bluuebunny/crossref_metadata_2025 huggingface dataset:
Impairment Tutorial: Impairment Classes and Ranges
Authors: Brigham Christopher R. , Mueller Kathryn
Published: December 2020

Many chapters in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) provide a range of numbers within four or five impairment classes, and evaluating physicians are required to justify the choice of a class and the impairment rating within the range specified for that class. The process of assigning a class is accomplished by an assessment of the patient's disease process, objective findings, activities of daily living (ADLs), and required continuing medical treatment. A table in the article provides hyperlinks to different scales for measurement of instrumental activities of daily living and ADL; use of these standardized instruments increases the reliability of assessing the impact on ADLs. After describing the patient's ability to perform ADLs, the evaluating physician should ensure that the physical examination and laboratory findings lead to the final diagnosis used for rating. To provide an impairment rating, the evaluator must identify and confirm a physiologic abnormality via physical examination or laboratory or x-ray findings consistent with the diagnosis. Impairment rating must be based on a clearly established diagnosis, not solely on subjective complaints from the patient. As with all impairment evaluations, the rating should be based on a thoughtful evaluation and obtaining the data needed to apply the criteria specified in the AMA Guides.
Impairment Tutorial: Impairment from Coronary Artery Disease: Fifth Edition Approach
Authors: Talmage James B. , Brigham Christopher R.
Published: December 2020

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.
Impairment Tutorial: Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating
Authors: Direnfeld Lorne , Talmage James , Brigham Christopher
Published: December 2020

This article was prompted by the submission of two challenging cases that exemplify the decision processes involved in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In both cases, the physical examinations were normal with no evidence of illness behavior, but, based on their histories and clinical presentations, the patients reported credible symptoms attributable to specific significant injuries. The dilemma for evaluators was whether to adhere to the AMA Guides, as written, or to attempt to rate impairment in these rare cases. In the first case, the evaluating neurologist used alternative approaches to define impairment based on the presence of thoracic outlet syndrome and upper extremity pain, as if there were a nerve injury. An orthopedic surgeon who evaluated the case did not base impairment on pain and used the upper extremity chapters in the AMA Guides. The impairment ratings determined using either the nervous system or upper extremity chapters of the AMA Guides resulted in almost the same rating (9% vs 8% upper extremity impairment), and either value converted to 5% whole person permanent impairment. In the second case, the neurologist evaluated the individual for neuropathic pain (9% WPI), and the orthopedic surgeon rated the patient as Diagnosis-related estimates Cervical Category II for nonverifiable radicular pain (5% to 8% WPI).
Impairment Tutorial: Consistency in Measurement
Authors: Brigham Christopher R.
Published: December 2020

The International Association of Industrial Accident Boards and Commissions (IAIABC) is an organization of medical directors, administrators, and administrative law judges for workers’ compensation systems. It was founded in 1914, and current membership represents 41 US states, the District of Columbia, Puerto Rico, 9 Canadian provinces, and 3 other governments in a forum for education and discussion regarding the various medical, legal, and administrative issues in workers’ compensation systems. In 2001, the IAIABC formed an Occupational Impairment Rating Guide Committee to study the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) and to suggest revisions specific to workers’ compensation. The committee's goal is to create a supplement to the AMA Guides for jurisdictions to consider for adoption to clarify and/or to replace methodology in the AMA Guides to make impairment rating more uniform and consistent. The IAIABC Guides has been developed to address impairment of the musculoskeletal system and impairment due to chronic pain with the goal of minimizing or eliminating the need for multiple independent medical evaluations and “dueling doctor depositions.” There are no plans to write supplemental guides for impairment of other body systems, and AMA and IAIABC are engaged in active dialog during the development of the AMA Guides, Sixth Edition.
Comparative Analysis: The State of Colorado Study, Part II
Authors: Brigham Christopher R. , Mueller Kathryn , Van Zet Douglas , Northrup Debra J. , Whitney Edward B. , McReynolds Martha M.
Published: December 2020

