Medical Association Guides Research Articles

Comparative Analysis of Upper Limb Impairment Rating Processes in the American Medical Association Guides Sixth Edition 2024 Versus 2008: Impact on Stakeholders.

The aims of the study are to evaluate how upper limb impairment ratings are affected by updates to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) Sixth Edition 2024 compared with the AMA Guides Sixth Edition 2008 and to investigate potential correlations with judicial, legislative, and economic factors. Two expert evaluators reviewed 31 upper limb clinical vignettes from the 2008 and 2024 versions. The impairment ratings for each version were compared. After following the impairment ratings steps in each version, the results for 2024 showed no significant differences when compared with the impairment ratings generated using 2008 methods (Cohen's kappa = 1.00). The updated AMA Guides Sixth Edition 2024 with improved, transparent processes and enhanced diagnosis-based impairment tables provides efficiency while retaining the accuracy, validity, and reliability of past versions of the AMA Guides .

Can Angular Deformity Due to Sacrococcygeal Fracture Cause Permanent Impairment? : Current State and Problems in Korea.

Disabilities can emerge due to traumatic spinal fractures. In terms of sacrococcygeal spine, because of its unique anatomic structure with minimal movement, the possibility for it to have a disability is relatively low. In Korea, unlike most disability criteria, private insurance companies acknowledge angular deformities caused by vertebral fractures as disabilities according to their degree, so there were several cases where patients required compensation, arguing angular deformity caused by sacrococcygeal fracture, which in some cases led to legal conflicts. Except the Act Welfare of Persons with Disabilities which recognizes only severe angular deformity affecting internal organs as disability and the industrial accident disability evaluation which does not recognize coccygeal fracture as disability but rarely recognizes sacral vertebra deformity equivalent to compressive deformation, there is little or no case where angular deformity is recognized as disability. Given the impairment evaluation standards in social insurance, McBride system, American Medical Association (AMA) guides, and newly proposed standards by the Korean Academy of Medical Sciences (KAMS), the most contentious point in the general terms and conditions of private insurance is spinal deformity. To overcome controversy over disability evaluation, the private insurance sector is now applying criteria for axial skeleton to sacrococcygeal vertebrae through revision of standards. Under these circumstances, it is fair to recognize sacrococcygeal fracture as impairment in terms of the pelvis only when the fracture leaves serious deformity and neurological symptoms with clear relevancy. Though it may not be easy to develop accurate disability evaluation standards, improvement is necessary to remove any irrationalities and make the standards as objective as possible.

Evaluating Covid-19 Injury Claims With a Focus on Workers' Compensation.

: COVID-19 illness can cause multiorgan illness. Some States have passed legislation granting a rebuttable presumption of causation by workplace exposure in certain occupations. This paper summarizes methodology for evaluating claimants utilizing known science and as well as information from the American Medical Association Guides resources.

PF754 PERMANENT IMPAIRMENT‐FREE, RELAPSE‐FREE SURVIVAL: A NOVEL COMPOSITE ENDPOINT TO EVALUATE LONG‐TERM SUCCESS IN ALLOGENEIC STEM CELL TRANSPLANTATION

