AMA Guides to the Evaluation of Permanent Impairment - Corrections
Introduction to Occupational Medicine...AMA Guides to the Evaluation of Permanent Impairment Sixth...
Transcript of Introduction to Occupational Medicine...AMA Guides to the Evaluation of Permanent Impairment Sixth...
IMPAIRMENT RATINGS
Bruce W. Randolph, MD, MPH
Assistant Professor
University of Arkansas for Medical Sciences
Preventive Occupational Environmental Medicine Clinic
Disclosures
I have no disclosures or conflicts of interest to reveal.
Objectives:
I. Understand the purpose and scope of an
Impairment Evaluation and Impairment Rating.
II. Understand how Impairment Ratings are derived.
III. Understand why two physicians may render
different impairment ratings for the same injury.
AMA Guides to the Evaluation of
Permanent Impairment Published by the American Medical Association
1958 - 1st Article published the
Journal of the American Medical
Association (JAMA).
“A Guide to the Evaluation of
Permanent Impairment of the
Extremities and Back”.
AMA Guides to the Evaluation of
Permanent Impairment Published by the American Medical Association
1958 – 1970 : Over the next 12 years,
12 additional articles were published
in JAMA.
AMA Guides to the Evaluation of
Permanent Impairment
1971- First Edition
1st Published in book form (Compendium of the 13 Guides)
Standardized an objective approach to
evaluating medical impairments.
AMA Guides to the Evaluation of
Permanent Impairment
The Guides are revised periodically:
Current scientific research
Evolving medical evidence
Clinical knowledge and judgment
Correct deficiencies and respond to criticism
AMA Guides to the Evaluation of
Permanent Impairment
1984 - Second Edition
1988 - Third Edition – Pie charts for
range of motion (ROM) impairment
evaluation of the upper extremities
1990 - Third Edition (Revised)
AMA Guides to the Evaluation of
Permanent Impairment
Fourth Edition (1993):
Diagnosis Related Estimates (DRE) or “Injury
Model” to evaluation of spinal injuries
Pain Chapter was introduced
AMA Guides to the Evaluation of
Permanent Impairment
Fifth Edition (2000):
Refined the Pain Chapter
Modified the DRE method
Expanded the ROM method for spinal
impairment evaluations.
AMA Guides to the Evaluation of
Permanent Impairment Sixth Edition (2007):
A “paradigm shift” to the assessment of impairment
Simplified
Adopts a contemporary model of disablement based on the International Classification of Functioning, Disability, and Health (ICF)
Functionally based
Diagnosed based with diagnoses being evidenced based
Internally consistent
Arkansas Workers Compensation Commission
RULE 099.34 - IMPAIRMENT RATING GUIDE
(Adopted July 1, 1994; revised June 9, 1995, effective July 1, 1995)
“The purpose of Rule 34 is to establish an
impairment rating guide to be used in the
assessment of anatomical impairment.”
Arkansas Workers Compensation Commission
RULE 099.34 - IMPAIRMENT RATING GUIDE (Adopted July 1, 1994; revised June 9, 1995, effective July 1, 1995)
To accomplish this purpose, the Arkansas
Workers’ Compensation Commission adopted
the Guides to the Evaluation of Permanent
Impairment (4th ed. 1993).
Arkansas Workers Compensation Commission
RULE 099.34 - IMPAIRMENT RATING GUIDE (Adopted July 1, 1994; revised June 9, 1995, effective July 1, 1995)
“Exclusive of any sections which refer to pain
and exclusive of straight leg raising tests or
range of motion tests when making physical or
anatomical impairment ratings to the spine.”
RULE 099.34 - IMPAIRMENT RATING GUIDE
“Objective findings” are those findings which
cannot come under the voluntary control of
the patient.
When determining physical or anatomical
impairment, cannot consider complaints of
pain
RULE 099.34 - IMPAIRMENT RATING GUIDE
“For the purpose of making physical or
anatomical impairment ratings to the spine,
straight leg raising tests or range of motion
tests shall not be considered objective
findings.”
RULE 099.34 - IMPAIRMENT RATING GUIDE
“Medical opinions addressing
compensability and permanent
impairment must be stated within a
reasonable degree of medical certainty.”
AMA Guides to the Evaluation of
Permanent Impairment, 4th Edition
AMA Guides, 4th Edition
“Provides a standard framework and method of
analysis through which physicians can
evaluate, report on, and communicate
information about the impairment of any
human organ system”
AMA Guides, 4th Edition
“The Guides can help provide consistent
and reliable acquisition, analysis,
communication, and utilization of
medical information”
AMA Guides, 4th Edition
“The major objective of the Guides is to define
the assessment and reporting of medical
impairments so that physicians can collect,
describe, and analyze information about
impairments in accordance with a single set of
standards”.
