AMA Guides® Newsletter - Issue Archive

Articles

1. Impairment Rating for Non-Specific Back Pain Under the AMA Guides, Sixth Edition: Medical Perspective

   James B. Talmage, Jay Blaisdell, Marjorie Eskay-Auerbach, Christopher R. Brigham

   Pages 3–6

   DOI: 10.1001/amaguidesnewsletters.2014.MarApr01

   Abstract

   Low back pain and disability are common and evaluating a patient with non-specific spinal pain may be challenging, including determining impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, provides ratable impairment for the diagnosis of “non-specific chronic, or chronic recurrent low back pain (also known as chronic sprain/strain, symptomatic degenerative disc disease, facet joint pain,” and others. The evaluator should consider the diagnosis of non-specific chronic back pain only when no category of specific diagnosis fits the case (eg, no fracture, no spinal stenosis) or when “no reliable physical examination or imaging findings” but the patient's history of pain is felt to be reliable. According to the AMA Guides, primary determinant between a class 0 and class 1 rating for non-specific chronic back pain is whether the evaluator gives credibility to the patient's subjective reports of pain and interference with activities of daily living (ADLs). An evaluator may choose to use the Pain Disability Questionnaire (reproduced in the article) and Table 17-6, Functional History Adjustment, Spine, to determine the Functional History Grade Modifier (GMFH). The diagnosis of non-specific chronic or chronic recurrent low back pain yields a positive impairment only when the evaluator feels the patient's pain, as quantified by the GMFH, is reliably reported. Because there are no diagnostic objective findings on physical examination or clinical studies, these modifiers are excluded.
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2. Impairment Rating for Non-Specific Back Pain Under the AMA Guides, Sixth Edition: The Legal Perspective

   Luann Haley

   Pages 6–7

   DOI: 10.1001/amaguidesnewsletters.2014.MarApr02

   Abstract

   The method for rating impairments for lumbar spine injuries has evolved over time and has changed with each edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The AMA Guides, Sixth Edition, uses a diagnosis-based impairment rating system as the template for evaluating impairment ratings for spinal conditions. A majority of US states use the AMA Guides to determine an impairment rating for injured workers and use this impairment rating to determine financial compensation, but no state system is the same as another's, and each state has a unique statutory scheme. Some cases warrant the finding of a permanent impairment when the injured worker has significant residual pain complaints and limitations that have been verified by the evaluator as being consistently present from the injury date. The AMA Guides, Sixth Edition, allows an assignment of permanent impairment, at the discretion of the evaluator, in cases of chronic lumbar sprains/strains. Evaluators should carefully consider whether it is appropriate to assign an award of permanent impairment for spinal conditions without verifiable objective findings. An evaluator's decision of no impairment vs class 1 impairment is a significant determination in compensation claims and will continue to include subjective factors until advances in medical science permit a more accurate assessment of complaints of non-specific back pain.
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3. Carpal Instability

   Mark S. Cohen

   Pages 8–10

   DOI: 10.1001/amaguidesnewsletters.2014.MarApr03

   Abstract

   The wrist is the articulation between the distal forearm bones (radius and ulna) and eight carpal bones. The most common carpal instability is between the scaphoid and lunate, termed scapholunate instability. Complete scapholunate dissociation results in a gap between the scaphoid and lunate on posterior–anterior (PA) radiographic projections (scapholunate gap). On lateral radiographs, the scaphoid assumes a flexed posture and the lunate extends, resulting in increased scapholunate and radiolunate angles. The second most common carpal instability patters is between the triquetrum and lunate, termed lunotriquetral instability. Ulnar translocation of the carpus, also known as carpal translation, refers to medial displacement of the entire carpus on the forearm (radius and ulna) and is the most common radiocarpal instability. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, carpal instabilities are rated using Table 15-3, Wrist Regional Grid; the impairment class is determined using Table 15-9, Clinical Studies Adjustment: Upper Extremities. Measurements from plain radiographs are used in Table 15-9 to characterize the instability as mild, moderate, or severe; these characterizations, in turn, determine the class. The assessment of carpal instability using radiographic measurements has limitations, particularly that the radiographic parameters used to grade impairment are imprecise; angular measurements between individual bones are particularly variable, and carpal bone axes can be difficult to determine due to bony overlap on plain radiographs.
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4. Left Ventricular Hypertrophy

   Steven L. Demeter

   Pages 11–15

   DOI: 10.1001/amaguidesnewsletters.2014.MarApr04

   Abstract

   The fourth, fifth, and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) use left ventricular hypertrophy (LVH) as a variable to determine impairment caused by hypertensive disease. The issue of LVH, as assessed echocardiographically, is a prime example of medical science being at odds with legal jurisprudence. Some legislatures have allowed any cause of LVH in a hypertensive individual to be an allowed manifestation of hypertensive changes. This situation has arisen because a physician can never say that no component of LVH was not caused by the hypertension, even in an individual with a cardiomyopathy or valvular disorder. This article recommends that evaluators consider three points: if the cause of the LVH is hypertension, is the examinee at maximum medical improvement; is the LVH caused by hypertension or another factor; and, if apportionment is allowed, then a careful analysis of the risk factors for other disorders associated with LVH is necessary. The left ventricular mass index should be present in the echocardiogram report and can guide the interpretation of the alleged LVH; if not present, it should be requested because it facilitates a more accurate analysis. Further, if the cause of the LVH is more likely independent of the hypertension, then careful reasoning and an explanation should be included in the impairment report. If hypertension is only a partial cause, a reasoned analysis and clear explanation of the apportionment are required.
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