Background:Permanent impairment of vital organs is one of transplant‐related health problems affecting quality of life and morbidity even in patients who did not develop graft‐versus‐host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo‐HCT), but no data are available on permanent impairment of multiple organs.Aims:Our aims were to evaluate long‐term trasplant success by estimating the cumulative incidence of permanent impairment and the probability of survival after allo‐HCT without permanent impairment, relapse or death, which we called permanent impairment‐free, relapse‐free survival (PIRFS).Methods:We estimated cumulative incidence of permanent impairment of six vital organs and a novel composite endpoint of PIRFS in a retrospective study including 164 recipients of first allo‐HCT in Konan Kosei Hospital. The vital organs whose function was assessed in this study were the heart, lungs, liver, digestive tracts, kidneys, and central nerve system. We used “The American Medical Association's Guides to the Evaluation of Permanent Impairment” to assess the degree of permanent impairment on the same scale in the different organs. We defined permanent impairment as over 26–30% impairment of the whole person in six organs by using whole person impairment rating. Persistence of impairment for more than 6 months after the diagnosis of impairment was required in order to regard the impairment as permanent. The impairment in the first 6 months after allo‐HCT was excluded to avoid misclassifying reversible impairment as permanent.Results:The median follow‐up period for the surviving patients was 1846 days (range, 425–4055). Conventional GVHD‐free/relapse‐free survival (GRFS) at 5 years and PIRFS at 5 years were 33.8% (95% CI, 26.5%–41.3%) and 40.6% (95% CI, 32.6%–48.4%). PIRFS was higher than GRFS at any time after allo‐HCT in the whole cohort. However, in patients who underwent umbilical cord blood transplantation (UCBT), PIRFS became lower than GRFS after day 397 post‐transplant. In the UCBT recipients, the 5‐year GRFS and PIRFS were 47.6% (95% CI, 34.3%–59.7%) and 39.2% (95% CI, 26.6%–51.5%). The 5‐year cumulative incidence of permanent impairment was 20.9% (95% CI, 13.7%–29.0%) in the survivors for ≥180 days without relapse. Using multivariate analysis, we showed that high disease risk (HR, 1.91; 95% CI, 1.26–2.88; P < 0.01) and KPS ≤90% at transplant (HR, 1.73; 95% CI, 1.14–2.63; P = 0.01) were significantly associated with the lower PIRFS. UCBT (HR, 2.35; 95% CI, 1.11–4.99; P = 0.03), acute GVHD grade 3–4 by day 180 (HR, 3.59; 95% CI, 1.04–12.4; P = 0.04) and thrombotic microangiopathy by day 180 (HR, 2.74; 95% CI, 1.10–6.87; P = 0.03) were significantly associated with the higher incidence of permanent impairment.Summary/Conclusion:Our study demonstrated that PIRFS represented healthy life for survivors after allo‐HCT and differed significantly based upon disease risk, KPS at transplant. The evaluation of PIRFS yields novel information regarding quality of long‐term survival after allo‐HCT, which cannot be represented even in well‐executed endpoints such as GRFS. Thus, we propose that PIRFS is a novel composite endpoint to evaluate long‐term transplant success in a different perspective from previous evaluation methods.image

Measuring Outcomes and Determining Long-Term Disability after Revision Amputation for Treatment of Traumatic Finger and Thumb Amputation Injuries

Disability ratings after finger amputations are based on anatomical injury according to the American Medical Association's Guides to the Evaluation of Permanent Impairment. These ratings determine disability and compensation, without considering validated outcomes measures. The authors hypothesize that patient-reported outcomes reflect function and health-related quality of life after traumatic finger amputations, and that Guides scoring does not accurately rate postamputation disability. Patients were classified by amputation: single finger, thumb, multifinger, or multifinger plus thumb. Eighty-four patients completed functional tests, the Jebsen-Taylor Hand Function Test, and patient-reported outcomes [Brief Michigan Hand Questionnaire (MHQ), Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the Short Form-36 health-related quality-of-life questionnaire). Patients were given disability scores according to the Guides. Pearson correlations between outcomes metrics were calculated, and linear regression evaluated associations between amputation group, Guides score, and outcomes measures. The Brief MHQ and Quick DASH questionnaires had significant correlation with functional tests, the Jebsen-Taylor test, and the physical component summary of Short Form-36. Only the Brief MHQ correlated with the mental component summary of the Short Form-36 (r=0.29, p=0.02). The Guides score only correlated with the Jebsen-Taylor test (r=0.47, p<0.001). Regression results indicate that the Brief MHQ, Quick DASH, and Guides score predict Jebsen-Taylor test score; however, amputation group and Guides score do not predict patient-reported outcomes. The American Medical Association Guides score represents anatomical and functional outcomes without addressing mental health and other components of disability. As a result, Guides scoring is inadequate for determining postamputation disability. In evaluating composite amputation outcomes, Brief Michigan Hand Questionnaire outperformed other metrics. Risk, II.