[Continued from the January/February 2004 issue of The Guides Newsletter.] To understand discrepancies in reviewers’ ratings of impairments based on different editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), users can usefully study the history of the revisions as successive editions attempted to provide a comprehensive, valid, reliable, unbiased, and evidence-based system. Some shortcomings of earlier editions have been addressed in the AMA Guides, Fifth Edition, but problems remain with each edition, largely because of the limited scientific evidence available. In the context of the history of the different editions of the AMA Guides and their development, the authors discuss and contextualize a number of key terms and principles including the following: definitions of impairment and normal; activities of daily living; maximum medical improvement; impairment percentages; conversion of regional impairments; combining impairments; pain and other subjective complaints; physician judgment; and causation analysis; finally, the authors note that impairment is not synonymous with disability or work interference. The AMA Guides, Fifth Edition, contrasts impairment evaluations and independent medical evaluations (this was not done in previous editions) and discusses impairment evaluations, rules for evaluations, and report standards. Upper extremity and lower extremity impairment evaluations are discussed in terms of clinical assessments and rating processes, analyzing important changes between editions and problematic areas (eg, complex regional pain syndrome).
Pain, Impairment, and Disability in the AMA Guides
Authors: Robinson James P. , Turk Dennis C. , Loeser John D.
Published: December 2020

This article clarifies important conceptual issues associated with the assessment of pain and considers reasons why pain should be considered in impairment and disability ratings. The authors address conceptual issues rather than specific pain assessment methods and limit the discussion to the musculoskeletal and neurologic injuries seen most frequently during impairment disability evaluations. Several groups of experts worked on the AMA Guides, and little is known about which elements of the AMA system are well substantiated and which need revision. In addition, the AMA Guides, as actually used, often differ from the guides as written. Self-reports that disability applicants provide about their experiences provide a first-person perspective that, in principle, may be important to assessors. Pain and “unbearable” sensations cannot be incorporated into impairment evaluations in the AMA Guides because pain is inherently subjective and because pain and its effects must be analyzed at the level of the whole person. In summary, although the AMA Guides, Fifth Edition, seems to support including pain in impairment ratings, this support is vitiated by inconsistencies in the conceptualization of impairment, contradictory information about how examiners should interpret pain, and inadequate guidance about how examiners should combine subjective and objective data.
Impairment Tutorial: Chapter 14 or 18 for Pain Complaints? Summation, Case Example, and Broader Implications
Authors: Barth Robert J.
Published: December 2020

In the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition, two chapters claim relevance for pain complaints that lack an objectively demonstrable general medical basis: Chapter 14, Mental and Behavioral Disorders, and Chapter 18, Pain. Parts 1 and 2 of this four-part series examined forms of mental illness that commonly invoke complaints of pain; Part 2 also evaluations using the mental/behavioral chapter vs the pain chapter, and Part 3 noted the self-negating nature of the pain chapter's rationale (ie, the pain chapter presents a rationale that, taken literally, indicates it should not be used). A detailed case example illustrates how the decision about using the mental/behavioral chapter or the pain chapter often can be clarified by simply performing a thorough clinical evaluation (see Part 2 of this series). Examiners should be aware of the role of thoughts, behavior, and environmental contingencies on presentations of chronic pain even when no scientifically credible and objective general medical findings explain the pain. For example, the AMA Guides points out that in as much as 85% of low back pain cases, no explanatory physical pathology can be identified; therefore, readers are encouraged to be mindful of the professional literature. The authors of this series deny any attempt to move all instances of chronic pain into the category of mental illness but report little reason not to do so.
Knee Osteoarthritis
Authors: Brigham Christopher R. , Brooks Charles N. , Talmage James B.
Published: December 2020

More than 20 million Americans have osteoarthritis (OA), which affects the knee more often than any other joint and is the most common cause of long-term disability in persons older than 65 years. Knee OA is common, particularly in older patients and especially the obese. Knee injury, depending on the severity and type, can increase the risk of developing and the rate of progression of OA. In assessing impairment for knee OA, the evaluator must obtain a thorough history and physical examination and identify all potential risk factors. To opine that an injury caused OA, the evaluator should demonstrate that the traumatized knee shows significant arthritis but that the contralateral uninjured knee is radiographically normal; for an evaluator to suggest that pre-existing arthritis was aggravated, the involved knee should show significantly more advanced OA than the contralateral joint. Joint space widths (cartilage intervals) of both knees must be measured carefully on anteroposterior films obtained standing with a film-to-camera distance of 90 cm (36 in) and the beam at the level of and parallel to the joint surface. Taking into account all of the data (history, physical findings, and radiographic measurements from both the involved and contralateral joint), the rating physician can assess causation, estimate impairment, and apportion the latter to one or more etiologies.
Acromioclavicular Joint Arthritis
Authors: Brooks Charles N. , Brigham Christopher R.
Published: December 2020

