2.  Objectives › Understand changes in 5 th and 6 th editions of the Guides › Understand how impairments are rated using the 6 th edition of the Guides › Be able to calculate simple ratings › How to critically read and evaluate an impairment rating › Identify common errors in ratings › Accurately and thoroughly represent the Guides, not my opinions

3.  OUTLINE › Define impairment › Brief history › Differences in content › Differences in application › Changes/clarifications/corrections › Present a case  5 th v 6 th editions  Disc terminology, bulge v herniation  Treatment of disc herniations  Physical examination  ROM  Waddel’s signs  Rate an impairment

5.  Impairment evaluation: › Medical evaluation performed by a physician using the Guides to determine impairment › Treating or non-treating › Assessment of individual medical condition and its effect on function

6. IImpairment ›A›A loss or loss of use or derangement of a body part, organ system, or organ function from its preexisting level. IImpairment rating: ›E›Estimate of the degree to which the impairment decreases the individuals ability to perform ADL’s –NOT WORK ACIVITIES. ›A›Assess functional limitation/loss – NOT DISABILITY ›“›“Consensus-derived percentage estimate of loss of activity reflecting severity for a given health condition, and the degree of associated limitations in terms of ADLs”

7. “I read somewhere that 77 per cent of all the mentally ill live in poverty. Actually, I'm more intrigued by the 23 per cent who are apparently doing quite well for themselves.”

8.  6 th edition released late 2007  5 th edition released 2001  First published in book form in 1971  Studies v Expert Consensus Opinion  NOT ALL conditions/problems are addressed in the Guides

9.  Cardiovascular- Heart and Aorta  Cardiovascular- Arteries  Respiratory system  Digestive system  Urinary and reproductive systems  Skin  Blood/Hematological  Endocrine system  ENT  Vision  Central and Peripheral nervous system  Mental and Behavioral  Spine  Upper extremities  Lower extremities  Pain

10.  Cardiovascular  Pulmonary system  Digestive system  Urinary and reproductive systems  Skin  Blood/Hematological  Endocrine system  Ear, nose and throat  Visual system  Central and Peripheral nervous system  Mental and Behavioral  Upper extremities  Lower extremities  Spine and pelvis

11.  Reasons to update the Guides 5 th edition › New medical data › Function and Impairment › World Health Organization’s International Classification of Functioning (ICF) › Reduce ambiguity › Increase consistency between chapters › Increase consistency between raters › Statement of principals

12.  Differences in content › Causation › Apportionment › Cultural differences › Pain chapter › Mental and Behavioral › “Constitution” of the Guides

13.  The concepts in this chapter are the fundamental principals of the Guides; they shall preempt anything in subsequent chapters that conflicts with or compromises these principals.  No impairment may exceed 100% whole person impairment. No impairment of arising from a member or organ may exceed the amputation value of that member.  All regional impairments in the same organ or body system shall be combined at the same level first and then combined by regions then whole person.  Impairments must be rated in accordance with the chapter relevant to the organ or system where the injury primarily arose or where the greatest dysfunction consistent with then objectively documented pathology remains.  Only permanent impairment may be rated according to the Guides, and only after Maximum Medical Improvement is certified  A licensed physician must perform impairment evaluations. Chiropractic doctors, if authorized by the appropriate jusridictional authority to perform rating under the Guides, should restrict rating to the spine.  A valid impairment evaluation report based on the Guides must contain the 3 step approach described in section 2.7  The evaluating physician must use knowledge, skill and ability generally accepted by the medical scientific community when evaluating an individual, to arrive at the correct impairment rating according to the Guides.  The Guides is based on objective criteria. The physician must use all clinical knowledge, skill and abilities in determining whether measurements, test results, or written historical information are consistent and concordant with the pathology being evaluated. If such findings, or an impairment estimate based on these findings, conflict with established medical principals, they cannot be used to justify an impairment rating.  Range of motion, and strength measurement techniques should be assessed carefully in the presence of apparent self- inhibition secondary to pain and fear.  The Guides do not permit the rating of future impairment.  If the Guides provides more than one method to rate a particular impairment or condition, the method producing the higher rating must be used.  Subjective complaints alone are generally no ratable under the Guides (see chapter 3 for potential exceptions).  Round all fractional impairment ratings, whether intermediate or final, to the nearest whole number.