Performing a lung disability evaluation: how, when, and why?

The objective of this review is to present a case-based clinical discussion on this topic. The article represents part of the proceedings of the Occupational and Environmental Lung Disease conference held by the American College of Chest Physicians at Toronto, Ontario, Canada, in 2013, and is based upon a nonsystematic review of the current literature by the author. Although the American Medical Association Guides to the Evaluation of Permanent Impairment is the mainstay for evaluating respiratory impairment, many other impairment schemata are currently available in the United States. Impairment evaluation for a case with chronic respiratory disease and a separate case with asthma is discussed. Pulmonary function tests are the cornerstone for evaluating respiratory impairment. Impairment values differ between various impairment schemata. Impairment evaluation for asthma may be particularly difficult.

The AMA Guides Use in Australia

The AMA Guides Use in Australia

HPCSA Serious Injury Narrative Test guideline

Current South African Road Accident Fund (RAF) legislation requires a medical determination of the seriousness of injuries sustained in motor vehicle accidents to determine whether the claimant is entitled to a claim for general damages. Such medical assessments are submitted in the form of RAF 4 Serious Injury Assessment Reports. Contested claims for serious injury are referred to the Health Professions Council of South Africa (HPCSA) Appeal Tribunals for final determination. The legislation prescribes 2 instruments, namely the American Medical Association (AMA) Guides (6th edition) and the Narrative Test for this purpose. Whereas the AMA Guides are published in a comprehensive book, and training courses are provided in their use, existing legislation does not provide any indication of the required structure, content or criteria of a Narrative Test report. This document is published by the HPCSA Appeal Tribunals as a guideline to the performance of the Narrative Test; what it is, reasons for applying it and who should compile it, as well as the required structure, content and criteria thereof. A Narrative Test Report should include relevant and meaningful comment in relation to each of the 6 sections described in the article.

The Prevalence and Severity of Lumbar Spine Motion Impairment in Normal Subjects

Crosssectional. To assess the prevalence and severity of lumbar spine motion impairment in normal subjects. A prior study of cervical and lumbar spine impairment indicated that a high percentage of normal subjects had impairment. A total of 579 normal subjects were assessed for lumbar spine motion impairment using 3 editions (Third Edition Revised, Fourth Edition, and Fifth Edition) of the American Medical Association Guides to the Evaluation of Permanent Impairment (AMA Guides). Eighty percent to 86% of normal subjects had impairment due to loss of lumbar motion. A high percentage of normal subjects will have lumbar spine impairment due to loss of lumbar motion using the AMA Guides.

Determining Injury-Relatedness, Work-Relatedness, and Claim-Relatedness

Abstract The American Medical Association's Guides to the Evaluation of Disease and Injury Causation (Causation) is an important component of the AMA Guides library and delineates a type of evaluation that is distinctly different from a diagnostic evaluation, a treatment planning evaluation, a prognosis evaluation, or an impairment evaluation. Causation provides a protocol for determining whether a clinical presentation, in the context of a legal or administrative claim, may be credibly attributed to a claimed cause. This article presents the evaluation protocol from Causation, provides self-assessment questions (so users can check how well they complied with the protocol), highlights the protocol's value as a model for scientifically credible practice in general, and clarifies that the protocol is relevant to claims that involve issues related to forensic causation. Courts and administrative systems have an extremely unfortunate emphasis on opinions from experts rather than on facts. The protocol from Causation is a good example of how clinicians can focus on facts and avoid surrendering to the court or administrative system's emphasis on opinions. The protocol is standardized, objective, fact-based, and scientifically credible and involves the following: establish a diagnosis; apply relevant findings; obtain and assess evidence of exposure; consider other relevant factors; scrutinize the validity of the evidence; and evaluate results and generate conclusions.

