Complex Regional Pain Syndrome: Impairment Assessment

Complex regional pain syndrome (CRPS) is characterized by chronic spontaneous and/or evoked regional pain disproportionate in severity, distribution, and/or duration to that typically experienced after a similar injury or illness. The pain may also begin without a known precipitant. While various authors have questioned the validity of the diagnosis, physicians will be asked to perform impairment ratings on patients diagnosed with CRPS. Hence, it is important to understand the issues associated with this syndrome; the diagnostic criteria for it, including the need to rule out other diagnoses that may explain the patient's presentation; and how to rate CRPS. The AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, provides approaches to assessing CRPS impairment that are refined in the Sixth Edition.

The AMA Guides in Pennsylvania “Post-Protz”: Act 111 and Case Law Update

Medical evaluators must understand the context for the impairment assessments they perform. This article exemplifies issues that arise based on the role of impairment ratings and what edition of the AMA Guides to the Impairment of Permanent Impairment (AMA Guides) is used. This discussion also raises interesting legal questions related to retroactivity, applicability of prior precedent, and delegation. On June 20, 2017, the Supreme Court of Pennsylvania handed down its decision, Protz v. WCAB (Derry Area Sch. Dist.), which disallows use of the “most recent edition” of the AMA Guides when determining partial disability entitlement under the Pennsylvania Workers’ Compensation Act. An attempted solution was passed by the Pennsylvania General Assembly and was signed into law Act 111 on October 24, 2018. Although it affirms that the AMA Guides, Sixth Edition, must be used for impairment ratings, the law reduces the threshold for total disability benefits from 50% to 35% impairment. This legislative adjustment benefited injured workers but sparked additional litigation about whether, when, and how the adjustment should be applied (excerpts from the laws and decisions discussed by the authors are included at the end of the article). In using impairment as a threshold for permanent disability benefits, evaluators must distinguish between impairment and disability and determine an appropriate threshold; they also must be aware of the compensation and adjudication process and of the jurisdictions in which they practice.

Effects of Aging on Impairment Ratings: Part 4: Musculoskeletal Issues

This article is the fourth of five in a series on the effects of age-related changes in impairment evaluations as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. The present article addresses the musculoskeletal system and differs from the first three articles, which focused on apportionment of an impairment rating between aging and other causes. The medical literature supports the notion that age-related osteoarthritis (OA) changes in the hand and digits frequently are associated with injury and/or repetitive motion. Thus, apportionment is indicated, but deciding which came first, the imaging abnormality or the injury, requires consummate skill on behalf of the rating physician. OA also occurs in the knees and hips of older individuals. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory disorder characterized by calcification and ossification of spinal ligaments and entheses and is unique, in the authors’ opinion, because of a positive correlation between aging and back pain caused by this condition. The article also addresses the association—or the lack thereof—between pathology and aging, as well as degenerative changes and symptoms, to facilitate causation analysis. For a fuller discussion of causation analysis for the spine, readers can consult the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition.

Spinal Alteration of Motion Segment Integrity Using the Sixth Edition

Spinal impairment evaluation includes determination of the presence or absence of alteration of motion segment integrity (AOMSI). The diagnosis-related estimate (DRE) method is the principal methodology used to evaluate spinal AOMSI impairment in the fourth and fifth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In the AMA Guides, Sixth Edition, impairment ratings are calculated using the diagnosis-based impairment (DBI) method that uses five impairment classes determined by diagnoses and specific criteria, adjusted by consideration of non-key factors and grade modifiers. This article includes a correction of numbers in the AMA Guides, Sixth Edition, Figure 17-6. The following factors must be considered to determine if AOMSI is present: 1) flexion/extension radiographs are performed when the individual is at maximum medical improvement and are technically adequate; 2) the proper methodology is used in obtaining measurements of translation and angular motion; 3) normal translation and angular-motion thresholds consistent with the literature are used in determining AOMSI. Imaging modalities such as videofluoroscopy, digital fluoroscopy, and upright/motion magnetic resonance imaging cannot be used to establish an AOMSI permanent impairment using the AMA Guides. A number of technical factors can affect the image quality associated with measurements of AOMSI, including film centering, artifacts, poor edge resolution, endplate normal variations and spurring, and use of analog rather than digital radiography.

Effects of Aging on Impairment Ratings: Part 3: Neurological and Associated Issues

This article is the third in a series of four that explore the effects of age-related changes in impairments as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. Specifically, this article focuses on evaluation of disturbances of the nervous system, divided for discussion here into four parts—the central nervous system (CNS), the peripheral nervous system, vision, and hearing—and offers guidance in using the AMA Guides, Fifth and Sixth Editions, in a variety of specific disorders within each group. For example, the CNS discussions address disorders of consciousness and awareness; sleep and arousal disorders; alterations in metal status, cognition, and highest integrative function; aphasia or dysphagia; emotional or behavioral disorders resulting from CNS causation (fifth edition only); chronic pain; and others. One of the most challenging issues in evaluating peripheral neuropathy regards carpal tunnel syndrome, and rating physicians should provide references in their reports to justify their position. Rating visual problems usually requires attention to the medical records to document preinjury visual status. The AMA Guides, Fifth and Sixth Editions, do not use age-adjusted corrections in assessing age-related diminished hearing, but local jurisdictions and circumstances may apply apportionment. In apportioning impairment due to aging, the examiner must understand both the science and the specific legal processes involved.

Effects of Aging on Impairment Ratings: Part 2: Internal Medicine Issues

This is the second of four articles that explore the effects of age-related changed in impairment evaluations according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions; specifically, this article completes the review of the internal medicine sections. With respect to the digestive system, the normal aging process affects gastrointestinal impairment ratings as found in the AMA Guides, Fifth and Sixth Editions, for gastroesophageal reflux disease, peptic ulcer disease, pancreatitis, diverticulitis, irritable bowel syndrome, fecal incontinence, and hemorrhoids. Cancers of the digestive system and infectious hepatitis were reviewed by the National Institutes of Health in The Burden of Digestive Diseases in the United States (2008), which should be reviewed when an impairment rating or apportionment is needed or for an individual with these conditions alleged to be the result of a compensable injury or illness. The normal aging process does not significantly affect the impairment ratings for renal disease (upper urinary tract disease), but, for individuals over 70, an age adjustment should be incorporated into the impairment rating. The AMA Guides, Fifth and Sixth Editions, also do not provide age-related modifications for urinary incontinence, but a rating physician may apply a discretionary apportionment. For diseases of the scrotum, testicles, epididymis, and spermatic cord, as well as for prostatic hypertrophy, neither edition of the AMA Guides makes age-related modifications; neither are modifications because of aging are made for the female reproductive tract, although raters are told to consider the physiological differences.