Susceptibility of functional impairment ratings to noncredible reporting in postsecondary students undergoing screening for ADHD

Parent-youth agreement on the youth’s functional impairment may have important implications for mental health service utilization, assessment, therapy goal development, and treatment engagement for adolescents. The present study examines parent-youth agreement on their perceptions of youth functional impairment in a predominantly racial/ethnic minority sample of adolescents utilizing outpatient mental health services. Parent and youth functional impairment ratings were compared, and agreement was estimated in multiple ways. On average, parents indicated higher levels of youth functional impairment compared to youth in their overall scores, and when differences existed between parents and youth at the functioning domain and item level. Although there was similarity in the proportion of parents and youth who reported total impairment above the clinical cut-off, actual agreement between parent-youth pairs was only slight. There appeared to be substantial variation in agreement levels when identifying problems in functional impairment at the domain and item levels, and some areas of strong consensus were identified. These findings highlight the need to consider parent-youth agreement in perceptions of functional impairment and the complexities that may underlie this agreement.

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Gait Apraxia in Multiple Sclerosis

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100008040 ◽

2009 ◽

Vol 36 (5) ◽

pp. 562-565 ◽

Cited By ~ 7

Author(s):

Nuhad E. Abou Zeid ◽

Brian G. Weinshenker ◽

B. Mark Keegan

Keyword(s):

Multiple Sclerosis ◽

Functional Impairment ◽

Cerebral Atrophy ◽

Gait Disorder ◽

Inclusion Criteria ◽

Mri Findings ◽

Exclusion Criteria ◽

Ataxic Gait ◽

T2 Lesions ◽

Impairment Ratings

Background:Gait apraxia is a gait disorder not attributable to motor, cerebellar, or sensory dysfunction. Gait impairment is common in Multiple Sclerosis (MS), but is mostly attributed to spasticity and ataxia. Impairment ratings scales are designed accordingly and do not separately evaluate apraxia.Objective:To describe 15 patients with gait apraxia resulting from MS as their major functional impairment.Methods:The Mayo Clinic database (1994-2007) was searched for the terms MS and gait apraxia. Inclusion criteria: Definite MS, significant gait apraxia. Exclusion criteria: alternative disorder causing apraxia, predominantly spastic/ataxic gait disorder.Results:9 (60%) of the patients were women, and 12 (80%) had a progressive MS course. Gait apraxia was evident at a median of 8 years (range 0-34) following MS onset. Median EDSS at recognition of gait apraxia was 6.5 (range 5-8). Cognitive dysfunction was present in 11 (73%) and neurogenic bladder dysfunction in 14 (93%). The commonest MRI findings were confluent periventricular T2 lesions, T1 hypointensity and generalized cerebral atrophy with symmetrical ex vacuo ventricular enlargement.Conclusion:Gait apraxia can cause significant functional impairment in MS patients, and may be underrecognized. The natural course of the neurological deficit in such patients is unknown, and may differ from that of MS patients with other ambulatory disabilities.

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The AMA Guides in Pennsylvania “Post-Protz”: Act 111 and Case Law Update

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2020.mayjun02 ◽

2020 ◽

Vol 25 (3) ◽

pp. 12-19

Author(s):

Justin D. Beck ◽

Judge David B. Torrey

Keyword(s):

Case Law ◽

General Assembly ◽

Disability Benefits ◽

Permanent Disability ◽

Sixth Edition ◽

Legal Questions ◽

The Supreme Court ◽

Recent Edition ◽

Impairment Ratings

Abstract Medical evaluators must understand the context for the impairment assessments they perform. This article exemplifies issues that arise based on the role of impairment ratings and what edition of the AMA Guides to the Impairment of Permanent Impairment (AMA Guides) is used. This discussion also raises interesting legal questions related to retroactivity, applicability of prior precedent, and delegation. On June 20, 2017, the Supreme Court of Pennsylvania handed down its decision, Protz v. WCAB (Derry Area Sch. Dist.), which disallows use of the “most recent edition” of the AMA Guides when determining partial disability entitlement under the Pennsylvania Workers’ Compensation Act. An attempted solution was passed by the Pennsylvania General Assembly and was signed into law Act 111 on October 24, 2018. Although it affirms that the AMA Guides, Sixth Edition, must be used for impairment ratings, the law reduces the threshold for total disability benefits from 50% to 35% impairment. This legislative adjustment benefited injured workers but sparked additional litigation about whether, when, and how the adjustment should be applied (excerpts from the laws and decisions discussed by the authors are included at the end of the article). In using impairment as a threshold for permanent disability benefits, evaluators must distinguish between impairment and disability and determine an appropriate threshold; they also must be aware of the compensation and adjudication process and of the jurisdictions in which they practice.

