AMA Guides® Newsletter - Issue Archive

Articles

1. Acromioplasty: Is It An Impairment?

   Charles N. Brooks

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.2002.MayJun01

   Abstract

   Acromioplasty can be performed open or arthroscopically and removes the spurred, curved, or hooked portion of the acromion. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) has not addressed whether acromioplasty itself constitutes an impairment. On the one hand, if impairment is defined as “a loss, loss of use, or derangement of any body part, organ system, or organ function,” then acromioplasty is an impairment because of the loss of a small portion of the scapula. On the other hand, acromioplasty generally results in improved function (ie, no or negative impairment) and may increase rather than decrease an individual's ability to perform the activities of daily living. This does not indicate that patients who undergo acromioplasty have no impairment whatsoever, and remaining motion deficits should be rated according to existing criteria in the AMA Guides. For example, failure to properly reattach the deltoid muscle or excessive acromial resection may result in deltoid weakness or strength. Often during acromioplasty, the removal of the clavicular spur is accomplished via excision of distal clavicle (resection arthroplasty), which is a permanent impairment. Acromionectomy, which is functionally similar to distal clavicular resection, and transposing the 10% upper extremity impairment rating for distal clavicular resection to a total acromionectomy appears to be justified.
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2. Letter to the Editor

   Tom Bohr

   Pages 3–3

   DOI: 10.1001/amaguidesnewsletters.2002.MayJun02

   Abstract

   The author of this letter responds to an article regarding fibromyalgia in the July/August 2001 issue of The Guides Newsletter and notes an error in the article's assertion that fibromyalgia patients are not more likely to have psychiatric disorders than are other patients with chronic pain (eg, rheumatoid arthritis) because of an error in a previous study (the Alabama fibromyalgia research group). The author of the letter asserts that 27 studies show excess psychopathology in fibromyalgia patients; the few articles that support a diagnosis of fibromyalgia are dated and somewhat weak in terms of methodology. In fact, the Alabama study suffered from referral bias at academic centers and has been refuted by at least two other groups that found that fibromyalgia patients do not seem to have excess psychopathology because the studies were conducted at academic medical centers and therefore suffer from the typical tertiary care referral bias associated with more severely affected patients. The letter writer also highlights the original article's assertion that 14% to 23% of fibromyalgia patients receive a formal diagnosis of somatization. This is a large group of patients, the writer suggests, and a less restrictive diagnosis of “undifferentiated somatoform disorder” or “pain disorder” would increase the incidence. Finally, further discussions of fibromyalgia should address the excess incidence of abuse (sexual, physical, and emotional) during the early life of these patients.
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3. Quick Consult: Quick Consult: Acromioplasty

   Pages 4–5

   DOI: 10.1001/amaguidesnewsletters.2002.MayJun03

   Abstract

   Different jurisdictions use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) for different purposes, and this article reviews a specific jurisdictional definition in the Province of Ontario of catastrophic impairment that incorporates the AMA Guides. In Ontario, a whole person impairment (WPI) exceeding 54% or a mental or behavioral impairment of Class 4 or 5 qualifies the individual for catastrophic benefits, and individuals who do not meet the test receive a lesser benefit. By inference, this establishes a parity threshold among dissimilar injuries and dissimilar outcome assessment scales for benefits. In Ontario, the Glasgow Coma Scale (GCS) identifies patients who have a high probability of death or of severely disabled survival. The GCS recognizes gradations of vegetative state and disability, but translating the gradations for rating individual impairment on ordinal scales into a method of assessing percentage impairments cannot be done reliably, as explained in the AMA Guides, Fifth Edition. The AMA Guides also notes that mental and behavioral impairment in Class 4 (marked impairment) or 5 (extreme impairment) indicates “catastrophic impairment” by significantly impeding useful functioning (Class 4) or significantly impeding useful functioning and implying complete dependency on another person for care (Class 5). Translating the AMA Guides guidelines into ordinal scales cannot be done reliably.
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4. Legal Update: Catastrophic Impairment: Catastrophic Impairment: Use of the AMA Guides in Ontario

   Edward Klimek

   Pages 6–7

   DOI: 10.1001/amaguidesnewsletters.2002.MayJun04

   Abstract

   Chapter 18, Pain, is the first attempt in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, to define comprehensive pain evaluation and rating. Chapter 18 focuses on situations in which the pain itself is a major cause of suffering, dysfunction, or medical intervention even though an examining physician can find no demonstrable active disease or autonomic changes. These statements likely would be rejected by rating systems that require a physiologic basis for rating. Other chapters in the AMA Guides typically account for pain as part of specific impairment ratings; for example, a physician who rates cervical spine impairment must decide if a rating for pain beyond the original rating is appropriate. Many rating systems would reject such a rating for pain because of its subjective nature, but, despite these difficulties, even restrictive rating systems may require the use of Chapter 18 because, according to the AMA Guides, no other available method exists for considering impairment of certain conditions such as postherpetic neuralgias or migraines. As the AMA Guides acknowledges, Chapter 18 seems to allow impairment ratings caused by pain and suffering but at the same time to forestall actually assigning a number. One hopes for refinements in our understanding of chronic pain treatment and outcomes; in the interim, knowledgeable raters should guide nonmedical personnel toward a reasonable understanding of this chapter.
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5. Legal Update: Rating Pain: Rating Pain: Chapter 18 and Workers’ Compensation

   Kathryn Mueller

   Pages 8–8

   DOI: 10.1001/amaguidesnewsletters.2002.MayJun05

   Abstract

   The first four editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) used the range of motion (ROM) method and derived impairment percentages. This method is reliable and works well to rate finger joint injuries such as fractures or sprains that cause reduced finger joint ROM, but it frequently underestimates the functional difficulty (impairment) caused by tendon injuries that restrict the excursion of tendons. For this reason, the AMA Guides, Fifth Edition, introduced a second method to rate ROM in fingers, the total active motion (TAM) method. When an evaluator calculates the patient's impairment using the traditional method from the first four editions of the AMA Guides, the impairment percentage is likely to underestimate the patient's “real world” difficulty or function; the TAM method measures flexion when the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints are in full simultaneous flexion, and it measures extension when all three joints are in full simultaneous extension. Based on an example and using the Combined Values Chart in the Fifth Edition and the traditional method (the only method allowed in the first four editions), one would assess a 16% impairment of the digit; using the TAM method now available in the Fifth Edition, the impairment is more appropriately estimated at 61%.
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6. Impairment Tutorial: Guides Fifth Edition's Total Active Motion (TAM) Method of Calculating Impairment of Fingers for Motion Loss

   James Talmage

   Pages 9–9

   DOI: 10.1001/amaguidesnewsletters.2002.MayJun06

7. Questions and Answers

   Pages 10–11

   DOI: 10.1001/amaguidesnewsletters.2002.MayJun07