Combining Values

2002 ◽  
Vol 7 (2) ◽  
pp. 1-4, 12 ◽  
Author(s):  
Christopher R. Brigham
Keyword(s):  
Lower Extremity ◽  
Upper Extremity ◽  
Evaluation Method ◽  
Proximal Phalanx ◽  
Common Error ◽  
The Third ◽  
Whole Person ◽  
Impairment Ratings ◽  
Upper Extremity Impairment ◽  
The Individual

Abstract To account for the effects of multiple impairments, evaluating physicians must provide a summary value that combines multiple impairments so the whole person impairment is equal to or less than the sum of all the individual impairment values. A common error is to add values that should be combined and typically results in an inflated rating. The Combined Values Chart in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, includes instructions that guide physicians about combining impairment ratings. For example, impairment values within a region generally are combined and converted to a whole person permanent impairment before combination with the results from other regions (exceptions include certain impairments of the spine and extremities). When they combine three or more values, physicians should select and combine the two lowest values; this value is combined with the third value to yield the total value. Upper extremity impairment ratings are combined based on the principle that a second and each succeeding impairment applies not to the whole unit (eg, whole finger) but only to the part that remains (eg, proximal phalanx). Physicians who combine lower extremity impairments usually use only one evaluation method, but, if more than one method is used, the physician should use the Combined Values Chart.

Comparative Analysis of Third Edition, Revised; Fourth; and Fifth Edition Ratings: The State of Colorado Study

2004 ◽  
Vol 9 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Christopher R. Brigham ◽  
Kathryn Mueller ◽  
Douglas Van Zet ◽  
Debra J. Northrup ◽  
Edward B. Whitney ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Upper Extremity ◽  
Interrater Reliability ◽  
The State ◽  
Fourth Edition ◽  
Department Of Labor ◽  
Independent Expert ◽  
Whole Person ◽  
Impairment Ratings ◽  
Upper Extremity Impairment

Abstract In 2002, the Department of Labor and Employment, the State of Colorado, performed a study to identify changes among the Third Edition, Revised (December 1990); the Fourth Edition (June 1993); and the Fifth Edition (November 2000) of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This three-part article summarizes the differences found. The study was based on a random sample of 250 cases identified by the Division of Workers’ Compensation of the State of Colorado and stratified into three broad categories: 40 upper extremity cases, 60 lower extremity cases, and 150 whole person cases. Only case records with adequate documented evidence to enable rating among all three editions of the AMA Guides were included. The average age of the examinee was 42.9 years (SD, 11.1 years, range, 18 to 71 years, 171 [68%] male); equal percentages of men and women were present in the upper extremity impairment ratings (20 men, 20 women), but lower extremity and whole person impairments occurred primarily among males (73% and 71% men, respectively). Interrater reliability was obtained from an independent expert medical review of 20% of the cases. Three figures show percentages of upper extremity, lower extremity, and whole person impairment according to the edition used; ratings generally are lower with more recent editions.

Impairment Tutorial: Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating

2003 ◽  
Vol 8 (5) ◽  
pp. 4-12
Author(s):  
Lorne Direnfeld ◽  
James Talmage ◽  
Christopher Brigham
Keyword(s):  
Upper Extremity ◽  
Radicular Pain ◽  
Illness Behavior ◽  
Orthopedic Surgeon ◽  
First Case ◽  
Clinical Presentations ◽  
Whole Person ◽  
Physical Examinations ◽  
Upper Extremity Impairment ◽  
The Individual

Abstract 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).

