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AMA 4 Guides Impairment Assessment Training E-Newsletter
December Edition


Issue date: Friday 14 December 2007

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IN THIS EDITION:

From the Chair

AMA 4 NEWS

Assessment Completion Rates

Did You Know?

Public Forum

Tape Recording Medical Information

Inappropriate Language

Legislation Changes Impacting Impairment Assessments

MODULES IN DETAIL

Having Trouble Placing an Assessment within a Class Using GEPIC?

Assessment of Disc-Replacement Surgery Cases

Upper Extremity Assessments in Review

Terminology in the Lower Extremity

Combining Impairments in Lower Extremities

Quick Tips for Impairment Assessment

Impairment Assessment Training Program 2008


From the Chair


We are approaching the end of our first year of impairment training run by AMA Victoria. All of the assessment parameters of our course suggest that we are on the right track. Many of the modules have been very popular, heavily booked and therefore not immediately available to all. The facilities at AMA (Vic ) for small group teaching have proved excellent. I am grateful for the talented input from the AMA (Vic) staff.

The Impairment Assessment Training Management committee is anxious to have this newsletter act as a forum for discussion for interested parties. We invite contributions – particularly those that will stimulate thought and discussion. Such contributions should be addressed to the Editorial Committee at iat@amavic.com.au

Season’s Greetings from the Management Committee.

Dr Tony Buzzard
Chair
Impairment Assessment Training Management Committee

AMA 4 NEWS

Assessment Completion Rates
90% of Stream 1 participants and 87% of Stream 2 participants who attended modules in 2007 submitted assessments. Both Stream 1 and Stream 2 participants excelled, achieving pass rates of 96% and 98% respectively.

Did You Know?
Newsletters from the previous training provider are now available online at www.iatvic.com.au/newsletters.aspx

Public Forum
The AMA 4 newsletter is not just a vital tool for information – it’s also a forum. Participants are invited to share their thoughts, issues and ideas on their AMA 4 training with our readership.

Please email us iat@amavic.com.au if you would like to share your experiences, and we will address these topics in upcoming issues.

Tape Recording Medical Information 1: Patient recording
(Excerpt taken from VWA IME Bulletin No. 8 - March 2007)

The Victorian WorkCover Authority’s (VWA’s) position on a worker or medical examiner (Independent Medical Examiner or Impairment Assessor)(IME or IA) tape recording an independent medical examination is based on the excerpt Surveillance Devices Act 1999 (Vic) (the Act).

In the context of an independent medical examination, the Act permits an injured worker to tape record an examination without the express or implied consent of the IME or IA because the worker is a party to the conversation. The Act permits any party to a private conversation to tape the conversation without the express or implied consent of each party to the conversation. However, it restricts a person from communicating or publishing a record of a private conversation or the substance or meaning of a conversation to a third party, unless it falls within a specified exception. The exceptions are:

  • a communication or publication that is made with the express or implied consent of each party to the private conversation; or
  • to a communication or publication that is no more than is reasonably necessary:
  • in the public interest; or
  • for the protection of the lawful interests of the person making it.

Notwithstanding this, the VWA favours the approach that injured workers and IME/IAs should be transparent and should not tape record an independent medical examination without prior notification.

Tape Recording Medical Information 2: Doctor recording
Medical Practitioners’ Board Guidelines advise that doctors should not tape an examination without the consent of the patient.

Doctors must also comply with the Health Records Act 2001 Vic, which provides that a doctor may record a consultation only with the express or implied consent of the patient (or person being assessed). A doctor should ensure that such a consent exists and is current.

In the absence of express or implied consent of the patient, a consultation is not to be recorded unless notice that a consultation is going to be recorded is provided to the patient. Even then, the consultation may be recorded only where recording a consultation is “necessary for the establishment, exercise or defence of a legal or equitable claim”. The right to record a consultation without consent is further tempered by the obligation that collection be “fair means and not in an unreasonably intrusive way”.

Doctors who are unsure if they are entitled in particular circumstances to tape with the patient’s knowledge but without the patient’s consent, should contact AMA Victoria or the Health Services Commission.

Inappropriate language
Re-produced from Bulletin Vol 3, September 07 with permission of the Medical Practitioners Board of Victoria

The patient had been referred to the occupational physician to assess his level of impairment in relation to work related claims. During the course of the consultation, the doctor interrupted the physical examination of the patient to view MRI scans. While viewing the MRI scans, the doctor used a number of expletives when describing to the patient the pathological findings that he observed. The patient was upset by the description and concerned that other doctors had not told him of the true extent of his problem. The doctor acknowledged that the comments had been inappropriate.

The Panel considered the use of expletives by a medical practitioner in the context of a consultation. It did not wish to take a moral stand and be unduly prescriptive about the limits of acceptable language. The Panel said that it understood that practitioners practise differently and often pitch their language in a way they consider appropriate. They establish rapport in ways that make patients feel more comfortable.

