WCLA MCLE 9-8-11
• AMA Guides (Part 2): How Impairment Is
Rated & More Case Studies
• Thursday September 8, 2011 from 12:00 noon
to 1:00 pm
• WCLA member Robert T. Bernat, JD, MD
• James R. Thompson Center Auditorium,
Chicago, IL
• 1.0 Hour General MCLE Credit
New Section 8.1b
820 ILCS 305/8.1b
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Sec. 8.1b. Determination of permanent partial disability. For accidental injuries that occur
on or after September 1, 2011, permanent partial disability shall be established using the
following criteria: (a) A physician licensed to practice medicine in all of its branches
preparing a permanent partial disability impairment report shall report the level of
impairment in writing. The report shall include an evaluation of medically defined and
professionally appropriate measurements of impairment that include, but are not limited to:
loss of range of motion; loss of strength; measured atrophy of tissue mass consistent with the
injury; and any other measurements that establish the nature and extent of the impairment.
The most current edition of the American Medical Association's "Guides to the Evaluation of
Permanent Impairment" shall be used by the physician in determining the level of
impairment. (b) In determining the level of permanent partial disability, the Commission
shall base its determination on the following factors: (i) the reported level of impairment
pursuant to subsection (a); (ii) the occupation of the injured employee; (iii) the age of the
employee at the time of the injury; (iv) the employee's future earning capacity; and (v)
evidence of disability corroborated by the treating medical records. No single enumerated
factor shall be the sole determinant of disability. In determining the level of disability, the
relevance and weight of any factors used in addition to the level of impairment as reported
by the physician must be explained in a written order.
KEY POINT
• Physicians rate impairment
– Medical determination
– Medical training required (Anatomy, Physiology)
• Judges rate disability
– Judge “factors in” NON-medical factors
• Doctor: “Do NOT think about the ability to do
his/her job, availability of similar jobs in the local
economy, etc., as that is the judge’s task, NOT
your task.”
3
Impairment DOES NOT equal Disability
• Example: both a lawyer and a pianist sustain
an amputation of the non-dominant little
finger.
– Both have the same impairment
• 100% of the digit, 10% of the hand,
9% of the upper extremity, 5% whole person
– The lawyer has no disability
– The pianist is unable to perform his occupation
• Totally disabled for his occupation
• Fully capable of many jobs
• Physician’s role: Determine IMPAIRMENT
4
Impairment is NOT Disability
• “In disability evaluation, the impairment
rating is ONE of several determinants of
disablement. Impairment rating is the
determinant most amenable to physician
assessment; it must be further integrated with
contextual information typically provided by
nonphysician sources regarding psychological,
social, vocational, and avocational issues.” –
page 6
Unless otherwise specified page numbers refer to the Guides, 6th
Edition
5
Basic AMA Guides Analysis
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Maximum Medical Improvement
Determine Diagnosis (DBI) & Class (CDX) (0-4)
Default Impairment is middle # in array of 5 in CDX
Adjust Default by Net Adjustment for Grade Modifiers (GM):
– Functional History (FH) (0-4)
– Physical Examination (PE) (0-4)
– Clinical Studies (CS) (0-4)
• Net Adjustment for each GM is GM minus CDX
• Move Default Impairment to left or right based on Net
Adjustment Formula (e.g. -2 net adjustment moves 2 spaces
to left)
• Never leave the CDX (e.g. +4 does not go into next CDX)
• Combine Impairments if necessary
Maximum Medical Improvement
• “Individual’s ability to work” is “beyond the
scope of the Guides.” pg. 24.
• “as good as they are going to be from the
medical and surgical treatment available” pg.
26
• “Date from which further recovery or
deterioration is not anticipated, although over
time (beyond 12 months) there may be some
expected change.” pg.26.
• Compare to IWCC Rule 7030.20 ( 6 months)
Diagnosis (DBI) & Class (CDX)
• DBI: Diagnosis; going down more severe
• CDX: 5 Classes 0-4; left to right more severe
• Regional Grids
– Upper Extremities (Chapter 15): Digit; Wrist;
Elbow; Shoulder (CTS is UE)
– Lower Extremities (Chapter 16): Foot & Ankle;
Knee; Hip (Foot is UE)
– Spine & Pelvis (Chapter 17): Cervical; Thoracic;
Lumbar; Pelvis
Cervical Spine Regional Grid
Methodology for Grade Determination WithinClass:
Grade Modifier
Functional History (FH or GMFH)
• Functional impact of the condition
– Subjective reports
– Self-report tool (administered, scored, consistent)
• UE: QuickDash (Disabilities Arm, Shoulder & Hand)
• LE: AAOS Lower Limb Questionnaire
• Spine: PDQ (Pain Disability Questionnaire)
• Determine GMFH (0-4)
• Subtract CDX from GMFH(GMFH-CDX)=net
GMFH
Adjustment Grid Summary
Functional History Adjustment: Spine
Grade Modifier
Physical Examination (PE or GMPE)
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“Facilitate communication by easing anxiety” pg. 28
“Patient should be encouraged to give full” effort”
“Extremities should be documented bilaterally”
“Specific measurements should be reproducible”
Determine GMPE (0-4)
Subtract CDX from GMPE(GMPE-CDX)= net GMPE
Physical Examination Adjustment: Spine
Physical Examination Adjustment: Spine (2)
Grade Modifier
Clinical Studies (CS or GMCS)
• Imaging & Electrodiagnostic: X-ray; MRI; EMG;
NCV
• Operative reports
• Current?