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Combining Values

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2002.marapr01 ◽

2002 ◽

Vol 7 (2) ◽

pp. 1-4, 12 ◽

Cited By ~ 1

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.

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Spine Impairment Evaluation: Sixth Edition Approaches

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.janfeb01 ◽

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.

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Medical and Legal Issues Raised by the Protz Decision Issued by the Pennsylvania Supreme Court

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2017.julaug03 ◽

2017 ◽

Vol 22 (4) ◽

pp. 12-13

Author(s):

LuAnn Haley ◽

Marjorie Eskay-Auerbach

Keyword(s):

Supreme Court ◽

Scientific Evidence ◽

Workers Compensation ◽

Sixth Edition ◽

Complex Concept ◽

The Supreme Court ◽

Compensation Claims ◽

Recent Edition ◽

Impairment Ratings ◽

Definition Of

Abstract Pennsylvania adopted the impairment rating provisions described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in 1996 as an exposure cap for employers seeking predictability and cost control in workers’ compensation claims. In 2017, the Supreme Court of Pennsylvania handed down the Protz decision, which held that requiring physicians to apply the methodology set forth in the most recent edition of the AMA Guides reflected an unconstitutional delegation of legislative power to the American Medical Association. The decision eliminates the impairment-rating evaluation (IRE) mechanism under which claimants were assigned an impairment rating under the most recent edition of the AMA Guides. The AMA Guides periodically are revised to include the most recent scientific evidence regarding impairment ratings, and the AMA Guides, Sixth Edition, acknowledges that impairment is a complex concept that is not yet defined in a way that readily permits an evidence-based definition of assessment. The AMA Guides should not be considered standards frozen in time simply to withstand future scrutiny by the courts; instead, workers’ compensation acts could state that when a new edition of the AMA Guides is published, the legislature shall review and consider adopting the new edition. It appears unlikely that the Protz decision will be followed in other jurisdictions: Challenges to using the AMA Guides in assessing workers’ compensation claims have been attempted in three states, and all attempts failed.

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Errata

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2008.marapr02 ◽

2008 ◽

Vol 13 (2) ◽

pp. 5-5

Keyword(s):

Psychotic Disorders ◽

Pain Syndrome ◽

Vestibular Disorders ◽

Loss Of Function ◽

Sixth Edition ◽

Neurologic Disorders ◽

Upper And Lower Extremities ◽

Impairment Ratings ◽

Extensive List ◽

Mental And Behavioral Disorders

Abstract Although most chapters in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, instruct evaluators to perform impairment ratings by first assigning a diagnosis-based class and then assigning a grade within that class, Chapter 13, The Central and Peripheral Nervous System, continues to use a methodology similar to that of the fifth edition. The latter was criticized for duplicating materials that were presented in other chapters and for producing different ratings, so the revision of Chapter 13 attempts to maintain consistency between this chapter and those that address mental and behavioral disorders, loss of function in upper and lower extremities, loss of bowel control, and bladder and sexual function. A table titled Summary of Chapters Used to Rate Various Neurologic Disorders directs physicians to the relevant chapters (ie, instead of Chapter 13) to consult in rating neurologic disorders; the extensive list of conditions that should be addressed in other chapters includes but is not limited to radiculopathy, plexus injuries and other plexopathies, focal neuropathy, complex regional pain syndrome, visual and vestibular disorders, and a range of primary mood, anxiety, and psychotic disorders. The article comments in detail on sections of this chapter, identifies changes in the sixth edition, and provide guidance regarding use of the new edition, resulting in less duplication and greater consistency.

