AMA Guides® Newsletter - Issue Archive

Articles

1. Prescription Narcotics: An Obstacle to Maximum Medical Improvement

   Robert J. Barth

   Pages 1–7

   DOI: 10.1001/amaguidesnewsletters.2011.MarApr01

   Abstract

   The increasingly severe epidemic of overuse, abuse, and death involving prescription narcotics is of specific relevance to workers’ compensation, which is the primary venue for use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Because of the scientific knowledge base regarding prescription narcotics for chronic benign pain, evaluators may question how any patient could credibly be considered to have reached maximum medical improvement (MMI) if that patient has a prescription for a narcotic. Hyperalgesia associated with narcotics does not appear to be permanent, but evidence indicates that prescription narcotics cause significant problems in addition to worsening pain: endocrine disruption, sleep abnormalities, immune system compromise, cognitive impairment, substance abuse, and generalized ill health and disability, among others. Evaluators may worry that refusing to evaluate a person who is not at MMI because they are receiving a prescription narcotic may unintentionally delay resolution of the person's claim. In a more efficient approach, an evaluator could undertake the complete evaluation process, including creating an impairment rating, and document in the evaluation report that the rating is being provided despite reasons to be concerned that the impairment is artificially inflated in a nonpermanent way by the unjustifiable narcotic prescription. Evaluators should not state that the impairment from side effects of the opioids is permanent.
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2. Case Example: Adjacent Segment Disease: What Is It, and How Is It Rated?

   Marjorie Eskay-Auerbach

   Pages 8–9

   DOI: 10.1001/amaguidesnewsletters.2011.MarApr02

   Abstract

   The incidence of cervical and lumbar fusion surgery has increased in the past twenty years, and during follow-up some of these patients develop changes at the adjacent segment. Recognizing that adjacent segment degeneration and disease may occur in the future does not alter the rating for a cervical or lumbar fusion at the time the patient's condition is determined to be at maximum medical improvement (MMI). The term adjacent segment degeneration refers to the presence of radiographic findings of degenerative disc disease, including disc space narrowing, instability, and so on at the motion segment above or below a cervical or lumbar fusion. Adjacent segment disease refers to the development of new clinical symptoms that correspond to these changes on imaging. The biomechanics of adjacent segment degeneration have been studied, and, although the exact mechanism is uncertain, genetics may play a role. Findings associated with adjacent segment degeneration include degeneration of the facet joints with hypertrophy and thickening of the ligamentum flavum, disc space collapse, and translation—but the clinical significance of these radiographic degenerative changes remains unclear, particularly in light of the known presence of abnormal findings in asymptomatic patients. Evaluators should not rate an individual in anticipation of the development of changes at the level above a fusion, although such a development is a recognized possibility.
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3. Case Example: Rating Lower Extremity Injuries Involving Multiple Diagnoses in One Region Using the AMA Guides, Sixth Edition

   Craig Uejo, Charles N. Brooks

   Pages 9–11

   DOI: 10.1001/amaguidesnewsletters.2011.MarApr03

   Abstract

   Injuries to a specific region can result in more than one diagnosis. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, states that, in most cases, only one diagnosis in a region (eg, hip, knee, or foot/ankle) is appropriate. If a patient has two significant diagnoses (eg, ankle instability and posterior tibial tendonitis), the examiner should use the diagnosis with the highest impairment rating in that region that is causally related. The rationale for this principle is that the rating for the diagnosis with the highest impairment also encompasses the functional loss of diagnoses with lesser impairment; it also attempts to prevent the use of multiple diagnoses to inflate the impairment rating. In the Case Example, a 62-year-old female teacher was tripped and fell on her left knee at work; the diagnoses were osteoarthritis and medial collateral ligament sprain. Despite activity modification and extensive treatment, she reported only moderate improvement; an orthopedic surgeon was consulted and recommended total knee replacement (TKR), but the patient declined and decided to retire with the option to consider TKR later, if necessary. Causation is an issue because tricompartmental arthritis clearly was not caused by the fall, but one wonders about the role of the individual's arthritis is unclear. Evaluators should be aware that such apportionment varies by jurisdiction.
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