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Erroneous Ratings: Part IV
In the last issue we examined some of the
common reasons for erroneous ratings, in this issue we will
look at how incorrect clinical assessment will result in an
erroneous rating.
There are many potential rating errors
resulting from inaccurate clinical or causation analysis.
These include inappropriate diagnosis, rating prior to being
at maximal medical improvement, using unreliable examination
findings, not considering what is normal for the individual,
and inaccurate causation assessment.
Incorrect clinical assessment can result in
the rating of impairment for a condition that is not present
or unrelated to the alleged injury. For example, the physician
may label a patient as having, “complex regional pain
syndrome” (CRPS) and rate for this disorder, whereas the more
accurate diagnosis is “somatization.” In the Guides
certain diagnoses are not typically associated with ratable
impairment, i.e. tendonitis or psychiatric illness; a
physician attempting to inflate a rating may choose to provide
another diagnostic label that would result in ratable
impairment.
Assessing impairment prematurely will often
result in an inflated impairment rating. The rating of
permanent impairment cannot occur until the patient has
achieved maximal medical improvement (MMI). MMI is defined on
page 601 as, “a condition or state that is well stabilized and
unlikely to change substantially in the next year, with or
without medical treatment.” Typically following an injury a
patient will improve over time, improved range of motion and
neurological function and resolution of ratable findings will
result in a lower impairment rating. MMI is often not achieved
until a minimum of six months to one year post injury. Cases
that often require a longer time frame for resolution include
carpal tunnel syndrome with ongoing neurological deficits,
hand injuries, and head injuries.
An erroneous rating will occur if the rating
is based on clinical findings that are erroneous. Findings
must be reproducible if they are to serve as a basis for
impairment rating. The Guides state in Section 2.5d on
page 20:
- Two measurements made by the same examiner using the
Guides that involve an individual or an individual’s
function would be considered consistent if they fall within
10% of each other. Measurements should be consistent between
two trained examiners or by one observer on two separate
occasions, assuming the individual’s condition is stable.
Many clinical findings are not totally
objective, i.e. independent of the examinee. For example, with
range of motion impairment rating, the rating is based on
findings of active motion, i.e. what the individual
demonstrates. An individual may display less range of motion
than actual capability. Neurological findings, such as reports
of diminished sensation, are dependent on self report and an
individual may demonstrate less strength than true capability.
In that an individual can demonstrate less capability than
they are truly capable of, however cannot demonstrate greater
capability than this limit, inconsistent examination findings
will nearly always result in greater impairment. Examiners
vary in their clinical examination skills; therefore there may
be a lack of reliability in demonstrating clinical findings.
The musculoskeletal chapters (Chapters 15 to
17) define standards for consistency. For example, in Chapter
15, The Spine, there is a lengthy discussion of the process of
obtaining spinal range-of-motion measurements using an
inclinometer. Section 15.8a, General ROM Method Measurement
Principles, on page 399 provides emphasis with italics.
- Pain, fear of injury, disuse, or neuromuscular
inhibition may limit mobility by diminishing the
individual’s effort, leading to inaccurately low and
inconsistent measurements. The physician should seek
consistency when testing active motion, strength, and
sensation. Tests with inconsistent results should be
repeated. Results that remain inconsistent should be
disregarded. When the physiologic measurements fail to match
known pathology, they should be repeated and, if still
inconsistent, disallowed until documented evidence is
provided for the abnormalities noted on the physical
examination.. . . The measurements and accompanying
impairment estimates may then be disallowed, in part or in
their entirety. There are multiple potential sources of
error in a quantitative physical examination... The
greatest source of error that occurs is due to test
administrator inexperience or lack of knowledge”
Using the spine as an example, there are other
findings that may not be reliable; including “spasm”,
“guarding”, “non-verifiable radicular complaints” and
neurological findings. It may be advantageous for physicians
wanting to demonstrate the need for ongoing treatment to
report findings that may not be observed by others. In
reviewing a report it is imperative to determine whether the
examination findings were reliable. This includes assessing
whether the physician has performed the examination to
determine the presence of consistent findings and comparing
examination findings to other observations since the patient
has been at maximal medical improvement; other sources of data
may include physician records, physical therapy records, and
surveillance.
Another common error is not considering what
is normal for the individual. The Fifth Edition discusses in
Section 1.2a Impairment the determination of normal. The
Guides state on page 2 “when evaluating an individual,
a physician has two options: consider the individual’s health
preinjury or preillness state or the condition of the
unaffected side as “normal” for the individual if this is
known, or compare that individual to a normal value defined by
population averages of healthy people. The Guides uses
both approaches.” Section 16.4c Method for Motion Impairment
Calculation states on page 453 “The measurements reported in
the impairment tables and pie charts reflect the accepted
average range(s) of motion for each joint. However, certain
people can have either lesser or greater joint flexibility
than average. It is therefore most important to always compare
measurements of the relevant joint(s) in both extremities. If
a contralateral “normal” joint has a less than average
mobility, the impairment value(s) corresponding to the
uninvolved joint can serve as a baseline and are subtracted
from the calculated impairment for the involved joint. The
rationale for this decision should be explained in the
report.” In this case the opposite extremity does serve as
“normal” for this individual, therefore losses should be
determined in relationship to this normal. Extremity
evaluations should always include examination of both sides.
