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- Author or Editor: Jay Blaisdell x
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Abstract
In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, range of motion (ROM) is used to calculate the physical examination modifier when the diagnosis-based impairment (DBI) method is used, ie, Table 15-8, Physical Examination Adjustment: Upper Extremities, and Table 16-7, Physical Examination Adjustment: Lower Extremities. The DBI method is preferable 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. The article outlines the steps for measuring ROM. Invalid results on the day of testing are declared after three consecutive efforts if the three measurements for a given plane of motion vary by more than 10 degrees from the average (mean) of these three measurements. The process can be tried again another day, or the DBI method can be used. All ROM measurements should be rounded to the nearest number ending in zero, and a figure provides examples of suitable annotations. Adjustments for functional history can be made if ROM is the only method used for rating, if results are deemed reliable and consistent with results from an activities of daily living questionnaire or other valid functional report, and if the current ROM impairment does not adequately capture the full impairment.
Abstract
Physicians use a variety of methodologies within the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, to rate nerve injuries depending on the type of injury and location of the nerve. Traumatic injuries that cause impairment to the peripheral or brachial plexus nerves are rated using Section 15.4e, Peripheral Nerve and Brachial Plexus Impairment, for upper extremities and Section 16.4c, Peripheral Nerve Rating Process, for lower extremities. Verifiable nerve lesions that incite the symptoms of complex regional pain syndrome, type II (similar to the former concept of causalgia), also are rated in these sections. Nerve entrapments, which are not isolated traumatic events, are rated using the methodology in Section 15.4f, Entrapment Neuropathy. Type I complex regional pain syndrome is rated using Section 15.5, Complex Regional Pain Syndrome for upper extremities or Section 16.5, Complex Regional Pain Syndrome for lower extremities. The method for grading the sensory and motor deficits is analogous to the method described in previous editions of AMA Guides. Rating the permanent impairment of the peripheral nerves or brachial plexus is similar to the methodology used in the diagnosis-based impairment scheme with the exceptions that the physical examination grade modifier is never used to adjust the default rating and the names of individual nerves or plexus trunks, as opposed to the names of diagnoses, appear in the far left column of the rating grids.
Abstract
Facial disfigurements, including those caused by burns (thermal, chemical, or electrical) or trauma, are rated in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Chapter 11, which also discusses occupational overexposure to sunlight, airborne chemicals, heavy metals, and allergens that may lead to head and neck cancers and degraded ability to breathe, chew, swallow, smell, or speak. Additional relevant impairments include those of olfaction and taste, chewing and swallowing, voice and speech, and of the upper respiratory passages. For upper air passage defects and voice and speech impairments, the evaluator assigns an impairment rating by selecting the relevant table or grid in Chapter 11 and then assigning the appropriate impairment class, as determined by the key factor. The patient's history is the key factor for upper air passage deficits, and the performance measures of audibility, intelligibility, and functional efficiency collectively act as the key factor for voice and speech impairments. Once they select an impairment class, evaluators can modify the rating within the impairment class by considering remaining variables. When rating the patient's ability to smell and taste or chew and swallow, raters do not use impairment classes or modifiers. Rather, they assign impairment within an allowable range largely based on professional judgment complemented by objective findings and a well-documented rationale.
Abstract
Upper extremity amputations are rated in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 15.6, Amputation Impairment, where text, tables, and figures guide evaluators in combining proximal diagnosis-based impairments (DBIs) and proximal range-of-motion impairments. The AMA Guides provides impairment grids for lower and upper extremity amputations, which are divided into five impairment classes (0 through 4), and each impairment class is further divided (except class 0) into five grades (A through E), each with its respective impairment rating that is expressed as a percentage of the extremity. Determining impairment class, and thus the default value of impairment, is straightforward if the amputation occurred directly at one of the points in the relevant grid; if the amputation occurred at another point, the evaluator should consult the appropriate figure to assess how the specific level of amputation corresponds with impairment percentages. An individual's proximal problems may lead to an increase in the impairment value because of the application of grade modifiers. Except in rare instances of bilateral upper extremity amputation or when the patient is unable to wear a prosthesis for a lower extremity amputation, the evaluator usually uses the default rating value within the selected impairment class as the final percentage rating. Evaluators are advised to re-read the amputation section in the AMA Guides before conducting an amputation evaluation.