Acromioclavicular joint (ACJ) arthritis is a common source of shoulder pain. Manifestations of the arthritis may include inferiorly projecting spurs that predispose an individual to impingement and rotator cuff tears and can result in permanent impairment due to shoulder weakness or motion loss. Rotator cuff tendinopathy generally is multifactorial, and tears usually result from a combination of intrinsic factors (loads transmitted, local blood supply, and age) and extrinsic factors (impingement, primarily). Surgery to eliminate impingement collectively is termed subacromial decompression. The AMA Guides to the Evaluation of Permanent Impairment provides no impairment rating for cheilectomy about acromioclavicular or other joints, and, because removal of this liability is beneficial, it results in no (and perhaps even negative) impairment. An individual whose job involves repetitive shoulder elevation and who develops impingement probably has a legitimate workers’ compensation claim, even if predisposed by preexisting bony prominences; in this scenario, the proximate cause was repetitive shoulder elevation. A case example demonstrates that if an individual with preexisting osteoarthritis of the ACJ is injured and disabled at work, the rotator cuff tear, although preexisting, was worsened during employment and probably will be covered under the claim. In legal terms, findings of disability associated with ACJ injuries may differ depending on the jurisdiction.
Special Feature: Complex Regional Pain Syndrome (CRPS): Unratable Through the Pain Chapter
Authors: Barth Robert J.
Published: December 2020

A sidebar titled “Rating Impairment for [complex regional pain syndrome] CRPS Type 1” in the March/April issue of The Guides Newsletter states: “Do NOT use the pain chapter to rate CRPS” because there is no well-defined pathophysiologic basis. That conclusion is contradicted by the pain chapter, which lists CRPS among conditions considered ratable, but accompanying text provides no explanation how this determination was made. This article attempts to resolve the conflict between the sidebar in The Guides Newsletter and the pain chapter. The lack of a well-defined pathophysiologic basis for CRPS is the reason for the position stated in the sidebar, and a review of the relevant professional literature confirms this reasoning. Further, the concept of CRPS itself is ambiguous and was intentionally designed to be “general” and “descriptive” and historically has been diagnosed using nonstandardized, idiosyncratic, or incompatible diagnostic systems. The AMA Guides to the Evaluation of Permanent Impairment is self-contradictory regarding diagnostic criteria and terminology (eg, is CRPS-1 synonymous with RSD, causalgia, or neither?). CRPS lacks any well-defined pathophysiology, is highly ambiguous and controversial, involves characteristics that compromise the credibility of any examinee making such a presentation, and is a good example of a condition that should be evaluated using the mental and behavioral disorders chapter.
Undiagnosed Mental Illness as the Cause of General Medical Disability Claims
Authors: Barth Robert J.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) warns physicians against minimizing psychiatric impairments but does not elaborate on this warning against minimizing the contribution of psychological factors to general medical impairment. Claims regarding spinal impairment are a useful example because the AMA Guides cites a study showing there is no general medical explanation for 85% of low-back pain cases. The list of mental illnesses that are commonly associated with complaints of physical pain includes somatoform, mood, anxiety, personality, psychotic factitious, and substance-related disorders. In one study, anxiety disorders accounted for 54% of the variance in pain severity reports and associated claims of disability. Psychological dysfunction leads only to subjective complaints such as pain but also can lead to objective physiological signs, for example, mental illness such as panic disorder, which includes objectively verifiably physical signs such as heart palpitations, sweating, and tremor. Claims of disability also have been associated with hypertension, cardiac issues, concussion, multiple sclerosis, and psoriasis. To credibly assess the possibility of mental illness as the cause of a general medical impairment claim is extremely demanding, and evaluators should think of the evaluation process in terms of days rather than hours. The steps in an evaluation protocol should mirror those described in the March/April 2005 issue of The Guides Newsletter and are summarized in the present article.
Case Exercise: Biomechanics in Rearend Motor Vehicle Collisions
Authors: Brooks Charles N. , Brigham Christopher R.
Published: December 2020

Multiple factors determine the likelihood, type, and severity of bodily injury following a motor vehicle collision and, in turn, influence the need for treatment, extent of disability, and likelihood of permanent impairment. Among the most important factors is the change in velocity due to an impact (Δv). Other factors include the individual's strength and elasticity, body position at the time of impact, awareness of the impending impact (ie, opportunity to brace, guard, or contract muscles before an impact), and effects of braking. Because Δv is the area under the acceleration vs time curve, it combines force and duration and is a useful way to quantify impact severity. The article includes a table showing the results of a literature review that concluded, “the consensus of human subject research conducted to date is that a single exposure to a rear-end impact with a Δv of 5 mph or less is unlikely to result in injury” in most healthy, restrained occupants. Because velocity incorporates direction as well as speed, a vehicular occupant is less likely to be injured in a rear impact than when struck from the side. Evaluators must consider multiple factors, including the occupant's pre-existing physical and psychosocial status, the mechanism and magnitude of the collision, and a variety of biomechanical variables. Recommendations based solely on patient history and physical findings (and, perhaps, imaging studies) may be ill-informed.
Global Assessment of Functioning
Authors: Leclair Norma , Leclair Steven , Barth Robert
Published: December 2020

