Understanding the AMA Guides to Impairment,

6th EditionPRESENTER:

Richard Radnovich, D.O., Medical Director,Injury Care Medical Center

Impairment Ratings Objectives

› Understand changes in 5th and 6th editions of the Guides

› Understand how impairments are rated using the 6th edition of the Guides

› Be able to calculate simple ratings › How to critically read and evaluate an impairment

rating› Identify common errors in ratings› Accurately and thoroughly represent the Guides, not

my opinions

Impairment Ratings OUTLINE

› Define impairment› Brief history› Differences in content› Differences in application› Changes/clarifications/corrections› Present a case

5th v 6th editions Disc terminology, bulge v herniation Treatment of disc herniations Physical examination

ROM Waddel’s signs

Rate an impairment

Impairment Ratings Impairment evaluation:

› Medical evaluation performed by a physician using the Guides to determine impairment

› Treating or non-treating› Assessment of individual medical condition

and its effect on function

Impairment Ratings Impairment

› A loss or loss of use or derangement of a body part, organ system, or organ function from its preexisting level.

Impairment rating:› Estimate of the degree to which the impairment

decreases the individuals ability to perform ADL’s –NOT WORK ACIVITIES.

› Assess functional limitation/loss – NOT DISABILITY› “Consensus-derived percentage estimate of loss of

activity reflecting severity for a given health condition, and the degree of associated limitations in terms of ADLs”

“I read somewhere that 77 per cent of all the mentally ill live in poverty. Actually, I'm more intrigued by the 23 per cent who are apparently doing quite well for themselves.”

Impairment Ratings 6th edition released late 2007 5th edition released 2001 First published in book form in 1971 Studies v Expert Consensus Opinion NOT ALL conditions/problems are

addressed in the Guides

Impairment Ratings Cardiovascular- Heart and Aorta Cardiovascular- Arteries Respiratory system Digestive system Urinary and reproductive

systems Skin Blood/Hematological Endocrine system ENT Vision Central and Peripheral nervous

system Mental and Behavioral Spine Upper extremities Lower extremities Pain

Impairment Ratings Pain Cardiovascular Pulmonary system Digestive system Urinary and reproductive

systems Skin Blood/Hematological Endocrine system Ear, nose and throat Visual system Central and Peripheral nervous

system Mental and Behavioral Upper extremities Lower extremities Spine and pelvis

Impairment Ratings Reasons to update the Guides 5th edition

› New medical data› Function and Impairment› World Health Organization’s International

Classification of Functioning (ICF)› Reduce ambiguity› Increase consistency between chapters› Increase consistency between raters› Statement of principals

Impairment Ratings Differences in content

› Causation› Apportionment› Cultural differences› Pain chapter› Mental and Behavioral› “Constitution” of the Guides

TABLE 2-1, Fundamental Principals of the Guides

The concepts in this chapter are the fundamental principals of the Guides; they shall preempt anything in subsequent chapters that conflicts with or compromises these principals.

No impairment may exceed 100% whole person impairment. No impairment of arising from a member or organ may exceed the amputation value of that member.

All regional impairments in the same organ or body system shall be combined at the same level first and then combined by regions then whole person.

Impairments must be rated in accordance with the chapter relevant to the organ or system where the injury primarily arose or where the greatest dysfunction consistent with then objectively documented pathology remains.

Only permanent impairment may be rated according to the Guides, and only after Maximum Medical Improvement is certified A licensed physician must perform impairment evaluations. Chiropractic doctors, if authorized by the appropriate jusridictional authority

to perform rating under the Guides, should restrict rating to the spine. A valid impairment evaluation report based on the Guides must contain the 3 step approach described in section 2.7 The evaluating physician must use knowledge, skill and ability generally accepted by the medical scientific community when evaluating

an individual, to arrive at the correct impairment rating according to the Guides. The Guides is based on objective criteria. The physician must use all clinical knowledge, skill and abilities in determining whether

measurements, test results, or written historical information are consistent and concordant with the pathology being evaluated. If such findings, or an impairment estimate based on these findings, conflict with established medical principals, they cannot be used to justify an impairment rating.

Range of motion, and strength measurement techniques should be assessed carefully in the presence of apparent self-inhibition secondary to pain and fear.

The Guides do not permit the rating of future impairment. If the Guides provides more than one method to rate a particular impairment or condition, the method producing the higher rating must

be used. Subjective complaints alone are generally no ratable under the Guides (see chapter 3 for potential exceptions). Round all fractional impairment ratings, whether intermediate or final, to the nearest whole number.

