AMA Guides - Sixth Edition: Evolving Concepts, Challenges and Opportunities Christopher R. Brigham, MD, MMS, FACOEM, FAADEP, CEDIR, CIME Senior Contributing Editor, AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition Chairman, Impairment Resources, LLC © 2011 Impairment Resources, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of Impairment Resources, LLC. AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. Table of Contents Learning Objectives ...................................................................................... 1 Seminar Director .......................................................................................... 2 Orientation .................................................................................................. 3 Chapter 1 - Conceptual Foundations and Philosophy ........................................ 10 Chapter 2 – Practical Applications of the Guides .............................................. 17 Chapter 3 - Pain-Related Impairment ............................................................ 20 Chapter 15 – The Upper Extremities .............................................................. 22 Chapter 16 - Lower Extremities .................................................................... 28 Chapter 17 – Spine and Pelvis ...................................................................... 32 Chapter 13 – Central and Peripheral Nervous System ...................................... 37 Chapter 14 – Mental and Behavioral Disorders ................................................ 39 Notes ........................................................................................................ 41 References ................................................................................................ 42 - 2 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. Learning Objectives As a result of this learning opportunity, you will be able to: 1. Discuss the International Classification of Functioning, Disability and Health (ICF) and its role in impairment evaluation. 2. Explain the reasons for revision of our prior approaches to impairment assessment. 3. Describe how to determine Diagnosis-Based Impairments, and make adjustments on the basis of the results of Functional History, Physical Examination, and Clinical Studies. 4. Demonstrate the ability to score Functional Inventories (including the QuickDASH, Lower Limb Outcome Scale, and Pain Disability Questionnaire). 5. Explain why methods used in previous editions (such as spinal range of motion assessment and strength determination) are no longer determinates. 6. Demonstrate the ability to rate most commonly rated disorders, including spinal pain, upper limb disorders (hand, wrist, elbow, shoulders and entrapments), lower limb disorders (foot / ankle, knee and foot), nervous system disorders, and pain. 7. Discuss challenges and opportunities associated with this evolution in impairment assessment. - 1 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. Seminar Director Christopher R. Brigham, MD is the Chairman of Impairment Resources, LLC. He is the Senior Contributing Editor for the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition, and was a contributor/author for several chapters, including Upper Extremities, Lower Extremities, and Spine. With the Fifth Edition, he served on the Advisory Committee and as a contributor. Dr. Brigham is Board-Certified in Occupational Medicine (ABPM), Founding Director of the American Board of Independent Medical Examiners (ABIME), Master Fellow, Academy of Independent Medical Examiners of Hawaii (AIMEH), a Fellow of the American College of Occupational Environmental Medicine (FACOEM), a Fellow of the American Academy of Disability Evaluating Physicians (FAADEP) with Certification in Evaluation of Disability and Impairment Rating (CEDIR), a Certified Independent Medical Examiner (CIME), a Certified Impairment Rater (CIR), and a graduate of the Washington University School of Medicine – St. Louis. He is the Editor of the AMA publications, The Guides Newsletter and The Guides Casebook. He was co-author of the text Understanding the AMA Guides in Workers’ Compensation, Third Edition, has written over two hundred published articles on impairment and disability evaluation and other texts, chaired the Medical Advisory Board for the Medical Disability Advisor, Fourth Edition, is featured in several video, audio, and web-based productions in the medicolegal field, and has trained thousands of physicians, attorneys, claims professionals, and fact-finders, throughout the US, Canada, and internationally. He is an experienced professional speaker. As a clinician with over thirty years experience, he has performed several thousand independent medical and impairment evaluations, providing him with excellent insight to the complexities of human potential, impairment, and disability. As a result of this experience, he has consulted for numerous organizations (including governmental jurisdictions). His curriculum vitae is available at