The Global Assessment of Functioning (GAF) is part five of the multiaxial diagnostic system for mental disorders outlined in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition–Text Revised (DSM-IV-TR). The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes the use of DSM-IV-TR in rating an individual's global functional capacity, which, like disability, is related directly to the effects of impairments. The AMA Guides, Fourth and Fifth Editions, do not provide numeric psychiatric impairment, and shortcomings plague the use of GAF to define disability—but even so, authorities ranging from the State of California to the Veterans Administration rely on GAF scores. A table shows the 100-point scale Global Assessment Scale in which higher scores indicate better functioning. The GAF has been modified to address deficiencies; a decision tree has been added and is summarized; and the editor of DSM-IV-TR has developed a computerized version that reportedly improves reliability and validity. Evaluators should bear in mind that the GAF helps evaluate the individual's functioning in three areas: psychological, social, and occupational (including the activities of daily living). The resulting score facilitates the creation of a treatment plan, evaluates its effectiveness, and predicts outcomes, but evaluators should be aware of its significant limitations.
Case Study: Cervical Spine Apportionment
Authors: Brigham Christopher R. , McEntire Aimee
Published: December 2020

Impairment apportionment refers to the distribution or allotment of impairment to different factors such as pre-existing injury, illness, or impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) provides instructions about calculating impairment ratings and advises concurrent consultation of specific state laws (eg, the state of California apportions disability differently than does the Longshore and Harbor Workers Act. A case example highlights some of the complexities of cervical spine apportionment. A 55-year-old man sustained a work-related cervical spine injury that aggravated pre-existing cervical pathology. The patient underwent anterior cervical discectomy and decompression, foraminotomies, C3-4 and C4-5, and a two-level anterior cervical interbody arthrodesis; the postoperative diagnosis was two level disc herniation, stenosis, and disc degeneration. The article discusses the Diagnosis-related estimate (DRE) vs the range-of-motion method (ROM). The DRE method is most widely used in the AMA Guides, but in certain specified situations, including a multilevel fusion such as that in the clinical example, the ROM method must be used. Because of the significant difference in values derived from the DRE and ROM methods, evaluators must be careful to apportion impairment in accordance with the method that served as the basis for the final rating (ie, the ROM method in this example). Apportionment becomes more complex when one considers the etiology of the underlying disease.
Upper Extremities Impairment Evaluation: Overview of Sixth Edition Approaches
Authors: Brigham Christopher R. , Uejo Craig , Melhorn J. Mark , Talmage James B.
Published: December 2020

In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, the chapter on the upper extremities is the longest and most complex, which reflects the complexities of the upper limb and the type of injuries encountered. This chapter incorporates the following changes: The International Classification of Functioning, Disability, and Health (ICF) Model of Functioning and Disability, developed by the World Health Organization, is used to provide a common basis for the description of human functioning and impairments. The principles of assessment have been simplified and clarified. Specific diagnosis-based rating tables for the most common injuries and diagnoses have been added, and an extensive discussion shows the definition of impairment classes and corresponding ranges of impairment for upper and lower extremities. A table and accompanying diagnosis-based impairment example provide examples of upper extremity diagnoses and associated class definitions and default impairment values. The physical examination has been simplified, and functional assessment is provided through focused history-taking, including information about activities of daily living and a functional assessment tool. The criteria for diagnosis of complex regional pain syndrome have been updated for consistency with current standards and other chapters. Among other modifications, the approach to entrapment neuropathy (eg, carpal tunnel syndrome) has changed, and only electrodiagnostically confirmed entrapment cases are ratable.
Assessing Mental and Behavioral Disorder Impairment: Overview of Sixth Edition Approaches
Authors: Leclair Norma , Leclair Steve , Barth Robert
Published: December 2020

