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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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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic & Lumbar Segments of The Spine By:
Luis Perez-Cordero & Craig Andrew Lange |
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Calculating
& Reporting California Impairment & The AMA Guides: 1,2,3 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 in 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 as well as considers subjective
symptoms within the diagnostic criteria and support of an impairment
percentage. Chapter 18 specifically
deals with situations above and beyond the effects of pain on Activities of
Daily Living (ADL). 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
worksheet does not replace the California requirement that the determination
of any impairment level must follow the AMA Guides established evaluation
criterion and be explained by a well-reasoned/rational medical opinion. It is not acceptable
to calculate impairment using ‘pre-programmed’ estimated values defined by
population averages without any regards to what is normal for the individual
or the reasons for the ROM limitations. 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/pain 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 P&S 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. Page 1 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine 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 in a California P&S medical report. Pain Add-On to Spinal Impairments 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. Can pain (01-03% WPI) be added to the maximum ranges of a DRE
Category? This appears to be an area
of dispute, even among the ‘experts’ of the AMA Guides. But the answer can be
found by the use of both The 5th Edition of AMA Guides and The
Schedule for Rating Permanent Disabilities (05PDRS). Dr. Linda Cocchiarella’s AMA Guides
companion Master the AMA Guides helps clarify the matter even further.
2005 PDRS, page 1-12: “A whole person impairment rating based
on the body or organ rating system of the AMA Guides (Chapter 3 though 17)
may be increased by up to 03% WPI if the burden of the worker’s condition has
been increased by pain-related impairment in excess of the pain component
already incorporated in the WPI rating in Chapters 3-17.” I.
AMA 5th Ed., Section 18.3d, page 573: How To Rate Pain-Related Impairment This
chapter (18) relies largely on self-reports by individuals. Thus, it differs
significantly from the conventional rating system, which relies
primarily on objective indices of organ dysfunction or failure (Chapters 3 to
17). The system assesses pain intensity; emotional distress related to pain,
and ADL deficits secondary to pain. ADL deficits are given the greatest
weight. An individual's pain-related impairment is considered un-ratable
if (a) behavior during the evaluation raises significant issues of
credibility, (b) clinical findings are atypical of a well-accepted
medical condition, or (c) the diagnosis is for a condition that is vague or
controversial. (Refer to the
Algorithm for Rating Pain- Figure 18-1.) A. First, physician evaluates the individual according to
the body or organ rating system, and determines an impairment percentage. During
the evaluation, the examiner also assesses pain-related impairment. B. If the body system impairment rating appears to adequately
encompass the pain experienced by the individual due to his or her medical
condition, his or her impairment rating is as indicated by the body system
impairment rating. C. If the individual appears to
have pain-related impairment that has increased the burden of his or her
condition slightly, the examiner may increase the percentage found in
A by up to 3%. 1.
For example, physician places a worker on Lumbar Spine Category III and
determines that based on the severity of both measurable and clinical
findings, a 12% best reflects his conventional impairment. Pain and discomfort were not considered as
part of this initial determination.
Now, physician considers the impact of pain on ADL and determines that
an additional 02WPI best reflects the impact of pain on physical activities
of daily living. The 02 is added (not
combined) to the 12 conventional impairment for a 14WPI that will then be
adjusted by the 05PDRS modifiers of FEC, Occupation and Age. D. The
examiner should perform a formal pain-related impairment assessment if any of
the following conditions are met: 1.
The
individual appears to have pain-related impairment that is substantially in
excess of the impairment determined in step A or 2.The individual has a well-recognized
medical condition that is characterized by pain in the absence of measurable
dysfunction of an organ or body part (see Table 18-1 for examples) or Page 2 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine 3. The individual
has a syndrome with the following characteristics: (a) it is
associated with identifiable organ dysfunction that is ratable according to
other chapters in the Guides; (b) it may be associated with a
well-established pain syndrome, but the occurrence or non-occurrence of the
pain syndrome is not predictable; so that (c) the impairment ratings provided
in step A do not capture the added burden of illness borne by the individual
because of his or her associated pain syndrome (see Table 18-2 for examples). E.
If the examiner performs a formal pain-related impairment rating, he or
she may increase the percentage found in step A by up to 03%, and he
or she should classify the individual's pain-related impairment into one of four
categories: mild (00), moderate (01), moderately severe (02), or severe (03).
