chapter focused on a single organ system and provided a description of the diagnostic and evaluative methods for assessing impairment at the organ system level and functional impairment of the whole person. Beginning with the Fourth and continuing into the Fifth Edition, a new chapter focused not on a single organ system but rather on pain. The author of this article takes issue with others who propose that pain should not only be conceptualized as a disabling factor but also as an impairment. Some have argued that, “[d]espite its stated intent, the [AMA] Guides does not maintain a clear focus on functional impairment … it blurs the line between impairment and disability. The [AMA] Guides defines impairment so broadly as to include disability, effectively confusing the 2 concepts.” For these very reasons, argues the author of this article, pain should not be conceptualized as an impairment, and rating schemes should not promote or reinforce inappropriate behavior, for example, by providing a reward for reporting more pain. The latter will lead to more diagnostic testing, more treatment, and more physician-prescribed work absence, culminating in the reinforcement of perceived illness and incapacity.

in AMA Guides® Newsletter
James B. Talmage
and
J. Mark Melhorn
in AMA Guides® Newsletter
Christopher R. Brigham
and
James B. Talmage
in AMA Guides® Newsletter
Charles N. Brooks
and
James B. Talmage
in AMA Guides® Newsletter
James B. Talmage
and
Christopher R. Brigham
in AMA Guides® Newsletter