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California Workers Compensation Impairment & Disability Rating Specialists |
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Luis
Pérez-Cordero |
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Craig A. Lange |
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Voice:
(415) 861-4040 / Bay Area Fax:
(415) 276-3741 Central Valley Fax:
(916) 848-3582 / Southern California Fax:
(619) 374-7334 California Workers Compensation Consistency of AMA Impairment Evaluation & Reporting: Part I: Upper Extremities A California Permanent Disability Rating starts with the
evaluating physician’s impairment rating in accordance with the medical
evaluation protocols and rating procedures set forth in the 5th
Edition of the AMA Guides. This
initial component is then ‘adjusted’
into a permanent disability rating to account for diminished future earning capacity
and the occupation and age of the injured employee at the time of the injury.
These components of the rating formula are found on the Schedule for Rating
Permanent Disabilities (PDRS). Chapters 3 to 17 of the AMA
Guides outline how imaging studies, signs and appropriate test results
support the use of not only Diagnosis Related/Based Estimates (DRE) or (DBE)
but of the distinct percentages for objective manifestations of
impairment. Yes, the AMA Guides emphasize
impairment ratings based on objective assessment but it also considers
subjective symptoms within the diagnostic criteria and support of an
impairment percentage. Chapter 18
specifically deals without situations above and beyond the effects of pain on
Activities of Daily Living (ADL). A whole person impairment rating based on the body
or organ rating system of the AMA Guides (Chapters 3 through 17) may be increased by
up to 03% WPI if the burden of the worker’s condition increases by
pain-related impairment in excess of the pain component already incorporated
in the WPI rating in Chapters 3 to 17. AMA 5th Ed., page 573 & 2005 PDRS, page
1-12. The fragmentation into 18 Chapters, of impairment
calculating rating criteria, might lead some users to believe that there are
no common rating principles applicable to any and all disabilities. Principles for determining impairment
values for ROM, DRE, DBE and the avoidance of duplication appear recurrently
from chapter to chapter. Rating
principles previously found in the 97PDRS, i.e., interpolation, rounding,
avoidance of duplication/pyramiding, combination of disabilities, etc. are
first addressed in Chapters 1 and 2.
Chapters 3 to 17 build on this foundation and expand these principles
as related to the specific body parts or organ systems. For both the upper and lower extremities,
the AMA Guides carries the concept of prior PD Schedules: that impairment
manifestations cannot exceed the value of amputation. Section 7 of the 05PDRS provides examples
and strengthens the concept in the description of the proper determination of
California impairment-to-disability. One thing is very clear by the requirements of both
the AMA Guides & California Code of Regulations - Evaluating Physician
must explain how the impairment was calculated. Attaching a computer generated report
and/or worksheets does not replace the California requirements that
determination of any impairment level must follow the AMA Guides established
evaluation criterion and be explained by a well-reasoned/rational medical
opinion. Evaluating
Physician must not fail to discuss how specific findings relate to and
compare with the applicable rating criteria used to determine impairment -
especially how impairment is determined with missing and/or limited data. AMA
5th Ed., Section 2.6b,page 22. Page 1 of 6 |
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Consistency of AMA Impairment Evaluation &
Reporting Part I: Upper Extremities Imaging study findings and unsupported
subjective complaints are worthless without a clinical correlation at the
time of examination. Symptoms
and complaints without integration to objective data (by the evaluating
physician) should not serve as the sole criterion upon which decisions about
impairment are made. General guidelines for the description and correlation
of any imaging or diagnostic can be found on AMA 5th Ed., page
378. AMA Guidance for
addressing the issues of causation, aggravation and apportionment, which
should be considered if the vocational causation is responsible for an
aggravation of symptoms, are found in AMA pages 10, 11 and 12. (Physician must also be aware of SB 899
apportionment requirements.) The report must show that the evaluating physician
has considered avocational factors, findings and symptomatology independent
of the permanent disability due to vocational causation. The evaluating physician
provides a well-reasoned opinion based on the review of the medical
records/history and considers pre-existing objective pathology,
symptomatology, work limitations secondary to pre-existing disability,
including time off from work or need for treatment. In determining an overall
level of impairment evaluating physician should always address the following
question: If it were not for the non-vocational factors or pre-existing
conditions, would this level of impairment exist? Consistency is the key word when addressing
impairment in a California P&S report.