Combining Values Chart

2012 ◽  
Vol 17 (2) ◽  
pp. 7-9
Author(s):  
Christopher R. Brigham
Keyword(s):  
Lower Extremity ◽  
Upper Extremity ◽  
Sixth Edition ◽  
Whole Person ◽  
The Individual

Abstract Evaluating physicians may need to account for the effects of multiple impairments using a summary value. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, the Combined Values Chart provides a method to combine two or more impairment percentages based on the formula A + B(1 – A) = the combined value of A and B. Using the Combined Values Chart and this formula, physicians can combine multiple impairments so that the whole person impairment is equal to or less than the sum of all the individual impairment values. The AMA Guides, Sixth Edition, specifies that “impairments are successively combined by first combining the largest number with the next largest remaining number, and then further combining it with the next largest remaining number … until all given impairment numbers are combined.” Impairment values within a region generally are combined and converted to whole person permanent impairment before being combined with values from other regions. The article reviews the AMA Guides, Sixth Edition, approach to combining upper extremity impairments, lower extremity impairments, and combining spinal impairments.

Impairment Tutorial: The Combined Values Chart

1998 ◽  
Vol 3 (6) ◽  
pp. 7-7
Author(s):  
Christopher R. Brigham
Keyword(s):  
Lower Extremity ◽  
Musculoskeletal System ◽  
Evaluation Method ◽  
Degenerative Joint Disease ◽  
Joint Disease ◽  
Specific Level ◽  
Organ Systems ◽  
Whole Person ◽  
Impairment Ratings ◽  
Hand Impairment

Abstract Impairment values are more often combined than added, and the Combined Values Chart in the AMA Guides to the Evaluation of Permanent Impairment can be used to calculate the combined value of two numbers. The values are derived from the formula A + B(1 – A) = the combined value of A and B, where A and B are the decimal equivalents of the impairment ratings. This mathematically prevents an estimate of impairment greater than 100%. With smaller numbers, the combined value may equal the arithmetic sum of the 2 numbers. Impairments of different organ systems are converted to whole person impairment ratings before combining. In most lower extremity impairment cases only one evaluation method is used, but certain circumstances justify combining impairments. Examples in the lower extremity include diagnosis-based estimates with short leg, degenerative joint disease (in the case of fractures in and about joints), and neurologic loss. Combining vs adding can be confusing, but one can nearly always combine, with the following exceptions for the musculoskeletal system: range of motion (ROM) deficits within an upper extremity; ROM deficits of the thumb; total hand impairment; rating hip or knee replacement results; and ROM deficits of the spine at a specific level.

To Combine or Not to Combine

2013 ◽  
Vol 18 (6) ◽  
pp. 9-9
Author(s):  
Mohammed I Ranavaya ◽  
Robert Rondinelli
Keyword(s):  
Upper Extremity ◽  
Single Case ◽  
General Rule ◽  
Lower Limbs ◽  
Limb Injuries ◽  
Whole Person ◽  
Sensory Motor ◽  
Common Unit ◽  
Upper Extremity Impairment ◽  
The Individual

Abstract Physicians must account for the effects of multiple impairments using a summary value. Sometimes, when dealing with multiple impairments in a single case, the evaluating physician may be confused about whether specific impairments are added or combined, particularly during the assessment of hand or limb injuries. Combining is accomplished by using the Combined Values Chart presented in the Appendix of each edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). With a few exceptions, the general rule is that all impairments should be combined. The combining must occur at the same hierarchal level (eg, upper extremity impairment can be combined only with another upper extremity impairment from the same limb), and whole person impairment (WPI) can be combined only with another WPI impairment. In case of impairments from a different limb (either from both upper or lower limbs) even though they may be expressed at the same hierarchal limb (eg, upper extremity or lower extremity), they should be combined at the WPI level only after the individual limb is fully rated and the final impairment for that limb is expressed at the WPI level. Evaluators should remember that impairing factors (sensory, motor, vascular, and so on) are combined at the smallest common unit (ie, digit < hand < upper extremity < whole person).

scholarly journals PERSON-CENTERED INTEGRATIVE DIAGNOSIS: CONCEPTS AND PROCEDURES