While practitioners may use expletives in certain contexts, the words used in this case were intended to graphically describe the patient’s pathology on his MRI scan. The Panel found that the comments were inappropriate and in no way served their intended purpose of putting the patient at ease or increasing his understanding, and in fact increased his level of anxiety.

The Panel concluded that this amounted to unprofessional conduct. The Panel cautioned the doctor about his use of language during consultations and required him to review his practice in this regard.

Legislation Changes impacting Impairment Assessments

On the 27 November 2007, both the Accident Compensation Act 1985 and Transport Accident Act 1986 were amended to reflect changes in relation to the assessment of permanent impairment. These changes arose as result of the legal decision previously advised to you as Mountain Pine Furniture P/L v Taylor (Mountain Pine Furniture Pty Ltd v Taylor [2007] VSCA 146) and provides clarity on important impairment assessment issues for Victoria’s transport accident and workers’ compensation schemes, namely:

  • Stability

The legislation now requires that the assessment of the degree of impairment resulting from an injury must be made “after the injury has stabilised”. This now requires the Impairment Assessor to address the issue of stabilisation in each impairment assessment undertaken.

  • Current Impairment Assessment

The legislation now requires the Impairment Assessor to assess the injured person’s degree of impairment based on the person’s current impairment as at the date of the assessment. This includes “any changes in the signs and symptoms following any medical or surgical treatment undergone by the worker in respect of the injury”.

This section ensures that for all chapters of the AMA4 Guides and for any alternative prescribed assessment methods, examiners undertake an assessment of the injured person at his or her “current impairment as at the date of the assessment”.

  • Omission of paragraph in 3.3d of AMA4 Guides

The legislation now removes the use of the paragraph on page 3/100 of the AMA4 Guides which states:

“with the Injury Model, surgery to treat an impairment does not modify the original impairment estimate, which remains the same in spite of any changes in the signs or symptoms that may follow the surgery and irrespective of whether the patient has a favourable or unfavourable response to treatment”.

This means Chapter 3.3 Musculoskeletal: The Spine, AMA4 assessment instruction applies with the exception of the above quoted paragraph.

Impact on the Accident Compensation Act 1985

The legislative amendments affect assessments undertaken by Impairment Assessors under section 91 of the Accident Compensation Act 1985.

For the WorkSafe scheme, the amendments apply to all section 98C Impairment Benefit claims, irrespective of when the injury occurred or when the claim for compensation under section 98C was made except that the amendments do not apply to:

  • the parties in Taylor; and
  • those workers who prior to 19 September 2007 attended, after the injury had stabilised, at least one independent impairment examination conducted in accordance with the decision in Taylor.

(These exceptions are limited and, as Impairment Assessors, all new and initial assessments should apply the amended legislative requirements as described above).

Impact on Transport Accident Act 1986

The legislative amendments affect assessments undertaken by Impairment Assessors under section 46 of the Transport Accident Act 1986.

For the TAC Scheme, The Transport Accident Act (TAA) has specified the requirement for stabilisation (Section 46A) in respect of an impairment determination since its introduction in 1986. The exceptions to this approach apply to:

  • minors
  • injured persons who wish to finalise their impairment benefit at 3 years post accident based on non stable injuries.

The legislative amendments will have no significant impact on the way in which TAC impairment assessments are performed. However, the TAA has incorporated the legislative amendments to:

  • remain consistent with the approach in applying the Guides between the TAC and WorkSafe schemes
  • to further clarify the requirement to assess a spine injury in a stable and current state including the effects of surgery.

Impact on the Wrongs Act 1958

Application of these amendments to public liability claims under the Wrongs Act 1958 remain currently under review by the Victorian Department of Justice. Further information will be provided to Impairment Assessors when available.

FURTHER INFORMATION AND MORE DETAILED TECHNICAL INTERPRETATION OF THE AMENDED LEGISLATION WILL BE INCORPORATED WITHIN EACH STREAM OF THE CORE AND SPINE MODULES IN 2008.

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Modules In Detail

 

Having Trouble placing an assessment within a class using GEPIC?

An extract from The Guide to the Evaluation of Psychiatric Impairment for Clinicians

The overall collective percentage impairment is within the percentage range of the median class. The final figure is determined by taking into account the person’s level of functioning, on the basis of clinical judgement.

Each median class includes descriptors which indicate a range of symptoms within that class. Each class has a low range, a mid range, and a high range.

The indicative ranges for each class are as follows:

 

Low range

Mid range

High range

Class One

0–1%

2–3%

4–5%

Class Two

10–12%

14–16%

18–20%

Class Three

25–30%

35–40%

45–50%

Class Four

55–60%

65–70%

70–75%

Class Five

75–80%

85–90%

95–100%

In coming to the final rating of the whole person psychiatric impairment the assessor should consider the range of descriptors and/or equivalent symptoms that emerged during the interview, as well as the findings on mental state examination.

