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California Workers Compensation Impairment & Disability Rating Specialists |
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Luis Pérez-Cordero / pdrating@pacbell.net |
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Craig A. Lange / craiglange@pacbell.net |
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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 |
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Consistency of AMA Impairment Evaluation &
Reporting: Part II: Lower 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. 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. It also considers subjective symptoms within the diagnostic
criteria in support of an impairment percentage. Chapter 18 specifically deals with those 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. 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. 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. A computer program calculating impairment is not a replacement for
a reasoned medical opinion and the measurable factors & findings
necessary to determine how the impairment rating was calculated. AMA 5th Ed., Section 2.6,
pages 21 to 22. 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
subjective complaints, to the impairment rating criteria of the AMA Guides
and to a reasoned medical opinion. 1. Lower
Extremities evaluation criteria: AMA 5th Ed., Chapter 17, page 523. 1.1.
The lower extremities are evaluated on the basis of anatomic
changes, Diagnostic Based Estimates (DBE), and functional changes.
1.2.
Complete and detailed examination of the lower extremities is
necessary. Impairment is based on examiner’s actual findings and requires
assessment of the: 1.2.1.
Skeletal framework 1.2.2.
The joints and associated soft tissues, (to include ROM, Ankylosis,
Amputation) 1.2.3.
Vascular system, and nervous system Page
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Consistency of AMA Impairment Evaluation &
Reporting Part II: Lower Extremities 1.3.
AMA 5th Ed., Table 17-1, page
525, lists the 13 methods that can be used to assess impairment. Anatomic
changes are assessed in the physical examination and supported with clinical
studies. Specific fractures,
joint replacements, bursitis, ligamentous instability, meniscectomies, etc.
are rated under the DBE criteria. When
functional implications have been clinically documented and the anatomic
changes are difficult to categorize, then the impairment can be addressed
under the functional impairment evaluating criteria. 1.4.
Avoiding Duplication of Impairment: AMA 5th Ed.,
Table 17-2, pages 526 & 527. Provides
evaluating physician with the guide of which evaluation methods can be
combined and it helps physician avoid combining methods that rate the same
condition. If more than one
method can be used to calculate impairment, the method that provides the
higher rating is used.
2. ROM
assessment requires that both extremities be compared and individual joints
be evaluated separately. Active Motion measurements take precedent. Page 2 of 4 |
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Consistency of AMA Impairment Evaluation &
Reporting Part II: Lower Extremities 2.1.
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). 2.2. If
restriction of motion is present, evaluating physician must comment on the
reason why: pain, muscle spasm, voluntary restriction, mechanical block, 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. The examination of injured
workers with spinal or spino-radicular difficulties, should also include
examination of the balance of the neuromusculoskeletal system, balance of
physical examination [neurological exam], and special
neurological/provocative test, as per L.C. 139.2 2.3. For
individuals with active ROM measurements below or above average population
values, physician must discuss the prior values and any subsequent loss.
Physician’s reasoning for the uses of estimated values for pre-injury
capacity functional loss must be included. 2.4. 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 from the calculated impairment for the ‘injured’
joint.
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Consistency of AMA Impairment Evaluation &
Reporting Part II: Lower Extremities 3. Impairment
of Peripheral Nerve Abnormalities (non-musculoskeletal
areas) 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. It also includes measurement of knee and ankle
reflexes. They are rated when an
objective verifiable diagnosis is present, supported by positive clinical
findings and loss of function. Documentation requires Nerve Conduction/EMG
studies with corresponding clinical corroboration by appropriate provocative
testing. Physician must indicate that the underlying
impairment is not due to spine pathology. (If due to spine, then rate under
the Spine Chapter.) 3.1.1.
AMA 5th Ed., Section 17.2l, Peripheral Nerve
Injuries. 3.1.2.
Table 17-37 - Impairment Due to Nerve Deficits,
AMA 5th Ed., page 552. 4. Peripheral
Vascular Disorders AMA 5th Ed., Table 17-38, page 554, are only
considered when objective testing establishes the presence of obstructive
physiology (claudication), including residual damage due to amputation. (AMA pg. 497). 5. Arthritis,
Skin Loss and Pain Syndromes. 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. 5.1.
Arthritis, AMA 5th Ed., Section
17.2h, page 544. Specific diagnostic
and evaluation criteria must be followed. Use for individuals with
documented findings (imaging studies) that are impaired by pain, weakness, or
stiffness, with functional ROM of the joints. 5.2.
Skin Loss, AMA
5th Ed., Section 17.2k, page 550.
Other skin disorders could be evaluated using criteria in AMA
Guides, Chapter 8. 5.3.
Criteria for Rating Impairment Related to Chronic
Pain, AMA 5th Ed., Section 17.2m, page 553. Causalgia,
RSD, Complex Pain Syndromes’ evaluation method is the same as that found
on Chapter 13 AMA 5th Ed., Section 13.8, page 343. 6. (DBE)
Diagnosis-Based-Estimates, AMA 5th Ed., Section 17.2j,
page 545. Impairment
determinations based more appropriately on diagnosis. Addresses specific impairment ratings
based on clinical condition and impact of impairment on ADL. Includes ratings
for hip/knee replacements based on a scoring system. Fractures, ligament injuries,
meniscectomies, foot deformities, hip/pelvis/femur/knee/ankle & foot
conditions. Only on very specific situations (See Table 17-2) are DBE’s
combined with other methods of assessment. 6.1.
Table 17-33 – Impairment Estimates, AMA
5th Ed., page 546. 6.2.
Scoring System for Rating Hip and Knee
Replacements, Tables 17-34 & 17-35, AMA 5th Ed., pages 548 & 549. Luis
Pérez-Cordero & Craig Andrew Lange Impairment &
Disability Rating Specialists Monday, October 10, 2005 Page 4 of 4 |