In addition, the examiner should determine whether the pain-related
impairment is ratable or un-ratable. Refer also to the 2nd paragraph on page 1-12 of the
05PDRS. Evaluating physician must remember that as per the 2005 PDRS, the maximum allowance for pain resulting
from a single injury is 03% regardless of the number of impairment resulting
from that injury. If all 3 segments
of the spine have been rated under DRE Categories, the physician doesn’t add
03% per spinal segment. Only a maximum of 03% divided according to impact of
pain on ADL is considered. When considering
adding pain impairment to a conventional rating, the conventional rating’s
components must not already incorporate pain (i.e., ROM causation is due to
pain and not mechanical block) and the medical justification for the addition
of pain must be clear and well reasoned, thus substantiating the
non-duplication of impairment. On
page 204 of Master The AMA Guides, Dr. Cocchiarella provides
insightful guidance for all evaluating physicians:
II. Supporting Vocational
Modifications, Work Limitations or Restrictions 4 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 an 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 basis 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. Page 3 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine 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. The basis for job modifications or work
restrictions is not and has never been complaints. Work Restrictions (Disability) describe the inability of an
individual to perform a specific or group of activities because of objective
clinical/measurable impairment factors.
·
Disability needs clinical corroboration and an objective base. ·
Disability needs to consider risk from a clinical point of view; not
from a subjective point of view, and Never because of the unfounded assertion
of a prophylactic need. ·
Disability becomes disability after a physician conducts a complete
examination and demonstrates by his application of medical-legal principles
that a functional limit exists. ·
Disability exists when an individual or others would be placed at
risk due to the presence of objective measurable impairment. Life choices, deconditioning and ‘comfort
level’ should never be the sole support for impairment/disability. The use of the word prophylactic is and has never been objective
evidence capable of proving/disproving or supporting impairment or
disability. Its misuse has only served to disguise the
lack of material findings [measurable objective & clinical] and in turn
create the facade of ‘reasonable medical probability’ when the only support
were unconfirmed assertions of disability [subjective complaints]. It’s never been a valid reason, as
required by WCAB § 10606 (f) (f) (i) (k) (m) (n), for the support of
impairment, disability or work modifications. ·
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
restrictions 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. The basis for job modifications
or work restrictions is not and has never been complaints. Work Restrictions (Disability) describe
the inability of an individual to perform a specific or group of activities
because of objective clinical/measurable impairment factors. Page 4 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic & Lumbar
Segments of The Spine ·
Disability needs clinical corroboration and an objective base. ·
Disability needs to consider risk from a clinical point of view; not
from a subjective point of view, and Never because of the unfounded assertion
of a prophylactic need. ·
Disability becomes disability after a physician conducts a complete
examination and demonstrates by his application of medical-legal principles
that a functional limit exists. ·
Disability exists when an individual or others would be placed at risk
due to the presence of objective measurable impairment. Life choices, deconditioning and ‘comfort
level’ should never be the sole support for impairment/disability. The use of the word prophylactic is and has never been objective
evidence capable of proving/disproving or supporting impairment or
disability. Its misuse has only served to disguise the
lack of material findings [measurable objective & clinical] and in turn
create the facade of ‘reasonable medical probability’ when the only support
were unsupported assertions of disability [subjective complaints]. It’s never been a valid reason, as
required by WCAB § 10606 (f) (f) (i) (k) (m) (n), for the support of
impairment, disability or work modifications. In a recent article 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. 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.
“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.
Page 5 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine · 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 IV.
DRE Rating Criteria - Diagnosis Related Estimates 1 & 2 ‘Injury’ is the common denominator in Workers
Compensation impairment and the DRE method remains the principal method to
evaluate an individual having an injury.
“The DRE method is the primary method used to evaluate individuals
with an injury. (AMA 5th Ed., 374)
Physician identifies findings (ROM, Symptoms, Signs, Appropriate Test Results)
supporting the DRE Category. DRE model relies on the history, physical
examination findings (neurological deficits not spinal motion), and the
results of clinical testing (Imaging studies, Electrodiagnostic, etc.) as
it attempts to document anatomical and physiological impairment relating to
an injury, rather than congenital developmental or age-related conditions. (AMA Guides Newsletter- May/June 2004). Master the AMA Guides (page 197) states that in
the case of multiple injuries or conditions, if the pathology affects
different spinal regions, the DRE method is applied to each region. Only when the pathology reoccurs or
repeats in the same spinal level or region is the ROM method use. Spinal level refers to an area bounded by
two vertebrae, a single spinal disk and associate nerve roots and nerves. 1.
