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.

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: The State of Colorado Study, Part III

2004 ◽  
Vol 9 (3) ◽  
pp. 1-12
Author(s):  
Christopher R. Brigham ◽  
Kathryn Mueller ◽  
Douglas Van Zet ◽  
Debra J. Northrup ◽  
Edward B. Whitney ◽  
...  
Keyword(s):  
Comparative Analysis ◽  
Lower Extremity ◽  
Range Of Motion ◽  
Scientific Evidence ◽  
Functional Limitations ◽  
The State ◽  
Fourth Edition ◽  
Functional Loss ◽  
Whole Person ◽  
Impairment Ratings

Abstract This article concludes the three-part discussion of differences among the editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): Third Edition Revised, Fourth, and Fifth Editions. The discussion begins with a comparison of different editions of the AMA Guides for evaluating lower extremity impairment and spinal impairment. The AMA Guides, Fourth Edition, introduced the Diagnosis related estimates (DRE) model, and in this edition the range-of-motion (ROM) model has only a limited role (ie, primarily as a differentiator). A table summarizes the criteria of spinal impairment criteria by edition of the AMA Guides. The authors summarize differences in the impairment ratings of various body systems based on the use of different editions of the AMA Guides, including differences in ratings of the cardiovascular, pulmonary, digestive, and other systems. Critiquing the AMA Guides, the authors call for improvements, including the following: add a system to rate permanent impairments, including functional limitations; base impairment ratings on scientific evidence and a valid whole person impairment scale; make the AMA Guides reliable, comprehensive, internally consistent, comprehensible, accessible (ie, the AMA Guides are complex and difficult to use, and not all physicians are capable of rating impairment), and acceptable. Despite the shortcomings, no other widely accepted basis to assess impairment is available, and future editions of the AMA Guides will improve the process of providing fair assessments of functional loss.

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.

Comparative Analysis of AMA Guides Ratings by the Fourth, Fifth, and Sixth Editions*

2010 ◽  
Vol 15 (1) ◽  
pp. 1-7
Author(s):  
Christopher R. Brigham ◽  
Craig Uejo ◽  
Aimee McEntire ◽  
Leslie Dilbeck
Keyword(s):  
Functional Outcomes ◽  
Interrater Reliability ◽  
Surgical Intervention ◽  
Total Joint Replacement ◽  
Fourth Edition ◽  
Sixth Edition ◽  
Functional Deficits ◽  
Whole Person ◽  
Tunnel Syndrome ◽  
Impairment Ratings

Abstract 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.

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).

Spinal Impairment Evaluation: Fifth Edition Changes

2001 ◽  
Vol 6 (1) ◽  
pp. 1-3
Author(s):  
Robert H. Haralson
Keyword(s):  
Spinal Cord ◽  
Lower Extremity ◽  
Range Of Motion ◽  
Upper Extremity ◽  
Spinal Cord Injuries ◽  
Clinical Findings ◽  
Fourth Edition ◽  
Treatment Results ◽  
Standard Terminology ◽  
Made In

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, was published in November 2000 and contains major changes from its predecessor. In the Fourth Edition, all musculoskeletal evaluation and rating was described in a single chapter. In the Fifth Edition, this information has been divided into three separate chapters: Upper Extremity (13), Lower Extremity (14), and Spine (15). This article discusses changes in the spine chapter. The Models for rating spinal impairment now are called Methods. The AMA Guides, Fifth Edition, has reverted to standard terminology for spinal regions in the Diagnosis-related estimates (DRE) Method, and both it and the Range of Motion (ROM) Method now reference cervical, thoracic, and lumbar. Also, the language requiring the use of the DRE, rather than the ROM Method has been strengthened. The biggest change in the DRE Method is that evaluation should include the treatment results. Unfortunately, the Fourth Edition's philosophy regarding when and how to rate impairment using the DRE Model led to a number of problems, including the same rating of all patients with radiculopathy despite some true differences in outcomes. The term differentiator was abandoned and replaced with clinical findings. Significant changes were made in evaluation of patients with spinal cord injuries, and evaluators should become familiar with these and other changes in the Fifth Edition.