2020 ◽  
Author(s):  
Ihsan M Salloum ◽  
Juan E. Mezzich
Keyword(s):  
Health Status ◽  
Paradigm Shift ◽  
Clinical Care ◽  
Well Being ◽  
Component Model ◽  
The Third ◽  
Whole Person ◽  
The Individual ◽  
Novel Model ◽  
Major Domain

The person-centered integrative diagnosis (PID) is a model that aims at putting into practice the vision of person-centered medicine affirming the whole person of the patient in context as the center of clinical care and health promotion at the individual and community levels. The PID is a novel model of conceptualizing the process and formulation of clinical diagnosis. The PID presents a paradigm shift with a broader and deeper notion of diagnosis, beyond the restricted concept of nosological diagnoses. It involves a multilevel formulation of health status (both ill and positive aspects of health) through interactive participation and engagement of clinicians, patients, and families using all relevant descriptive tools (categorization, dimensions, and narratives). The current organizational schema of the PID comprises a multilevel standardized component model integrating three main domains. Each level or major domain addresses both ill health and positive aspects of health. The first level is the assessment of health status (ill health and positive aspects of health or well-being). The second level includes contributors to health, both risk factors and protective factors. The third major level includes health experience and values. Experience with the PID through a practical guide in Latin America supported the usefulness and adequacy of the PID model.

Case Study: Carpal Tunnel Syndrome

2004 ◽  
Vol 9 (5) ◽  
pp. 4-10
Keyword(s):  
Grip Strength ◽  
Carpal Tunnel ◽  
Carpal Tunnel Release ◽  
Permanent Disability ◽  
Left Hand ◽  
Whole Person ◽  
Tunnel Syndrome ◽  
Impairment Ratings ◽  
The Individual

Abstract This Case Study involves a 49-year-old, right-handed laborer whose impairment rating was performed by two surgeons in California following right- and left-hand endoscopic carpal tunnel release surgeries. He was evaluated by both physicians as permanent and stationary with 30% disability according to one rater and 19% by the second rater. Both raters used grip strength measurements tested using a dynamometer by the first evaluating physician and also discussed by the second evaluator. Both evaluators assessed permanent disability. The authors of this Case Study now pause to ask about problems associated with these reports and how the case should be rated; readers are encouraged to perform their own assessments before continuing with the answers and discussion that appear several pages later in this issue of The Guides Newsletter. The authors note that neither report met standards defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): both histories are inadequate (eg, results of any sensory testing), as is the clinical discussion. Further, the AMA Guides indicates that it is inappropriate to rate the individual based on weakness of grip strength. In this, as in other aspects of the initial ratings, the evaluators should have followed the AMA Guides more closely, citing appropriate text and tables both for the conduct of the tests and arriving at appropriate impairment ratings. Doing so, in this instance, would result in a rating of 2% whole person permanent impairment.

Upper Extremity Impairment Scenarios–Challenges in Rating

1999 ◽  
Vol 4 (3) ◽  
pp. 1-4
Author(s):  
Frank Jones ◽  
James B. Talmage
Keyword(s):  
Upper Extremity ◽  
Shoulder Dislocation ◽  
Proximal Phalanx ◽  
Lateral Epicondylitis ◽  
Strength Loss ◽  
Flexor Digitorum Profundus ◽  
Functional Consequences ◽  
Recurrent Shoulder Dislocation ◽  
Upper Extremity Impairment ◽  
Flexor Digitorum

Abstract This article discusses situations in which an evaluating physician may find rating according the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) cumbersome, including fingertip injuries, transection of flexor digitorum sublimis tendon, medial and lateral epicondylitis, upper extremity amputations, and recurrent shoulder dislocation. On finding decreased motion at a finger distal interphalangeal joint (DIP) or thumb interphalangeal (IP) joint, the examiner should carefully assess the functional consequences and ensure the rating adequately addresses the impairment but does not rate the same problem twice. Laceration of the distal palm or proximal phalanx of a finger resulting in isolated transection of the flexor digitorum sublimis tendon (flexor digitorum profundus tendon remains intact) is a challenging scenario. Medial and lateral epicondylitis are not mentioned in the AMA Guides because usually they resolve with time. Grip strength loss usually is not an appropriate way to rate epicondylitis because pain limits grasp in this condition. Impairment ratings for upper extremity amputations may not be consistent in terms of the location where the procedure is used. Recurrent shoulder dislocation may complicate an initial traumatic dislocation, particularly in younger patients and must be medically documented rather than anecdotally reported. When faced with a situation that is not covered in the AMA Guides, the rating physician should consider analogous situations, consult other manuals or guidelines, or discuss the case with other experienced evaluators.