Abstract
Pelvic fractures are relatively uncommon, and in workers’ compensation most pelvic fractures are the result of an acute, high-impact event such as a fall from a roof or an automobile collision. A person with osteoporosis may sustain a pelvic fracture from a lower-impact injury such as a minor fall. Further, major parts of the bladder, bowel, reproductive organs, nerves, and blood vessels pass through the pelvic ring, and traumatic pelvic fractures that result from a high-impact event often coincide with damaged organs, significant bleeding, and sensory and motor dysfunction. Following are the steps in the rating process: 1) assign the diagnosis and impairment class for the pelvis; 2) assign the functional history, physical examination, and clinical studies grade modifiers; and 3) apply the net adjustment formula. Because pelvic fractures are so uncommon, raters may be less familiar with the rating process for these types of injuries. The diagnosis-based methodology for rating pelvic fractures is consistent with the process used to rate other musculoskeletal impairments. Evaluators must base the rating on reliable data when the patient is at maximum medical impairment and must assess possible impairment from concomitant injuries.
Abstract
This article provides an overview of the conceptual foundations of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Impairment assessment in the sixth edition underwent a “paradigm shift” compared to the AMA Guides, Fifth Edition, in which its impairment rating methodology is based on the World Health Organization's (WHO's) International Classification of Functioning, Disability and Health (ICF) framework. Impairment rating is but one of several determinants of disability, and the one most amenable to physician assessment.
Abstract
Appropriately assessing impairment mandates that the physician be familiar with the principles of assessing impairment, as reflected in Chapter 1, Conceptual Foundations and Philosophy, and Chapter 2, Practical Applications of the Guides. Based on this knowledge, the physician will then apply the processes and criteria provided in specific chapters. All impairment rating reports should be divided into three main sections: clinical evaluation, analysis of the findings, and discussion. To obtain the highest level of competency, the rating physician should be familiar with jurisdictional requirements that effectively supplant AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) methodology.
Abstract
The most common source of occupational skin disease is contact dermatitis, an inflammation caused by exposure to an allergen. Whenever possible, the evaluating physician should rely on objective evidence such as lichenification, excoriation, and hyperpigmentation rather than subjective complaints. Patch testing, biopsy, and sensory discrimination tests are reliable tools at the evaluating physician's disposal. Disfigurements of the face are rated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 11.3, The Face, and Chapter 8, The Skin, is used for all other skin impairments. The evaluating physician records the history of the injury, evaluates the patient, and, in consultation with Table 8-3, notes any objective clinical studies to diagnose the pathology. The functional history, physical examination findings, and diagnostic test findings values then are assigned using Table 8-2; the functional history acts as the key factor and determines the patient's impairment class, physical examination, and diagnostic test findings, each acting as non-key factors, or modifiers. Finally, the non-key factors are used to modify the impairment rating from its default value within its impairment class, and the result is the final skin impairment rating expressed as whole person impairment. Chapter 8 is used only rarely in impairment rating in workers’ compensation cases, and examiners should study the chapter carefully before using it.
Abstract
Like the diagnosis-based impairment (DBI) method and the range-of-motion (ROM) method for rating permanent impairment, the approach for rating compression or entrapment neuropathy in the upper extremity (eg, carpal tunnel syndrome [CTS]) is a separate and distinct methodology in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Rating entrapment neuropathies is similar to the DBI method because the evaluator uses three grade modifiers (ie, test findings, functional history, and physical evaluation findings), but the way these modifiers are applied is different from that in the DBI method. Notably, the evaluator must have valid nerve conduction test results and cannot diagnose or rate nerve entrapment or compression without them; postoperative nerve conduction studies are not necessary for impairment rating purposes. The AMA Guides, Sixth Edition, uses criteria that match those established by the Normative Data Task Force and endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM); evaluators should be aware of updated definitions of normal from AANEM. It is possible that some patients may be diagnosed with carpal or cubital tunnel syndrome for treatment but will not qualify for that diagnosis for impairment rating; evaluating physicians must be familiar with electrodiagnostic test results to interpret them and determine if they confirm to the criteria for conduction delay, conduction block, or axon loss; if this is not the case, the evaluator may use the DBI method with the diagnosis of nonspecific pain.