AMA Guides, 4th Edition
“ Two physicians, following the methods
of the Guides to evaluate the same
patient, should report similar results and
reach similar conclusions”
AMA Guides, 4th Edition
“ If two physicians who examine a patient
and use the methods of the Guides do
not obtain similar results and reach
similar conclusions, the book can be
used to resolve the discrepancies.”
AMA Guides, 4th Edition
“If the clinical findings are fully
described, any knowledgeable observer
may check the findings with the Guide
criteria”
Basic Principles AMA Guides, 4th Edition
The Guides only apply to permanent impairments
Permanent impairments are adverse conditions that
are stable and unlikely to change
Evaluating the magnitude of these impairments is the
purview of the physician
Determining disability is usually not the physician’s
responsibility
Basic Principles – continued AMA Guides, 4th Edition
Impairment: the loss, loss of use, or
derangement of any body part, system, or
function.
Disability: a decrease in, or the loss or absence
of, the capacity of an individual to meet :
personal, social, or occupational demands
statutory or regulatory requirements.
Basic Principles – continued AMA Guides, 4th Edition
Permanent impairments are evaluated in
terms of how they affect the patient’s
daily activities including occupation.
Activities of Daily Living AMA Guides, 4th Edition
Self care and personal hygiene
Eating and preparing food
Communication
Speaking and Writing
Maintaining one’s posture
Activities of Daily Living AMA Guides, 4th Edition
Standing, walking, and sitting
Caring for the home and personal finances
Traveling and moving about
Recreational and social activities
Work activities
Basic Principles – continued AMA Guides, 4th Edition
“An impairment percentage represents
an informed estimate of the degree to
which an individual’s capacity to carry
out daily activities has been diminished.”
Basic Principles – continued AMA Guides, 4th Edition
“The impairment percentage derived by
using Guides criteria represent estimates
rather than precise determination.”
Impairment AMA Guides, 4th Edition
An alteration of an individual’s health status
A deviation from normal in a body part or
organ system and its functioning
Conditions that interfere with an individual’s
“activities of daily living”
The loss, loss of use, or derangement of any
body part, system, or function
Permanent Impairment AMA Guides, 4th Edition
Impairment that has become static or well
stabilized with or without medical treatment
and is not likely to remit despite medical
treatment
Impairment is unlikely to change substantially
and by more than 3% in the next year with or
without medical treatment.
Impairment Rating AMA Guides, 4th Edition
Analyzing data accumulated in the course of
an impairment evaluation
Comparing those data with Guides criteria to
estimate the extent of impairment
Impairment ratings prepared according to
Guides criteria are estimates of impairment
Impairment Rating AMA Guides, 4th Edition
“The impairment estimate or rating is
simply a number..….it does not convey
any information about the person or the
impact of the impairment on the person’s
capacity to meet personal, social, or
occupational demands.”
Impairment Rating AMA Guides, 4th Edition
It is not an estimate of disability – “an
alteration of an individual’s capacity to
meet personal, social, or occupational
demands, or statutory or regulatory
requirements, because of an
impairment.”
AMA Guides, 4th Edition
“ It must be emphasized and clearly
understood that impairment percentages
derived according to Guides criteria
should not be used to make direct
financial awards or direct estimates of
disabilities.”
AMA Guides, 6th Edition
“The primary purpose of the Guides is to
rate impairment to assist adjudicators
and others in determining the financial
compensation to be awarded to
individuals who, as a result of injury or
illness, have suffered measurable
physical and/or psychological loss.”
Rules for Evaluation AMA Guides, 4th Edition
Estimate the extent of the patient’s primary
impairment or impairing condition - the
condition that seems to be of most concern to
the patient
Assess the current state of the impairment
according to the criteria in the Guides
The estimate should be based on current
findings and evidence
Rules for Evaluation AMA Guides, 4th Edition
“Physician must use clinical skills and
judgment is assessing whether or not the
results of measurements or tests are
plausible and related to the impairment
being evaluated”
Rules for Evaluation AMA Guides, 4th Edition
“The physician’s judgment, experience,
training, skills, and thoroughness in
examining the patient and applying the
findings to Guides criteria will be factors
in estimating the degree of the patient’s
impairment”
Rules for Evaluation AMA Guides, 4th Edition
“95% to100% whole person impairment is
considered to represent almost total
impairment, a state that is approaching
death”
Rules for Evaluation AMA Guides, 4th Edition
Measurements should be consistent between two
trained observers or examiners
Two measurements made by the same examiner may
be expected to lie within 10% of each other
Final estimated whole person impairment percent
may be rounded to the nearer of the two nearest
values ending in 0 or 5.