Consistency of imaging studies, to clinical findings on examination,
to the medical/treatment histories, to the impairment rating criteria of the
AMA Guides and to a reasoned medical opinion. Vocational Rehabilitation To determine
if the employee’s need for job modifications are truly based on an objective
clinical foundation, the evaluating physician must analyze vocational task
and provide and explanation of the impact of the medical impairment on
vocational activities. Any
determination of need for job modifications or QIW status requires a
demonstrable foundation of clinical signs or other independent measurable
abnormalities. Emphasizing residual capacity over activity
limitations the physician determines the bases for any limitation of
activities as supported by objective measurable and clinical
information. Careful consideration
must be given to the concepts of physical harm, current ability and perceived
or actual tolerance for the inability to perform vocational activities.
Physician should not lightly ‘preclude’ activities and functional loss not
supported by an appropriate impairment level. Some questions to consider: ·
Risk (Harm): Q: Do the work activities pose a ‘substantial risk’
of significant harm to self or others?
Risk is not an increase in previously present symptoms like pain or
fatigue. ·
Capacity – Current Ability: Q: Is EE physically able to perform essential job
functions? Q: Are current strength, flexibility &
endurance levels up to capacity, or are current abilities reduced due to
deconditioning? ·
Tolerance -
Ability to Endure sustained work activities. Q: Able to do
specific tasks? Variable comfort level? Q: If any, what
pychophysiological factors are affecting the individual’s ability to tolerate
greater levels of subjective symptomatology? Job modifications or vocational rehabilitation must
be substantiated by realistic facts and findings suitably identified in the
formulation of the reasoned/logical medical opinion. The word ‘prophylactic’ can no longer be
the proper support for job restrictions or modifications. Page 2 of 6 |
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Consistency of AMA Impairment Evaluation &
Reporting Part I: Upper Extremities Its use is not objective evidence capable of proving/disproving impairment or disability. It only serves to disguise the lack of material findings and in turn create the facade of ‘reasonable medical probability.’ It’s never been valid reason, as required by WCAB § 10606 (f) (f) (i) (k) (m) (n), for the support of impairment, disability or work modifications. Upper
Extremities 1. It is the physician's
responsibility to: (1) include a relevant description of body habitus and any general
observations such as a limp, obvious discomfort while sitting/standing, etc.,
(2) evaluate all joints on an injured extremity (if measurements or
observations are normal physician should simply state “normal”), (3) include the voluntary active arc of
motion of the injured over the un-injured and appropriate circumferential
measurements of the involved muscle groups (evaluating physician should also
record abnormal, excessive or limited range of motion,
including ankylosis). AMA 5th Ed., Chapter 16, page 433. 1.1.
Impairment is based on examiner’s actual findings. (AMA
pg. 435) 1.2.
Impairment evaluation must address abnormal ROM, Ankylosis,
Amputation, Peripheral Vascular & Nerve System and other disorders. (AMA pg. 435) 1.3.
ROM Assessment requires that both extremities be compared and
individual joints be evaluated separately. Active Motion measurements take
precedent. (AMA pg. 451) 1.4.
If an individual has previous measurements of function that were
below or above average population values, physician may discuss the prior
values and any subsequent loss for the individual based on the physician’s
estimate of the individual’s pre-injury capacity. 1.5.
If a contra lateral ‘normal’ joint has a less than average mobility,
the impairment value(s) corresponding to the uninvolved joint can serve as a
baseline and are subtracted rom the calculated impairment for the ‘injured’
joint. (AMA pg.453) 1.6.
Physician needs to validate the reasons for the
restrictions of ROM and provide a complete a detailed examination of the
upper extremities. (AMA pg 435) 1.7.
Clearly state if the active motion recorded is ‘normal’ for the
individual, even when less than ‘estimated normals’. 1.8.
If restriction of motion is present, evaluating physician must
comment on the reason why; pain, muscle spasm, voluntary restriction, etc. Gentle passive range of motion may be
performed in addition to active range of motion to determine whether the
restriction is due to pain or mechanical block. 2.