Impairment Ratings Changes/clarifications/corrections

› Sample report› Pain disability questionnaire› Cardiovascular› Pulmonary› Urology› Visual › Psyche› Upper extremity› Lower extremity› Spine

Impairment Ratings http://www.ama-assn.org/go/amaguidessixthedition-errata

Guides6@ama-assn.org› Print request: Guides 6th edition Clarifications and Corrections› Name, Mailing address

Impairment Ratings Differences in application

› Utilization of ‘Uniform Template’› “Key Factors”› ‘Class’ of injury› Default ratings› “Non-key Factors”

Objective tests, clinical studies/labs Physical exam findings Functional assessments

Name

Date of InjuryDate of Birth

1.Determine KEY FACTORS to be rated2.Is the examinee at MMI for this KEY FACTOR3.Determine CLASS of Key Factor (0, 1, 2, 3, or 4)

_______4.Determine GRADE of within Class

________(NOTE: the default Grade is always ‘C’, the percentage impairment that ‘C’ represents will vary depending

on Class)5.Determine GRADE MODIFIERS

a. Grade Modifiers for FUNCTION (0, 1, 2, 3, or 4) _______

b. Grade Modifiers for EXAMINATION (0, 1, 2, 3, or 4) ________

c. Grade Modifiers for CLINICAL STUDIES (0, 1, 2, 3, or 4) _______6.ADJUST GRADE to the left or right the number of columns

based on the formula:REMEMBER: the numbers for this problem will be 0, 1, 2, 3, or 4

as determined above.(Grade modifier for FUNCTION # -- CLASS #)

Ernesto from BoliviaUS 7 years, married to US

citizen

Fell off forklift from ~12 feet› Low back – L4-5 disc

herniation, persistent R foot weakness, pain in Right lower extremity

› Shoulder – Full thickness rotator cuff and labral tear, surgically repaired, pain with certain movements.

› Previous low back injury 18 months ago. Treated with PT, released

to full duty, occasional lumbar and radiating pain

Impairment Ratings Determine “KEY FACTOR”

› Review medical records› Interview examinee› Physical exam› Diagnoses

Impairment Ratings Is there a category for each KEY

FACTOR? Is there more than one way to rate that

KEY FACTOR?

“Herniated disc, herniated nucleus pulposus, ruptured disc, prolapsed disc (used nonspecifically), protruded disc (used nonspecifically), and bulging disc (used nonspecifically) have all been used in the literature in various ways to denote imprecisely defined displacement of disc material beyond the interspace. The absence of clear understanding of the meaning of these terms and lack of definition of limits that should be placed on an ideal general term have created a great deal of confusion in clinical practice and in attempts to make meaningful comparisons of research studies.”

Fardon: Spine, Volume 26(5).March 1, 2001.E93-E113

Herniation = Bulge? Herniation ≠ Bulge?

Herniation has both specific and general meanings

The Guides do not indicate nomenclature they use

Radiologists do not necessarily follow standards

Fardon: Spine, Volume 26(5).March 1, 2001.E93-E113

Impairment RatingsAre there any other “Key Factors”?

Impairment RatingsMaximum Medical Improvement

Impairment Ratings How severe is the KEY FACTOR? Identify the CLASS for each KEY FACTOR

› 0 - no symptoms› 1 - mild or intermittent symptoms, controlled with

medications› 2 – constant mild symptoms, intermittent moderate

symptoms despite ongoing treatment› 3 – constant moderate symptoms, intermittent severe

symptoms, despite ongoing treatment› 4 – constant severe symptoms, intermittent extreme

symptoms, despite ongoing treatment

Impairment Ratings Adjustments for non-key factors

› Functional history Pain during activity Medications Disability questionnaire

› Physical examination ROM Atrophy Alignment Strength Palpatory findings

› Clinical studies Imaging Electrodiagnostic studies

Impairment Ratings Apportionment

› What is apportionment› When is it needed› “Apportionment is an allocation of causation

among multiple factors that caused or significantly contributed to the injury or disease and resulting impairment”

Impairment Ratings Apportionment calculation:

› Calculate the current impairment› Calculate what impairment existed at the moment of

the current event, based on best available data.› Deduct the prior impairment from the current

impairment(Total Impairment) – (Previous Impairment) = Final

Impairment › Requires accurate data› Same method› Explain reasoning

Impairment Ratings Combining

› Multiple impairments in different systems? Combine using combined values chart

› Multiple impairments in the same region? Choose most impairing, but can be combined if the most impairing diagnoses does not adequately reflect the loss.

› Multiple impairments, same system but different parts/regions? Combine using combined values chart

› Multiple impairments based on range of motion losses? Add values for ROM loss are added? Choose most impairing, but can be combined if the most impairing diagnoses does not adequately reflect the loss.

› All percentages being combined must be in same units (UEI, WPI)

[ ] Name, demographic and/or identifying information[ ] History of the event [ ] Mechanism of injury, date of onset

[ ] Course of illness [ ] Symptoms initially [ ] Previous examination findings (at time of initial diagnosis, if available) [ ] Treatment and responses to treatment [ ] diagnostic studies and their results[ ] Social history

[ ] Work history[ ] Past medical/surgical history

[ ] Current status[ ] Current symptoms

[ ] Aggravating or relieving factors[ ] Locations of symptoms[ ] Review of systems

[ ] Physical exam findings[ ] Current treatment/medications

[ ] Impairment rating[ ] MMI status[ ] Examiner’s diagnosis and rating

[ ] Explanation (page or table referenced, how calculations were made)[ ] Apportionment (if applicable, calculations, reasoning)

[ ] Restrictions[ ] Treatment recommendations[ ] Diagnostic recommendations

IMPAIRMENT RATING EVALUATION

Richard Radnovich, D.O.dr.radnovich@injurycaremedical.com

Impairment Ratings Summary

› Impairment ratings measure loss of function, not disability

› Get corrected pages› Ratings are used provide consistency › Do not assume that the impairment rating is

correct› Do not be afraid to calculate simple ratings› Check combined numbers