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Abstract
The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) Fourth Edition, states that peripheral nerve impairments are determined by determining the percentage of the patient's motor and sensory loss. This article discusses the six steps necessary to rate a peripheral nerve impairment of the upper extremity: First, identify the nerve or nerves affected using relevant tables and figures. Second, locate the table that lists the nerve identified, and record the maximum loss attributed to that nerve for motor and sensory function. A table lists peripheral nerve charts in the AMA Guides, including nerves rated, table and page numbers, and type of rating (upper or lower extremity, foot, and so on). Third, grade the motor deficit of the nerve, and, using the appropriate table, find the percentage range and choose a number within the range that is appropriate for the patient; multiply the graded percentage by the total motor impairment found in step two. Fourth, determine the total deficit for the nerve by combining the motor and sensory deficits using the Combined Values Chart. Fifth, combine the total nerve deficit with other appropriate impairments. A table instructs raters how to convert to a whole person impairment. Sixth, grade the sensory deficit of the nerve. An example illustrates application of the six steps.
Abstract
This letter responds to “Evaluating impairment from allergic disorders” in the March/April 1999 issue of The Guides Newsletter. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not provide clear direction about whether allergies themselves constitute impairment. Consider a worker whose symptoms of asthma subsequent to workplace exposure to toluene diioscyanate resolve when he or she is removed from the job and is no longer exposed to the chemical. Because everyday exposure to diisocyanates is not common and the patient no longer requires medication, one could conclude the patient has no impairment. In contrast, consider a patient who has developed latex allergies as a result of being a health care worker and has experienced two anaphylactic reactions at work after entering rooms where powdered latex gloves had been used and must travel with an epinephrine pen. This person would have a minimum of a Class I impairment because of the few limitations of this person's activities of daily living (ADLs) and the condition requires no or intermittent treatment. Both patients might feel they had permanent changes in their body functions that required permanent changes in their ADLs. Clinicians who make evaluations should be aware of patients’ need for medications or monitoring, the severity of the patient's reactions, and limitations on social activities (eg, need for medications and need to avoid seasonal pollens).
Abstract
The first four editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) used the range of motion (ROM) method and derived impairment percentages. This method is reliable and works well to rate finger joint injuries such as fractures or sprains that cause reduced finger joint ROM, but it frequently underestimates the functional difficulty (impairment) caused by tendon injuries that restrict the excursion of tendons. For this reason, the AMA Guides, Fifth Edition, introduced a second method to rate ROM in fingers, the total active motion (TAM) method. When an evaluator calculates the patient's impairment using the traditional method from the first four editions of the AMA Guides, the impairment percentage is likely to underestimate the patient's “real world” difficulty or function; the TAM method measures flexion when the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints are in full simultaneous flexion, and it measures extension when all three joints are in full simultaneous extension. Based on an example and using the Combined Values Chart in the Fifth Edition and the traditional method (the only method allowed in the first four editions), one would assess a 16% impairment of the digit; using the TAM method now available in the Fifth Edition, the impairment is more appropriately estimated at 61%.
Abstract
This article reviews portions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) that are useful to evaluators making individual case decisions in various legal systems. The first step is a determination of permanency, and evaluators should know that many state laws have unique definitions of “maximum medical improvement.” Next, the evaluator should establish a definitive diagnosis that identifies the existence of an abnormality and impairment of the activities of daily living. Based on his or her judgment and expertise, training, skill, and thoroughness, the evaluating physician must use clinical judgment regarding whether or not the results of tests or impairment measurements are reasonable for a particular patient and the impairment under evaluation. The AMA Guides notes that an evaluator may increase an impairment rating after determining that the estimate for the anatomic impairment does not sufficiently reflect the severity of the patient's condition. When findings between two physicians differ, then the stability of the medical issue may be in question, and the involved physicians should be in communication and should have access to all prior physician reports and test results. Evaluators may need to educate patients about the difference between impairment and disability. Clear report writing is the key to successful impairment evaluations.
Abstract
Before the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, spine impairment was based on range of motion (ROM) testing combined with ratings for specific spine disorders and neurologic impairment. The AMA Guides, Fourth Edition, uses the Injury or Diagnosis-related Estimates (DRE) Model to rate spinal impairment. This model is based on history, physical examination (but not ROM unless ROM is used as a differentiator), and other test data. Table 71, DRE Impairment Category Differentiators, lists DRE impairment category differentiators and discusses the differences between ratings, choosing between differentiators, and their reliability and validity. Guarding is “a spasm of muscles to minimize motion or agitation of sites affected by injury or disease,” and spasm often is overreported by physicians who are unaware of its definition. Loss of reflexes, presenting as diminished or absent deep tendon reflexes, remains the hallmark of objective physical evidence. Decreased circumference is associated with atrophy. Loss of motion segment integrity is measured on lateral flexion and extension x-rays. Loss of bowel or bladder control suggests significant spinal cord injury. The final differentiator is bladder studies, measured using a cystometrogram and showing unequivocal neurologic compromise of the bladder with resulting incontinence.
Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) has been adopted by many jurisdictions for evaluating permanent impairment. The AMA Guides is formally accepted by means of adoptive language in each jurisdiction's statutes or regulatory code, and this adoptive language falls into one of three types: The first type specifies a particular edition of the AMA Guides for use. Such language has the advantage of being unambiguous, but it fails to take into account subsequent editions. The second type of adoptive language specifies use of the latest or most recent edition of the AMA Guides and ensures currency; states such as Kentucky, New Hampshire, and New Mexico are jurisdictions that employ this type of language. The third type of adoptive language does not indicate which edition of the AMA Guides to use, and in these jurisdictions the courts must decide which edition to use. A chart lists 26 states, the edition of the AMA Guides used in the state, and the source; the chart also includes states such as Arizona, Georgia, Massachusetts, Nevada, South Carolina, and Washington in which the adoptive language is unclear regarding which edition to use, and in these jurisdictions a court would decide which edition should be used.
Abstract
Chapter 11, Ear, Nose, Throat, and Related Structures of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, includes a new section on voice impairment, a new table on vestibular disorders, and information regarding combined facial disorders and disfigurements. Impairments are based on anatomic, physiological, and functional approaches and involve the assessment of subjective information (eg, statements provided by the patient) and objective factors determined by clinical examination or functional tests. The rating of hearing loss is unchanged from the Fourth Edition in the AMA Guides, Fifth Edition, and tables guide the conversion of monoauricular and binaural hearing impairments into whole person impairments. A tinnitus rating can be combined with the binaural hearing impairment loss before conversion to a whole person permanent impairment. Total disfigurement of the face can be graded between 16% and 50%; a table guides evaluators in rating facial disorders or disfigurement. Impairments of the nose, throat, and related structures include respiration, mastication, deglutition, olfaction and taste, speech, and voice. Although hearing loss is measured using anatomic, physiological, and functional approaches, many other assessments in Chapter 11 are based on interference in the activities of daily living, and the examiner must perform a careful assessment and apply the criteria in the AMA Guides.
Abstract
Because of their education and training, treating physicians often address causality only in terms of differential diagnosis (ie, what is causing the individual's symptoms and signs). Etiology also can be considered from a prophylactic or therapeutic standpoint (ie, how to prevent recurrent injury or eliminate the cause of an illness). In workers’ compensation, causation analysis extends beyond diagnosis, prophylaxis, and treatment and must consider whether the condition is attributable to the workplace. The terms cause, effect, exacerbation, and aggravation have specific meanings in the AMA Guides to the Evaluation of Permanent Impairment and are defined, with discussion. Three criteria must be met before causation is established in workers’ compensation: the cause is medically probable; the effect is medically probable; and the cause and effect probably are etiologically related (ie, the occupational trauma likely caused the injury, or the exposure caused the illness). A table presents the steps in a causation analysis in workers’ compensation: 1) define the injury, activity, or exposure (cause); 2) establish the diagnosis; 3) determine generic causation; specifically, determine if the reported mechanism, activity, or exposure ever causes the patient injury or disease; 4) determine specific causation in this instance and determine if another (more probably) nonoccupational cause was involved.
Abstract
A 1999 study of adults showed hearing loss was the fifth most common disability in the US population, and almost 50% of workers in carpentry, plumbing, and mining had hearing impairment. Determining hearing impairment according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 11.2a, Criteria for Rating Impairment Due to Hearing Loss, is straightforward, if limited. Examiners should be aware that hearing can be temporarily impaired by recent exposure to loud noise and should test only after an extended period without such exposure. Audiometers should be properly calibrated, and technicians must be appropriately trained to obtain accurate measurements. The evaluator should separately test both of the individual's ears at 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz (the representative or test frequencies) and then identify the total worst ear decibel level using the AMA Guides Table 11-1 or 11-2. The evaluator can use Tale 11-3 to convert hearing impairment to whole person loss. Tinnitus also can be rated if a hearing loss in that ear affects speech discrimination; in such instances, the tinnitus rating is limited to a 5% loss. The article includes a Hearing Impairment Rating Sheet that can be used to record data from the hearing impairment evaluation.