Common Tips for IMEs: Musculoskeletal Conversions: Musculoskeletal Conversions

2002 ◽  
Vol 7 (6) ◽  
pp. 13-15
Author(s):  
Christopher R. Brigham
Keyword(s):  
Cervical Spine ◽  
Lumbar Spine ◽  
Lower Extremity ◽  
Range Of Motion ◽  
Middle Finger ◽  
Conversion Factors ◽  
Whole Person ◽  
Upper Extremity Impairment ◽  
Hand Impairment ◽  
Little Finger

Abstract Most impairments are expressed ultimately as a whole person impairment, and the musculoskeletal chapters of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) include instructions for converting regional impairments to whole person impairments using a percentage relationship. This article presents an extensive table that incorporates the conversion factors for extremity and spinal impairments. Occasionally evaluators need to convert spinal impairments from whole person to impairment of the spine, a process that is explained in the AMA Guides, Section 15.13. The conversion factors differ depending on whether the impairment was obtained using the Diagnosis-related estimate (DRE) method or the range-of-motion (ROM) method. For example, a 5% whole person impairment is an 8% upper extremity impairment, a 9% hand impairment, 23% thumb impairment, 46% index/middle finger impairment, or 93% ring/little finger impairment. The same 5% whole person impairment would convert to a cervical spine impairment of 14% cervical spine if the DRE method were used and 6% if the ROM method were used. For the lumbar spine, this would convert to 7% lumbar spine impairment if the DRE method were used and 6% if the ROM method were used. The table in this article provides values for converting foot to lower extremity impairment and for converting whole person impairment to regional spinal impairment.

Erroneous Impairment Ratings Companion: Impairment Rating Critique and the Longshore and Harbor Workers’ Compensation Act

2006 ◽  
Vol 11 (4) ◽  
pp. 10-11
Author(s):  
Craig Uejo ◽  
Phil Walker
Keyword(s):  
Upper Extremity ◽  
Administrative Law ◽  
Workers Compensation ◽  
Department Of Labor ◽  
The Us ◽  
Expert’S Opinion ◽  
Impairment Ratings ◽  
Board Decision ◽  
Upper Extremity Impairment ◽  
Expert Physician

Abstract A 2005 Benefits Review Board decision by the US Department of Labor, Peter J. Desjardins vs Bath Iron Works Corporation affirmed a decision and order (2004-LHC-1364) regarding the utility of impairment rating critique. The administrative law judge credited the rating opinion of an expert physician reviewer (who had not seen the claimant) over that of the treating physician. The claimant's physician was awarded 20% upper extremity impairment, but, following the review and opinion of an expert reviewer, the award was reduced to 4%. The claimant appealed, largely on the argument that the expert reviewer had reviewed the report by the patient's physician, not the claimant himself and that the expert's opinion properly relied on the correct use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The appeals judges noted that the administrative judge properly noted that the AMA Guides was suitable for use (and was the basis of the treating physician's award). The administrative law judge found that the expert reviewer's opinion was based on the specifics of the present case and on his knowledge and application of the AMA Guides, which together warranted determinative weight, based on the expert reviewer's credentials, experience, and well-reasoned opinion. This decision confirms that expert reviewers can provide evidence for the fact finder to evaluate the treating physician's opinion to determine if it is well reasoned and documented.

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