• Determine GMCS (0-4)
• Subtract CDX from GMCS(GMCS-CDX)=net
GMCS
Clinical Studies Adjustment: Spine
Net Adjustment Formula
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CDX = Class of Diagnosis (Regional Grid)
GMFH = Grade Modifier Functional History
GMPE = Grade Modifier Physical Exam
GMCS = Grade Modifier Clinical Studies
Net Adjustment = (GMFH-CDX) + (GMPE-CDX) + (GMCS-CDX)
CDX will always be same in Net Adjustment
Each subtotal can be positive or negative
Total Net Adjustment can be positive or negative
Move grade within CDX to right or left of Default based on
Net Adjustment (+ right; - left)
Net Adjustment Formula
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CDX = Class of Diagnosis = 2
Default = 11 ( 9 10 11 12 13)
GMFH = Grade Modifier Functional History = 2
GMPE = Grade Modifier Physical Exam = 3
GMCS = Grade Modifier Clinical Studies = 2
Net Adjustment = (GMFH-CDX) + (GMPE-CDX) + (GMCS-CDX)
Net adjustment = (2-2) + (3-2) + (2-2)= 0 + 1 + 0 = +1
Move grade within CDX to right or left of Default based on
Net Adjustment (+ right; - left)
• Default is 11, move +1 to right = 12% WPI
Example Spine (Cervical) 17-4 pg. 585
• 44 yo male sustained blow to posterior aspect of
neck from machine support; studies revealed C7T1 disc herniation; managed conservatively;
refused surgery despite continued symptoms; 1
year post injury; neck pain radiating to ulnar
aspect of left hand; numbness of ring and little
fingers; increased symptoms with minimal
activity
• Functional History: PDQ score 120
• Physical Exam: Decreased neck ROM; + cervical
compression with C8 radicular pain; decreased C8
sensation and motor weakness (3/5)
• Clinical Studies: MRI posterolateral HNP C7-T1;
EMG left C8 fibrillation potentials
Example Spine (Cervical) 17-4 pg. 585
• Diagnosis: (Table 17-2) Regional Impairment Diagnosis
for Cervical Spine is consistent with “Intervertebral disc
herniation and/or AOMSI at a single level with medically
documented findings; with or without surgery and with
documented radiculopathy at the clinically appropriate
level present at the time of the examination”; assigned to
Class 2, default Grade C value is 11% (CDX=2)
• Functional History: (Table 17-6) Grade 3 modifier
based on symptoms with minimal activity (3) and
PDQ score 120 (3) (FH=3)
• Physical Exam: (Table 17-7) Grade 2 modifier based
on sensory and motor findings; decreased neck
ROM; + cervical compression with C8 radicular pain;
decreased C8 sensation and motor weakness (3/5)
(PE=2)
• Clinical Studies: (Table 17-9) Grade 2 modifier based
on positive EMG left C8 fibrillation potentials (CS=2)
Example Spine (Cervical) 17-4 pg.585
• CDX = 2 (diagnosis disc herniation w/radiculopathy)
• FH = 3 (PDQ =120)
• PE = 2 (3/5 motor weakness)
• CS = 2 (EMG single nerve root)
• Net adjustment: (GMFH-CDX) + (GMPE-CDX) + (GMCS-CDX)
• Net Adjustment: FH(3-2) + PE(2-2) + CS(2-2) = +1
• Net Adjustment = +1, move one position to right
from default
• Default is 11%; +1 move to the right is 12%
• Final Answer: 12% WPI
Cervical Spine Regional Grid Table 17-2
Cervical Spine Regional Grid
Table 17-2
Cervical FH
Table 17-6
Cervical PE
Table 17-7
Cervical CS
Table 17-9
Cervical Spine Regional Grid
Table 17-2
Example Knee Injury 16-9 pg. 526
• 52 yo male; slips while carrying sheet rock; pop in knee; torn ACL
& bucket handle tear medial meniscus; arthroscopic ACL
reconstruction & meniscectomy; 1 year post surgery; pain
• Functional History: “nearly total functional loss of his extremity”
reportedly
• Physical Exam: Mild laxity of the ACL; 5° loss of terminal
extension; 5° flexion contracture; normal flexion; no effusion;
severe limp in the exam room; normal gait when exiting the
exam room
• Clinical Studies: MRI had confirmed torn ACL and bucket handle
tear of medial meniscus (pre-op study); current weight-bearing
X- rays show bioabsorbable fixation of the ACL in good position