A Selective Critical but Constructive Desktop Appraisal of theAmerican Medical Association Guides to the Evaluation of Permanent Impairment (AMA 6)

AbstractThis desktop review has been conducted, from the reviewers' perspective, to evaluate the merits, advantages and disadvantages of adopting the 6th edition of theAmerican Medical Association (AMA6) Guides for the Evaluation of Permanent Impairment.The reviewers do not make any recommendation as to whetherAMA6should or should not be adopted by any particular jurisdiction, but rather provide comment from the perspective of a critical but constructive appraisal of published material. The observations reported represent the opinions of the reviewers, based on their appraisal of selected sections ofAMA4,AMA5andAMA6and the associated literature.AMA6has become surrounded by considerable controversy. At the time of review, at least two jurisdictions in the United States have voted against adoption ofAMA6. While the paradigm shift away from the World Health Organization (WHO) International Classification of Impairment, Disability and Handicap (ICIDH) framework to the WHO International Classification of Functioning, Disability and Health (ICF) framework has attempted to ‘move with the times’, andAMA6has attempted to reach higher levels of internal consistency and interrater and intrarater reliability, the methods used to achieve a radical change in theGuideshas come under criticism. It is quite difficult to distinguish between speculative and substantive criticism, because of paucity or obscurity in both source documents and subsequent commentary. A range of concerns have been identified.

Assessment of Functional Limitation After Necrotizing Soft Tissue Infection

Previous literature on necrotizing soft tissue infections (NSTIs) has focused on its diagnosis and high mortality, but to our knowledge, none have reported on the functional outcomes of patients surviving this devastating disease. The purpose of this study was to evaluate the management and assess factors associated with decreased physical function in patients who survived this life-threatening infection. A retrospective review was conducted on patients treated for NSTI in whom an evaluation of functional status was performed between 2002 and 2006. Measurements were based on the American Medical Association Guides of impairment rating, and categorized into a functional class from "minimal or no limitation" to "severe limitation." Multivariate analyses were performed to discern independent factors associated with functional limitation. Final disposition status after discharge was also recorded. A total of 297 patients were treated for NSTI during this time. Of these, 119 (41%) patients met inclusion criteria for review. Mean number of débridements and coverage procedures were 3.4 and 2.0, respectively. Although mean percent functional limitation was 7.1, which is classified as "minimal or no limitation," 30% of patients had "mild" to "severe" functional limitation. Extremity involvement was independently associated with a higher functional limitation class (P < .01). Functional limitation may challenge recovery from NSTI in many survivors. In this series, the involvement of an extremity predicted a higher functional limitation class at the time of discharge. Development of validated functional assessment tools and accurate longitudinal follow-up are necessary to measure the functional impact of NSTI.

Development of the Korean Academy of Medical Sciences Guideline for rating the impairment in the brain injured and brain diseased persons with motor dysfunction.

To develop an objective and scientific method to evaluate the brain injured and brain diseased persons with motor dysfunction, American Medical Association's Guides to the Evaluation of Permanent Impairment was used as an exemplar. After the motor dysfunction due to brain injury or brain disease was confirmed, active range of motion and muscle strength of affected extremities were measured. Also, the total function of extremities was evaluated through the assessment of activities of daily living, fine coordination of hand, balance and gait. Then, the total score of manual muscle test and functional assessment of impaired upper and lower extremity were added, respectively. Spasticity of upper and lower extremity was used as minus factors. Patients with movement disorder such as Parkinson's disease were assessed based on the degree of dysfunction in response to medication. We develop a new rating system based on the concept of total score.

