For workers’ compensation, most requests for a permanent impairment rating of low back injuries involve the diagnostic labels of nonspecific chronic low back pain or intervertebral disk herniation. Use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, to choose the right diagnosis and class for these injuries is the first step and involves correctly choosing between “nonverifiable radicular complaints” and “residual radiculopathy.” Evaluators must be able to distinguish persisting radiculopathy, as defined in the sixth edition, from resolved radiculopathy and from nonverifiable radicular complaints and to support findings with objective clinical evidence. Clinical evidence of chronic radiculopathy might include motor weakness, muscle atrophy, impaired sharp–dull discrimination, and/or abnormal electrodiagnostic tests, provided the findings are persistent and there are reflex abnormalities. When considering radiculopathy in the appropriate spine grid of the AMA Guides, Sixth Edition, the evaluator must distinguish radicular (limb) symptoms that are continuous, intermittent, or completely resolved. Positive electromyography (EMG) studies for acute radiculopathy are a sufficient objective finding to state the person has radiculopathy on the date of the test; individuals with positive needle EMG do have persisting radiculopathy at maximum medical improvement, but this does not mean that radiculopathy must persist despite time and treatment.
In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, range of motion (ROM) is used to calculate the physical examination modifier when the diagnosis-based impairment (DBI) method is used, ie, Table 15-8, Physical Examination Adjustment: Upper Extremities, and Table 16-7, Physical Examination Adjustment: Lower Extremities. The DBI method is preferable for calculating upper and lower extremity ratings, but in instances specified by the regional grid, the evaluator may choose to use the ROM method, typically because it yields a higher impairment rating. The article outlines the steps for measuring ROM. Invalid results on the day of testing are declared after three consecutive efforts if the three measurements for a given plane of motion vary by more than 10 degrees from the average (mean) of these three measurements. The process can be tried again another day, or the DBI method can be used. All ROM measurements should be rounded to the nearest number ending in zero, and a figure provides examples of suitable annotations. Adjustments for functional history can be made if ROM is the only method used for rating, if results are deemed reliable and consistent with results from an activities of daily living questionnaire or other valid functional report, and if the current ROM impairment does not adequately capture the full impairment.
Low back pain and disability are common and evaluating a patient with non-specific spinal pain may be challenging, including determining impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, provides ratable impairment for the diagnosis of “non-specific chronic, or chronic recurrent low back pain (also known as chronic sprain/strain, symptomatic degenerative disc disease, facet joint pain,” and others. The evaluator should consider the diagnosis of non-specific chronic back pain only when no category of specific diagnosis fits the case (eg, no fracture, no spinal stenosis) or when “no reliable physical examination or imaging findings” but the patient's history of pain is felt to be reliable. According to the AMA Guides, primary determinant between a class 0 and class 1 rating for non-specific chronic back pain is whether the evaluator gives credibility to the patient's subjective reports of pain and interference with activities of daily living (ADLs). An evaluator may choose to use the Pain Disability Questionnaire (reproduced in the article) and Table 17-6, Functional History Adjustment, Spine, to determine the Functional History Grade Modifier (GMFH). The diagnosis of non-specific chronic or chronic recurrent low back pain yields a positive impairment only when the evaluator feels the patient's pain, as quantified by the GMFH, is reliably reported. Because there are no diagnostic objective findings on physical examination or clinical studies, these modifiers are excluded.
Upper extremity amputations are rated in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 15.6, Amputation Impairment, where text, tables, and figures guide evaluators in combining proximal diagnosis-based impairments (DBIs) and proximal range-of-motion impairments. The AMA Guides provides impairment grids for lower and upper extremity amputations, which are divided into five impairment classes (0 through 4), and each impairment class is further divided (except class 0) into five grades (A through E), each with its respective impairment rating that is expressed as a percentage of the extremity. Determining impairment class, and thus the default value of impairment, is straightforward if the amputation occurred directly at one of the points in the relevant grid; if the amputation occurred at another point, the evaluator should consult the appropriate figure to assess how the specific level of amputation corresponds with impairment percentages. An individual's proximal problems may lead to an increase in the impairment value because of the application of grade modifiers. Except in rare instances of bilateral upper extremity amputation or when the patient is unable to wear a prosthesis for a lower extremity amputation, the evaluator usually uses the default rating value within the selected impairment class as the final percentage rating. Evaluators are advised to re-read the amputation section in the AMA Guides before conducting an amputation evaluation.
Nonspecific spinal pain and intervertebral disc herniations are common, and in evaluating spinal impairment physicians should carefully assess the significance of imaging findings, physical examination findings, and reports of limb pain. A case example illustrates key principles in assessing cervical pain in an individual with questionable arm complaints. A 62-year-old man had a slip and fall injury. Imaging studies revealed degenerative disc disease with disc bulges and without specific disc herniations according to the radiologists, but his physician reviewed magnetic resonance imaging (MRI) films and reported multiple disc herniations. The case example illustrates the significance of the finding of degenerative disc disease, determining whether to rate for “soft tissue and nonspecific conditions” or “motion segment lesions,” and assessing “nonverifiable radicular complaints.” The authors note that cervical degenerative disc “disease” is more aptly a radiologic diagnosis reflecting aging rather than a clinical syndrome and does not necessarily imply that the degenerative disc disease is the cause of the pain. To distinguish between nonverifiable radicular complaints without objective evidence of radiculopathy and unreliable vague complaints involving the extremity, evaluators should determine that the complaints are consistently and repetitively recognized in medical records and that they lie in the distribution of a single nerve root that the examiner can name. The diagnosis of “intervertebral disc herniation” cannot be made, and instead the “nonspecific chronic pain” diagnosis can be used. Nor can the diagnosis of alteration of motion segment integrity be used because the case lacks radiographically documented instability.
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