with a normal 5 mm joint space in all compartments
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Example Knee Injury 16-9 pg. 526
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Requires the examiner to pick one diagnosis for the region; the anterior
instability diagnosis was chosen; meniscal tear reflected in adjustments
Diagnosis: (Table 16-3) Regional Impairment Diagnosis for LE Knee
consistent with “Cruciate or collateral ligament injury with mild laxity
“assigned to Class 1; default Grade C value is 10% LEI (CDX=1)
• Functional History: (Table 16-6) Not used because judged unreliable in
the presence of only mild instability and no atrophy; could have been 4
(FH=NA)
• Physical Exam: Grade 1 modifier; instability not used as grade modifier
since stability was used in class assignment (could have been 2/3
based on instability); no atrophy would be grade 0; 5° flexion
contracture would be rated at 10% LEI (Table 16-23); 10% LEI rating is
“mild” (Table 16-25) which is Grade 1 PE modifier for ROM (Table 167) (PE=1)
• Clinical Studies: (Table 16-8) Grade 2 modifier; ACL reconstruction in
good position without joint space narrowing on current weight bearing
x-rays by itself would be a grade 1 or mild pathology adjustment;
meniscal tear and subsequent repair (documented in the operation
report) would justify moving up grade 2 for the final clinical studies
adjustment (CS=2)
•
31
Example Knee Injury 16-9 p 526
• CDX = 1 (diagnosis ACL w/mild laxity ; meniscal injury
not used)
• FH = 4 (but not utilized as INVALID)=NA
• PE = 1 (flexion contracture)
• CS = 2 (meniscal repair in operative report)
• Net Adjustment: (GMFH-CDX)+(GMPE-CDX)+(GMCS-CDX )
• Net Adjustment: FH(NA)+PE(1-1)+CS(2-1)= +1
• Net Adjustment = + 1, move one position to right
from default
• Default is 10%; + 1 move to the right is 12%
• Final Answer: 12% LEI
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Example Knee Injury Regional Grid
Table 16-3
Knee Injury Functional History
Table 16-6
Knee Injury Physical Exam
Table 16-7
Knee Injury Range of Motion
Tables 16-23 & 16-25
Knee Injury Clinical Studies
Table 16-8
Knee Injury Adjusted
Table 16-3
Example Arm Injury 15-9 pg. 417
• 55 year old man sustains injury lifting tire; popping
sensation and acute onset of pain; ruptured biceps
tendon; surgery refused; at MMI, complaints of
decreased strength and pain
• Functional History: pain w/activity; QuickDASH score 30
• Physical Exam: tenderness noted in the antecubital fossa
(elbow); stregth in flexion and supination diminished to
4/5; 1 cm. atrophy compared to opposite; ROM elbow
normal
• Clinical Studies: MRI elbow confirmed tear of the distal
biceps tendon
Example Arm Injury 15-9 pg. 417
• Diagnosis: (Table 15-4) Regional Impairment Elbow
diagnosis of “Distal biceps tendon rupture” per criteria of
“residual loss of strength and normal range of motion,”
assigned to Class 1 UEI with midrange default value of 5%
UEI (CDX=1)
• Functional History: (Table 15-7) Grade 2 modifier based
on pain w/ normal activity; higher than Grade 1 because
of QuickDASH 30 (FH=2)
• Physical Exam: (Table 15-8) Grade 1 modifier due to
muscle atrophy of 1 cm. (PE=1)
• Clinical Studies: (Table 15-9) NA since MRI defines the
diagnosis (could have been 1/2) (CS=NA)
Example Arm Injury 15-9 pg. 417
Impairment Rating Analysis
• CDX = 1 (diagnosis distal biceps tendon rupture w/loss of
strength)
• FH = 2 (pain with normal activity)
• PE = 1 (1 cm. atrophy)
• CS = NA (MRI defines the diagnosis criteria)
• Net Adjustment: (GMFH-CDX)+(GMPE-CDX)+(GMCS-CDX )
• Net Adjustment: FH(2-1)+PE(1-1)+CS(NA)= +1
• Net Adjustment = +1, move one position to right from default
• Default is 5% UEI; +1 move to the right is 6%UEI
• FINAL ANSWER: 6% UEI
Arm Injury Regional Grid
Table 15-4
Arm Injury Functional History
Table 15-7
Arm Injury Physical Exam
Table 15-8
Arm Injury Clinical Studies
Table 15-9
Arm Injury Adjusted
Table 15-4