The AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition (Cocchiarella L,
Andersson G, AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition, AMA Press, 2001) is the most
commonly used reference source for rating permanent
impairment. Most evaluations in the areas of worker’s
compensation, personal injury, or private disability utilize
the AMA Guides to the Evaluation of Permanent
Impairment, Fifth Edition. It is an essential
reference for rating permanent impairment. Since its
inception, however, numerous questions have been commonplace
throughout the past and present editions of the Guides.
Common questions from providers, insurers, attorneys and
patients are related to clinical definitions used within the
Guides, the application of specific methodologies used
for rating an injury, missing diagnostic terms or categories,
and rationale for rating specific diseases/injuries within a
specific numerical range.
The Guides Newsletter published by the AMA Press is
a bimonthly publication complement essential to anyone
using the AMA Guides to the Evaluation of Permanent
Impairment for rating impairment. The
Guides Newsletter keeps you constantly updated
on the newest developments in impairment issues and provides
access to nationally recognized experts who offer the
practical, real-life facts you need to make difficult
decisions with confidence.
This series of articles will be used to help summarize some
of the key points of clarification documented in past issues
of The Guides Newsletter. References to specific issues
will be provided to allow anyone the opportunity to review the
entire issue/article for assistance in understanding and
accuracy of reporting.
Although the most widely used edition is the Fifth Edition,
a few states continue to utilize past editions of the
Guides due to legislative reasons. Many states use a
statutory schedule for amputations, hearing loss, visual loss,
hernias, and disfigurement. Some states may use a statutory
schedule and use of any specific guidelines.(1) This summary
series of articles will focus on the most recent Fifth
Edition.
"Asymmetry of Spinal Motion"
This first article will focus on the examination descriptor
"Asymmetry of Spinal Motion" as referenced from a previous
Guides Newsletter article titled, “Objectifying the
Spinal Impairment Examination: Fifth Edition Approaches by
Robert Haralson, III, MD, and Christopher R. Brigham, MD.(2)
Within this article by Drs. Haralson and Brigham, the article
discusses the Diagnosis Based Estimate (DBE) Methodology
utilized within the Guides Fifth Edition and the
clinical objective descriptors used for classifying a
particular patient within a DBE category.
With this article, the authors noted: "A careful and
thorough physical examination is a critical component of the
spinal impairment evaluation. As in the Fourth Edition. there
are two examination methods - The Diagnosis Related Estimates
(DRE) method and the Range of Motion (ROM) method. Evaluators
prefer the DRE method, which they use in the vast majority of
the cases involving an injury. The Fifth Edition states in
Section 15.2, "The DRE method is the principal methodology
used to evaluate an individual who has had a distinct injury."
(5th ed, 372). In the Fifth Edition there are differences in
how the methods are selected and how the DRE methods are
defined. The elements of physical examination are described in
Section 15.1a Interpretation of Symptoms and Signs (5th ed,
374-378)"
The objective examination descriptors were described as:
"Objective findings are those that the evaluator can see or
feel without input from the examinee (eg. the loss of a
reflex). Conversely, subjective findings are those that
require a response from the examinee (eg. pain).
Unfortunately, some of the objective findings described in the
Guides require the evaluator to objectify the spinal
examination in order to place an individual in the appropriate
DRE Category."
It was pointed out that the primary difference in rating
between the AMA Guides Fourth Edition versus the Fifth
Edition, is that the Fifth Edition asks the evaluators to take
into account treatment results. Therefore, a patient’s
condition will need to be evaluated at the time they are at
Maximal Medical Improvement (MMI). Objective examination
findings at the time of the evaluation will be thereby used to
categorize the patient into the specific DRE Category.
In the Fourth Edition, the rating was based solely on the
results of the injury. A major change in the Fifth Edition is
that evaluators now take into account the treatment results.
As a result, the DRE rating is based on objective findings at
the time of the evaluation. The objective findings are: muscle
spasm muscle guarding: asymmetric spinal motion (previously
call dysmetria): nonverifiable radicular pain: reflexes:
neurological changes such as weakness of loss of sensation,
atrophy, radiculopathy and electrodiagnostic changes:
alteration of motion segment integrity: cauda equina like
syndrome: and urodynamic tests. Certain historical findings
proven by imaging studies (eg. radiculopathy) may also help
the evaluator categorize a patient. Box 15-1, Definition of
Clinical Findings Used to Place an Individual in a DRE
Category (5th ed. 382), specifies the clinical findings used
in a DRE Model Classification. In this article, we examine the
definitions provided for each of these findings.
The categories of objective findings within the Fifth
Edition are:
- Muscle Spasm
- Muscle Guarding
- Asymmetry of Spinal Motion
- Nonverifiable Radicular Root Pain
- Reflexes
- Weakness and Loss of Sensation
- Atrophy
- Radiculopathy
- Electrodiagnostic Verification of Radiculopathy
- Motion Segment Integrity
- Cauda Equina and Urodynamic Tests.
Of these
clinical descriptors, one of the most common findings
improperly used at time of MMI is Asymmetry of Spinal Motion.
Frequently, evaluators note “asymmetry of motion” to the spine
when a patient has limited movement in any spinal motion plane
not symmetric with the opposite motion plane. A common example
is when an evaluator documents different degrees of motion in
the right versus left lateral bending planes. This is not
“asymmetry of spinal motion” as described within the Fifth
Edition.
Asymmetric motion of the spine in one of the three
principal planes is sometimes caused by muscle spasm or
guarding. That is, if an individual attempts to flex the
spine, he or she is unable to do so moving symmetrically;
rather, the head or trunk leans to one side. To qualify as
true asymmetric motion, the finding must be reproducible and
consistent and the examiner must be convinced that the
individual is cooperative and giving full effort. (5th ed.
382)
Pointed out in The Guides Newsletter article by
Haralson and Brigham, the description of “dysmetria” occurs
when an examinee moves to the side as he or she flexes and
extends avoiding pain. This finding likely occurs when
persistent muscle pathology is present such as guarding or
spasm. In other words, “Asymmetry of Spinal Motion” would be
unusually rare as an isolated finding. In addition, if
associated with the descriptors of muscle spasm or guarding,
the evaluator must verify reproducibility and determine
appropriateness of the finding. Injuries with non-
reproducible or non-organic examination findings must be
heavily scrutinized to insure accuracy of the findings and
impairment rating.
In summary, this article is the first in a series of
articles that should be used to help evaluators gain from past
articles and discussions authored in the Guides
Newsletter. This particular article discussed the finding
of “Asymmetry of Spinal Motion,” and its common misuse by
evaluators when rating less severe spinal injuries within the
DRE methodology outlined within the AMA Guides to
the Evaluation of Permanent Impairment, Fifth Edition.
Look for additional articles in this series, The Guides
Newsletter – Important Clinical Concepts from Past Issues,
in upcoming issues of this ezine.
References:
(1)Errors in Impairment Rating: Challenges and
Opportunities By Christopher R. Brigham, MD, Craig Uejo, MD,
MPH, and Leslie Dilbeck. (2)The Journal Worker’s Compensation,
Summer 2006 (in press), Fifth Edition: The New Standard By
Christopher Brigham, MD, MMS; James B. Talmage, MD; and Leon
H. Ensalada, MD, MPH. The Guides Newsletter
November/December 2000. (3) Objectifying the Spinal
Impairment Examination: Fifth Edition Approaches By Robert
Harralson, III, MD, and Christopher R. Brigham, MD. The Guides
Newsletter November/December 2001.
