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.

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 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.

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.

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.

Effects of Aging on Impairment Ratings: Part 4: Musculoskeletal Issues

2019 ◽  
Vol 24 (6) ◽  
pp. 3-11
Author(s):  
Stephen L. Demeter ◽  
Charles N. Brooks ◽  
J. Mark Melhorn
Keyword(s):  
Medical Literature ◽  
Diffuse Idiopathic Skeletal Hyperostosis ◽  
Older Individuals ◽  
Repetitive Motion ◽  
Age Related ◽  
Spinal Ligaments ◽  
Impairment Ratings ◽  
Effects Of Aging ◽  
Causation Analysis ◽  
Injury Causation

Abstract This article is the fourth of five in a series on the effects of age-related changes in impairment evaluations as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. The present article addresses the musculoskeletal system and differs from the first three articles, which focused on apportionment of an impairment rating between aging and other causes. The medical literature supports the notion that age-related osteoarthritis (OA) changes in the hand and digits frequently are associated with injury and/or repetitive motion. Thus, apportionment is indicated, but deciding which came first, the imaging abnormality or the injury, requires consummate skill on behalf of the rating physician. OA also occurs in the knees and hips of older individuals. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory disorder characterized by calcification and ossification of spinal ligaments and entheses and is unique, in the authors’ opinion, because of a positive correlation between aging and back pain caused by this condition. The article also addresses the association—or the lack thereof—between pathology and aging, as well as degenerative changes and symptoms, to facilitate causation analysis. For a fuller discussion of causation analysis for the spine, readers can consult the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition.

Carpometacarpal (CMC) Joint Subluxation: Causation Analysis and Impairment Evaluation

2012 ◽  
Vol 17 (5) ◽  
pp. 1-7
Author(s):  
J. Mark Melhorn ◽  
Christopher R. Brigham ◽  
James B. Talmage
Keyword(s):  
Physical Examination ◽  
Radiographic Evaluation ◽  
X Rays ◽  
Plausible Mechanism ◽  
Impairment Ratings ◽  
Sufficient Magnitude ◽  
Causation Analysis ◽  
Injury Causation ◽  
Current Science ◽  
Cmc Joint

Abstract Carpometacarpal (CMC) joint subluxation refers to the changes that occur in the CMC joint as seen on x-rays and observed during physical examination. The CMC joint is the most commonly involved arthritic joint in the hand, and arthritis may appear in localized or systemic forms. A diagnosis of thumb-CMC arthritis is based on symptoms of localized pain, tenderness, and instability on physical examination and radiographic evaluation. The AMA Guides to the Evaluation of Disease and Injury Causation provides a protocol for assessing causation and requires that all three of the following criteria must be met: 1) the patient has an illness compatible with a disease-producing agent or an injury; 2) the worker's exposure in the occupational environment potentially caused the disease or is a plausible mechanism of injury of sufficient magnitude to cause the condition; and 3) the preponderance of evidence supports the disease or injury as occupational in origin. If any one of the three is possible but not probable, causation has not been established. The authors review several published articles and conclude that, based on the clinical facts and current science, CMC joint subluxation is unrelated to work and instead is reflective of aging. The article concludes with a comparison of impairment ratings of CMC-related disability using the fifth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment, both of which lead to identical impairment ratings but by different means.

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.

scholarly journals Verifying the Accuracy of Digital Goniometer Range of Motion Measurements for In-Person and Telemedicine Visits

2020 ◽  
Vol 3 (S3) ◽  
pp. 31-39
Author(s):  
Langton Zack ◽  
◽  
Johnson Mari ◽  
Reed Zach ◽  
Alchemy John ◽  
...  
Keyword(s):  
Standard Deviation ◽  
Clinical Setting ◽  
Interrater Reliability ◽  
Error Tolerance ◽  
Clinical Settings ◽  
Average Difference ◽  
Average Standard Deviation ◽  
Motion Measurements ◽  
The Difference ◽  
Flexion And Extension

