AMA Guides 5 th Edition –History, Applications and Current Use

1. AMA Guides 5th Edition –History, Applications and Current Use Key Concepts, Philosophy and Application of the Guides Linda Cocchiarella MD, MSc

2. AMA Guides 5th -History and Applications • Framework for revision of the AMA Guides 4th edition • Changes in the 5th compared with the 4th edition • Examples with ratings from the Fifth edition • Criticisms of the 5th Edition • Why Still the 5th Edition ?

3. Framework for Revision of the AMA Guides -4th to 5th Edition • Evolutionary approach from 4th ed, June 1993 to 5th edition 2000 • Update diagnostic and/or examination criteria , improve internal consistency • Include stakeholders from different groups: medical and key leaders in workers compensation legal policy: • - Peter Barth, John Burton and Emily Spieler • Medical society input, expansion of contributors -chapter chairs, reviewers and contributors, academicians

4. Framework for Revision of the AMA Guides -4th to 5th Edition (2000) • No reduction or alteration of the impairment ratings which were based upon prior consensus, unless required to rectify inconsistencies or errors • No further reduction in spine ratings given reductions from 3rd to 4th editions • Activities of Daily Living (ADL) impacted- Determine ratings • Flexibility in ratings (ranges) to incorporate variations in presentation of conditions • Use of clinical cases to clarify concepts

5. Key Guides Principles • Evaluate impairment • “Impairment is a loss, loss of use or derangement of any body part, organ system or organ function. “ • Impairments- ratable or non-ratable. • Superficial finger scar- imp, no rating • Deep finger scar with loss of ROM-rate

6. Importance of Impairment vs Impairment Rating • Impairment- altered condition • Impairments- ratable or non-ratable. • Superficial finger scar- imp, no rating • Deep finger scar with loss of ROM-rate • Consequences of injury- shoulder tendonitis from use of a crutch • Impairment rating- impact of impairment on ability to perform Activities of Daily Living (ADL)

7. Principles-Disability • Disability- • “an alteration of an individual's capacity to meet personal, social or occupational demands or statutory or regulatory requirements because of an impairment.” • IR # Disability • Guides doesn’t rate disability • State determines criteria for disability rating

8. Definitions and Principles- Chapters 1` and 2 • Raters- treating or IME provider • Pain separate rating- when beyond expected level for pain for impairment, 1-3% • Impairment ratings based upon condition severity and impact on ADL • Numerical ratings rounded to nearest whole number, not to 0 or 5% as in 4th • Integration of subjective and objective factors • Treatment effects adjustment- 1-3%

9. Activities of Daily Living • ADL-social , recreational and work activities were removed from the definition of ADL • IADL (Instrumental ADL) were included with sample questionnaires provided to assess ADL • Providers can use any validated scale for a more in-depth assessment of ADL • Ratings within a category are based upon ADL

10. Key PrinciplesTable 1-2 Activities of Daily Living Needed to Determine IR when a Range is Possible

11. Use of Activities of Daily Living (ADL) Score (+) = impacted • Self care: 4/5 + • Communication: 2/2 + • Physical Activity: 0/1 + • Sensory Activity: 1/1 + • Nonspecialized hand:3/3 + • Sexual function: 0/2 + • Sleep: 1/2 + • Avg Score: 11/16 = 69% • RATING Range (1-9%) • .69 (9%) = 6%

12. Definitions and Principles- Chapters 1` and 2 • MMI- changed to constitute a stable condition, no substantial change in the next year with or without treatment ( 3% change no longer included ) • Normal- based upon population or individual comparisons • Subjective concerns (fatigue , pain, ) if not accompanied by measurable abnormalities are not given separate ratings.

13. Subjective versus Objective Findings • Subjective reports are corroborated by objective studies based upon the history of injury and clinical findings • Objective findings generally override subjective reports • Case: 48 yr old airplane cabin cleaner, obese, bending and cleaning at work, twists knee, knee pain, subsequent meniscal tear • Case: 58 year old teacher, falls on buttocks, develops bilateral shoulder, and low back pain - consider alternate diagnoses

14. Respiratory Chapter • Diagnostic criteria for normal lung function -lower limit of normal, or the 95% CI based upon the American Thoracic Society recommendations • Criteria for occupational asthma established- scoring of 3 criteria- postbronchodilator FEV1, % change FEV1, provocative testing of methacholine (PC 20=8) • Includes reactive airways • e.g.: Asthmatic, work related due to exposures to recycling waste, occasional bronchodilator use. Asthma score 1, rating 10% (range 10-25%)

15. Digestive System Chapter • Colon and rectal ratings were increased to be consistent with upper digestive tract ratings • Ratings in both organ systems depend upon residual function and symptoms • Case example: 65 year old chemist, prior asbestos exposure, develops peritoneal mesothelioma, small intestine resection, subsequent incisional hernia, symptomatic Small intestine class 3 (25-49%), combine colon class 2 (10-24%)

16. Neurology Chapter • Most extensive changes besides pain chapter • Dementia ratings new • New criteria for Complex Regional Pain Syndrome • Case- 58 year old roof worker fell from platform, head injury, subdural hematoma, seizures resolved, neuropsychological testing confirmed mild cognitive decline, rating of 15-29% based upon severity, ADL impact, chronic headaches rated separately at 1-3% WPI

17. Spine Chapter • DRE preferred, category ranges provided, 5-8% instead of 5% as in 4th edition, additional 1-3% for above average pain; ROM limited use • Case: 62 year old tree trimmer, chronic LBP, clinical findings of radiculopathy, MRI with multilevel disc bulges and herniations, EMG/NCV studies positive for neuropathy at L5-S1, rating DRE category III, 10-13% WPI

