AMA Guides - Sixth Edition

1 AMA Guides - Sixth Edition : Evolving Concepts, challenges and opportunities Christopher R. Brigham, MD, MMS, FACOEM, FAADEP, CEDIR, CIME. Senior Contributing Editor, AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition Chairman, Impairment Resources, LLC. 2011 Impairment Resources, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of Impairment Resources, LLC. AMA Guides Sixth Edition : Evolving Concepts, challenges and opportunities 2011 Impairment Resources, LLC All rights reserved. Table of Contents Learning Objectives .. 1. Seminar Director .. 2. Orientation .. 3. Chapter 1 - Conceptual Foundations and Philosophy .. 10. Chapter 2 Practical Applications of the Guides .

2 17. Chapter 3 - Pain-Related Impairment .. 20. Chapter 15 The Upper Extremities .. 22. Chapter 16 - Lower Extremities .. 28. Chapter 17 Spine and Pelvis .. 32. Chapter 13 Central and Peripheral Nervous System .. 37. Chapter 14 Mental and Behavioral Disorders .. 39. Notes .. 41. References .. 42. -2- AMA Guides Sixth Edition : Evolving Concepts, challenges and opportunities 2011 Impairment Resources, LLC All rights reserved. Learning Objectives As a result of this learning opportunity, you will be able to: 1. Discuss the International Classification of Functioning, Disability and Health (ICF). and its role in impairment evaluation. 2. Explain the reasons for revision of our prior approaches to impairment assessment. 3. Describe how to determine Diagnosis-Based Impairments, and make adjustments on the basis of the results of Functional History, Physical Examination, and Clinical Studies.

3 4. Demonstrate the ability to score Functional Inventories (including the QuickDASH, Lower Limb Outcome Scale, and Pain Disability Questionnaire). 5. Explain why methods used in previous editions (such as spinal range of motion assessment and strength determination) are no longer determinates. 6. Demonstrate the ability to rate most commonly rated disorders, including spinal pain, upper limb disorders (hand, wrist, elbow, shoulders and entrapments), lower limb disorders (foot / ankle, knee and foot), nervous system disorders, and pain. 7. Discuss challenges and opportunities associated with this evolution in impairment assessment. -1- AMA Guides Sixth Edition : Evolving Concepts, challenges and opportunities 2011 Impairment Resources, LLC All rights reserved. Seminar Director Christopher R. Brigham, MD is the Chairman of Impairment Resources, LLC. He is the Senior Contributing Editor for the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition , and was a contributor/author for several chapters, including Upper Extremities, Lower Extremities, and Spine.

4 With the Fifth Edition , he served on the Advisory Committee and as a contributor. Dr. Brigham is Board-Certified in Occupational Medicine (ABPM), Founding Director of the American Board of Independent Medical Examiners (ABIME), Master Fellow, Academy of Independent Medical Examiners of Hawaii (AIMEH), a Fellow of the American College of Occupational Environmental Medicine (FACOEM), a Fellow of the American Academy of Disability Evaluating Physicians (FAADEP) with Certification in Evaluation of Disability and Impairment Rating (CEDIR), a Certified Independent Medical Examiner (CIME), a Certified Impairment Rater (CIR), and a graduate of the Washington University School of Medicine . St. Louis. He is the Editor of the AMA publications, The Guides Newsletter and The Guides Casebook. He was co-author of the text Understanding the AMA Guides in Workers'. Compensation, Third Edition , has written over two hundred published articles on impairment and disability evaluation and other texts, chaired the Medical Advisory Board for the Medical Disability Advisor, Fourth Edition , is featured in several video, audio, and web-based productions in the medicolegal field, and has trained thousands of physicians, attorneys, claims professionals, and fact-finders, throughout the US, Canada, and internationally.

5 He is an experienced professional speaker. As a clinician with over thirty years experience, he has performed several thousand independent medical and impairment evaluations, providing him with excellent insight to the complexities of human potential, impairment, and disability. As a result of this experience, he has consulted for numerous organizations (including governmental jurisdictions). His curriculum vitae is available at -2- AMA Guides Sixth Edition : Evolving Concepts, challenges and opportunities 2011 Impairment Resources, LLC All rights reserved. Orientation The American Medical Association's Guides to the Evaluation of Permanent Impairment serves as the standard for defining impairment in most workers' compensation, motor vehicle casualty and personal injury cases. The Sixth Edition1, published in December 2007, introduces new approaches to rating impairment, using innovative methodology to enhance the relevancy of impairment ratings, improve internal consistency, promote greater precision and simplify the rating process.

