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.

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.

Nonspecific Chronic Back Pain: Sixth Edition Approaches

2019 ◽  
Vol 24 (5) ◽  
pp. 14-15
Author(s):  
Jay Blaisdell ◽  
James B. Talmage
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Intervertebral Disk ◽  
Key Factors ◽  
Sixth Edition ◽  
Whole Person ◽  
Class 1 ◽  
A Cell ◽  
Intervertebral Disk Herniation ◽  
The Individual

Abstract Ratings for “non-specific chronic, or chronic reoccurring, back pain” are based on the diagnosis-based impairment method whereby an impairment class, usually representing a range of impairment values within a cell of a grid, is selected by diagnosis and “specific criteria” (key factors). Within the impairment class, the default impairment value then can be modified using non-key factors or “grade modifiers” such as functional history, physical examination, and clinical studies using the net adjustment formula. The diagnosis of “nonspecific chronic, or chronic reoccurring, back pain” can be rated in class 0 and 1; the former has a default value of 0%, and the latter has a default value of 2% before any modifications. The key concept here is that the physician believes that the patient is experiencing pain, yet there are no related objective findings, most notably radiculopathy as distinguished from “nonverifiable radicular complaints.” If the individual is found not to have radiculopathy and the medical record shows that the patient has never had clinically verifiable radiculopathy, then the diagnosis of “intervertebral disk herniation and/or AOMSI [alteration of motion segment integrity] cannot be used.” If the patient is asymptomatic at maximum medical improvement, then impairment Class 0 should be chosen, not Class 1; a final whole person impairment rating of 1% indicates incorrect use of the methodology.

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).

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.

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.

Amputation Evaluation: Sixth Edition Approaches

2019 ◽  
Vol 24 (2) ◽  
pp. 6-11
Author(s):  
Jay Blaisdell ◽  
James B. Talmage
Keyword(s):  
Lower Extremity ◽  
Range Of Motion ◽  
Upper Extremity ◽  
Lower Extremity Amputation ◽  
Specific Level ◽  
Sixth Edition ◽  
Extremity Amputation

Abstract Upper extremity amputations are rated in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 15.6, Amputation Impairment, where text, tables, and figures guide evaluators in combining proximal diagnosis-based impairments (DBIs) and proximal range-of-motion impairments. The AMA Guides provides impairment grids for lower and upper extremity amputations, which are divided into five impairment classes (0 through 4), and each impairment class is further divided (except class 0) into five grades (A through E), each with its respective impairment rating that is expressed as a percentage of the extremity. Determining impairment class, and thus the default value of impairment, is straightforward if the amputation occurred directly at one of the points in the relevant grid; if the amputation occurred at another point, the evaluator should consult the appropriate figure to assess how the specific level of amputation corresponds with impairment percentages. An individual's proximal problems may lead to an increase in the impairment value because of the application of grade modifiers. Except in rare instances of bilateral upper extremity amputation or when the patient is unable to wear a prosthesis for a lower extremity amputation, the evaluator usually uses the default rating value within the selected impairment class as the final percentage rating. Evaluators are advised to re-read the amputation section in the AMA Guides before conducting an amputation evaluation.

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).

Impairment Tutorial: Lower Extremities Impairment Evaluation: Overview of Sixth Edition Approaches

2008 ◽  
Vol 13 (5) ◽  
pp. 7-8
Author(s):  
Christopher R. Brigham
Keyword(s):  
Lower Extremity ◽  
Lower Limb ◽  
Functional Ability ◽  
Peripheral Nerves ◽  
Lower Extremities ◽  
Meniscus Repair ◽  
Upper Extremities ◽  
Sixth Edition ◽  
Whole Person ◽  
Symptoms And Signs