http://www.impairment.com/PDFFiles/BrighamC_CV.pdf - 2 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. Orientation The American Medical Association’s Guides to the Evaluation of Permanent Impairment serves as the standard for defining impairment in most workers’ compensation, motor vehicle casualty and personal injury cases. The Sixth Edition1, published in December 2007, introduces new approaches to rating impairment, using innovative methodology to enhance the relevancy of impairment ratings, improve internal consistency, promote greater precision and simplify the rating process. The approach is based on a modification of the conceptual framework of the International Classification of Functioning, Disability, and Health (ICF),2 although the fundamental principles underlying the Guides remain unchanged. To appreciate the impact of the Sixth Edition, it is useful to understand the history and structure of the Guides, previous criticisms, and the new approaches used in the Sixth Edition. Case examples illustrate the appropriate application of the Sixth Edition. Use of the Guides The AMA Guides to the Evaluation of Permanent Impairment is the basis for defining impairment in the vast majority of workers’ compensation jurisdictions, and the use of the most recent Edition will be required immediately by certain state jurisdictions and for Federal and Longshore and Harbor Workers’ Act cases. The Guides started in 1958 with publication by the American Medical Association (AMA) of the article, “A Guide to the Evaluation of Permanent Impairment of the Extremities and Back”3; this was followed by additional guides published in the Journal of the American Medical Association. In 1971 a compendium of 13 guides became the First Edition.4 The Second Edition5 was published thirteen years later in 1984, with publication of the Third Edition6 in 1988. The Third Edition was the first to use the Swanson methodology7 which assigned discreet impairment ratings to specific range of motion (ROM) deficits of the upper extremities. Although the Third Edition was replaced two years later by the Third Edition, Revised8, which is still used by the State of Colorado for workers compensation cases, the use of ROM “pie charts” to assess impairment from upper extremity ROM deficits was retained. The Fourth Edition9, published in 1993, provided many refinements, including the Diagnosis- Related Estimates (DRE) or “injury” model for the evaluation of spinal injuries, alternative approaches to assessing lower extremity impairment, and a pain chapter. The DRE model was unique in allowing for assignment of an impairment rating based solely on the diagnosis, even if MMI had not yet been reached. The Fourth Edition is still used for assessing workers compensation cases in Alabama, Arkansas, Kansas, Maine, Maryland, South Dakota, Texas, and West Virginia. The Fifth Edition10, published in 2000, was nearly twice the size of its predecessor, provided more detailed directives in all chapters, and modified the approaches used for spinal impairment evaluation by providing guidance on choice of the rating method and providing ranges for Diagnosis-Related Estimates (DRE) categories. The Fifth Edition is used in California, Delaware, Georgia, Hawaii, Idaho, Iowa, Kentucky, Nevada, New Hampshire, North Dakota, Ohio, Vermont and Washington. The Sixth Edition represents this continued evolution in impairment evaluation. Many states require the use of the “most recent Edition” of the Guides either by statute or code; States using the Sixth Edition are Alaska, Arizona, Connecticut, Indiana, Louisiana, Massachusetts, Mississippi, Montana, New Mexico, Oklahoma, Pennsylvania, Rhode Island, Tennessee and Wyoming11. The most recent edition is also expected to remain the standard for automobile casualty and personal injury cases, both domestically and internationally. Some of the countries abroad that use the Guides include Australia, Canada, Hong Kong, Korea, New Zealand, and South Africa. - 3 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. The Sixth Edition is the new standard for all other cases. Federal workers' compensation laws cover all federal employees (including postal workers) and citizens of Washington, DC. Federal systems include Federal Employees’ Compensation Act (FECA), Energy Employees Occupational Illness Compensation Program Act, and Longshore and Harbor Workers’ Compensation Act (LHWCA). Under the Federal Employees’ Compensation Act (FECA 5 USC 8107) benefit is given for permanent impairment to specific body parts including extremities, hearing, vision, and loss of specific organs. Under the Longshore and Harbor Workers’ Compensation Act ratings are performed for “scheduled injuries” (e.g., a scheduled member of the body defined by section 8(c)(1)-(20) of the LHWCA).12 This includes upper extremity injuries (with the exception of the shoulder), lower extremity injuries, and hearing loss. The Guides are often used to quantify the extent of injuries resulting from an automobile casualty or personal injury. Insurers may use an impairment