INFORMATION FOR ATTORNEYS > Back To Newsletter List

Shaw Chiropractic
A Medical-Legal Newsletter for Personal Injury Attorneys
by Dr. Steven W. Shaw

AMA Impairment Guides: 5th Edition, Part 3

In this second newsletter of our series I will continue to present information regarding the new edition of the AGuides@. Some of the information is significantly different than prior editions while other information remains unchanged. Both are important to appreciate the application of the Guides in our everyday practice.

The question always arises as to when an impairment exam should be performed on a patient. I have had attorneys request impairment exams shortly after the onset of care while other attorneys ask that we wait at least 1 year. The Guides offer this suggestion. They say that "An impairment should not be considered permanent until the clinical findings indicate that the medical condition is static, and well stabilized, often termed the date of maximum medical improvement". In prior editions of the Guides there were suggestions of 6 months or 1 year but none of the Guides made specific recommendations. Therefore, I will make this recommendation which I believe is reasonable. Six months of documented relative stability suggests that further improvement is unlikely. I believe that this represents the shortest time frame. Assuming that some degree of improvement will occur during the first 1-3 months of management the earliest an impairment should be performed would be 7-9 months post trauma. Of course, there are circumstances when impairments can be made earlier or later but for the majority of connective tissue injuries this seems a reasonable time frame.

Regarding impairment rating evaluations, let me comment that performing an impairment rating evaluation on a patient is not part of usual management or reporting (although in our personal injury practice it is understood that the issue should be addressed). A request for an impairment rating evaluation should come from a third party such as an attorney, judge, agency or adjuster. I strongly suggest that when a letter of representation is sent to a treating doctor that a specific request is made that upon completion of care an impairment evaluation be performed. This will avoid issues which have come up during expert testimony regarding why a doctor performed an impairment evaluation when there was no written request for one.

Increasing Ratings

The guides allow for an increase in an impairment of 1%-3% if the examining physician believes that an impairment may misrepresent the actual impairment due to a treatment effect or lack of treatment . For example, a person with an acute disc herniation who has undergone epidural steroid injection with complete pain relief may justify a rating increase. This is because despite the effectiveness of treatment the underlying impairing illness remains present.

Whole Person vs Regional Impairments

The Guides recommend using Whole Person Impairments (WPI) impairments. However, most third parties are looking for Regional Impairments (RI). As it relates to the spine, the Guides offer a criteria for converting whole person impairments to regional spine impairments. They do this by dividing the WPI by the percent of spine function that has been assigned to the region. For some reason, the percent of spine function assigned to each region is different depending on the rating method used. Using the Diagnostic Related Estimates (DRE) method, the spine function percentages are 35%, 20% and 75% for the Cervical, Thoracic and Lumbar areas respectively. Using the Range of Motion (ROM) method, the percentages are 80%, 40% and 90% respectively. There is no explanation for the difference between rating methods and, frankly, it seems illogical.

As an example, a person with a neck injury rated as a 10% WPI using the DRE method would have a corresponding 29% RI of the Cervical spine. If the same 10% was determined using the ROM method, the RI of the cervical spine would be 12.5%. Quite a difference for the same spinal area. I'm sure that this apparent error will be clarified in future issues of "The Guides Newsletter". However, at this time these are the rules.

I suspect that there will be those doctors and lawyers who will use this information to inappropriately increase impairments to unreasonable levels. I personally believe it misrepresents the patient's true impairment. I suggest that you ask the impairment rating physician to use terminology which will assure continuity between the 5th edition and prior editions. As en example, I suggest the following terminology: "As a result of the injuries sustained on 1/1/01, Mr. Smith has a 10% whole person impairment as it relates to the cervical spine"