In any practice that deals with injuries and
accidents it is inevitable that there will be those few people
who present with a permanent impairment of some nature. In
order to provide an accurate assessment of one’s disability
there is a standard of care by which a proper assessment
and determination of impairment can be reached.
The Guides to the Evaluation
of Permanent Impairment is the standard. Currently in
its fourth edition the text is compiled by a list of contributors
and editors of the American Medical Association. Started
in the 50’s this guide provides objective measurements
and computations for determining body impairments. The ratings
are based upon measurable objective findings such as range
of motion, strength, deformity, loss of sensation, and loss
of organ function.
In thirty-eight states
and two US territories the use of The guides to the Evaluation
of Permanent Impairment is mandated or recommended by law
in worker’s compensation cases. In litigation cases the
use of the guides is strongly recommended as an objective measurement
of individual impairment.
Ratings are given stated
as a percentage of loss for any affected body part or organ
as well as a percentage of loss of function on the body as
a whole.
The Guides defines
an impairment as "an alteration of an individual’s
health status ... assessed by medical means. An impairment
is a deviation from normal in a body part or organ system and
its functioning." The ratings apply to those impairments
that are felt to be permanent. Permanency is defined as "adverse
conditions that are stable and unlikely to change." The
Guides address those impairments that are felt to be permanent
and unlikely to change with any further surgery, time or therapy.
This type of impairment will affect one’s ability to
continue on with their normal activities of daily living.
In assessing an impairment
there must be a thorough patient history including an explanation
of the accident, an understanding of the patients home and
work life. There must documentation stating how the patient
can no longer perform his or her work duties and the affects
on home life. While not everyone’ job may require heavy
lifting, overhead work or throwing, patients who have impairments
along these lines may not be able to enjoy their normal sports
or family activities. This history must also include all treatment
venues that have been tried and their success or failures also
documented.
A comprehensive physical
examination needs to be carried out even from the initial presentation
of the patient. Depending on the system that is involved adequate
range of motion, strength, functional capacity of organ systems
and neuro/sensory losses must be documented. With therapy or
surgery one must be able to documented any improvement or treatment
failure. Once a physician feels that the patient has reached
a maximal end point only then can a permanent impairment be
adequately assessed.
Pain in and of itself is
not something that can be measured objectively. In general
the disability ratings for various organ systems make allowances
for the pain that may accompany the disability. The exception
to this is those patients with chronic pain. The Guides has
a special chapter on the assessment of chronic pain. Even in
these assessments it is noted that pain is subjective. The
most accurate assessment will be based on one’s ability
to carry out there activities of daily living in their work,
home and social situations.. An individual who complains of
constant pain but has no objective limitations in their activities
of daily living has no impairment. If there are objective limitations
of their activities it must be permanent and not likely to
improve with any further intervention or surgery.
Patients need to realize
that the Guidelines are quite specific and relatively
strict. The complete loss of the thumb of the dominant hand
is considered to be a 40% loss of function of the hand (Figure
3 ,Table 1, page 3/18) This calculates to a 36% impairment
of the upper extremity ( Table 2, page 3/19.) This is then
calculate to a 22% impairment of the whole body (Table 3, page
3/20.) A compression fracture of a lumbar vertebrae of greater
than 50 percent of its height is rated as a 12% impairment
of the whole body (Table 75, page 3/113.) A total hip or fracture
prosthesis with fair results is calculated to be an impairment
of 50% of the lower extremity and 20% of the whole person (Table
64, page 3/84.) |
