AMA Guides® Newsletter - Issue Archive

Articles

1. Spinal Impairment Evaluation: Fifth Edition Changes

   Robert H. Haralson

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.2001.JanFeb01

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, was published in November 2000 and contains major changes from its predecessor. In the Fourth Edition, all musculoskeletal evaluation and rating was described in a single chapter. In the Fifth Edition, this information has been divided into three separate chapters: Upper Extremity (13), Lower Extremity (14), and Spine (15). This article discusses changes in the spine chapter. The Models for rating spinal impairment now are called Methods. The AMA Guides, Fifth Edition, has reverted to standard terminology for spinal regions in the Diagnosis-related estimates (DRE) Method, and both it and the Range of Motion (ROM) Method now reference cervical, thoracic, and lumbar. Also, the language requiring the use of the DRE, rather than the ROM Method has been strengthened. The biggest change in the DRE Method is that evaluation should include the treatment results. Unfortunately, the Fourth Edition's philosophy regarding when and how to rate impairment using the DRE Model led to a number of problems, including the same rating of all patients with radiculopathy despite some true differences in outcomes. The term differentiator was abandoned and replaced with clinical findings. Significant changes were made in evaluation of patients with spinal cord injuries, and evaluators should become familiar with these and other changes in the Fifth Edition.
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2. Clinical Update: Evaluation of Low Back Pain

   True Martin, Christopher R. Brigham, Charles N. Brooks

   Pages 3–10, 12

   DOI: 10.1001/amaguidesnewsletters.2001.JanFeb02

   Abstract

   This article provides an overview of the neurological examination and diagnostic studies commonly used in the evaluation of low back pain, information that is essential for both clinical assessment and impairment rating in the AMA Guides to the Evaluation of Permanent Impairment. Clinical evaluation begins with a careful review of medical records. After taking a thorough history, the physician performs the physical examination, including neurological testing, on the patient. The clinical evaluation also determines data needed for impairment evaluation. Neurological examination helps distinguish among the various types of pathology suggested by the history, but to some extent the neurological examination lacks sensitivity and specificity and only about two-thirds (69%) of patients with documented L4-L5 or L5-S1 disc herniations demonstrated weakness or deep tendon reflex changes. To maximize information from the evaluation, physicians routinely test for nonorganic physical signs. Isolated positive signs have no clinical or predictive value, and only a score of three or more positive signs is considered clinically significant. Further, these tests were not designed to detect malingering. Used in isolation, the history, neurological examination, and various diagnostic studies do not have the necessary sensitivity and specificity to diagnose and identify the structural pathology responsible for lumbar radiculopathy. Integrating these components into a logical, unbiased evaluation, physicians usually can perform an accurate assessment.
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3. Case Studies: Spinal Impairment Evaluation: Comparison of the Third Edition Revised, Fourth, and Fifth Editions

   Christopher R. Brigham

   Pages 4–7, 9

   DOI: 10.1001/amaguidesnewsletters.2001.JanFeb03

   Abstract

   Significant differences exist regarding spinal impairment rating among the Third Edition Revised, and the Fourth and Fifth Editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Table 1 summarizes the rating criteria used in these three editions. The AMA Guides, Third Edition Revised used only the method that was subsequently labeled the Range of Motion (ROM) Model or Method to assess impairment. The AMA Guides, Fourth Edition, introduced the Injury or Diagnosis-related estimates (DRE) Method, but it had a limited role, primarily as a differentiator, when a patient's final category of disability was in doubt. The AMA Guides, Fifth Edition retains both ROM and DRE, but they are termed methods rather than models. The DRE Method remains the principal means to evaluate an individual who has an injury, but changes were made regarding when and how it is used. In specified cases, the ROM Method is used to assess impairment not caused by an injury (eg, multilevel involvement, recurrent radiculopathy, or multiple pathologic episodes that produce alteration of motion segment integrity or radiculopathy). Table 2 presents seven exemplar cases that demonstrate the differences in impairment ratings among the three editions, and the text discusses the ratings and differences among the outcomes according to edition used.
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4. Literature Review

   James B. Talmage

   Pages 4–9

   DOI: 10.1001/amaguidesnewsletters.2001.JanFeb04