6 The approach is based on a modification of the conceptual framework of the International Classification of Functioning, Disability, and Health (ICF),2 although the fundamental principles underlying the Guides remain unchanged. To appreciate the impact of the Sixth Edition , it is useful to understand the history and structure of the Guides , previous criticisms, and the new approaches used in the Sixth Edition . Case examples illustrate the appropriate application of the Sixth Edition . Use of the Guides The AMA Guides to the Evaluation of Permanent Impairment is the basis for defining impairment in the vast majority of workers' compensation jurisdictions, and the use of the most recent Edition will be required immediately by certain state jurisdictions and for Federal and Longshore and Harbor Workers' Act cases. The Guides started in 1958 with publication by the American Medical Association (AMA) of the article, A guide to the Evaluation of Permanent Impairment of the Extremities and Back 3; this was followed by additional Guides published in the Journal of the American Medical Association.

7 In 1971 a compendium of 13 Guides became the First The Second Edition5 was published thirteen years later in 1984, with publication of the Third Edition6 in 1988. The Third Edition was the first to use the Swanson methodology7 which assigned discreet impairment ratings to specific range of motion (ROM) deficits of the upper extremities. Although the Third Edition was replaced two years later by the Third Edition , Revised8, which is still used by the State of Colorado for workers compensation cases, the use of ROM pie charts to assess impairment from upper extremity ROM deficits was retained. The Fourth Edition9, published in 1993, provided many refinements, including the Diagnosis- Related Estimates (DRE) or injury model for the evaluation of spinal injuries, alternative approaches to assessing lower extremity impairment, and a pain chapter. The DRE model was unique in allowing for assignment of an impairment rating based solely on the diagnosis, even if MMI had not yet been reached.

8 The Fourth Edition is still used for assessing workers compensation cases in Alabama, Arkansas, Kansas, Maine, Maryland, South Dakota, Texas, and West Virginia. The Fifth Edition10, published in 2000, was nearly twice the size of its predecessor, provided more detailed directives in all chapters, and modified the approaches used for spinal impairment evaluation by providing guidance on choice of the rating method and providing ranges for Diagnosis-Related Estimates (DRE) categories. The Fifth Edition is used in California, Delaware, Georgia, Hawaii, Idaho, Iowa, Kentucky, Nevada, New hampshire , North Dakota, Ohio, Vermont and Washington. The Sixth Edition represents this continued evolution in impairment evaluation. Many states require the use of the most recent Edition of the Guides either by statute or code; States using the Sixth Edition are Alaska, Arizona, Connecticut, Indiana, Louisiana, Massachusetts, Mississippi, Montana, New Mexico, Oklahoma, Pennsylvania, Rhode Island, Tennessee and Wyoming11.

9 The most recent Edition is also expected to remain the standard for automobile casualty and personal injury cases, both domestically and internationally. Some of the countries abroad that use the Guides include Australia, Canada, Hong Kong, Korea, New Zealand, and South Africa. -3- AMA Guides Sixth Edition : Evolving Concepts, challenges and opportunities 2011 Impairment Resources, LLC All rights reserved. The Sixth Edition is the new standard for all other cases. Federal workers' compensation laws cover all federal employees (including postal workers) and citizens of Washington, DC. Federal systems include Federal Employees'. Compensation Act (FECA), Energy Employees Occupational Illness Compensation Program Act, and Longshore and Harbor Workers' Compensation Act (LHWCA). Under the Federal Employees' Compensation Act (FECA 5 USC 8107). benefit is given for permanent impairment to specific body parts including extremities, hearing, vision, and loss of specific organs.

10 Under the Longshore and Harbor Workers' Compensation Act ratings are performed for scheduled injuries ( , a scheduled member of the body defined by section 8(c)(1)-(20) of the LHWCA).12 This includes upper extremity injuries (with the exception of the shoulder), lower extremity injuries, and hearing loss. The Guides are often used to quantify the extent of injuries resulting from an automobile casualty or personal injury. Insurers may use an impairment rating as one of the factors in determining the reserve or settlement value of a claim. Insurers and attorneys may use this as factor considered in quantifying the impact of an injury and the associated case value. In some states, suits under no-fault automobile insurance are limited to cases where a specific defined impairment threshold has been met; in these states the Guides play an important role in providing numerical data to indicate that the threshold has indeed been met.