Like anything else, the new 6th Edition AMA Guides are just another tool. The AMA has tried painstakingly to get the guides right time and time again, however this time they seem to be on the right track. Gone are the days of range of motion models and big impairment for little injuries. What we have here is a very conservative AMA Guides to the Evaluation of Permanent Impairment.

They’ve finally included a chiropractic physician, Dr. Stanley S. Kaplan as a contributing author. For decades, Dr. Kaplan, a board certified chiropractic orthopedist (yes, there is such a thing) has developed many of the formulas for rating of muculoskeletal conditions in many of the previous editions of “The Guides” and are still in use today. Dr. Kaplan has been teaching attorneys and physicians of all disciplines how to use the guides. Dr. Kaplan’s course is the “cliff notes” of the impairment guides. You get all the meat and potatoes without any of the fluff. I had the privilege of interning with Dr. Kaplan and his partner Dr. Paul Lombardi in 1991. Helping him edit his workbook prior to a series of impairment rating seminars gave me great insight and a lot of practice at rating patients.

In Cocoa, FL where Dr. Kaplan practiced, whenever a judge would have the opinions of several physicians regarding the impairment of a patient’s condition, if Dr. Kaplan’s opinion was offered, it was always the one chosen as the most accurate by the judge;

Similarly, if you have a case where the reports of various treating physicians or IME physicians include impairment ratings and those impairment rating come from a variety of guideline editions, the 6th Edition is considered the most accurate. As such, it is the 6th edition based impairment that will be deemed the most accurate.

For musculoskeletal injuries, The 6th Edition uses formulas based on:

  • Impairment Class: A classification of functional impairment that categorizes patient’s by the severity of their symptoms/conditions.
  • GMFH: Grade Modifier Functional History. This is based on how the pain impacts the patients day to day activities. Do they have pain with sedentary activity, normal activity or do moderate or heavy physical activity provoke their pain? The 6th Edition references PDQs (Pain Disability Questionnaires) to assess this and this GMFH is given a number based on the PDQ score.
  • GMPE: Grade Modifier Physical Exam. This grade modifier is dependent on the positive findings upon physical exam. The specific findings that are accepted are listed in the guides themselves.
  • GMCS: Grade Modifier Clinical Studies. Clinical studies are things such as X-ray, CT-scan, MRI, etc.
  • CDX: Represents the impairment class the patient is assigned to which establishes a base impairment starting number. Starting from the center/middle number in this class, this number is modified up or down based on the grade modifiers (GM), FH (Functional History, PE (Physical Examination) and CS (Clinical Studies). It gives the physician the starting point for their impairment, which is then modified up or down by a formula based on the GMFH, GMPE and GMCS.

Sounds easy right? (Yeah, that’s what I thought too)

The formula for calculating an impairment looks like this:

(GMFH-CDX) + (GMPE-CDX) + (GMCS-CDX) = Impairment Class Modifier

Brings back some bad memories of high school algebra-doesn’t it?

This formula, calculates whether or not you will be adding a couple points to the impairment base number or subtracting a couple points, or leaving it alone.

Having been calculating hundreds of impairments per year per Dr. Stan Kaplan’s method since 1991, I was pretty darn comfortable with it. The 6th Edition comes along and suddenly my first impairment calculation takes me nearly 45 minutes. But I figured it out. 45 minutes to figure out that the impairment wasn’t a 6%, but a 7%. All that time – all that work for 1 little percent!

So I began to develop systems to make it a more efficient process. The 6th Edition really sifts out those meaningless little non-injuries. If someone has a 3% nowadays as calculated by the 6th Edition methodology, you better believe it’s a real 3% physical impairment – 3% irreparable damage to the body.

The physicians that treat your clients will need to be using scientifically accepted outcomes questionnaires like the Pain Disability Questionnaire. It’s starts from day-1 on the initial intake, done again periodically throughout care and of course on the final examination. This not only tracks the effectiveness of care, it also supports ongoing care by validating medical necessity. In the end, the resulting PDQ number will go into the equation for rating impairment.

The 6th Edition also figures in positive or negative diagnostic imaging results in 2 ways. A positive cervical herniated disc on MRI will take the patient’s impairment from a “Soft Tissue And Non-Specific Conditions” category, where the impairment rating range is from 1% to a maximum of 3% (remember I said it was conservative???) to the “Motion Segment Lesions” category, where the impairments range from 4% to a maximum of 7%. So a positive MRI can make a big difference in the resulting impairment number.

Here’s the kicker…If a patient has (and I quote) “Documented history of sprain/strain type injury, now resolved, or occasional complaints of neck pain with no objective findings on examination”, there is no impairment rating. Zero, nada, bubkis, zilch! No more pain or occasional pain without any positive findings = 0%.

In the 5th Edition and all prior editions of the AMA Guides, you could easily get a 5% out of this due to the soft tissue component, now, not so much.

A patient with a herniated disc in the neck and soft tissue strain with continued symptoms in the lower back could easily be a 10% impairment. But this will be dependent on

(1) Good objective clinical findings (orthopedic / neurological tests)

(2) Positive physical exam findings (straight leg raise, cervical compression tests)

(3) Results of Scientifically accepted and validated Outcome Questionnaires.

(4) Good documentation (preferably dictation or EMR / EHR system)

It seems high time that the quality of physician will make more of a difference in your cases with these new 6th Edition Guidelines. Make sure the doctors that treat your clients use standard orthopedic and neurological tests (and be able to explain them to a jury), use good quality CT/MRI centers, use outcome questionnaires throughout the patients care and of course good documentation of clinical records.

It turns out the new 6th Edition AMA Guides are simple to use (even in spite of my initial impairment report taking me 45 minutes). They seem to be more accurate and the results of which will trump the results of any prior edition of the AMA Guides.

Lastly, remember 1 thing about impairment rating. The impairment rating represents the permanent physical damage to the body. This in and of itself may or may not mean much. However it is how the physical impairment relates to the ability of that person to do work or their activities of daily living that is of utmost importance. This of course is what we call disability.

I like to give the example of the professional soccer player and the concert pianist. Both get into a car accident and both have the index finger of their right hand severed. Both have the same physical impairment. In soccer, using your hands is a penalty and doesn’t impact his ability to play professional soccer-life goes on. For the concert pianist, well, she isn’t so lucky. Although they have the same exact physical impairment, the concert pianists professional career is over. She may be able to teach music theory in a school, but she’ll never be able to play a concerto in front of an audience again. She has a 100% disability.

So, the impairment rating is simply a tool. How this relates to your client’s activities of daily living or ability to work is what really counts. Make sure your doctor uses PDQ or similar to asses how your injuries are affecting your work, your play, your life.

Dr. Todd Narson, Miami Beach, FL

Dr. Narson is a 2-term past president of the Florida Chiropractic Association’s Council on Sports Injuries, Physical Fitness & Rehabilitation and was honored as the recipient of the coveted Chiropractic Sports Physician of the Year Award in 1999-2000. His is a diplomate of the American Chiropractic Board of Sports Physicians. He has been qualified as an expert witness in Miami-Dade Country and has consulted with insurance companies, defense firms and conducted forensic file/peer reviews. He practices in Miami Beach, Florida at the Miami Beach Family & Sports Chiropractic Center; A Facility for Natural Sports Medicine.

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