Objectives Understand changes in 5 th and 6 th editions of the
Guides Understand how impairments are rated using the 6 th edition
of the Guides Be able to calculate simple ratings How to critically
read and evaluate an impairment rating Identify common errors in
ratings Accurately and thoroughly represent the Guides, not my
opinions
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OUTLINE Define impairment Brief history Differences in content
Differences in application Changes/clarifications/corrections
Present a case 5 th v 6 th editions Disc terminology, bulge v
herniation Treatment of disc herniations Physical examination ROM
Waddels signs Rate an impairment
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Impairment evaluation: Medical evaluation performed by a
physician using the Guides to determine impairment Treating or
non-treating Assessment of individual medical condition and its
effect on function
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IImpairment AA loss or loss of use or derangement of a body
part, organ system, or organ function from its preexisting level.
IImpairment rating: EEstimate of the degree to which the impairment
decreases the individuals ability to perform ADLs NOT WORK
ACIVITIES. AAssess functional limitation/loss NOT DISABILITY
Consensus-derived percentage estimate of loss of activity
reflecting severity for a given health condition, and the degree of
associated limitations in terms of ADLs
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I read somewhere that 77 per cent of all the mentally ill live
in poverty. Actually, I'm more intrigued by the 23 per cent who are
apparently doing quite well for themselves.
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6 th edition released late 2007 5 th edition released 2001
First published in book form in 1971 Studies v Expert Consensus
Opinion NOT ALL conditions/problems are addressed in the
Guides
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Cardiovascular- Heart and Aorta Cardiovascular- Arteries
Respiratory system Digestive system Urinary and reproductive
systems Skin Blood/Hematological Endocrine system ENT Vision
Central and Peripheral nervous system Mental and Behavioral Spine
Upper extremities Lower extremities Pain
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Cardiovascular Pulmonary system Digestive system Urinary and
reproductive systems Skin Blood/Hematological Endocrine system Ear,
nose and throat Visual system Central and Peripheral nervous system
Mental and Behavioral Upper extremities Lower extremities Spine and
pelvis
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Reasons to update the Guides 5 th edition New medical data
Function and Impairment World Health Organizations International
Classification of Functioning (ICF) Reduce ambiguity Increase
consistency between chapters Increase consistency between raters
Statement of principals
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Differences in content Causation Apportionment Cultural
differences Pain chapter Mental and Behavioral Constitution of the
Guides
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The concepts in this chapter are the fundamental principals of
the Guides; they shall preempt anything in subsequent chapters that
conflicts with or compromises these principals. No impairment may
exceed 100% whole person impairment. No impairment of arising from
a member or organ may exceed the amputation value of that member.
All regional impairments in the same organ or body system shall be
combined at the same level first and then combined by regions then
whole person. Impairments must be rated in accordance with the
chapter relevant to the organ or system where the injury primarily
arose or where the greatest dysfunction consistent with then
objectively documented pathology remains. Only permanent impairment
may be rated according to the Guides, and only after Maximum
Medical Improvement is certified A licensed physician must perform
impairment evaluations. Chiropractic doctors, if authorized by the
appropriate jusridictional authority to perform rating under the
Guides, should restrict rating to the spine. A valid impairment
evaluation report based on the Guides must contain the 3 step
approach described in section 2.7 The evaluating physician must use
knowledge, skill and ability generally accepted by the medical
scientific community when evaluating an individual, to arrive at
the correct impairment rating according to the Guides. The Guides
is based on objective criteria. The physician must use all clinical
knowledge, skill and abilities in determining whether measurements,
test results, or written historical information are consistent and
concordant with the pathology being evaluated. If such findings, or
an impairment estimate based on these findings, conflict with
established medical principals, they cannot be used to justify an
impairment rating. Range of motion, and strength measurement
techniques should be assessed carefully in the presence of apparent
self- inhibition secondary to pain and fear. The Guides do not
permit the rating of future impairment. If the Guides provides more
than one method to rate a particular impairment or condition, the
method producing the higher rating must be used. Subjective
complaints alone are generally no ratable under the Guides (see
chapter 3 for potential exceptions). Round all fractional
impairment ratings, whether intermediate or final, to the nearest
whole number.