DRE Evaluation Criteria: - AMA 5th Ed, page 379 & 398 & – AMA 5th Ed., pages 405
& 406. 1.1.
Clinical findings must be correlated to the imaging studies, which
have been used to confirm a diagnosis. Without clinical correlation, a ‘positive’
imaging study in itself does not make the diagnosis or cannot be used as the
sole support for an impairment rating. 1.2.
The P&S report must clearly outline physician’s evaluating
criteria and its support. 1.3.
For determining
impairment based on the clinical diagnosis related findings refer
to pages 381 to 398 (Chapter 15) AMA Guides –5th Edition. 2.
Box 15-1 provides the necessary definitions evaluating physician can use to
assign an individual to DRE categories I, II or III. (AMA Guides, page 382). Page 6 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic & Lumbar
Segments of The Spine
AMA Guides, Section
15.1a, page 374 requires that evaluating physician’s history
taking and reporting describe in detail the chief complaints and the quality,
severity, anatomic location, frequency, and duration of symptoms. Employee’s description of complaints
(including pain, numbness, paresthesias, weakness) and how these factors
interfere with activities of daily living (ADL), can further assist
evaluating physician to pinpoint a specific WPI% within a given DRE
category. Page 7 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine In deciding where to place an individual’s
impairment rating within a range, the physician needs to consider all the
criteria applicable to the condition, which includes performing activities
of daily living (ADL), and estimate the degree to which the medical
impairment interferes with these activities. AMA Guides, page 20. On
page 204 of Master The AMA Guides, Dr. Cocchiarella states: ·
Use the DRE method as the method of
choice (for rating spinal impairment). ·
When determining what end of the range
to use, determine whether the condition and its impact on ADL is consistent
with that condition, or if the impairment has led to worse functioning. If
ADL are more severely impacted than expected for the condition, use the upper
end of the scale.
The DRE Tables: (1) Cervical Spine: AMA 5th Ed., Table
15-5, page 392, (2) Thoracic Spine: AMA 5th Ed., Table 15-4, page 389, and
(3) Lumbar Spine: AMA 5th Ed., Table 15-3, page 384. Page 8 of 11 |
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Consistency
of AMA Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine SPINAL ROM RATING METHOD The
P&S report must clearly outline physician’s evaluating criteria and its
clinical support. 1.
AMA 5th Ed., (Chapter
15), Section 15.8 (a, b & c), pages 398 to 422. 2. Calculating ROM of
impairments, must abide to the precise criteria outlined by the AMA 5th Ed., Section
15.8a, page 399. 3.
Evaluating Physician should avoid: 4. Using unexplained ROM limitations of one or more spinal segments for calculating
impairment under AMA 5th Ed., Section 15.9 (lumbar spine), Section 15.10
(thoracic spine), or Section 15.11 (cervical spine). 5. Using pre-existing degenerative disc disease as the only clinical
support for the use of the ROM method. 6. Master the AMA Guides, page
197:
In the case of multiple injuries or conditions, if the pathology affects
different spinal regions, the DRE method is applied to each region. Only when the pathology reoccurs or
repeats in the same spinal lever or region is the ROM method used. Spinal level refers to an area bounded by
two vertebrae, a single spinal disk and associate nerve roots and nerves 7.
ROM applies: 7.1.
Where there is recurrent radiculopathy caused by a new or
recurrent disk herniation or where there is new radiculopathy caused by a
recurrent injury to the same spinal region 7.2.
New Injury means an injury to a spine area that
was essentially injured free before the incident even though other aging
or pre-existing asymptomatic degenerative changes might be present. 7.3.
Recurrent Injury refers to an injury to a spine
region that has a history of injury.
Refers to the same condition, which is asymptomatic between
episodes. Condition is also
considered recurrent if symptoms increase from or is still considered to be
due to, or is a normal progression of the original condition. 8.
ROM method is only used to rate individuals with (1)
multilevel fractures, (2) recurrent radiculopathy, (3) multilevel
radiculopathy, (4) multilevel loss of structural integrity, (5) jurisdictional
requirement or no-injury evaluations. (AMA 5th Ed., 398). One exception occurs when individuals,
having corticospinal tract involvement and are treated with decompression and
multilevel fusion, are rated via the DRE method because it is difficult to
assess ROM with paralysis. 8.1.