Disability Evaluation of the Pain : The Present and Prospect in Korea

Pain has long been regarded as a subjective symptom. Recently, however, some regard a type of intractable chronic pain as a disease. Furthermore, chronic persistent pain becomes a cause of permanent impairment (PI). In 6th edition, the American Medical Association (AMA) Guides has rated the pain as a PI. In Korea, pain has been already been rated as a PI. Here, we examined the present status and the prospect of disability evaluation for the pain in Korea. Pain can be rated as a PI by the Workmen's Compensation Insurance Act (WCIA) and Patriots and Veterans Welfare Corporation Act (PVWCA) in Korea. We examined the definition, diagnostic criteria and grades of the pain related disability (PRD) in these two acts. We also examined legal judgments, which were made in 2005 for patients with severe pain. We also compared the acts and the judgments to the criteria of the 6th AMA Guides. The PRD can be rated as one of the 4 grades according to the WCIA. The provisions of the law do not limit the pain only for the complex regional pain syndrome (CRPS). The PRD can be rated as one of the 3 grades by the PVWCA. If there were objective signs such as osteoporosis, joint contracture and muscle atrophy corresponding to the CRPS, the grade is rated as 6. When the pain always interferes with one's job except easy work, the grade is rated as high as 5. In Korea, judicial precedents dealt the pain as a permanent disability in 2005. Although there were no objective criteria for evaluation of the PRD, pain has been already rated as a PI by the laws or judicial precedents, in Korea. Thus, we should regulate the Korean criteria of PRD like the AMA 6th edition. We also should develop the objective tools for evaluation of the PRD near in future.

Korean guideline development for the evaluation of permanent impairment of the spine: proposal by the Korean Academy of Medical Sciences Committee.

The criteria for the evaluation of spinal impairment are diverse, complex, and have no standardized form. This makes it difficult and somewhat troublesome to accurately evaluate spinal impairment patients. A standardized guideline was studied for the evaluation of spinal impairment, based on the American Medical Association (AMA) Guides and the McBride method. This guideline proposal was developed by specialty medical societies under the Korean Academy of Medical Sciences. In this study, the grades of impairment were assessed by dividing patients into three different categories: spinal cord impairment, spinal injury impairment and spinal disorder impairment. The affected regions of the spine are divided into three: the cervical region, the thoracic region, and the lumbosacral region. The grade of impairment was differentially evaluated according to the affected region. The restricted range of motion was excluded in the evaluation spinal impairment because of low objectivity. Even though the new Korean guideline for the evaluation of spinal impairment has been proposed, it should be continuously supplemented and revised.

Development of Korean Academy of Medical Sciences Guideline Rating the Physical Impairment: Lower Extremities

Lower Extremities Committee of Korean Academy of Medical Sciences Guideline for Impairment Rating develops new guidelines which are based on McBride method, American Medical Association Guides, Disability evaluation by The Korean Orthopaedic Association, The Korean Neurosurgery Society, and Korean Academy of Rehabilitation Medicine. The committee analyzed and discussed to create an ideal method practical in Korea. Our committee endeavors to develop new methods which are easy to use, but are suitable for professional use and also independent from the examinee's intentions. The lower extremities are evaluated on the basis of anatomic change, functional change, and diagnosis based evaluation. Nine methods are used to assess the lower extremities. Anatomic assessment includes leg length discrepancy, ankylosis, amputation, skin loss, peripheral nerve injury, and vascular disease. In functional assessment, range of motion and muscle strength are included. Diagnosis-based assessments are used to evaluate impairment caused by specific fractures, deformities, ligament instability, meniscectomies, post-traumatic arthritis, fusion of the foot, and lower extremity joint replacements.