18. Upper extremity • Can rate more than one condition in a body part , eghumerus fracture and carpal tunnel syndrome, if not rating the same condition twice • Limited options to rate tendon impairments • A revised approach to entrapment neuropathies eg CTS • Case: 38 yr old chef with left ulnar neuropathy s/p transposition with chronic pain and scar sensitivity and CTS • Rating methods: ulnar neuropathy, elbow range of motion, combined with possible rating for skin- scar sensitivity or grip strength ; Use highest and most specific rating method • Strength not used if reduced due to pain ; Justify approach • CTS rated separately

19. Lower Extremity Chapter • Case: 48 ye old construction worker in ditch, twists, patella and knee pain, repeat meniscal tear, partial medial and lateral meniscectomy, 10% LE- Diagnosis Based Estimate (DBE). • DBE rating can be combined with arthritis of knee or patella if applicable

20. Criticisms of AMA Guides 5th Edition • Evidence based medicine inclusion insufficient • Ratings don’t reflect loss of function • Lack of internal consistency • 6th edition – • Clearer integration of history, physical exam, clinical studies and functional status • Diagnosis based ratings preferable for many conditions • Efforts to decrease intra rater variability with set ratings

21. Why the Guides 5th is Still In Use – Concerns Regarding the 6th Edition • Lack of transparency in its development • Evidence based supplanted with the editorial board’s consensus view on diagnostic criteria • Eg Reactive Airways Disease and carpal tunnel syndrome EMG/NCV diagnostic criteria are not agreed upon in the medical literature (see references) • Ratings are generally lower with the 6th edition without justification • Function as assessed has minimal impact on rating • Required criteria for rating eg specialized questionnaires may be outdated, culturally insensitive and lead to lowered ratings

22. References-Medical • Linda Cocchiarella , Stephen J. Lord. Master the AMA Guides 5th: A Medical and Legal Transition to the Guides to the Evaluation of Permanent Impairment,  5th ed. Edition 2001 • Linda Forst, MD, MPH, Lee Friedman, et al. Reliability of the AMA Guides to the Evaluation of Permanent Impairment . JOEM Volume 52, Number 12, December 2010. CONCLUSIONS/RECOMMENDATIONS The Guides fifth and sixth editions of the AMA are relatively reliable and consistent tools for rating impairment of low back injuries. The impairment ratings using the sixth edition of the AMA Guides are somewhat lower than the fifth and do not meet the claims made of improvement in reliability. • Dr. John Kuhnlein 6th Edition AMA Guides Task Force Report .https://www.iowaworkcomp.gov/sites/authoring...gov/files/kuhnleinreport.pdf • RDRondinelli - PM&R, 2009 - Changes for the new AMA Guides to impairment ratings: implications and applications for physician disability evaluations • Seabury, Seth A. et al. , MSHS. American Medical Association Impairment Ratings and Earnings Losses Due to Disability. Journal of Occupational and Environmental Medicine: March 2013 - Volume 55 - Issue 3 - p 286–291Methods: a case-control study of 21,663 workers' compensation claimants in California with impairment ratings under the AMA Guides, fifth edition. Results: Impairment ratings were strongly associated with earnings losses: losses for ratings of 1, 10, and 20 were 9.0%, 21.9%, and 34.6%, respectively (P < 0.01). Losses differed significantly across body regions. For example, losses were 21.0% for spine impairments compared with 18.4% overall (P = 0.014).

23. References-Legal/Institute Sponsored • D DeBias - J. Marshall L. Rev., 2016 – HeinOnline • Protecting Injured Workers by Eliminating the Use of the American Medical Association Guides in the Evaluation of Permanent Partial Disability • Robert Moss, David McFarland, CJ Mohin NCCI Workers Compensation Legislative Research: iton Impact on Impairment Ratings from the American Medical Association’s Sixth Edition of the Guides to the Evaluation of Permanent Impairment, and Ben Haynes, July 2012 • The results of this study provide evidence that a decrease in the average impairment rating is realized when a state switches from the fifth edition to the sixth edition of the AMA Guides, all else being equal. After controlling for claim maturity, the three states studied show:  In Montana, the average impairment decreased by approximately 28%  In Tennessee, the average impairments decreased by approximately 25% and 16% for whole body and part of body, respectively  In New Mexico, the average impairments decreased by approximately 32% and 6% for whole body and part of body, respectively • Emily A. Spieler (RE)ASSESSING THE GRAND BARGAIN: COMPENSATION FOR WORK INJURIES IN THE UNITED STATES, 1900-2017 * Rutgers Law Journal http://www.rutgerslawreview.com/wp-content/uploads/2018/03/2-EmilyASpielerAssessingthe.pdf • Emily Spieler Testimony Before the Subcommittee on Workforce Protections Committee on Education and Labor U.S. House of Representatives November 17, 2010 Chairwoman Woolsey, Ranking Member McMorris-Rodgers and Members of the Subcommittee on Workforce Protections of the Committee on Education and Labor:Written Statement of Emily A. Spieler, J.D. Dean and Edwin W. Hadley ... • http://republicans.edlabor.house.gov/uploadedfiles/11.17.10_spieler.pdf https://edworkforce.house.gov/uploadedfiles/11.17.10_spieler.pdf • Emily Spieler, Peter Barth, John F. Burton, Jr, Jay Himmelstein, Linda Rudolph (2000) Recommendations to Guide Revision of the Guides to the Evaluation of Permanent Impairment. JAMA 283 (4) 519-523. 2

24. Thank You