Chapter 14, Mental and Behavioral Disorders, in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, defines a process for assessing permanent impairment, including providing numeric ratings, for persons with specific mental and behavioral disorders. These mental disorders are limited to mood disorders, anxiety disorders, and psychotic disorders, and this chapter focuses on the evaluation of brain functioning and its effects on behavior in the absence of evident traumatic or disease-related objective central nervous system damage. This article poses and answers questions about the sixth edition. For example, this is the first since the second edition (1984) that provides a numeric impairment rating, and this edition establishes a standard, uniform template to translate human trauma or disease into a percentage of whole person impairment. Persons who conduct independent mental and behavioral evaluation using this chapter should be trained in psychiatry or psychology; other users should be experienced in psychiatric or psychological evaluations and should have expertise in the diagnosis and treatment of mental and behavioral disorders. The critical first step in determining a mental or behavioral impairment rating is to document the existence of a definitive diagnosis based on the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The article also enumerates the psychiatric disorders that are considered ratable in the sixth edition, addresses use of the sixth edition during independent medical evaluations, and answers additional questions.
Use of the AMA Guides in State Workers' Compensation Systems: 2009 Update
Authors: Brigham Christopher R. , Walker Jenny
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is the most widely used basis for determining impairment and is used in state workers’ compensation systems, federal systems, automobile casualty, and personal injury, as well as by the majority of state workers’ compensation jurisdictions. Two tables summarize the edition of the AMA Guides used and provide information by state. The fifth edition (2000) is the most commonly used edition: California, Delaware, Georgia, Hawaii, Kentucky, New Hampshire, Idaho, Indiana, Iowa, Kentucky, Massachusetts, Nevada, North Dakota, Ohio, Vermont, and Washington. Eleven states use the sixth edition (2007): Alaska, Arizona, Louisiana, Mississippi, Montana, New Mexico, Oklahoma, Pennsylvania, Rhode Island, Tennessee, and Wyoming. Eight states still commonly make use of the fourth edition (1993): Alabama, Arkansas, Kansas, Maine, Maryland, South Dakota, Texas, and West Virginia. Two states use the Third Edition, Revised (1990): Colorado and Oregon. Connecticut does not stipulate which edition of the AMA Guides to use. Six states use their own state specific guidelines (Florida, Illinois, Minnesota, New York, North Carolina, and Wisconsin), and six states do not specify a specific guideline (Michigan, Missouri, Nebraska, New Jersey, South Carolina, and Virginia). Statutes may or may not specify which edition of the AMA Guides to use. Some states use their own guidelines for specific problems and use the Guides for other issues.
Sleep Impairment
Authors: Uejo Craig , Demeter Stephen
Published: December 2020

In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, distal clavicle resection (resection arthroplasty of the acromioclavicular joint [ACJ]) results in ratable impairment, but only a single diagnosis within a region may be rated. Therefore, if another impairing condition is present in the shoulder region (eg, impingement syndrome or rotator cuff disease) only that resulting in the greatest causally related impairment is rated. In the setting of an occupational or other compensable injury or illness, causation of the impairment often is a key issue because, typically, only impairment that is causally related to the injury can be rated. For example, assume that a lifting injury at work caused a tear in a rotator cuff tendon that was already attenuated by repetitive impingement on inferiorly projecting spurs from longstanding degenerative arthritis of the ACJ. If surgery was performed for a traumatic rotator cuff tear and the distal clavicle also was resected due to preexisting ACJ arthritis, the latter surgery is not considered to be related to the injury. In other words, because the ACJ arthritis was neither caused nor worsened by the injury, this condition is not rated. The distal clavicular resection may have been warranted to diminish pain due to ACJ arthritis and/or eliminate the distal clavicle as a source of impingement.
Comparative Analysis of AMA Guides Ratings by the Fourth, Fifth, and Sixth Editions*
Authors: Brigham Christopher R. , Uejo Craig , McEntire Aimee , Dilbeck Leslie
Published: December 2020

In December 2007, the American Medical Association published the sixth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), following previous editions published in 2000 (fifth edition) and 1993 (fourth edition). To assess the effects of changes in whole person impairment ratings across editions, the authors selected 200 cases of whole person impairment and reevaluated each according to criteria in the three editions. Interrater reliability was confirmed when an independent reviewer checked 15% of the cases and found agreement within 1% in all but one of the thirty cases checked. Tables and figures in the article compare average whole person impairment in terms of sixth edition chapters; by edition; and by category (nonsurgical vs surgical intervention) and edition. On the basis of the sample and their comparisons, the authors conclude that the effect for patients based on their diagnostic impairment is small, and greater difference is seen for results obtained using the fifth edition compared with the fourth edition. The observed changes were expected and result primarily from the following: surgery and therapy should improve function and thus should not routinely increase impairment; there are improved functional outcomes for carpal tunnel syndrome and total joint replacement; and certain common conditions that resulted in functional deficits but no ratable impairment in previous editions now should be ratable. The study showed excellent interrater reliability with sixth edition ratings, which was an important goal for the new edition.
Measuring Hip Motion
Authors: Brooks Charles N.
Published: December 2020