Peripheral Nerve Abnormalities is based on the anatomic distribution and
severity of loss of functions resulting from (1) sensory deficits or pain and
(2) motor deficits and loss of power. Sharon (AMA pg. 481). Without CRPS, abnormal ROM values are
not added to peripheral nerve lesions. 3.
Entrapment/Compression Neuropathies are rated when an
objective verifiable diagnosis is present, supported by positive clinical
findings and loss of function. Documentation requires Nerve Conduction
Studies & EMG studies (AMA pg. 493).
Additional impairment values are not given for decreased grip
strength. (AMA pg. 494) 4.
Vascular Disorders are only considered when objective testing
establishes the presence of obstructive physiology. (AMA pg. 497) Page 3 of 6 |
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Consistency of AMA Impairment Evaluation &
Reporting Part I: Upper Extremities 5.
Bone & Joint Disorders, resection or implant arthroplasty,
musculo-tendinous disorders and loss of strength are used when the impairment
criteria addressed on 1.13 to 1.16 have not adequately encompassed the extent
of the impairment (AMA pg. 499). Evaluating
physician must be aware of the overlapping pathomechanics inherent among
these conditions and closely follow the impairment evaluation criteria to
avoid duplication of impairment. 6.
Skin Disorders, including disfigurement, scars and skin grafts,
are evaluated using criteria in AMA Guides, Chapter 8. 7.
Grip/Pinch & Strength: Decreased strength cannot be rated in the
presence of (1) decreased motion, (2) painful
conditions, (3) deformities or (4) amputations, since they prevent
effective application of maximal force in the region being evaluated. AMA 5th Ed., pages 508 to 510 7.1.
When the reduction of dynamometer readings is due to decreased
motion, painful conditions, deformities or absence of parts, decreased
strength is not a valid anatomic impairment factor in which to base any work
capacity functional loss - other objective anatomic findings take
precedent. (AMA 5th Ed., pg.508).
7.2.
When dynamometer measurements are taken, if maximum effort is
exerted, the data obtained will follow a bell curve. With maximum exertion/strength being
greatest near the mid point. If
upper extremity pain is present, strength may be decreased, but the bell
curve pattern should be evident. 7.3.
The use of dynamometer readings that have been affected by other
disability factors such as pain, limitations of motion, muscle weakness,
musculature atrophy, deconditioning, pain, lack of full effort or voluntary
restriction, etc., creates an unrealistic result and produces a greater
amount of Permanent Disability than actually exists. 7.4.
With the proper measurable/clinical finding and abiding to the AMA
calculating criteria, physician can refer to Tables 16-31 & 16-32. The physician also must: 7.4.1.
Use unaffected or un-injured arm measurements, when
rating a single extremity. 7.4.2.
Repeat tests at least 3 times, at different points
during the examination. 7.4.3.
Validate that there is no a variance greater than
20% in the tests results. 7.4.4.
Assess consistency of effort by plotting out the
grip strength measurements at the five hand settings, or testing using the
rapid exchange technique. 7.5.
”Several syndromes involving the upper extremity are attributed to
tendinitis, fasciitis or epicondylitis. The most common of these are the stubborn
conditions of the origins of the flexor and extensor muscles of the forearm
where they attach to the medial and lateral epicondyles or the humerus. Although these conditions may be
persistent for some time, they are not given a permanent impairment rating unless
there is some other factor that must be considered.” (Objective
measurable or clinical factor – not pain.) AMA 5th Ed., page 507 7.6.
Impairment
ratings considering these syndromes (tendinitis) are only given an
impairment rating: 7.6.1.
If there is
another objective impairment present, i.e., ROM, 7.6.2.
The Syndrome
was treated surgically 7.6.3.
The condition
was caused by an underlying impairment such as tendon rupture. Page 4 of 6 |
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Consistency of AMA Impairment Evaluation &
Reporting Part I: Upper Extremities 7.7.
Manual Muscle Testing for Elbow/Shoulder Strength Deficits 7.8.
Addresses ability to move a joint through a full ROM against gravity,
or move it against additional resistance applied by the examiner. AMA 5th
Ed., 509. (Table 16-35, page 510).