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, takes approaches to the lower extremities that are consistent with Chapter 15, Upper Extremities (reviewed in the March/April 2008 issue of The Guides Newsletter). Because there is a comparatively smaller spectrum of diagnoses in the lower extremities, Chapter 16 is less complex and is shorter than Chapter 15. The purposes of the lower extremity are transfer and mobility, and, in comparison to the upper extremity, the lower extremity provides greater stability than flexibility. This chapter's principles of assessment define the standards for interpreting symptoms and signs, functional history, physical examination, and clinical studies. Examiners may use the Lower Limb Instrument developed by the American Academy of Orthopaedic Surgery as an adjunct to defining functional ability, but values are not provided to define a specific grade modifier. Most lower extremity impairments are based on Diagnosis-related impairments, and an impairment example case demonstrates the use of the Knee Regional Grid to asses a partial meniscus repair. An associated table illustrates the resulting whole person impairment values associated with these examples and gives the probable impairments based on the fifth edition. The article also discusses impairments of the peripheral nerves, amputation, and range of motion. Mastery of one chapter of the AMA Guides facilitates performing ratings using other chapters.

Rating Cognitive Impairment, Part 2: Objective and Evidence-Based Integration of Neuropsychology Testing

2017 ◽  
Vol 22 (2) ◽  
pp. 6-12
Author(s):  
Robert J. Barth ◽  
John E. Meyers
Keyword(s):  
Hearing Loss ◽  
Hearing Impairment ◽  
Binaural Hearing ◽  
Speech Discrimination ◽  
Sixth Edition ◽  
Age Related ◽  
Whole Person ◽  
The Individual ◽  
Loss Of Hearing ◽  
Relationship Of

Abstract Hearing impairment rating determination is described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 11.2a, Criteria for Rating Impairment Due to Hearing Loss. A hearing impairment evaluation for adults who have acquired language skills is derived from a pure-tone audiogram and always is based on the functioning of both ears even though hearing loss may be present in only one ear. Audiometers should be properly calibrated, and technicians should be appropriately trained to obtain accurate measurements. Audiograms typically are obtained at four frequencies (test frequencies): 500, 1000, 2000, and 3000 Hz, which are considered to be representative of everyday auditory speech ranges. The evaluator tests the individual's right and left ears at the test frequencies and adds the decibel levels for each of these frequencies for each ear separately; consults Table 11-2, Computation of Binaural Hearing Impairment; and finally consults Table 11-3, Relationship of Binaural Hearing Impairment to Impairment of the Whole Person. Tinnitus can be rated if the individual experiences hearing loss in the ear and this loss affects speech discrimination; loss is limited to a maximum of 5% loss. The AMA Guides provides no correction in the hearing section for age-related loss of hearing, although the latter may be apportionable. A table presents a model hearing impairment report.

Quick Consult: Quick Consult: Acromioplasty

2002 ◽  
Vol 7 (3) ◽  
pp. 4-5
Keyword(s):  
Glasgow Coma Scale ◽  
Outcome Assessment ◽  
High Probability ◽  
Vegetative State ◽  
Behavioral Impairment ◽  
Whole Person ◽  
Ordinal Scales ◽  
Probability Of Death ◽  
The Individual ◽  
Assessment Scales

Abstract Different jurisdictions use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) for different purposes, and this article reviews a specific jurisdictional definition in the Province of Ontario of catastrophic impairment that incorporates the AMA Guides. In Ontario, a whole person impairment (WPI) exceeding 54% or a mental or behavioral impairment of Class 4 or 5 qualifies the individual for catastrophic benefits, and individuals who do not meet the test receive a lesser benefit. By inference, this establishes a parity threshold among dissimilar injuries and dissimilar outcome assessment scales for benefits. In Ontario, the Glasgow Coma Scale (GCS) identifies patients who have a high probability of death or of severely disabled survival. The GCS recognizes gradations of vegetative state and disability, but translating the gradations for rating individual impairment on ordinal scales into a method of assessing percentage impairments cannot be done reliably, as explained in the AMA Guides, Fifth Edition. The AMA Guides also notes that mental and behavioral impairment in Class 4 (marked impairment) or 5 (extreme impairment) indicates “catastrophic impairment” by significantly impeding useful functioning (Class 4) or significantly impeding useful functioning and implying complete dependency on another person for care (Class 5). Translating the AMA Guides guidelines into ordinal scales cannot be done reliably.

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