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Shaw Chiropractic AMA OPINIONS ON THE INTERPRETATION OF THE GUIDELINES A recent newsletter from the American Medical Association titled "The Guides Newsletter" addressed some salient impairment issues. Issues which the trial attorney should be familiar with to assure that the determination of impairment by the treating physician is both accurate and appropriate. James B. Talmage, M.D. is a fellow of the American Academy of Disability Evaluating Physicians. In his article titled "Non-verifiable Radicular Complaints" he addresses the apparent difficulty in interpretation of the guides as it relates to subjective complaints radiating to an extremity. He makes the interesting observation that the term itself, non-verifiable radicular complaints, is an oxymoron. He points out that if a complaints is non-verifiable how does one know it is radicular (Radicular-originating from the spinal nerve roots). Table 71 of the 4th edition on page 109 describes the different category systems of the injury model (aka Diagnostic Related Estimates Model). The injury model categorizes impairment based upon the presence or absence of differentiators and/or structural inclusions and is said to be the preferred method rather than the Functional or Range of Motion Model. A Category II impairment describes non-verifiable radicular complaints which if present warrant that a 5% impairment exists. A frequent error in interpretation of the guides is to assign a Category II impairment when the patient is in actuality a Category I candidate. More than likely this misinterpretation is a result of the previous version of the Guides which indicates that the Specific Spinal Disorders Chart was the preferred method. This chart described complaints of 6 months duration with a rating of 5%. There was no need for specific lesions, just medically documented lack of improvement and persistent complaints. To make the determination that a patient has a Category II impairment the physician should be able to, from examination and history, identify a specific nerve root origin of the pain. Generalized spine and extremity pain is not sufficient to be diagnosed as radicular. There are many other potential causes of referred extremity pain including sclerotogenous pain patterns, vascular insufficiency patterns, plexopathies, myelopathies, neuropathies and more. Some of these are ratable while others are not. A clinical history of trauma with degenerative joint changes associated with foraminal compromise at C5 with unilateral lateral brachial pain would be consistent with radiculopathy diagnosis. A complaint of neck pain with generalized arm pain would not be consistent with radiculopathy. To document a pattern of suspected nerve root involvement the attending physician should at the very least have history and examination findings which are suggestive of mono-radicular symptoms. Further, if symptoms persist the doctor’s notes should address the consideration of electrodiagnostic evaluation with electromyography or somatosensory evoked potentials. If these tests are ordered and positive, imaging studies should be considered as well. Do these sophisticated and costly diagnostic procedures need to be performed? Absolutely not. They need only be considered and an explanation of thought process described in the treatment notes. Then the non verifiable radicular complaints would be substantiated and a Category II (5%) rating applied. This information is important since more and more physicians are being called upon to justify the logic behind the rating process. An astute defense attorney armed with an understanding of the guides can pick apart the impairment of the unprepared, uninformed or under educated physician. Make sure your client’s treating physician has the education and training in impairment rating and can substantiate their opinions regarding the application of the guides if used as a reference. For 1997 we are planning an educational seminar series geared specifically to the needs of trial attorneys. Clearly, this will be one of the topics we will address. The programs will be held bimonthly in Hartford and are scheduled to begin in March. If you want to contacted regarding the program please let us know. Also, your feedback regarding location, time, length and topics would be greatly appreciated. Below is a list of our preliminary topics which we are preparing: Basic Anatomy and Physiology
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