Accurate measurement of hip motion is important in initial diagnosis, assessing progression over time, evaluating treatment outcomes, and rating impairments of this joint. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, range-of-motion (ROM) measurements are still a factor because the physical examination and other adjustment tables are used to select the grade and final rating. Further, ROM deficits may be used to derive a stand-alone rating when other tables refer the rater to motion impairment or if no diagnosis-based section is applicable for impairment rating. Hip motions generally are measured using a large goniometer, although an electronic inclinometer also may be used. Examiners must conduct tests in accordance with measurement instructions in the AMA Guides. From the standpoint of impairment rating, hip extension, at least beyond neutral, is irrelevant; if a patient does not have a flexion contracture of at least 10°, there is no extension impairment. Examiners should compare both extremities; active or voluntary motion is performed by the active contraction of the governing muscles and should be evaluated first. During this and other measurements, patients may have a tendency to extend or guard, thus producing an erroneously inflated measurement. Examiners must ensure that such behaviors do not occur and should record only the correct measurement.
Measuring Shoulder Motion
Authors: Brigham Christopher R.
Published: December 2020

Measuring and documenting shoulder motion is important for many reasons, including diagnosis, determining the severity and progression of a disorder, assessing the results of treatment, and evaluating impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition provides guidance for the process of assessing abnormal motion of the shoulder, specifically Section 15.7a, Clinical Measurements of Motion, and Section 15.7g, Shoulder Motion. The shoulder has greater mobility than any other joint of the body, and movement there usually is composite rather than in a single plane; as a result, single movements are difficult to isolate. In the AMA Guides, universal goniometers with long arms are used to measure shoulder range of motion (ROM). Measurements of joint motion must be performed and recorded consistently because interrater reliability is reduced if instruments are incorrectly placed or if overlying soft tissue distorts the measurement. Active motion is obtained with full muscle force and cooperation after warm-up, and the ROM examination is performed by recording the active measurements from three separate ROM efforts. Patients may self-limit during the assessment of active range of motion or exert submaximal effort on manual strength testing because of pain and/or apprehension, so all measurements should fall within 10° of the mean and both sides should be tested.
Comparative Analysis of Impairment Evaluations by the 1996 Florida Uniform Permanent Impairment Rating Schedule (FUPIRS) and the AMA Guides™ Fourth, Fifth, and Sixth Editions
Authors: Brigham Christopher R. , McEntire Aimee , Uejo Craig
Published: December 2020

The Florida workers’ compensation system uses the 1996 Florida Uniform Permanent Impairment Rating Schedule (FUPIRS), that was based in part on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Third Revised and Fourth Editions (the latter published in 1993). The authors ask if changes in the AMA Guides resulted in different impairment ratings and different awards. To these ends, the authors examined seventy-five cases that were randomly selected from a cohort of two hundred cases that was studied previously [see The Guides Newsletter, January/February 2010]. The average whole person impairment (WPI) per case was 5.3% WPI according to FUPIRS; 5.3% WPI according to the AMA Guides, Fourth Edition; 5.8% WPI according to the fifth edition; and 4.6% WPI according to the sixth edition. The difference between the WPIs was tested using a paired sample t test (alpha = .05), and results showed that the difference in WPI between FUPIRS and the sixth edition (0.7% WPI) was not statistically significant. The authors acknowledge that the limited range of impairment values in this study may have contributed to the lack of statistical significance when group means are compared because 84% of the cases were rated 10% WPI or less. The authors call for an expanded study to determine if meaningful differences exist between rating methodologies in a more diverse, less skewed sample.
Body Member Impairments: Scheduled Awards and the Federal Employees' Compensation Act
Authors: Brigham Christopher R.
Published: December 2020

This article focuses on the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in evaluating Office of Workers’ Compensation Programs (OWCP), Federal Employees’ Compensation Act (FECA) scheduled loss cases for an accepted work-related condition. Effective May 1, 2009, the Division of Federal Employees’ Compensation (DFEC), which administers FECA, adopted the AMA Guides, Sixth Edition, noting that DFEC has used the AMA Guides for more than fifty years, dating back to the first Guide for Extremities and Back (1958). The scheduled award provision of the OWCP FECA and implementing regulations set forth the number of weeks of compensation to be paid for permanent loss, or loss of use, of body members listed in the schedule. The FECA regulations that define impairment are consistent with the definition provided in the AMA Guides, Sixth Edition, except for impairments of the lungs. Also, pain is included as a component of the medical condition (diagnosis) and should not be measured separately unless the pain does not correlate with objective findings or bodily dysfunction. The article includes several special determinations under FECA, including loss of body parts, loss of hearing or vision, loss of function of bodily organs, lung impairment, and impairments in other organs.
Rating Spinal Stenosis: AMA Guides Sixth Edition Case Example
Authors: Eskay-Auerbach Marjorie
Published: December 2020

