AMA Guides® Newsletter - Issue Archive

Articles

1. AMA Guides, Sixth Edition: Skin Impairment, An Overview

   Jay Blaisdell, James B. Talmage

   Pages 3–4

   DOI: 10.1001/amaguidesnewsletters.2018.MayJun01

   Abstract

   The most common source of occupational skin disease is contact dermatitis, an inflammation caused by exposure to an allergen. Whenever possible, the evaluating physician should rely on objective evidence such as lichenification, excoriation, and hyperpigmentation rather than subjective complaints. Patch testing, biopsy, and sensory discrimination tests are reliable tools at the evaluating physician's disposal. Disfigurements of the face are rated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 11.3, The Face, and Chapter 8, The Skin, is used for all other skin impairments. The evaluating physician records the history of the injury, evaluates the patient, and, in consultation with Table 8-3, notes any objective clinical studies to diagnose the pathology. The functional history, physical examination findings, and diagnostic test findings values then are assigned using Table 8-2; the functional history acts as the key factor and determines the patient's impairment class, physical examination, and diagnostic test findings, each acting as non-key factors, or modifiers. Finally, the non-key factors are used to modify the impairment rating from its default value within its impairment class, and the result is the final skin impairment rating expressed as whole person impairment. Chapter 8 is used only rarely in impairment rating in workers’ compensation cases, and examiners should study the chapter carefully before using it.
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2. Reliability of Cervical Spine Palpation

   Edward I. Dagher

   Pages 5–6

   DOI: 10.1001/amaguidesnewsletters.2018.MayJun02

   Abstract

   Palpitation is an important component of a comprehensive musculoskeletal and neurologic examination of the cervical spine in individuals with neck pain, but examiners should not base diagnostic conclusions (eg, facetogenic pain) and interventional procedures on palpatory findings alone. A methodological approach to palpation of the posterior neck includes evaluation of the paraspinal musculature, the tissues that overlie the facet (zygapophyseal) joints, and the midline spinous processes. Although studies have shown low interexaminer reliability, palpation is an important component of the physical examination for determining general anatomic regions of symptoms and in establishing rapport with the examinee. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the diagnosis-related estimate (DRE) or injury method lists both muscle spasm and muscle guarding as potential physical exam findings by palpation. In this edition, the range-of-motion method for rating spinal impairment states that an examiner cannot find muscle spasm on exam and rate the individual's impairment on the same day because, by definition, the individual is not at maximum medial improvement. Despite acceptance by the AMA Guides, Fifth Edition, neither spasm nor guarding appears to be a reliable finding on palpation. The AMA Guides, Sixth Edition, provides a different method for determining spinal impairment, and the authors recommend limiting physical examination findings used in impairment rating to those with acceptable interrater reliability.
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3. Maximum Medical Improvement: Jurisdictional Perspectives

   Charles N. Brooks, Christopher R. Brigham

   Pages 7–9

   DOI: 10.1001/amaguidesnewsletters.2018.MayJun03

   Abstract

   Maximum medical improvement (MMI) and its multiple synonyms are important terms to understand because one cannot determine permanent impairment until a condition has resolved or reached a stable plateau with respect to improvement. Further, in many jurisdictions MMI represents the date beyond which temporary or all benefits cease or time-loss compensation (temporary disability benefits) may be terminated. Because each arena is to some extent unique, evaluating physicians should become familiar with MMI or the term used and its definition in the applicable federal, state, or provincial law or insurance policy. A table shows the terminology used by various US workers’ compensation jurisdictions, but there is no universal definition for MMI. The fourth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) says only that “an impairment should not be considered ‘permanent’ until the clinical findings, determined during a period of months, indicate that the medical condition is static and well stabilized. The AMA Guides, Fifth Edition, defines MMI as “a condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment” but acknowledges the possibility of “some change.” Similarly the sixth edition states that MMI is the “point at which a condition has stabilized and is unlikely to change (improve or worsen) substantially in the next year, with or without treatment”; signs and symptoms may wax and wane, but further recovery or deterioration is not anticipated.
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4. Rating Physical Residuals of Breast Disfigurement

   Stephen L. Demeter

   Pages 10–13

   DOI: 10.1001/amaguidesnewsletters.2018.MayJun04

   Abstract

   A 48-year-old woman was working as a hostess in a lounge and was struck in the chest when a fight arose; afterwards, she noticed discomfort and a warm sensation in her left breast, which over the course of months remained smaller and also became distorted in comparison with her previous size, shape, contour, and comparison with her right breast. Ten years previously, she had received double lumen prostheses (saline on the outside and silicone gel on the inside). One year later she was found to be at maximum medical improvement (MMI) and described no signs or symptoms although her sexual life reportedly changed, with less frequency and satisfaction. Tables present the fifth edition criteria for rating permanent impairment due to skin disorders; fifth edition criteria for rating permanent impairment due to facial disorders and/or disfigurement; and sixth edition criteria for rating permanent impairment due to mammary disorders. Section 10.9 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, mentions that coexisting psychiatric impairment would be rated using the mental and behavioral disorders chapter, which contains one reference to cosmetic abnormalities and requires a “severe cosmetic deformity with no ability to lactate.” Thus the only way to provide an impairment rating using the fifth edition for this individual is to perform a psychological evaluation; in the sixth edition, it is the only permissible rating.
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5. Q&A: Rating an Ankle Fracture

   Christopher R. Brigham, Charles Brooks, James B. Talmage

   Pages 13–15

   DOI: 10.1001/amaguidesnewsletters.2018.MayJun05