AMA Guides® Newsletter - Issue Archive

Articles

1. Case Example: Spinal Impairment: California Case

   Christopher R. Brigham, James Talmage, Marjorie Eskay-Auerbach, Patty Stevens

   Pages 1–6

   DOI: 10.1001/amaguidesnewsletters.2011.JanFeb01

   Abstract

   Accurate, unbiased impairment ratings must follow the procedures and processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This Case Example from California in 2010 illustrates some problems that result from rating a lumbar injury as if it were an inguinal hernia. At critical issue in this case is whether sufficient clinical findings were available to support a rating for lumbar radiculopathy; the evaluating (and also, treating) physician gave the patient the benefit of doubt with a rating of “nonverifiable radicular (nerve root) pain” but did not address the patient's ability to perform activities of daily living (ADLs). The State of California Workers’ Compensation Appeals Board (WCAB) affirmed on August 20, 2010, that the State relies on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, to determine impairment. WCAB noted that “medical opinion that departs unreasonably from a strict application of the [AMA] Guides can be challenged, and it would not be acceptable as substantial evidence.” In the present case, the rating provided by the evaluating physician was based on an obviously inapplicable section of the AMA Guides and is not appropriate. Evaluators must use the procedures defined in the AMA Guides, perform evaluations according to the standards in the AMA Guides, and do so without bias.
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2. Case Example: Lumbar Spine Injury, Treated with Spinal Injections

   Christopher R. Brigham, James Talmage, Marjorie Eskay-Auerbach, Charles McGhee

   Pages 7–11

   DOI: 10.1001/amaguidesnewsletters.2011.JanFeb02

   Abstract

   This Case Example illustrates common questions associated with the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, including the selection of appropriate methodology and the issue of whether spinal injections are considered to be ratable events. A 32-year-old male worker in California sustained a work-related low back injury and was examined by a chiropractic Qualified Medical Examiner (QME). The patient was referred for magnetic resonance imaging, which showed multiple lumbar disk protrusions and an L4-5 annular fissure. An epidural steroid injection at L5-S1 was of limited benefit, but bilateral L4-5 and L5-S1 facet injections, followed by chiropractic care, precluded any need for medial branch blocks or a facet rhizotomy. On presentation to the QME, the individual reported experiencing low back pain 10% of the time; this was rated 3/10 and was localized around the lumbar and lumbosacral region and was exacerbated with prolonged sitting or playing sports. The evaluator provided a rating of the lumbar spine using the range of motion (ROM) method, but the AMA Guides, Fifth Edition, states that the Diagnosis-related estimate (DRE) must be used because the impairment is due to an injury. The article demonstrates in detail how the DRE method would be applied in this case. The performance of epidural and facet injections does not constitute a ratable surgical event because these are not intradiscal injections intended to produce permanent anatomic changes in the disk.
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3. Case Example: Rating Upper Extremity Injuries Involving Multiple Conditions in Same Extremity Using the AMA Guides, Sixth

   Craig Uejo

   Pages 12–13

   DOI: 10.1001/amaguidesnewsletters.2011.JanFeb03

   Abstract

   Some injuries to the extremities can be associated with multiple injuries or diagnoses, and, in such cases, evaluators should recall that the functional history adjustment can be considered only for the single highest rated condition. This Case Example illustrates the proper rating methodology using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition section on The Upper Extremities. A 58-year-old male automotive mechanic fell at work on an oil-slickened floor and landed directly on his left outstretched hand and wrist, as well as the lateral part of his left elbow. At maximum medical improvement (MMI), the individual complained of moderate pain at rest and severe pain with repetitive forceful gripping and grasping. Radiographs taken at MMI showed a healed distal radius fracture in anatomic position with no posttraumatic arthritis and no carpal instability. The AMA Guides, Sixth Edition, allows use of only one of two methodologies: the Diagnosis-based impairment (DBI) methodology or the range-of-motion (ROM) method. Because ROM findings at the left elbow and wrist were recorded as normal and because the greater impairment that is causally related to the injury is used to rate the impairment, the DBI methodology is appropriate here. Only a single diagnosis is rated per region, and a case that involves more than a single region in the same extremity can be rated for separate impairments based on the separate regional conditions or diagnoses.
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4. Questions and Answers

   Christopher R. Brigham, Gunnar Andersson, Marjorie Eskay-Auerbach, James B. Talmage, Craig Uejo

   Pages 14–15

   DOI: 10.1001/amaguidesnewsletters.2011.JanFeb04