Spinal stenosis refers to narrowing of the spinal canal that may result in compression of the spinal cord, or cauda equina. The most common type of spinal stenosis is degenerative stenosis associated with the natural process of aging. In the lumbar spine, the narrowing may result in compression of spinal nerve roots, causing a constellation of symptoms that may include lower pack pain, neurogenic claudication, and lower extremity pain. This case illustrates the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition process of assessing impairment for spinal stenosis. The case involves a 54-year-old male truck driver whose lumbar spine was injured when he unloaded and lifted a tire; he underwent lumbar decompression at L3-4 and L4-5, and fourteen months after surgery was evaluated as being at maximum medical improvement, was able to walk, and could void spontaneously. In a one-page final medical report, the patient's physician hand wrote a note assigning 29% whole person impairment without a medical rationale to support the rating. The author of this case example first notes that the medical reporting does not support placing this patient in class 4, and the examinee's condition is most consistent with a class 1 rating for spinal stenosis. Using Section 17.3, Adjustment Grids and Grade Modifiers: Non-Key Factors, an evaluator would conclude a grade B, 6% whole person impairment for the lumbar spine.
Case Example: Lumbar Spine Injury, Treated with Spinal Injections
Authors: Brigham Christopher R. , Talmage James , Eskay-Auerbach Marjorie , McGhee Charles
Published: December 2020

This Case Example illustrates common questions associated with the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, including the selection of appropriate methodology and the issue of whether spinal injections are considered to be ratable events. A 32-year-old male worker in California sustained a work-related low back injury and was examined by a chiropractic Qualified Medical Examiner (QME). The patient was referred for magnetic resonance imaging, which showed multiple lumbar disk protrusions and an L4-5 annular fissure. An epidural steroid injection at L5-S1 was of limited benefit, but bilateral L4-5 and L5-S1 facet injections, followed by chiropractic care, precluded any need for medial branch blocks or a facet rhizotomy. On presentation to the QME, the individual reported experiencing low back pain 10% of the time; this was rated 3/10 and was localized around the lumbar and lumbosacral region and was exacerbated with prolonged sitting or playing sports. The evaluator provided a rating of the lumbar spine using the range of motion (ROM) method, but the AMA Guides, Fifth Edition, states that the Diagnosis-related estimate (DRE) must be used because the impairment is due to an injury. The article demonstrates in detail how the DRE method would be applied in this case. The performance of epidural and facet injections does not constitute a ratable surgical event because these are not intradiscal injections intended to produce permanent anatomic changes in the disk.
Case Example: Adjacent Segment Disease: What Is It, and How Is It Rated?
Authors: Eskay-Auerbach Marjorie
Published: December 2020

The incidence of cervical and lumbar fusion surgery has increased in the past twenty years, and during follow-up some of these patients develop changes at the adjacent segment. Recognizing that adjacent segment degeneration and disease may occur in the future does not alter the rating for a cervical or lumbar fusion at the time the patient's condition is determined to be at maximum medical improvement (MMI). The term adjacent segment degeneration refers to the presence of radiographic findings of degenerative disc disease, including disc space narrowing, instability, and so on at the motion segment above or below a cervical or lumbar fusion. Adjacent segment disease refers to the development of new clinical symptoms that correspond to these changes on imaging. The biomechanics of adjacent segment degeneration have been studied, and, although the exact mechanism is uncertain, genetics may play a role. Findings associated with adjacent segment degeneration include degeneration of the facet joints with hypertrophy and thickening of the ligamentum flavum, disc space collapse, and translation—but the clinical significance of these radiographic degenerative changes remains unclear, particularly in light of the known presence of abnormal findings in asymptomatic patients. Evaluators should not rate an individual in anticipation of the development of changes at the level above a fusion, although such a development is a recognized possibility.
International Use of the AMA Guides to the Evaluation of Permanent Impairment
Authors: Ranavaya Mohammed , Brigham Christopher R.
Published: December 2020