INTRODUCTION This paper offers empirical evidence of the accuracy of the clinical application of the RateFast Goniometer smartphone app. Using multiple comparative measures and interrater reliability measures, this paper investigates the effective ness of this digital goniometer app for physicians practicing in both the office and in telemedicine clinical settings. METHODS Three experiments were performed to test the reliability of the RateFast Goniometer app. The first involved measuring preset angles to test its accuracy. The second experiment involved measuring randomly drawn angles to determine if switching users has any effect on the results. The last experiment measured shoulder angles (flexion and extension planes) of 53 volunteers to determine the accuracy of the RateFast Goniometer app in both haptic mode (for use in an in -person clinical setting) and camera mode (for use in a telemedicine clinical setting). RESULT In the first experiment, the average difference between measurements was 0.6° and the average standard deviation was 0.3°. In the second experiment, the angles measured with the RateFast goniometer were less than those measured with a protractor, averaging to a difference of 0.9°. In the third experiment, the haptic mode measurements and the camera mode measurements had an average difference of 1.2° and the standard deviation of the difference between haptic and camera measurements was determined to be 4.7° across all volunteers. CONCLUSION In all three experiments, the error rate found using the RateFast Goniometer app which is within the error tolerance according to the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition (AMA Guides), which stipulates that measurements of shoulder angles must be within 10% of one another. The RateFast Goniometer app and similar digital goniometer applications can be used to accurately measure angles in both in -person and telemedicine settings according to the standards of accuracy set forth in the AMA Guides.

Quick Reference: Motion at the Wrist, Elbow, and Shoulder

2005 ◽  
Vol 10 (2) ◽  
pp. 6-6
Keyword(s):  
Daily Living ◽  
Patient Advocacy ◽  
Body Part ◽  
Organ System ◽  
The Body ◽  
Organ Function ◽  
Reference Motion ◽  
Whole Person ◽  
Body Organ ◽  
Impairment Ratings

Abstract When they assess impairment, examiners must determine what “loss, loss of use, or derangement of any body part, organ system, or organ function,” occurred, according to the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition. At the same time, the AMA Guides cautions examiners to avoid “double dipping,” or rating the same impairment twice: “Related but separate conditions are rated separately[,] and impairment ratings are combined unless criteria for the second impairment are included in the primary impairment.” For example, it is not appropriate for an examiner who is rating spinal impairment using a Diagnosis-related estimate (DRE) category to award an additional 3% whole person impairment (WPI) beyond the baseline rating for the category because of limitation in activities of daily living (ADLs), presumably at least in part because of residual pain, and then to award a further impairment rating for pain based on Chapter 18. Rather, the AMA Guides notes that “the impairment ratings in the body organ system chapters make allowance for any accompanying pain.” Duplicative and, therefore, erroneously inflated ratings sometimes are performed by physicians who are less experienced in using the AMAGuides or those who, due to patient advocacy or other reason, want to maximize ratings.

Rating Knee Impairments

2018 ◽  
Vol 23 (1) ◽  
pp. 14-16
Author(s):  
Jay Blaisdell ◽  
James Talmage
Keyword(s):  
Lower Extremity ◽  
Physical Examination ◽  
Range Of Motion ◽  
Patellofemoral Pain ◽  
Sixth Edition ◽  
Whole Person ◽  
Causation Analysis

Abstract Workers who kneel for major portions of their workday (eg, floor and roof installers) may be prone to inflammation of the knee bursae and patellofemoral pain. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), range-of-motion (ROM) and diagnosis-based impairment (DBI) are the two possible stand-alone methods for rating knee impairment. The ROM method was widely used in previous editions of the AMA Guides, but at present DBI is the method of choice for calculating impairment. To rate knee impairment using the DBI method, the physician first chooses the appropriate diagnosis from the Knee Regional Grid in the AMA Guides, Sixth Edition. Next, the physician chooses the appropriate impairment class for the diagnosis and then selects the appropriate grade modifiers. The physician applies the net adjustment formula to determine lower extremity impairment and finally converts the final lower extremity impairment to whole person impairment. Two or more conditions often are found in the knees and require causation analysis in which the physician should choose the single causally related diagnosis that will yield the highest impairment rating. Modifiers should be chosen based on reliable findings that have not been used previously to assign either the diagnosis or impairment class. The ROM method can be used to select the physical examination grade modifier or as a stand-alone rating if the physician offers a rationale that is supported by the AMA Guides.

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