In the next issue of the ezine we will examine
errors in causation assessment that lead to erroneous ratings.
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Greetings!
Are you located in one of our office areas or planning on
visiting? We feel blessed to have offices in three wonderful
locations: Portland, Maine, San Diego, California and Oahu,
Hawaii. We enjoy visiting with our clients. If you are
traveling to one of these areas please let us know, we would
enjoy meeting you. If you are attending the RIMS Conference in
Honolulu in April, let us know; we are both exhibiting and
have a special event planned.
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How Well Do You Know the
Guides? |
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Do you know how well you know the Guides or what
your weak area is when it comes to the Guides? Are you
better at the spine than the upper extremities?
As we travel from state to state and have the opportunity
to dialog with our clients we find that many have commonly
stated they “don’t know what they don’t know” when it comes to
the Guides. Most professionals new to use of the
Guides have this problem. Our firm recognizes the
difficulty in learning the Guides. We have developed
two tools in assisting physicians, attorney and claims
adjusters in determining their proficiency in the
Guides. The assessment is a great learning experience
and an excellent return on a very modest investment.
The first tool is a Mini-Assessment involving 20 items
which will take approximately 1 hour of time. Each question is
based on a random selection of questions from specific areas
of the Guides. Therefore, each examination is
different. The weighting is consistent with the ratings
performed. Approximately 25% of the items are on the
principles, 25% spine, 25% upper extremity, and remaining 25%
lower extremity and other areas.
If you want a more in-depth assessment we have developed
the AMA Guides Skills Assessment. This is a dynamic
assessment involving 60 questions which will take
approximately 2-3 hours of time. Each question is based on a
random selection of questions from specific areas of the
Guides. Therefore, each examination is different. The
weighting is consistent with the ratings performed.
Approximately 25% of the items are on the Principles of the
Guides, 25% spine, 25% upper extremity, and the
remaining 25% lower extremity and other areas.
Our firm believes that it is important to have a gauge on
your comprehension of the Guides so that you may know
how to best handle Guides issues. Why not take this
test today? |
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AMA Guides:
The Next Step: Advanced Skills & Practical
Application |
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Don't Miss this Seminar! Presented by Chris Brigham,
MD & Phil Walker, JD
This advanced seminar will provide attendees with the
knowledge to assess impairment in complex areas such as
multiple upper & lower extremity injuries and
corticospinal tract injuries. There will also be discussion on
common areas of misuse and abuse of the Guides along
with current trends seen with erroneous ratings.
Physicians, attorneys and claims staff are encouraged to
attend.
- Date: August 4, 2006
- Where: San Francisco Airport Marriott
- Time: 7:30am- 4:30pm
- Price: $395.00/attendee (Group discounts available)
- Register On-Line or Call 619.299.7377 or 888.262.1202
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Register Here! |
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April
Webinar 102 Series! |
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AMA Guides Webinar 102 - Presented by Leslie
Dilbeck, CIR
Case Exercises builds on basic knowledge to master the use
of the Guides. This seminar is based on a series of
case exercises that illustrate the impairment evaluation
process. In advance participants can independently assess
cases. During the seminar Ms. Dilbeck and Dr. Brigham will go
through the rating process step-by-step.
Webinar Dates: All sessions 2-4pm P.S.T
- Chapter 17: Lower Extremities: Thurs. April 6, 2006
- Chapter 16: Upper Extremities: Thurs. April 13, 2006
- Chapter 15: Spine: Thurs. April 20, 2006
- Chapters 3 - 13: Thurs. April 27, 2006
- Price: $395.00/attendee
- Register Online or Call 619-299-7377
- Limited Space- Register Now!
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Register |
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ACOEM
Pre-Conference Presented by Brigham Walker! |
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Chris Brigham, MD & Phil Walker, JD will be teaching
the pre-conference, two day course on May 5 & 6: "Master
the AMA Guides" as part of the American Occupational
Health Conference (AOHC May 5-10, 2006). This seminar is
case-oriented and designed for physicians and others who want
to improve their ability to rate impairments. They have
received superb reviews: informative, lively, and not to be
missed!