In the United States, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is used in state and federal workers’ compensation systems and in automobile casualty and personal injury arenas. The AMA Guides is used in similar ways internationally. Most workers’ compensation jurisdictions in Canada use the AMA Guides formally by statute or regulation or accept its use informally as a standard tool to rate impairment. In Australia, the AMA Guides is used in both federal (Australian Commonwealth) and individual states’ (or territories’) compensation schemes; two tables show how almost all states in Australia have legislated various editions of the AMA Guides for use in workers’ compensation and motor traffic accident compensation schemes. New Zealand's Accident Compensation Commission (ACC) previously used the AMA Guides, Fourth Edition; beginning in July 2011 ACC uses the sixth edition. Hong Kong uses the AMA Guides as a reference in evaluating workers’ compensation and motor vehicle claims; Malaysia uses the AMA Guides officially in adjudication; and impairment rating in Asian countries such as Taiwan, Korea, and Singapore are influenced by the philosophy and principles of the AMA Guides. South Africa uses the AMA Guides, Sixth Edition, to determine serious injury, and other editions are used in South Africa's workers’ compensation schemes. Many countries in Europe and the Middle East use the AMA Guides as a reference for determining impairment and in workers’ compensation and social welfare schemes.
Heart Transplant Impairment Evaluation
Authors: Demeter Stephen L.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not specifically address how to rate heart transplants, but by applying principles used in rating similar illnesses, the evaluator can assess permanent impairment. The fourth and fifth editions of the AMA Guides contained directions for rating impairment created by a heart transplantation. Since these editions appeared, more heart, kidney, lungs, hands, and even faces have been transplanted. The AMA Guides, Sixth Edition, provides guidance only on rating individuals who received a kidney transplant, but this article describes a method for rating individuals following cardiac transplant and using principles in the cardiovascular chapter in the sixth edition of the AMA Guides. The steps are as follows: 1) rate using Table 4-7 Criteria for Rating Impairment due to Cardiomyopathies; 2) use classes 2, 3, or 4 for rating the posttransplant individual; 3) an individual who is posttransplant with totally normal cardiac physiological function is rated as class 2, level A; 4) combine with the burden of treatment compliance impairment caused by antirejection medications; and 5) combine with impairment found in any other organ system resulting from medications used to treat the heart, infections, and rejection. This article shows that if a specific, medically documented injury or illness is not addressed in the AMA Guides, the evaluator can apply the rating principles used in rating similar conditions in order to determine impairment.
Can Acromioplasty Result in Impairment?
Authors: Melhorn J. Mark , Brooks Charles N. , Talmage James B.
Published: December 2020

To determine if an acromioplasty is impairing, an evaluator must know shoulder anatomy, the diagnosis or diagnoses, what treatment was provided, and the patient's present status. Over time, the earlier classification of shoulder impingement has been modified, and the current classification was adopted in 1994. At present, acromioplasty often is not the primary surgery but rather is one component of subacromial decompression with or without concomitant rotator cuff and/or intra-articular shoulder surgery. Until the sixth edition, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) did not address the question whether acromioplasty itself constitutes an impairment. In the fourth and fifth editions of the AMA Guides, although open or arthroscopic acromioplasty commonly results in temporary shoulder pain, stiffness, and weakness, the surgical procedure itself, barring complication, results in no permanent impairment. According to the AMA Guides, Sixth Edition, if an acromioplasty eliminated impingement and resulted in no pain or significant objective findings at maximal medical impairment, no impairment occurred. Diagnosis-based impairment is considered the rating method of choice, but range of motion is used primarily in the physical examination adjustment grid. Further, surgical error and/or complications may result in ratable motion and/or strength deficits. The AMA Guides, Fourth and Fifth Editions, also provide a means to rate impairment due to any concomitant distal clavicular resection.
Sixth Edition and Illinois
Authors: Brigham Christopher R.
Published: December 2020

The state of Illinois has undergone major workers’ compensation reform with the passage of House Bill 1698, and from September 1, 2011, one of the factors used to determine a permanent partial disability (PPD) rating is an impairment evaluation according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Previously, the Illinois Workers’ Compensation Commission used a body of case law that set forth general parameters to guide PPD assessment, and the Commission would not allow testimony for any doctor's opinion regarding the percent of disability. Adding the use of the AMA Guides should increase the reliability of these awards. Impairment rating is only one factor that will be considered in determining the level of PPD, and other factors include the injured employee's occupation; age at the time of injury; the employee's future earning capacity; and evidence of disability corroborated by the treating physician's medical records. No single factor should be the sole determinant of disability, and the fact finder must use judgment and must document the rationale for the decision. Basing the impairment rating on the AMA Guides as a starting point should result in both a more valid and more reliable process to determine PPD.