AMA
Guides page 374: “The DRE method is the primary method used
to evaluate individuals with an injury. The ROM method is only used to
evaluate individuals with an injury at more than one level in the same spinal
region and in certain individuals with recurrent pathology.” 9.
In those situations in
which the AMA allows determining impairment based on the range of motion
method. (AMA Guides, pages 398-422) Page 9 of 11 |
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Consistency of AMA
Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine 9.1.
Evaluating physician must ensure that
adequate warm-up movements have been performed. AMA 5th Ed., page 399. 9.2.
Measure ROM and determine any angle of ankylosis
or any restricted motion that is present. AMA 5th Ed., page 399 & 403. 9.3.
Perform at least 3 measurements of each
motion and determine which measurements meet reproducibility criteria and
calculate the average of each set of 3 measurements. 9.3.1.
If acute muscle spasm is present, this
should be noted in the examiner’s report. However,
the mobility measurements would not be valid for estimating permanent
impairment. Rating should be deferred until after any acute
exacerbation of the chronic condition has subsided. AMA 5th Ed., page 399. 9.4.
Physician must seek consistency; repeat
tests when necessary or discard all together when re-testing remains
inconsistent. AMA 5th Ed., page 399. 9.4.1.
“The physician should seek consistency when
testing active motion, strength and sensation. Tests
with inconsistent results should be repeated. Results that remain inconsistent should be disregarded.
When the physiologic measurements fail to match known pathology they
should be repeated and, if still inconsistent, disallowed until documented
evidence is provided for the abnormalities noted on the physical examination.”
AMA 5th Ed., page 399: 9.5.
Clinical findings must be correlated to the
imaging studies, which have been used to confirm a diagnosis. Without
clinical correlation, a ‘positive’ imaging study in itself does not make the
diagnosis and cannot be used as the sole support for an impairment rating.
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Consistency of AMA
Impairment Evaluation & Reporting: Part III: Cervical Thoracic &
Lumbar Segments of The Spine 9.6.
Neurologic Impairment:
For the neurological component of ROM evaluation criteria refer to AMA Guides
Section 15.12, page 423 and page 403, Section 15.8d. 9.7.
Clinical Diagnosis Impairment: For determining impairment based on this portion
of the ROM Method, refer to AMA 5th Ed., pages 398 to 404. AMA 5th Ed., Table
15-7 on page 404. The impairment rating values found in the guides
represent estimates of the extent of impairments based on the physician's
judgment, experience, training, skill, and thoroughness. Considerations of
factors such as sensitivity, specificity, accuracy, reproducibility,
interpretation of lab test results and clinical procedures, as well as
recognition of variability among the interpretations of different observers, are
variables affecting the determination of a WPI. Completeness and
reliability of the medical documentation are an integral part of the
impairment rating process and strengthen the numeric impairment figures
derived from a well-structured set of thorough observation and testing as
outlined in the AMA Guides evaluation criteria. No comprehensive P&S medical report is immune from the
requirement that determination of any impairment level must follow the AMA
Guides established evaluation criterion and be supported by anatomic/clinical
findings as well as be explained by a well-reasoned/rational medical
opinion. Evaluating physician must obtain clinical information from
medical records and through performance of a physical examination and compare
clinical information from several sources to check for consistency. (AMA 5th
Ed., 19 & 593) It is the
evaluating physician’s responsibility to resolve disparities when possible,
if the clinical information is inconsistent. Physician must avoid duplicating or ‘creating’ impairment by
providing incomplete reporting of findings, misuse of proper
evaluation criteria, giving incomplete description of medical studies or by
disregarding AMA assessment and evaluation criteria. (AMA 5th Ed., 374 to 377). 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. Bibliography 1 Linda Cocchiarella
& Gunnar BJ Anderson: Guides to the Evaluation of Permanent
Impairment, Fifth Edition. American Medical Association, United
States, 2001. http://www.ama-assn.org/ 2 Linda Cocchiarella & Stephen
J. Lord: Master The AMA Guides Fifth. American Medical
Association, United States, 2001 3 California Code of
Regulations; Article 7, § 9805: Schedule for Rating Permanent
Disabilities. January 2005 Edition; http://www.dir.ca.gov/dwc/PDR.pdf 4 James B. Talmage, & J. Mark Melhorn: A Physician’s
Guide to Return to Work. American Medical Association, United States
of America, 2005. Luis
Pérez-Cordero & Craig Andrew Lange Impairment & Disability Rating Specialists Friday, December 02, 2005 Page 11 of 11 |