Rules for Evaluation AMA Guides, 4th Edition
“The impairment percentages shown in the
chapters that consider the various organ
systems make allowance for the pain that may
accompany the impairing conditions.”
Rules for Evaluation AMA Guides, 4th Edition
“If an individual’s prosthesis or assistive
device can be removed or it use
eliminated relatively easily, the organ
system should be tested without the
device.”
Rules for Evaluation AMA Guides, 4th Edition
“If the assistive device is not easily
removable, ….. the organ system’s
functioning should be evaluated with the
device in place.”
Rules for Evaluation AMA Guides, 4th Edition
“If a patient declines therapy for a
permanent impairment, that decision
should neither decrease nor increase the
estimated percentage of the patient’s
impairment”.
Rules for Evaluation AMA Guides, 4th Edition
“It should be understood that the Guides
does not and cannot provide answers
about every type and degree of
impairment”.
AMA Guides, 4th Edition
Causation
“A physical, chemical, or biologic factor
contributed to the occurrence of a
medical condition”
AMA Guides, 4th Edition
Aggravation
“A physical, chemical, or biologic factor, which
may or may not be work related, contributed to
the worsening of a preexisting medical
condition or infirmity is such a way that the
degree of permanent impairment increased by
more than 3%.”
AMA Guides, 4th Edition
Recurrence
“ A recurrence requires no identifiable incident
as a trigger to the medical condition in
question; rather, the patient has a resumption
of symptoms or signs that can be related to the
previously existing medical condition or
injury.”
Medical Assessment of Impairment AMA Guides, 4th Edition
Step One: Gather thorough and complete historical
information on the medical condition
Step Two: Analyze the history, clinical, laboratory, and
radiological findings to determine the nature and
extent of the impairment or dysfunction of the affected
body part or system.
Step Three: Compare the results of the analysis with
the criteria specified in the Guides for the particular
body part, system, or function.
Step One: Gather Information
Medical History
Physical Examination
Lab Tests and Diagnostic Procedures
Radiological Studies
Rehabilitation Evaluation
Medical Record Review
Medical History:
Onset and course of symptoms and condition
Findings on previous examination(s)
Treatments and response to treatments
Relevant occupational exposures or accidents
Current health status
Current medications
Past medical history
Medical Assessment of Impairment AMA Guides, 4th Edition
The strength of the medical support for
an impairment estimate (rating) depends
on the completeness and reliability of the
medical documentation.
Range of Motion AMA Guides, 4th Edition
“The tables of Chapter 3 are based on the active
range of motion, which is determined with the
patient’s full effort and cooperation”
“Evaluating the range of motion of an extremity or
spine of the spine is a valid method of estimating an
impairment”
“The result of such evaluations should be consistent
and concordant with the presence or absence of
pathologic signs and other medical evidence”
Arkansas Workers Compensation Commission
RULE 099.34 - IMPAIRMENT RATING GUIDE
“Exclusive of any sections which refer to pain
and exclusive of straight leg raising tests or
range of motion tests when making physical or
anatomical impairment ratings to the spine.”
Range of Motion AMA Guides, 4th Edition
“…..the full range possible of active motion
should be carried out by the subject and
measured by the examiner.”
“The examiner may check the range of passive
motion, however in the Guides, the range of
active motion takes precedence”.
RULE 099.34 - IMPAIRMENT RATING GUIDE
“Objective findings” are those findings which
cannot come under the voluntary control of the
patient.
When determining physical or anatomical
impairment, cannot consider complaints of
pain
Range of Motion AMA Guides, 4th Edition
“Range of motion measurements are
rounded to the nearest 10 degree.”
“The impairment percentages shown in
Chapter 3 make allowance for pain….”
The Spine AMA Guides, 4th Edition
Two approaches to estimating impairment:
“Injury Model” ( DRE – Diagnosis Related Estimate)
“Range of Motion Model” – not applicable in Arkansas
due to Rule 099.34.
The Spine AMA Guides, 4th Edition
The Injury Model relies on evidence of:
Neurologic deficits
Uncommon adverse structural changes, such as
fractures, dislocation, and loss of motion segment
integrity.”
“Surgery to treat an impairment does not modify the
original impairment”
The Spine AMA Guides, 4th Edition
Common Developmental Findings:
Spondylolysis – 7% of adults
Spondylolisthesis – 3% of adults
Herniated Disk without radiculopathy - >30% of adults
by age 40
Aging changes – 40% of adults after age 35
Impairment Ratings
Factors that may influence impairment rating:
Competence and experience of the examiner
Patient’s Personality
Financial Motives