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.

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.

Comparative Analysis of Impairment Evaluations by the 1996 Florida Uniform Permanent Impairment Rating Schedule (FUPIRS) and the AMA Guides™ Fourth, Fifth, and Sixth Editions

2010 ◽  
Vol 15 (6) ◽  
pp. 5-7
Author(s):  
Christopher R. Brigham ◽  
Aimee McEntire ◽  
Craig Uejo
Keyword(s):  
Comparative Analysis ◽  
Statistical Significance ◽  
Limited Range ◽  
Compensation System ◽  
Fourth Edition ◽  
Paired Sample ◽  
Sixth Edition ◽  
Whole Person ◽  
Impairment Ratings ◽  
The Difference

Abstract 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.

Spine Impairment Evaluation: Sixth Edition Approaches

2009 ◽  
Vol 14 (1) ◽  
pp. 1-5
Author(s):  
Craig Uejo ◽  
Marjorie Eskay-Auerbach ◽  
Christopher R. Brigham
Keyword(s):  
Functional Status ◽  
Spinal Injury ◽  
Current Medical ◽  
Clinical Testing ◽  
Medical Evidence ◽  
Sixth Edition ◽  
Whole Person ◽  
Rating Process ◽  
Impairment Ratings ◽  
Class Assignment

Abstract Evaluators who use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, should understand the significant changes that have occurred (as well as the Clarifications and Corrections) in impairment ratings for disorders of the cervical spine, thoracic spine, lumbar spine, and pelvis. The new methodology is an expansion of the Diagnosis-related estimates (DRE) method used in the fifth edition, but the criteria for defining impairment are revised, and the impairment value within a class is refined by information related to functional status, physical examination findings, and the results of clinical testing. Because current medical evidence does not support range-of-motion (ROM) measurements of the spine as a reliable indicator of specific pathology or permanent functional status, ROM is no longer used as a basis for defining impairment. The DRE method should standardize and simplify the rating process, improve validity, and provide a more uniform methodology. Table 1 shows examples of spinal injury impairment rating (according to region of the spine and category, with comments about the diagnosis and the resulting class assignment); Table 2 shows examples of spine impairment by region of the spine, class, diagnosis, and associated whole person impairment ratings form the sixth and fifth editions of the AMA Guides.

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.

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.

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.

Impairment Tutorial: Headache Impairment

2008 ◽  
Vol 13 (5) ◽  
pp. 11-11
Author(s):  
Kenneth Subin ◽  
Christopher R. Brigham
Keyword(s):  
Organ Dysfunction ◽  
Fourth Edition ◽  
Sixth Edition ◽  
Migraine Headaches ◽  
Whole Person ◽  
Impairment Score ◽  
Specific Organ

Abstract The approach to assessing impairment for headaches differs among the fourth, fifth, and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In summary, the fourth edition provides only a qualitative, nonnumeric rating. In the fifth edition, an examiner can give up to 3% whole person permanent impairment. Using the sixth edition of the AMA Guides, an examiner may determine up to 5% whole person permanent impairment for migraine headaches for Chapter 13 and up to 3% whole person impairment for other headaches according to Chapter 3. With respect to the AMA Guides, Fourth Edition, unless other objective features can be rated according to specific organ dysfunction, headache impairment is a qualitative, nonnumeric rating, and “The vast majority of patients with headache[s] will not have permanent impairments.” In some defined cases, the fifth edition facilitates calculation of a pain related impairment score (that specifically is not an impairment rating) that is used to describe the severity of the pain, for which up to 3% whole person impairment may be provided. The sixth edition of the AMA Guides provides a quantitative whole person impairment rating up to 5% whole person impairment for migrainous headaches and 3% whole person impairment for nonmigrainous headaches.

Assessing Impairment and Disability in the Pain Patient

2016 ◽  
Vol 21 (1) ◽  
pp. 3-10
Author(s):  
Steven D. Feinberg ◽  
Christopher R. Brigham ◽  
Lee Ensalada
Keyword(s):  
Chronic Pain ◽  
Social Factors ◽  
Work Capacity ◽  
Pain Patient ◽  
Clinical Issues ◽  
Sixth Edition ◽  
Functional Deficits ◽  
Significant Disability ◽  
Impairment Ratings ◽  
Eligibility Requirements

Abstract Assessing impairment and/or disability in the pain patient often is difficult due to both administrative and clinical issues; in addition, the terms impairment and disability are misunderstood. Chronic pain complaints may be associated with significant disability, but typically the physician defines clinical issues, functional deficits, and, when requested, impairment; disability most often is an administrative determination. The biopsychosocial approach currently is viewed as most appropriate perspective for understanding, assessing, and treating chronic pain disorders and acknowledges a complex and dynamic interaction among biological, psychological, and social factors. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, discusses the assessment of pain and eligibility requirements for pain-related impairment (PRI). Some physicians feel that the AMA Guides’ approach to PRI does not adequately address the “disability” and functional loss caused by some chronic pain states, but the AMA Guides is limited, mostly, to describing measurable objective changes or impairment. The AMA Guides is not intended to be used for direct estimates of loss of work capacity (disability), and impairment percentages derived according to the AMA Guides criteria do not measure work disability. Impairment ratings in the AMA Guides already have accounted for impairment-associated pain, including that experienced in areas distant to the specific site of pathology.

Key Principles in Using the Guides (Part I)

1997 ◽  
Vol 2 (1) ◽  
pp. 1-2
Author(s):  
Henry J. Roth ◽  
Christopher R. Brigham
Keyword(s):  
Full Range ◽  
Evaluation Process ◽  
Moderate Pressure ◽  
Fourth Edition ◽  
Active Motion ◽  
Organ Systems ◽  
Whole Person ◽  
Impairment Ratings ◽  
Definition Of

Abstract The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) Fourth Edition, is based on fundamental principles, particularly Chapter 1, Impairment Evaluations, Chapter 2, Records and Reports, and the Glossary. This article (continued in the next issue) discusses and clarifies 21 key principles for using the AMA Guides. For example, the AMA Guides applies only to permanent impairments, and impairment percentages are estimates, not precise determinations. All impairment ratings should be combined to express an impairment of the whole person. The AMA Guides establishes an evaluation process, and the medical rating itself is not the process or purpose addressed. An impairment estimate is simply a number and does not convey information about the effects of the impairment on the person's activities of daily living. A definition of normal requires nuanced evaluations in which physicians are asked to express opinions about the absence or presence of disability. Examiners should evaluate the patient's full range of possible active motion without the application of moderate pressure to the joint. Some patients with extremity pain or other symptoms may not have evidence of permanent impairment, and if the effects on different organ systems contribute to impairment, these estimates should be combined. [Continued in the March/April 1997 The Guides Newsletter]

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