Consistency of AMA Impairment Evaluation : Spine Pt 3

Saturday, December 31, 2005 | 0

The following is the third and final in the article series "Consistency of AMA Impairment Evaluation: Spine"

By: Luis Perez-Cordero & Craig Andrew Lange

SPINAL ROM RATING METHOD

The P&S report must clearly outline physician's evaluating criteria and its clinical support.

1. AMA 5th Ed., (Chapter 15), Section 15.8 (a, b & c), pages 398 to 422.

2. Calculating ROM of impairments, must abide to the precise criteria outlined by the AMA 5th Ed., Section 15.8a, page 399.

3. Evaluating Physician should avoid:

4. Using unexplained ROM limitations of one or more spinal segments for calculating impairment under AMA 5th Ed., Section 15.9 (lumbar spine), Section 15.10 (thoracic spine), or Section 15.11 (cervical spine).

5. Using pre-existing degenerative disc disease as the only clinical support for the use of the ROM method.

6. Master the AMA Guides, page 197: In the case of multiple injuries or conditions, if the pathology affects different spinal regions, the DRE method is applied to each region. Only when the pathology reoccurs or repeats in the same spinal lever or region is the ROM method used. Spinal level refers to an area bounded by two vertebrae, a single spinal disk and associate nerve roots and nerves.

7. ROM applies:

7.1. Where there is recurrent radiculopathy caused by a new or recurrent disk herniation or where there is new radiculopathy caused by a recurrent injury to the same spinal region.

7.2. New Injury means an injury to a spine area that was essentially injured free before the incident even though other aging or pre-existing asymptomatic degenerative changes might be present.

7.3. Recurrent Injury refers to an injury to a spine region that has a history of injury. Refers to the same condition, which is asymptomatic between episodes. Condition is also considered recurrent if symptoms increase from or is still considered to be due to, or is a normal progression of the original condition.

8. ROM method is only used to rate individuals with (1) multilevel fractures, (2) recurrent radiculopathy, (3) multilevel radiculopathy, (4) multilevel loss of structural integrity, (5) jurisdictional requirement or no-injury evaluations. (AMA 5th Ed., 398). One exception occurs when individuals, having corticospinal tract involvement and are treated with decompression and multilevel fusion, are rated via the DRE method because it is difficult to assess ROM with paralysis.

8.1. AMA Guides page 374: "The DRE method is the primary method used to evaluate individuals with an injury. The ROM method is only used to evaluate individuals with an injury at more than one level in the same spinal region and in certain individuals with recurrent pathology."

9. In those situations in which the AMA allows determining impairment based on the range of motion method. (AMA Guides, pages 398-422)

9.1. Evaluating physician must ensure that adequate warm-up movements have been performed. AMA 5th Ed., page 399.

9.2. Measure ROM and determine any angle of ankylosis or any restricted motion that is present. AMA 5th Ed., page 399 & 403.

9.3. Perform at least 3 measurements of each motion and determine which measurements meet reproducibility criteria and calculate the average of each set of 3 measurements.

9.3.1. If acute muscle spasm is present, this should be noted in the examiner's report. However, the mobility measurements would not be valid for estimating permanent impairment. Rating should be deferred until after any acute exacerbation of the chronic condition has subsided. AMA 5th Ed., page 399.

9.4. Physician must seek consistency; repeat tests when necessary or discard all together when re-testing remains inconsistent. AMA 5th Ed., page 399.

9.4.1. "The physician should seek consistency when testing active motion, strength and sensation. Tests with inconsistent results should be repeated. Results that remain inconsistent should be disregarded. When the physiologic measurements fail to match known pathology they should be repeated and, if still inconsistent, disallowed until documented evidence is provided for the abnormalities noted on the physical examination." AMA 5th Ed., page 399.

9.5. Clinical findings must be correlated to the imaging studies, which have been used to confirm a diagnosis. Without clinical correlation, a 'positive' imaging study in itself does not make the diagnosis and cannot be used as the sole support for an impairment rating.

Click here for Table A-2 Recoding ROM Measurements for The Spine.

9.6. Neurologic Impairment: For the neurological component of ROM evaluation criteria refer to AMA Guides Section 15.12, page 423 and page 403, Section 15.8d.

9.7. Clinical Diagnosis Impairment: For determining impairment based on this portion of the ROM Method, refer to AMA 5th Ed., pages 398 to 404. AMA 5th Ed., Table 15-7 on page 404.

The impairment rating values found in the guides represent estimates of the extent of impairments based on the physician's judgment, experience, training, skill, and thoroughness. Considerations of factors such as sensitivity, specificity, accuracy, reproducibility, interpretation of lab test results and clinical procedures, as well as recognition of variability among the interpretations of different observers, are variables affecting the determination of a WPI.

Completeness and reliability of the medical documentation are an integral part of the impairment rating process and strengthen the numeric impairment figures derived from a well-structured set of thorough observation and testing as outlined in the AMA Guides evaluation criteria. No comprehensive P&S medical report is immune from the requirement that determination of any impairment level must follow the AMA Guides established evaluation criterion and be supported by anatomic/clinical findings as well as be explained by a well-reasoned/rational medical opinion.

Evaluating physician must obtain clinical information from medical records and through performance of a physical examination and compare clinical information from several sources to check for consistency. (AMA 5th Ed., 19 & 593) It is the evaluating physician's responsibility to resolve disparities when possible, if the clinical information is inconsistent. Physician must avoid duplicating or 'creating' impairment by providing incomplete reporting of findings, misuse of proper evaluation criteria, giving incomplete description of medical studies or by disregarding AMA assessment and evaluation criteria. (AMA 5th Ed., 374 to 377).

In determining an overall level of impairment evaluating physician should always address the following question: If it were not for the non-vocational factors or pre-existing conditions, would this level of impairment exist?

Consistency is the key word when addressing impairment in a California P&S report. Consistency of imaging studies, to clinical findings on examination, to the medical/treatment histories, to the impairment rating criteria of the AMA Guides and to a reasoned medical opinion.

Bibliography

1 Linda Cocchiarella & Gunnar BJ Anderson: Guides to the Evaluation of Permanent Impairment, Fifth Edition. American Medical Association, United States, 2001. http://www.ama-assn.org/

2 Linda Cocchiarella & Stephen J. Lord: Master The AMA Guides Fifth. American Medical Association, United States, 2001

3 California Code of Regulations; Article 7, section 9805: Schedule for Rating Permanent Disabilities. January 2005 Edition; http://www.dir.ca.gov/dwc/PDR.pdf

4 James B. Talmage, & J. Mark Melhorn: A Physician's Guide to Return to Work. American Medical Association, United States of America, 2005.

Article series by Luis Perez-Cordero & Craig Andrew Lange, Impairment & Disability Rating Specialists. They can be reached at pdrating@pacbell.net.

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