Development of Korean Academy of Medical Sciences Guideline-Rating the Impairment in Pain

Pain-related impairment assessment by the fifth edition of the American Medical Association Guides had many ambiguous points, and therefore, it was not applicable directly in Korea. Several disputable pain disorders were excluded from the list of impairment evaluation, and complex regional pain syndrome was chosen as the first object of impairment evaluation. Scales such as Korean version of modified Barthel index for assessing the activity of daily livings and Beck Depression Inventory for assessing depression were added, and pain severity, pain treatment, pain behavior, etc. were scored. In order to objectify as much as possible and to remove the room for misuse, we develop a new rating system based on the concept of total score.

Letter to the Editor,

To the Editor: I refer to the paper by Ryu, Hong, Jung, Hwang, Jung, Jeong, Rah and Suh (2009) (1). The assessment of psychiatric disability is difficult and fraught with methodological problems and the review by Ryu and colleagues tends to perpetuate the use of methods of assessment which have no firm evidence base as well as ignoring some significant problems with the use of the American Medical Association Guides as well as the Psychiatric Impairment Rating Scale (PIRS). To be fair there is little in the way of objective evaluation of assessment scales in the literature. However data were published providing some validation of the use of the PIRS in 2008 (2, 3). This endeavoured to provide some empiric evaluation and a basis for further research. A problem arising in the review is the omission of a comment that the PIRS is not designed to assess disability for work, being specifically mandated for the assessment of non-economic loss. Because of this it cannot be directly compared to the AMA 6th Guidelines in regard to whole person impairment. Also the Brief Psychiatric Rating Scale (BPRS) was specifically designed for the assessment of psychosis (4) and most patients presenting for evaluation in the context of compensation present primarily with anxiety and depressive disorders. Current research is focussed in two areas. The assessment of fitness for work, in which there are three main components, availability to work, the ability to interact with others and performance of work place duties, and the assessment of non work related disability. Early studies in this second domain indicate four major areas of disability to be assessed, one reflecting the effects of stigmatisation, one relating to self care and relationships with family, one relating to cognitive function such as memory and decision making and one related to interactions with the wider community. There are a number of other wider issues concerning the validity of the use of a percentage scale when the data are of an ordinal rather than interval nature which also deserve consideration by the authors. Yours sincerely,

Development of the Korean Academy of Medical Sciences Guideline for rating physical impairment.

Systematic and effective welfare for the disabled is possible when there are scientific and objective criteria demonstrating either presence or severity of the impairment. We need our own scientific criteria suitable for our culture and society, since the impairment is influenced by them. In 2007, we established the Developing Committee of Korean Academy of Medical Sciences (KAMS) Guideline for Impairment Rating under KAMS supervision. We included all fixed and permanent physical impairments after a sufficient medical treatment. The impairment should be stable and medically measurable. If not, it should be reevaluated later. We benchmarked the American Medical Association Guides. The KAMS Guideline should be scientific, objective, valid, reasonable and practical. In particular, we tried to secure objectivity. We developed the KAMS Guideline for Impairment Rating.

A Prospective Study to Validate an Impairment Questionnaire for Major Trauma Survivors

To develop and validate an impairment questionnaire that will provide an estimate of whole-person impairment in patients who have suffered major trauma. This was a multicenter prospective study involving a convenience sample of 43 volunteer participants who had sustained major trauma within 1 yr of study commencement. Patients were recruited from two trauma centers in Ontario, Canada. The impairment questionnaire was developed as a self-administered questionnaire based on the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition. Clinician assessments of whole-person impairment showed adequate interrater (r > or = 0.55, P < or = 0.03) and intrarater (r > or = 0.62, P < or = 0.055) reliabilities across dimensions. The impairment questionnaire correlated significantly with clinician assessments at the initial visit (r > or = 0.57, P < 0.001) and at follow-up (r > 0.60, P < 0.001). Comparison of the physical and emotional subcategories of the impairment questionnaire, whole-person impairment ratings by physicians, and the Short Form 36 demonstrated good convergent and divergent validity of the impairment questionnaire. The impairment questionnaire is a reliable and valid self-administered tool that can be used to evaluate physical impairment after major trauma.