AMA Guides® Newsletter - Issue Archive

Articles

1. Relevance of the Social Security Listings in the Assessment of Severity of Mental and Behavioral Impairments per the Fourth and Fifth Editions

   Steven W. Leclair, Norma J. Leclair

   Pages 1–6

   DOI: 10.1001/amaguidesnewsletters.2008.SepOct01

   Abstract

   Establishing a valid and reliable impairment rating for persons with mental and behavioral disorders is particularly challenging. This article focuses on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, Chapter 14, Mental and Behavioral Disorders; because of similarities between the fourth and fifth editions, most comments here apply as well to the fifth edition. The section regarding mental and behavioral disorders is based in the US Social Security Administration (SSA) disability determination. The AMA Guides measures impairment in the same four areas of functioning designated by SSA: activities of daily living; social functioning; concentration, persistence, and pace (ie, focused attention); and deterioration or decompensation in work-like settings (“adaptation”). The assessment of severity of impairment is based on the five-level SSA approach and is applied to each of the four areas of functioning. The authors define and interpret the practical meanings of terminology in the AMA Guides associated with classes of severity: no impairment (self-explanatory); mild impairment (compatible with most useful functioning); moderate impairment (compatible with some but not all useful functioning); marked impairment (significantly impedes useful functioning); and extreme impairment (not compatible with useful functioning). Impairment ratings are truly applicable only when clinicians can approach the process in a consistent manner using consistent terminology and methodology; the latter two will improve both the understanding of the rating process and its reliability and validity.
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2. Impairment Tutorial: Lower Extremities Impairment Evaluation: Overview of Sixth Edition Approaches

   Christopher R. Brigham

   Pages 7–8

   DOI: 10.1001/amaguidesnewsletters.2008.SepOct02

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, takes approaches to the lower extremities that are consistent with Chapter 15, Upper Extremities (reviewed in the March/April 2008 issue of The Guides Newsletter). Because there is a comparatively smaller spectrum of diagnoses in the lower extremities, Chapter 16 is less complex and is shorter than Chapter 15. The purposes of the lower extremity are transfer and mobility, and, in comparison to the upper extremity, the lower extremity provides greater stability than flexibility. This chapter's principles of assessment define the standards for interpreting symptoms and signs, functional history, physical examination, and clinical studies. Examiners may use the Lower Limb Instrument developed by the American Academy of Orthopaedic Surgery as an adjunct to defining functional ability, but values are not provided to define a specific grade modifier. Most lower extremity impairments are based on Diagnosis-related impairments, and an impairment example case demonstrates the use of the Knee Regional Grid to asses a partial meniscus repair. An associated table illustrates the resulting whole person impairment values associated with these examples and gives the probable impairments based on the fifth edition. The article also discusses impairments of the peripheral nerves, amputation, and range of motion. Mastery of one chapter of the AMA Guides facilitates performing ratings using other chapters.
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3. Guides Case Exercise: Carpal Tunnel Syndrome

   Pages 9–10

   DOI: 10.1001/amaguidesnewsletters.2008.SepOct03

   Abstract

   Case exercises are an effective way to increase one's understanding of the appropriate application of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Following is one of more than seventy cases that are included in the new edition of The Guides Casebook. This case illustrates the process of assessing impairment for carpal tunnel syndrome using the fourth, fifth, and sixth editions. In this case, a 45-year-old woman who packed boxes on an assembly line developed insidious onset numbness and tingling in her right, dominant hand. A nerve conduction study was consistent with a sensory conduction delay, and she underwent a carpal tunnel release. Physical examination revealed normal monofilament testing and normal two-point discrimination (5 mm) in all digits, and focal muscle testing results were normal, without atrophy. According to an assessment using the fourth edition, 0% whole person impairment was given because no objective evidence showed ongoing sensory or motor deficits. According to the AMA Guides, Fifth Edition, the patient would receive a 1% whole person impairment because in the past the diagnosis of carpal tunnel syndrome was confirmed by electrophysiological studies. Use of the sixth edition yields 1% whole person impairment on the basis of the patient's QuickDASH score of 0 and, providing her with the benefit of the doubt, one would assign the lowest impairment for grade modifier 1, ie, 1% whole person impairment.
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4. Impairment Tutorial: Headache Impairment

   Kenneth Subin, Christopher R. Brigham

   Pages 11–11

   DOI: 10.1001/amaguidesnewsletters.2008.SepOct04

   Abstract

   The approach to assessing impairment for headaches differs among the fourth, fifth, and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In summary, the fourth edition provides only a qualitative, nonnumeric rating. In the fifth edition, an examiner can give up to 3% whole person permanent impairment. Using the sixth edition of the AMA Guides, an examiner may determine up to 5% whole person permanent impairment for migraine headaches for Chapter 13 and up to 3% whole person impairment for other headaches according to Chapter 3. With respect to the AMA Guides, Fourth Edition, unless other objective features can be rated according to specific organ dysfunction, headache impairment is a qualitative, nonnumeric rating, and “The vast majority of patients with headache[s] will not have permanent impairments.” In some defined cases, the fifth edition facilitates calculation of a pain related impairment score (that specifically is not an impairment rating) that is used to describe the severity of the pain, for which up to 3% whole person impairment may be provided. The sixth edition of the AMA Guides provides a quantitative whole person impairment rating up to 5% whole person impairment for migrainous headaches and 3% whole person impairment for nonmigrainous headaches.
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