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Shaw Chiropractic AMA Impairment Guides: 5th Edition, Part 1 They're finally here!!! The 5th edition of the AMA Guides to the Evaluation of Permanent Impairment has been released for distribution. Those of us who have had our orders in since the scheduled release in October of 1999 were among the first to receive the new guides. The new book is nearly twice the size of the 1994 released 4th edition (339p v. 613 p) and has added more in depth detail regarding it=s application. In this first of three (or more) newsletters on the Guides I will review what I believe are some interesting changes which you will need to know to effectively use the Guides with your client's files. From my first reading of the guides, what strikes me most is the flexibility given to the examining physician when determining impairment. Prior editions were somewhat rigid while this one allows for significant physician subjectivity. Interesting statements such as "Evaluating physicians may use their clinical judgement, however, and comment on any significant age or gender effect for a particular individual" and AThe physician should use clinical judgement regarding normal structure and function and estimate what is normal for the individual based upon the physicians knowledge or estimate of the individual's preinjury or preillness conditions are examples of the new approach. Further evidence of this change in philosophy is the change from specific DRE impairments to DRE ranges of impairments. For example, a DRE Category II in the cervical spine was an absolute 5% in the 4th edition. The 5th edition gives the physician a range to choose from of 5%-8%. The input based upon the physician=s clinical experience makes this new edition more of a guide than a regulation. It also allows for more realistic determinations of impairment given the intangibles which make for the art of a clinical practice. You may be thinking that this philosophy change may result in larger impairments from physicians but other aspects of the guides are more confining. The guides are full of clinical examples of how impairments should be performed. These examples appear to be quite conservative and if taken in the wrong context may lead toward inappropriately small impairments. For example, the guides demonstrate a 0% impairment of a 37 year old subject with intermittent neck pain with full ranges of motion but pain on extremes. No value is given for tenderness or for the diagnosis of a intermittent cervical strain. At casual reading this may sound like the standard cervical connective tissue injury. However, post-traumatic patients generally have functional limitations in ranges of motion and often have a sprain component to the injury. Also, if you added muscle guarding and/or spasm or non-verifiable radicular complaints with a specific injury history and findings the patient would have been rated between 5% and 8%. Your impairment rating physicians should be aware of this subtlety and be prepared to address any challenges to their opinions. Another interesting point which has been controversial in prior editions but cleared up in this edition is that of who is qualified to use the guides and who should perform impairment evaluations. The 5th edition is clear that impairments should be performed only by a licenced physician. In Connecticut, physicians include doctors holding the title of MD, DO, DC and ND. This eliminates any concerns about the chiropractic physician using the AMA Guides and testifying using the guides as a reference. The guides also point out that data arrived from other health care practitioners such as audiologists, occupational therapists and physical therapists can be considered as useful information but that only the licenced physician should use the data and relate it to permanent impairment. I find it ironic that health care professionals such as occupational therapists and physical therapists are barred from doing impairment determinations since they are specifically trained to assess functional capacity, ADLs and work tolerances. However, the guides are specific in their opinion on this topic and you should be aware of it. You should also know that the AMA Guides are not authoritative and a physician or other health practitioner may choose to use some other form of impairment rating evaluation system. In the next several issues I will review the concepts of Whole Person vs. Regional Impairments, DRE vs. ROM impairments, ratings based upon Pain, use of inclinometers, report preparation, motion segment integrity impairments, radiculopathy and disc injuries, the DRE category system. If you have any questions or recommendations for topics to be covered email me at Dr.Shaw@shawchiropractic.com or call 800-232-6824. Also, visit our new web site at www.shawchiropractic.com and offer us some input |
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