15.  Changes/clarifications/corrections › Sample report › Pain disability questionnaire › Cardiovascular › Pulmonary › Urology › Visual › Psyche › Upper extremity › Lower extremity › Spine

16.  http://www.ama-assn.org/go/amaguidessixthedition-errata http://www.ama-assn.org/go/amaguidessixthedition-errata  Guides6@ama-assn.org Guides6@ama-assn.org › Print request: Guides 6 th edition Clarifications and Corrections › Name, Mailing address

18.  Differences in application › Utilization of ‘Uniform Template’ › “Key Factors” › ‘Class’ of injury › Default ratings › “Non-key Factors”  Objective tests, clinical studies/labs  Physical exam findings  Functional assessments

23.           ‘  ’   ‘  ’           

24. Ernesto from Bolivia US 7 years, married to US citizen Fell off forklift from ~12 feet › Low back – L4-5 disc herniation, persistent R foot weakness, pain in Right lower extremity › Shoulder – Full thickness rotator cuff and labral tear, surgically repaired, pain with certain movements. › Previous low back injury 18 months ago.  Treated with PT, released to full duty, occasional lumbar and radiating pain

28.  Determine “KEY FACTOR” › Review medical records › Interview examinee › Physical exam › Diagnoses

29.  Is there a category for each KEY FACTOR?  Is there more than one way to rate that KEY FACTOR?

36. Fardon: Spine, Volume 26(5).March 1, 2001.E93-E113

37. Herniation = Bulge? Herniation ≠ Bulge?  Herniation has both specific and general meanings  The Guides do not indicate nomenclature they use  Radiologists do not necessarily follow standards

38. Fardon: Spine, Volume 26(5).March 1, 2001.E93-E113

41. Are there any other “Key Factors”?

42. Maximum Medical Improvement

44.  How severe is the KEY FACTOR?  Identify the CLASS for each KEY FACTOR › 0 - no symptoms › 1 - mild or intermittent symptoms, controlled with medications › 2 – constant mild symptoms, intermittent moderate symptoms despite ongoing treatment › 3 – constant moderate symptoms, intermittent severe symptoms, despite ongoing treatment › 4 – constant severe symptoms, intermittent extreme symptoms, despite ongoing treatment

46.  Adjustments for non-key factors › Functional history  Pain during activity  Medications  Disability questionnaire › Physical examination  ROM  Atrophy  Alignment  Strength  Palpatory findings › Clinical studies  Imaging  Electrodiagnostic studies

58.  Apportionment › What is apportionment › When is it needed › “Apportionment is an allocation of causation among multiple factors that caused or significantly contributed to the injury or disease and resulting impairment”

59.  Apportionment calculation: › Calculate the current impairment › Calculate what impairment existed at the moment of the current event, based on best available data. › Deduct the prior impairment from the current impairment (Total Impairment) – (Previous Impairment) = Final Impairment › Requires accurate data › Same method › Explain reasoning

62.  Combining › Multiple impairments in different systems? Combine using combined values chart › Multiple impairments in the same region? Choose most impairing, but can be combined if the most impairing diagnoses does not adequately reflect the loss. › Multiple impairments, same system but different parts/regions? Combine using combined values chart › Multiple impairments based on range of motion losses? Add values for ROM loss are added? Choose most impairing, but can be combined if the most impairing diagnoses does not adequately reflect the loss. › All percentages being combined must be in same units (UEI, WPI)

67. [ ] Name, demographic and/or identifying information [ ] History of the event [ ] Mechanism of injury, date of onset [ ] Course of illness [ ] Symptoms initially [ ] Previous examination findings (at time of initial diagnosis, if available) [ ] Treatment and responses to treatment [ ] diagnostic studies and their results [ ] Social history [ ] Work history [ ] Past medical/surgical history [ ] Current status [ ] Current symptoms [ ] Aggravating or relieving factors [ ] Locations of symptoms [ ] Review of systems [ ] Physical exam findings [ ] Current treatment/medications [ ] Impairment rating [ ] MMI status [ ] Examiner’s diagnosis and rating [ ] Explanation (page or table referenced, how calculations were made) [ ] Apportionment (if applicable, calculations, reasoning) [ ] Restrictions [ ] Treatment recommendations [ ] Diagnostic recommendations IMPAIRMENT RATING EVALUATION

68. Richard Radnovich, D.O. dr.radnovich@injurycaremedical.com

69.  Summary › Impairment ratings measure loss of function, not disability › Get corrected pages › Ratings are used provide consistency › Do not assume that the impairment rating is correct › Do not be afraid to calculate simple ratings › Check combined numbers