Evaluating Shoulder Impairment

1998 ◽  
Vol 3 (5) ◽  
pp. 1-3
Author(s):  
Richard T. Katz ◽  
Sankar Perraraju
Keyword(s):  
Peripheral Nerve ◽  
Upper Extremity ◽  
Sensory Loss ◽  
Motor Deficits ◽  
Nerve Lesion ◽  
Fourth Edition ◽  
Specific Patient ◽  
Industrial Medicine ◽  
Shoulder Motion ◽  
Upper Extremity Impairment

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, offers several categories to describe impairment in the shoulder, including shoulder amputation, abnormal shoulder motion, peripheral nerve disorders, subluxation/dislocation, and joint arthroplasty. This article clarifies appropriate methods for rating shoulder impairment in a specific patient, particularly with reference to the AMA Guides, Section 3.1j, Shoulder, Section 3.1k, Impairment of the Upper Extremity Due to Peripheral Nerve Disorders, and Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. A table shows shoulder motions and associated degrees of motion and can be used in assessing abnormal range of motion. Assessments of shoulder impairment due to peripheral nerve lesion also requires assessment of sensory loss (or presence of nerve pain) or motor deficits, and these may be categorized to the level of the spinal nerves (C5 to T1). Table 23 is useful regarding impairment from persistent joint subluxation or dislocation, and Table 27 can be helpful in assessing impairment of the upper extremity after arthroplasty of specific bones of joints. Although inter-rater reliability has been reasonably good, the validity of the upper extremity impairment rating has been questioned, and further research in industrial medicine and physical disability is required.

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 Ratings: Observations Based on Review of More Than 6,000 Cases

2010 ◽  
Vol 15 (2) ◽  
pp. 1-10
Author(s):  
Christopher R. Brigham ◽  
Craig Uejo ◽  
Leslie Dilbeck ◽  
W. Frederick Uehlein
Keyword(s):  
Error Rate ◽  
Interrater Reliability ◽  
Average Difference ◽  
Similar Difference ◽  
Expert Review ◽  
Whole Person ◽  
Impairment Ratings ◽  
Causation Analysis ◽  
Number Of Authors

Abstract The goal of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is “to provide a standardized, objective approach to evaluating medical impairment,” resulting in reliable, reproducible impairment ratings with high levels of interrater consistency. The authors reviewed 6233 impairment ratings that took place between July 2006 and January 2010 that reflected 11991 ratable diagnoses and found poor interrater reliability (78% disagreement rate). A previous study conducted in 2005 was published in The Guides Newsletter (May/June and July/August 2006 issues) and evaluated 2100 cases for impairment rating review and found that 80% of ratings resulted in different outcomes when reviewed by an expert reviewer. The current study found an average difference of 10.0% whole person permanent impairment (WPI) between the original WPI ratings calculated with the fifth edition and the revised ratings after expert review; the 2005 study found a similar difference, 9.9% WPI. The reasons for poor interrater reliability with fifth edition ratings are many and include inaccurate clinical and causation analysis, failure to use the AMA Guides appropriately, and bias. The error rate in this study was lowest for patients in Hawaii, where the AMA Guides, Fifth Edition, has been used since 2001, only a relatively small number of authors who have been trained in the use of the AMA Guides perform the evaluations, there is no systematic coaching by attorneys about how to use the AMA Guides, and impairment ratings are routinely reviewed to determine their accuracy.

Shoulder Impairment Rating: Sixth Edition Clarifications

2018 ◽  
Vol 23 (5) ◽  
pp. 11-15
Author(s):  
J. Mark Melhorn
Keyword(s):  
Range Of Motion ◽  
First Grade ◽  
Fourth Edition ◽  
Sixth Edition ◽  
Cuff Tear ◽  
Shoulder Range Of Motion ◽  
Impairment Ratings ◽  
Upper Extremity Impairment ◽  
Shoulder Range ◽  
Motion Method

Abstract A request for an impairment rating using both the fourth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) demonstrated two interesting facts: In the sixth edition, Table 15-34, Shoulder Range of Motion has two typographical errors. First, Grade Modifier 3 (column 6) and the Internal Rotation (IR) (row 12) lists ≤20° ER = 8% UEI; this should be ≥20° ER = 8% UEI; and Grade Modifier 4 (column 7) and IR (row 12) lists: 20° to 50° IR = 6% UEI, ≥60° IR or 10° IR to ER = 0% UEI; this should be ≥60° IR or 10° IR to ER = 10% UEI. Second, the impairment rating using the fourth and sixth editions resulted in the same total impairment. A case example presents a 54-year-old male who experienced a right shoulder strain that was determined to be a right shoulder rotator cuff tear of the supraspinatus and infraspinatus muscles. The patient was evaluated for impairment based on the range-of-motion method in the fourth edition of the AMA Guides, and 13% upper extremity impairment was determined. Using the sixth edition produced similar results, demonstrating how similar impairment ratings can be based on the fourth and sixth editions.

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