rating as one of the factors in determining the reserve or settlement value of a claim. Insurers and attorneys may use this as factor considered in quantifying the impact of an injury and the associated case value. In some states, suits under no-fault automobile insurance are limited to cases where a specific defined impairment threshold has been met; in these states the Guides play an important role in providing numerical data to indicate that the threshold has indeed been met. In Florida, as an insured’s claims for pain and suffering are subject to limits as a basis for recovery outside the automobile no-fault system the Guides are used to define permanent loss. The Guides impairment ratings are used in different ways, depending on the type of case and the jurisdiction. Although impairment is a different concept than disability, some jurisdictions use impairment as a proxy for the latter, while others use the impairment rating value in a formula that results in a disability rating. Still other jurisdictions are similar to motor vehicle insurers in using the impairment value as a threshold indicator for a more serious injury or illness. Challenges and Criticisms of Prior Editions There are many challenges associated with the use of the Guides, including criticisms of the Guides themselves, the use of impairment rating numbers, and a high error rate.13 14 15 16 17 18 19 20 Previous criticisms include:  Failure to provide a comprehensive, valid, reliable, unbiased, and evidence-based rating system.  Impairment ratings did not adequately or accurately reflect loss of function.  Numerical ratings were more the representation of “legal fiction than medical reality.” Therefore, the following changes were recommended:  Standardize assessment of Activities of Daily Living (ADL) limitations associated with physical impairments.  Apply functional assessment tools to validate impairment rating scales.  Include measures of functional loss in the impairment rating.  Improve overall intrarater and interrater reliability and internal consistency. Studies have demonstrated poor inter-rater reliability and revealed that many impairment ratings are incorrect, more often rated significantly higher than appropriate.21 While treating physicians, who by definition are advocates for their patients, have been particularly prone to overrate impairment, physicians who have not been adequately trained in the use of the Guides also commonly provide erroneous ratings, with it more common for rating errors to increase rather than decrease ratings. - 4 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. Sixth Edition Approaches and Developmental Process The Guides defines the process for evaluating impairment. Clinical discussions among physician colleagues regarding potential severity of an illness or injury typically involve four basic points of consideration: 1) What is the problem (diagnosis)? 2) What symptoms and resulting functional difficulty does the patient report? 3) What are the physical findings pertaining to the problem? 4) What are the results of clinical studies? In a similar manner, these same basic considerations are used by the physicians to evaluate and communicate about impairment, although, given the use of ratings as the basis for monetary awards, physicians are always cognizant of the need to be certain that subjective and other objectively nonquantifiable aspects of the clinical presentation are consistent with both the diagnosis and the patient’s objective findings. The Sixth Edition expands the spectrum of diagnoses recognized in impairment rating, considers functional consequences of the impairment as a part of each physician’s detailed history, refines the physical examination, and clarifies appropriate clinical testing. International Classification of Functioning, Disability and Health The Sixth Edition uses the framework based upon the International Classification of Functioning, Disability and Health (ICF), a comprehensive model of disablement developed by the World Health Organization. This framework, illustrated in Figure 2, is intended for describing and measuring health and disability at the individual and population levels. The ICF is a classification of health and health related domains that describe body functions and structures, activities and participation. The domains are classified from body, individual and societal perspectives. The ICF systematically groups different domains for a person in a given health condition (e.g. what a person with a disease or disorder does do or can do). Functioning is an umbrella term encompassing all body functions, activities and participation; similarly, disability serves as an umbrella term for impairments, activity limitations or participation restrictions. Since an individual's functioning and disability occurs in a context, the ICF also includes a list of environmental factors. Figure 2. ICF Model of Disablement - 5 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. The following definitions are used in the ICF to facilitate communications and standardization:  Body functions: physiological functions of body systems (including psychological functions).  