- Start Date: Friday, May 05, 2006
- End Date: Saturday, May 6, 2006
- Event Time: 8:00am - 5:00pm
- Location: Hyatt Regency Century Plaza Hotel: Los
Angeles, CA
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Register Here! |
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Tools of the
Trade: Jamar Dynamometer |
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This is the fifth and final article of a series which is
taking a closer look at credibility in physical examinations.
Again we consider the common question among our industry
colleagues as they evaluate the data used for determining
permanent impairment in a case, “How do you know if physical
examination findings are reliable, accurate and valid?” The
methodology set forth in the Guides for each region
examined sets the evaluation standards for practitioners as they
examine patients for impairment ratings.
This article will focus on the use of the Jamar Dynamometer
for measuring grip strength. The Guides discuss in
detail the protocols for doing grip strength evaluation.
According to the Guides grip strength is rarely used
to rate impairment. The inappropriate rating of grip strength
is a common error. In the rare case where it is applicable, it
is essential that the measurements be reliable. This is
particularly problematic since strength is dependent on the
effort provided by the patient.
The following are essential principals for doing this type
of evaluation as taken from the Guides Section 16.8b
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Tests repeated at intervals during an examination are
considered to be reliable if there is less than 20%
variation in the readings. If there is more than 20%
variation in the readings, one may assume the individual is
not exerting full effort. The test is usually repeated three
times with each hand at different times during the
examination, and the values are recorded and later compared.
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Grip strength measurements must be performed in a
standard manner because altering wrist, forearm, and/or
elbow position will change the results. The generally
accepted position for measurements is for the individual to
be seated with back against the chair and feet flat on the
floor. The arm should be relaxed beside the lateral torso,
the elbow flexed at 90°, and the forearm and wrist in
neutral position. Grip strength measurements may be taken
with a Jamar dynamometer. The second (4 cm) or third (6 cm)
position, according to the size of the hand, usually allows
the individual to apply maximal force comfortably.
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Two techniques have been reported to help detect
individuals who exert less than maximal effort on grip
strength testing. Stokes pointed out that the plotting of
grip strength measurements from each of the five handle
settings of the Jamar dynamometer would produce a
bell-shaped curve. Those individuals not exerting maximal
effort will produce results yielding a straight line or a
flat curve.
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An alternate method is the rapid exchange grip
technique. The grip strength first is determined by standard
techniques. The individual then is instructed to grip the
dynamometer with maximal effort, first with one hand, then
quickly with the other hand, for at least five exchanges.
Individuals who did not exert maximal effort with the
standard technique will record significantly higher strength
readings. If they become aware of this, the strength of both
hands will drop dramatically.
The goal of our “Tools of the Trade” series has been to
provide insight on the directives given in the Guides
on data collection. It is our desire that you have found this
series to be beneficial in your profession whether you perform
evaluations or assess impairment evaluation reports for
accuracy, consistency and reliability.
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Sale Of The
Month! Guides Training CD Rom |
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 This new computer-based training, just published by the
AMA, and authored by Dr. Brigham, serves as an interactive
method of study providing a self-paced learning experience for
the musculoskeletal and pain sections of the AMA Guides
Fifth Edition. Designed to provide a basic overview along with
detailed instruction on how to correctly use and execute
Chapters 15-18. Excellent for those new to evaluating
impairment and also effective as a refresher resource.
Training is done at your pace, with helpful toolbars, a
glossary, find feature, and interactive review questions at
the end of each chapter. The reviews of this unique learning
resource have all been very positive. After completing the
training the user will be able to:
- Explain the content and structure of the Guides
Fifth Edition.
- Demonstrate the ability to perform the process for
rating impairment of the spine, upper extremities, lower
extremities, and pain.
- Discuss the essential elements of a quality impairment
evaluation.
- Price: $245.00
- Save $50.00!
- Buy On-Line or Call 619-299-7377
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Calendar of
Events |
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Dr. Brigham is a featured speaker at the upcoming events:
- California Applicant’s Attorney Association with Steven
Feinberg, MD, Wailea, Maui, April 3-4, 2006
- California Orthopaedic Association, San Diego, CA, April
21-23, 2006
- American Occupational Health Conference, Los Angeles,
CA, May 5-6, 2006
- California Association of Joint Powers Authority, South
Lake Tahoe, CA, September 20-22, 2006
Please visit us at our exhibit at these conferences. If you
are planning on attending any of the following, please email
us to let us know.
- California Self-Insurers Association, Downey, CA, March
27, 2006
- Risk & Insurance Management Society 2006 Honolulu
Conference, Honolulu, HI, April 23-27, 2006
- California Workers Compensation Defense Attorneys
Association, Lake Tahoe, CA, May 18-21, 2006
- National Workers' Comp & Disability Conference, Las
Vegas, NV, November 14-16, 2006
Email
Us to Tell Us Your Coming to an Event. We want to meet
you.
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