New Permanent Impairment Guidelines Require Additional Education and Training for DCs

The AMA's Guides to the Evaluation of Permanent Impairment (the Guides) has become the most recognized and generally accepted source for permanent impairment ratings. In the U.S., 40 of 51 jurisdictions (District of Columbia and 50 states) use the Guides. There is a growing trend internationally to adopt a system of impairment assessment such as in the Guides. It is used in Canada, Australia, New Zealand, South Africa and some European countries.

This new edition incorporates updates in diagnostic criteria, key definition clarification, and more user-friendly applications based on a blend of evidence-based principles and specialty society consensus recommendations. This enhances the readability, usability and consistency of this impairment rating system. Since the most current criteria, procedures, and prevailing medical opinion are incorporated, it is strongly recommended that the fifth edition be used as directed by statute, regulation or administrative/legal practice.

As in previous editions, the Guides falls short of the goals of an absolute resource for assessing impairment. Though shortcomings of previous editions were addressed and challenges remain, it is the best available system.

The fifth edition has significant changes, which will require additional education and training for the chiropractic practitioner. Among those changes:

1. The Guides went from 339 pages to 613. There are three additional chapters, for a total of 18. The musculoskeletal system is covered in three chapters, the cardiovascular system in two.
2. Some percentages have been changed for greater scientific accuracy or to achieve consistency. Most have been retained because there is no recent scientific data to support specific changes.
3. Activities of Daily Living (ADLs) sections have been expanded to include validated Instrumental Activities of Daily Living scales.
4. Resultant functional limitations are reflected by the severity and limitations of organ/body system impairment.
5. Within some musculoskeletal regions, different body parts or areas of the spine are given different weights to reflect relative importance to a region's overall functioning.
6. Apportionment analysis is addressed. The Guides offers three caveats that need to be verified before apportionment can be considered.
7. It defines features of impairment evaluation differently. The fourth edition stated:

"This comparison is distinct from the preceding clinical evaluation and need not be performed by the physician who did that evaluation; rather, any knowledgeable person can compare the clinical findings with the Guides criteria" and determine whether or not the impairment estimates reflect those criteria.

Compare this to the "Defining Impairment Evaluations" in the fifth edition on page 18:

"An impairment evaluation is a medical evaluation performed by a physician, using a standard method as outlined in the Guides to determine permanent impairment associated with a medical condition."

Another differently expressed excerpt from the Guides, on page 18, "Who Performs Impairment Evaluations?" says:

"Impairment evaluations are performed by a licensed physician. The physician may use information from other sources, such as hearing results obtained from audiometry by a certified technician. However, the physician is responsible for performing a medical evaluation that addresses medical impairment in the body or organ system and related systems. A state may restrict the type of practitioner allowed to perform an impairment evaluation, and some require additional state certification and other criteria, such as a minimum number of hours of practice, before the physician is approved as an impairment evaluator.

"Physicians are encouraged to check with their local workers' compensation agencies, industrial accident boards, or industrial commissions concerning their prerequisites."

 

8. The organ system where the problems originated or where the dysfunction is greatest is the chapter to be used for rating impairment.
9. The Guides discusses adjustments (1-3 percent) for effects of treatment or lack of treatment.
10. The Guides discusses changes in impairment from prior ratings, using other editions.
11. Recommended are specific elements to be included in all impairment-rating reports.
12. The use of DRE and ROM methods has been modified. Applications are described in greater detail.
13. Impairment is only rated when maximum medical improvement (MMI) has been reached.
14. DRE method encompasses a 1-3 percent range.
15. Spinal cord injury is rated within the nervous system chapter using a functional approach.
16. More specifically defined objective findings replace the "differentiators."
17. Alterations of motion segment integrity have been redefined.
18. The Guides excludes work from activities of daily living (ADL) and from the impairment percentages.
19. Pain may be rated if there is an underlying organic cause and permits an increased rating up to three percent.

Many chiropractic providers will be unaware of the recent release of the fifth edition, even though workers' compensation jurisdictions that mandate the use of the "most current edition" will have made the transition. We strongly suggest that providers obtain re-certification and training in the fifth edition from a CCE-approved chiropractic college or equivalent program.

References

1. Cocchiarella L, Anderson G. Guides to the Evaluation of Permanent Impairment, Fifth Edition, American Medical Association, November 2000.
2. The Guides Newsletter. American Medical Association, November/December 2000.

Warren Jahn,DC,MPS,FACO, DACBSP
Roswell, Georgia

Leanne N. Cupon,DC,DABFP