Body structures: anatomic parts of the body such as organs, limbs, and their components.  Activity: execution of a task or action by an individual.  Participation: involvement in a life situation.  Impairments: problems in body function or structure such as a significant deviation or loss.  Activity limitations: difficulties an individual may have in executing activities.  Participation restrictions: problems an individual may experience in involvement in life situations. The ICF model reflects the dynamic interactions between an individual with a given health condition, the environment, and personal factors. Impairment, activity limitations and limitations in participation are not synonymous; an individual may have impairment and significant limitations in most activities but be able to participate in a specific life situation of relevance, have minor impairment and activity limitations with inability to participate in a specific life situation, or any permutation of these three factors. Use of the ICF model does not indicate that the Guides will now be assessing disability rather than impairment. Rather, the incorporation of certain aspects of the ICF model into the impairment rating process reflects efforts to place the impairment rating into a structure that promotes integration with the ICF constructs for activity limitations and limitations in participation, ultimately enhancing its applicability to situations in which the impairment rating is one component of the “disability evaluation process”. - 6 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. Impairment Classes and Diagnosis-based Grids The ICF classification uses five impairment classes, which permits rating of patients who range from having no problems to having significant problems. In the Sixth Edition “diagnosis-based grids” were developed for each organ system. These grids use commonly accepted consensus-based criteria to classify most diagnoses relevant to a particular organ or body part into five classes of impairment severity ranging from Class 0, normal, to Class 5, very severe. The final impairment is determined by adjusting the initial impairment rating given by factors that may include physical findings, the results of clinical tests, and functional reports by the patient. The basic template of the diagnosis-based grid is common to each organ system and chapter; therefore although there is variation in the ancillary factors used to develop the impairment rating (depending on the body part), there is greater internal consistency between chapters than was seen formerly. This uniform diagnosis-based approach is a significant change from the anatomical approach that was the primary approach with many previous musculoskeletal assessments. However, there are similarities to other approaches used in the Fourth and Fifth Editions. For example, as mentioned previously, spinal impairment assessments have typically been based on the Diagnosis-Related Estimates Method, with specific findings or diagnoses used to assign the patient to a category. In the Fifth Edition the patient is assigned to one of five categories, with the first category having no ratable impairment and the other four categories having four possible impairment values. Thus, a patient with a lumbar radiculopathy would be assigned to a DRE Lumbar Category III which would lead to a whole person impairment rating of between 10% and 13% using the Fifth Edition (choice of a level is based upon the examiner’s judgment regarding limitations in activities of daily living (ADLs) as a result of the impairment). Although the Fourth Edition also used the DRE system, there was not an allowance for variation in the impact of a given diagnosis upon ADLs so the rating for Category III was fixed at 10% whole person permanent impairment. Likewise, although lower extremity impairments had been based on thirteen possible approaches in the Fifth Edition, the most commonly used approach is the Diagnosis-Based Estimates where specific impairment values are provided for diagnoses. For example, a patient with a partial medial meniscectomy is assigned 1% whole person permanent impairment. Rating systems previously used for the lower extremity likewise did not provide for adjustments based on functional difficulties, physical examination findings, or the results of clinical studies. The Preface to the Sixth Edition states that the features of the new edition include 22:  A standardized approach across organ systems and chapters.  The most contemporary evidence-based concepts and terminology of disablement from the ICF.  The latest scientific research and evolving medical opinions provided by nationally and internationally recognized experts.  Unified methodology that helps physicians calculate impairment ratings through a grid construct and promotes consistent scoring of impairment ratings.  A more comprehensive and expanded diagnostic approach.  