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Sixth Edition: the New Standard

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2008.janfeb01 ◽

2008 ◽

Vol 13 (1) ◽

pp. 1-12

Author(s):

Christopher R. Brigham ◽

Robert D. Rondinelli ◽

Elizabeth Genovese ◽

Craig Uejo ◽

Marjorie Eskay-Auerbach

Keyword(s):

Review Process ◽

Peer Review Process ◽

World Health ◽

International Classification Of Functioning ◽

Revision Process ◽

Sixth Edition ◽

Impairment Ratings ◽

Health Organization ◽

Impairment Severity

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, was published in December 2007 and is the result of efforts to enhance the relevance of impairment ratings, improve internal consistency, promote precision, and simplify the rating process. The revision process was designed to address shortcomings and issues in previous editions and featured an open, well-defined, and tiered peer review process. The principles underlying the AMA Guides have not changed, but the sixth edition uses a modified conceptual framework based on the International Classification of Functioning, Disability, and Health (ICF), a comprehensive model of disablement developed by the World Health Organization. The ICF classifies domains that describe body functions and structures, activities, and participation; because an individual's functioning and disability occur in a context, the ICF includes a list of environmental factors to consider. The ICF classification uses five impairment classes that, in the sixth edition, were developed into diagnosis-based grids for each organ system. The grids use commonly accepted consensus-based criteria to classify most diagnoses into five classes of impairment severity (normal to very severe). A figure presents the structure of a typical diagnosis-based grid, which includes ranges of impairment ratings and greater clarity about choosing a discreet numerical value that reflects the impairment.

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Impairment Tutorial: Rating Facial Disfigurement After an Injury

Guides Newsletter ◽

10.1001/amaguidesnewsletters.1998.julaug04 ◽

1998 ◽

Vol 3 (4) ◽

pp. 6-6

Author(s):

Marc T. Taylor

Keyword(s):

Current Work ◽

Workers Compensation ◽

Loss Of Function ◽

Facial Disfigurement ◽

Work Related ◽

Work Related Injury ◽

Compensation Claim ◽

Impairment Ratings

Abstract This article discusses two important cases that involve the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). First, in Vargas v Industrial Com’n of Arizona, a claimant had a pre-existing non–work-related injury to his right knee as well as a work-related injury, and the issue was apportionment of the pre-existing injury. The court held that, under Arizona's statute, the impairment from the pre-existing injury should be subtracted from the current work-related impairment. In the second case, Colorado courts addressed the issue of apportionment in a workers’ compensation claim in which the pre-existing injury was asymptomatic at the time of the work-related injury (Askey v Industrial Claim Appeals Office). In this case, the court held that the worker's benefits should not be reduced to account for an asymptomatic pre-existing condition that could not be rated accurately using the AMA Guides. The AMA Guides bases impairment ratings on anatomic or physiologic loss of function, and if an examinee presents with two or more sequential injuries and calculable impairments, the AMA Guides can be used to apportion between pre-existing and subsequent impairments. Courts often use the AMA Guides to decide statutorily determined benefits and are subject to interpretation by courts and administrative bodies whose interpretations may vary from state to state.

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Impairment Rating and Spinal Cord Injuries: Revisiting the Guides

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2010.mayjun01 ◽

2010 ◽

Vol 15 (3) ◽

pp. 1-7

Author(s):

Richard T. Katz

Keyword(s):

Spinal Cord ◽

Spinal Cord Injuries ◽

Functional Independence ◽

Outcome Data ◽

Multiple Organ ◽

Loss Of Function ◽

Sixth Edition ◽

Organ Systems ◽

Cord Injury ◽

Impairment Ratings

Abstract This article addresses some criticisms of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) by comparing previously published outcome data from a group of complete spinal cord injury (SCI) persons with impairment ratings for a corresponding level of injury calculated using the AMA Guides, Sixth Edition. Results of the comparison show that impairment ratings using the sixth edition scale poorly with the level of impairments of activities of daily living (ADL) in SCI patients as assessed by the Functional Independence Measure (FIM) motor scale and the extended FIM motor scale. Because of the combinations of multiple impairments, the AMA Guides potentially overrates the impairment of paraplegics compared with that of quadriplegics. The use and applicability of the Combined Values formula should be further investigated, and complete loss of function of two upper extremities seems consistent with levels of quadriplegia using the SCI model. Some aspects of the AMA Guides contain inconsistencies. The concept of diminishing impairment values is not easily translated between specific losses of function per organ system and “overall” loss of ADLs involving multiple organ systems, and the notion of “catastrophic thresholds” involving multiple organ systems may support the understanding that variations in rating may exist in higher rating cases such as those that involve an SCI.

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