AMA Guides® Newsletter - Issue Archive

Articles

1. Impairment Rating in Traumatic Brain Injury

   Nathan D. Zasler, Michael F. Martelli, Mark C. Bender

   Pages 1–9

   DOI: 10.1001/amaguidesnewsletters.2003.SepOct01

   Abstract

   Traumatic brain injury (TBI) usually is described in terms of the severity of the initial neurologic insult and is defined by the Glasgow Coma Scale (GCS) score; the presence and duration of amnesia (retrograde and anterograde); and the presence and duration of alteration in or loss of consciousness. According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), the evaluating physician should consider the following: narrative history; most recent clinical evaluation; assessment of current clinical status; plans for future treatment; diagnosis and clinical impressions; and estimated time for full or partial recovery. Individuals who present with brain disease or damage also may experience impairments in several parts of the body or nervous system. Physicians who evaluate TBI must be familiar with numerous relevant sections in Chapter 13, The Central and Peripheral Nervous System, as shown in a table in the article. Individual impairments can be combined using the Combined Values Chart in the AMA Guides. Also, the AMA Guides requires the examiner to grade mental status impairment based on the individual's ability to perform activities of daily living and may require neuropsychological testing. The evaluation of TBI impairment and disability is by no means a simple undertaking for any clinician, and evaluators must familiarize themselves with disability and impairment evaluation protocols and their limitations.
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2. Impairment Tutorial: Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating

   Lorne Direnfeld, James Talmage, Christopher Brigham

   Pages 4–12

   DOI: 10.1001/amaguidesnewsletters.2003.SepOct02

   Abstract

   This article was prompted by the submission of two challenging cases that exemplify the decision processes involved in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In both cases, the physical examinations were normal with no evidence of illness behavior, but, based on their histories and clinical presentations, the patients reported credible symptoms attributable to specific significant injuries. The dilemma for evaluators was whether to adhere to the AMA Guides, as written, or to attempt to rate impairment in these rare cases. In the first case, the evaluating neurologist used alternative approaches to define impairment based on the presence of thoracic outlet syndrome and upper extremity pain, as if there were a nerve injury. An orthopedic surgeon who evaluated the case did not base impairment on pain and used the upper extremity chapters in the AMA Guides. The impairment ratings determined using either the nervous system or upper extremity chapters of the AMA Guides resulted in almost the same rating (9% vs 8% upper extremity impairment), and either value converted to 5% whole person permanent impairment. In the second case, the neurologist evaluated the individual for neuropathic pain (9% WPI), and the orthopedic surgeon rated the patient as Diagnosis-related estimates Cervical Category II for nonverifiable radicular pain (5% to 8% WPI).
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3. Clinical Update: Grip Strength: An Uncommon Impairment

   Christopher R. Brigham

   Pages 6–11

   DOI: 10.1001/amaguidesnewsletters.2003.SepOct03

   Abstract

   Upper extremity impairment rarely is assessed using grip strength, according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), because results can be influenced by subjective factors that are difficult to control, including sex, age, comorbidities, fatigue, handedness, time of day, pain, and the individual's cooperation. The AMA Guides, Section 16.5b, Impairment Evaluation Methods, discusses the approach used for rating peripheral nerve injuries, but this section applies only to specific nerve lesions with resulting weakness of the muscles supplied or sensory changes. Strength correlates only poorly with performance of the activities of daily living, and grip strength testing using a dynamometer or other types of isometric strength testing has not been shown to reliably discriminate between submaximal and maximal efforts. Grip strength usually is not used in the presence of decreased motion, painful conditions, deformities, or absence of body parts (eg, missing digit), nor is it used to rate weakness from a peripheral nerve lesion. In rare cases, the AMA Guides allows the use of loss of strength (eg, due to a severe muscle tear that healed leaving a palpable muscle defect). Impairment ratings based on objective anatomic findings take precedence, and loss of strength is rarely combined and only if based on unrelated etiologic or pathomechanical causes.
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