Precise documentation of functional outcomes, physical findings, and clinical test results, as modifiers of impairment severity.  Increased transparency and precision of the impairment ratings.  Improved physician interrater reliability. The Sixth Edition reflects movement toward these features; however such change will not be immediately achieved. Thus it should be considered a step in the evolution of the Guides rather than as an end point in and of itself. Development Process The Sixth Edition process involved many participants – including physicians who use the Guides and the staff of the AMA, all of whom were tasked to develop the Sixth Edition in the context of the aforementioned principles. The process was guided by an Editorial Panel and an Advisory Committee, and features an open, well-defined, and tiered, peer review process. The Editorial Panel was established to include a Medical Editor (Robert Rondinelli, MD), five Section Editors (Elizabeth Genovese, MD, Richard Katz, MD, Kathryn Mueller, MD Mohammed Ranavaya, MD, and Tom Mayer, MD), a Senior Contributing Editor (Christopher R. Brigham, MD), and four core Editorial Staff members. The editorial process used an evidence-based foundation when possible, primarily as the basis for determining diagnostic criteria, and a Delphi panel approach to consensus building regarding the impairment ratings themselves. When there was not a compelling rationale to alter impairment ratings from what they had - 7 - www.impairment.com AMA Guides Sixth Edition: Evolving Concepts, Challenges and Opportunities © 2011 Impairment Resources, LLC All rights reserved. been previously, consistency of the ratings with those provided in prior editions was the default. The Section Editors led a group of 53 specialty-specific, expert contributors in developing the chapters and in conjunction with the Senior Contributing Editor wrote considerable portions of the revised chapters. The review process involved over 140 physicians, attorneys and other professionals. An Advisory Committee was developed to provide ongoing discussion of items of mutual concern and current issues in impairment and disability. The group is comprised of numerous representatives from medical specialty societies and experts from certification and teaching organizations and workers’ compensation systems. The primary objectives of the Advisory Committee were:  Serve as a resource to the Guides Editorial Panel by giving advice on impairment rating as relevant to the member’s specialty.  Provide documentation to staff and the Editorial Panel regarding the medical appropriateness of changes under consideration for inclusion in the Guides.  Assist in the review and further development of relevant impairment issues and in the preparation of technical education material and articles pertaining to the Guides.  Promote and educate its membership on the use and benefits of the Guides. Sixth Edition Structure The Sixth Edition is 634 pages in length and is comprised of 17 chapters; it is similar in length to the Fifth Edition (613 pages) and has one less chapter since the Cardiovascular System is now a single chapter. Chapter 1, Conceptual Foundations and Philosophy and Chapter 2, Practical Applications of the Guides define the overall approaches to assessing impairment. Most impairment ratings are performed for musculoskeletal painful conditions; therefore the most commonly used chapters will be Chapter 15, The Upper Extremities, Chapter 16, The Lower Extremities, and Chapter 17, The Spine and Pelvis. Chapter 3, Pain-Related Impairment, Chapter 13, The Central and Peripheral Nervous System and Chapter 14, Mental and Behavioral Disorders will also be frequently referenced. Chapters 4 to 12 focus on other organ systems and structures. A comparison of chapters and length is presented in Table 1. Table 1. Comparison of AMA Guides Chapters: Fourth, Fifth and Sixth Editions Sixth Edition Fifth Edition Fourth Edition Chapter Title Length Chapter Length Chapter Length 1 Conceptual Foundations and Philosophy 18 1 15 1 6 2 Practical Application of the Guides 12 2 8 2 6 3 Pain 16 18 28 15 12 4 Cardiovascular System 30 3, 4 62 6 32 5 Pulmonary System 24 5 30 5 16 6 Digestive System 28 6 26 10 14 7 Urinary and Reproductive System 30 7 30 11 14 8 Skin 24 8 18 13 14 9 Hematopietic System 30 9 22 7 8 10 Endocrine System 34 10 34 12 14 11 Ear, Nose, Throat, and Related Structures 34 11 32 9 12 12 Visual System 40 12 28 8 14 13 Central and Peripheral Nervous System 26 13 52 4 14 14 Mental and Behavioral Disorders 36 14 16 14 12 15 Upper Extremities 110 16 90 3.1 60 16 Lower Extremities 64 17 42 3.2 19 17 Spine 46 15 60 42 Total Pages 602 593 309 The most significant change with the Sixth Edition is the development of Impairment Classification Grids based on the ICF model. To appreciate the overall impact of the Sixth Edition it is helpful to summarize the chapters most often referenced, the first two chapters, the musculoskeletal chapters, and the chapters on the nervous system and mental and behavioral disorders. - 8 - www.impairment.com