Many of the AMA Guides concepts are not new
to California Workers Compensation.
Both the Labor Code, The California Code of Regulations and a
multitude of cases have defined basic concepts, which continue to help us
understand the standards of what constitutes substantial medical evidence on
a California P&S medical report. In a recent article at
workcompcentral, the Honorable WCAB
Judge Pamela W. Foust states: California Evidence Code section 140
defines the term, evidence, as "testimony, writings, material objects,
or other things presented to the senses that are offered to prove the
existence or nonexistence of a fact." The phrase, substantial evidence,
does not appear in the Evidence Code but definitions can be found in the case
law. Probably the most widely accepted definition of substantial evidence is
relevant evidence that a reasonable person might accept as adequate to
support a conclusion. Page 5 of 6 |
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Consistency of AMA Impairment Evaluation &
Reporting Part I: Upper Extremities Notwithstanding these considerations, substantial evidence is
simply evidence that is believable. At the extreme ends of the spectrum, the
concept will be easy to apply. If any reasonable person could read a medical
report and find the doctor's conclusion to be persuasive, that's substantial
evidence, assuming the report is based on accurate facts. On the other hand,
if the doctor's opinion would insult the intelligence of any reasonable
person or elicit the reaction that it could only happen this way on a cold
day in hell, the report is not substantial evidence. ·
LC§ 4620 – Medical Legal Report must be capable of proving/disproving a
disputed medical fact. In determining whether a report meets the requirements
of the subdivision, a WCAB Judge shall give full consideration to the substance,
as well as form of the report as required by applicable statues and
regulations. “A worker’s compensation judge’s determination based
on a medical report that is just a string of unsubstantiated conclusions is
no better than judicial dart-throwing. For the medical report to be usable,
it should clearly explain how the medical conclusions are reached and in a
way that someone who is not a medical expert can understand.” – Honorable
Alan Eskenazi, WC Judge. Minimal Standards: Factual History, Medical
History, Medical Examination, Reasoned Opinion (the opinion must address the
disputed issues). “Where the
physician addresses the disputed medical facts, applies the case facts, applies
his expertise, and renders a rational opinion, then the expert medical
opinion has ‘probative value’ to assist the court to resolve disputed
issues.” - Honorable W. Ordas & N S Udkovick, WC Judges ·
8 CCR § 10606 - The medical report must be clear as to any loss of work capacity,
be it objective physical findings, disabling effects of pain, work
restrictions or a percentage of pre-injury capacity functional loss. If there is no residual impairment
(disability) the report should state so.
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8 CCR § 9793 (c) – “Comprehensive Medical-Legal Evaluation” means an
evaluation of an employee which {a} results in the preparation of a narrative
medical report prepared and attested to in accordance with LC§ 4628,
any applicable procedures promulgated under LC§ 139.2 and the
requirements of 8 CCR § 10606, and {b} is either performed by a (QME), (AME), or (PTP). ·
‘Pass Through’
Reports - “ The physician has not
bothered to perform any reasoned analysis at all. There are merely
unsupported conclusions with no basis.
In this type of report usually one or two sentences of ‘conclusions’
[reasoned medical opinion?] are usually hallmarked by having no factual or
medical reasons expressed for the conclusion.” Honorable W.
Ordas & N S Udkovick, WC Judges New court decisions are sure to come; but guiding criteria can still
be found in the following cases: ·
Le
Vesque vs. WCAB (1970) 1 Cal. 3d 627, 35 CCC 16 ·
Hegglin
vs. WCAB (1971) 4 Cal 3d 162, 36 CCC 93.
·
Minniear
vs. Mt. San Antonio Community College District (1996) SBR257801, Cal. Comp
Cases 1055 ·
Kuelen
vs. WCAB (1998) 66 Cal. App. 4th 1089,1096 ·
Boyd
v. WCAB (1997) 62 CCC 498 ·
Rachel Daly v. WCAB, Stanford Hospital 5 WCAB
Rptr. 10,022 Luis
Pérez-Cordero Craig
Andrew Lange Impairment &
Disability Rating Specialists Tuesday, September 13, 2005 Page 6 of 6 |