Differences in application Utilization of Uniform Template Key
Factors Class of injury Default ratings Non-key Factors Objective
tests, clinical studies/labs Physical exam findings Functional
assessments
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Ernesto from Bolivia US 7 years, married to US citizen Fell off
forklift from ~12 feet Low back L4-5 disc herniation, persistent R
foot weakness, pain in Right lower extremity Shoulder Full
thickness rotator cuff and labral tear, surgically repaired, pain
with certain movements. Previous low back injury 18 months ago.
Treated with PT, released to full duty, occasional lumbar and
radiating pain
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Determine KEY FACTOR Review medical records Interview examinee
Physical exam Diagnoses
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Is there a category for each KEY FACTOR? Is there more than one
way to rate that KEY FACTOR?
Herniation = Bulge? Herniation Bulge? Herniation has both
specific and general meanings The Guides do not indicate
nomenclature they use Radiologists do not necessarily follow
standards
How severe is the KEY FACTOR? Identify the CLASS for each KEY
FACTOR 0 - no symptoms 1 - mild or intermittent symptoms,
controlled with medications 2 constant mild symptoms, intermittent
moderate symptoms despite ongoing treatment 3 constant moderate
symptoms, intermittent severe symptoms, despite ongoing treatment 4
constant severe symptoms, intermittent extreme symptoms, despite
ongoing treatment
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Adjustments for non-key factors Functional history Pain during
activity Medications Disability questionnaire Physical examination
ROM Atrophy Alignment Strength Palpatory findings Clinical studies
Imaging Electrodiagnostic studies
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Apportionment What is apportionment When is it needed
Apportionment is an allocation of causation among multiple factors
that caused or significantly contributed to the injury or disease
and resulting impairment
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Apportionment calculation: Calculate the current impairment
Calculate what impairment existed at the moment of the current
event, based on best available data. Deduct the prior impairment
from the current impairment (Total Impairment) (Previous
Impairment) = Final Impairment Requires accurate data Same method
Explain reasoning
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Combining Multiple impairments in different systems? Combine
using combined values chart Multiple impairments in the same
region? Choose most impairing, but can be combined if the most
impairing diagnoses does not adequately reflect the loss. Multiple
impairments, same system but different parts/regions? Combine using
combined values chart Multiple impairments based on range of motion
losses? Add values for ROM loss are added? Choose most impairing,
but can be combined if the most impairing diagnoses does not
adequately reflect the loss. All percentages being combined must be
in same units (UEI, WPI)
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[ ] Name, demographic and/or identifying information [ ]
History of the event [ ] Mechanism of injury, date of onset [ ]
Course of illness [ ] Symptoms initially [ ] Previous examination
findings (at time of initial diagnosis, if available) [ ] Treatment
and responses to treatment [ ] diagnostic studies and their results
[ ] Social history [ ] Work history [ ] Past medical/surgical
history [ ] Current status [ ] Current symptoms [ ] Aggravating or
relieving factors [ ] Locations of symptoms [ ] Review of systems [
] Physical exam findings [ ] Current treatment/medications [ ]
Impairment rating [ ] MMI status [ ] Examiners diagnosis and rating
[ ] Explanation (page or table referenced, how calculations were
made) [ ] Apportionment (if applicable, calculations, reasoning) [
] Restrictions [ ] Treatment recommendations [ ] Diagnostic
recommendations IMPAIRMENT RATING EVALUATION
Summary Impairment ratings measure loss of function, not
disability Get corrected pages Ratings are used provide consistency
Do not assume that the impairment rating is correct Do not be
afraid to calculate simple ratings Check combined numbers