The assessor should consider both the descriptors for each class and equivalent symptoms that might not be listed amongst the descriptors. The assessor should assess the severity of each symptom or descriptor and/or the number of symptoms or descriptors present. As a result of this clinical assessment the assessor should use clinical judgement to determine where the final figure lies.The assessor should consider in which part of the median class these descriptors and/or equivalent symptoms would fall, e.g. if the individual assessed has symptoms which lie within median class 2, and these symptoms were relatively minimal in severity or there were only a few symptoms this indicates a final value in the low range for class 2 (10–12%). If the descriptors equivalent symptoms were more numerous and/or more severe the final value is likely to be mid range (14–16%). If the individual has most of the descriptors and/or equivalent symptoms for median class 2 or fewer but more severe descriptors and/or equivalent symptoms the final value would be in the upper range (18–20%). These indicative ranges are to provide guidance to clinicians and do not preclude the use of final values lying between them, e.g., 13%.

Assessment of Disc-Replacement Surgery Cases

By Associate Professor Peter Lowthian, Spine Reference Group

While the AMA 4 guidelines do not mention the surgical procedure of "disc replacement" per se, they do not in fact mention any specific surgical procedures, so in that regard these cases are no different from any other surgical cases. The impairments are based on DREs which involve certain symptoms, signs and in some cases radiological findings or ancilliary tests.

The assessment in this case, as for other cases involving spinal surgery, is affected by recent legislative changes (See elsewhere in this Newsletter) and the decision earlier this year in the Mountain Pine v Taylor case. (See Newsletter of September 7: www.iatvic.com.au/newsletters.aspx)

The decision in Mountain Pine v Taylor determined that surgery did not alter the assessment of a claimant – the assessment had to be based on the pre-operative situation.

However, subsequent changes to the Accident Compensation Act (covering Workcover claimants) reverses this approach for claimants covered by this act and mean that the assessment for relevant claimants is made after the injury has stabilised and based on the person’s current impairment as at the date of the assessment. The Transport Accident Act has been changed to conform with the Accident Compensation Act. Personal injury claimants of any kind other than under the TAC or Workcover schemes are covered by the Wrongs Act. The Wrongs Act has to date not been changed to mirror the changes made to the other two acts.

Disc Replacement Assessments under the Accident Compensation Act or Transport Accident Act.

In the case of a disc replacement, then it would be expected that the procedure would have been performed for a disc injury, with or without radiculopathy. The assessment must be done when the worker is stable post-operatively and the doctor must confirm that.

Assessment under the Wrongs Act

If the assessment is of a claimant under the Wrongs Act, or a claimant who is described in Section 296 of the Accident Compensation Act as amended by Section 28 of the Transport Accident Act and Accident Compensation Act Amendment Act 2007 as an exception to the cases covered by the recent legislative changes (see summary on page 2), the approach is as follows.

In the case of a disc replacement, then it would be expected that the procedure would have been performed for a disc injury, with or without radiculopathy. Thus the pre-operative DRE would either be DRE 2 or DRE 3, depending on the pre-operative findings. It is essential that the assessing doctor have sufficient information of the injured persons pre-operative state to make that assessment, and this may require the assessor asking the referring party to obtain more information from the treating doctors.

The Court of Appeal decision also determined that the doctor must also assess the injured person at the time of the assessment, as the assessment must be done when the injured person is stable post-operatively and the doctor must confirm that.

If there has been a deterioration in the condition of the injured person following the operation, the doctor should also state whether the surgery has caused the deterioration (ie worsening of the DRE), rather than the deterioration being due to a progression of the pre-operative condition. For if the worsening is due to progression of the preoperative condition then the higher DRE is the correct one for the injured person. On the other hand, if the surgery has caused the deterioration of the DRE then the pre-operative DRE is the correct one.

See also the September IAT e-Newsletter for details of the process to be undertaken in relation to pre-operative assessments pursuant to Mountain Pine v Taylor.

Upper Extremity Assessments in Review

By Dr Anthony Berger, Hand & Upper Extremity Reference Group

Many stages are involved in Upper Extremity Impairment Assessments and any deviation or incorrect use of a table or calculation can have significant effects on the final impairment rating. Some of the impairment ratings are inherently inaccurate with a wide variation in results especially in the determination of percentage sensory loss and motor weakness using tables 11 and 12. All other ratings for motion loss etc are far more accurate and reproducible. Errors in rating impairments however still occur due to incorrect application of some tables and simple arithmetic errors.

One common source of errors is seen with the measurements of Impairment due to Other Disorders of the Upper Extremity, Section 3.1m, Tables 18 – 30. The common rule for all of these assessments using Tables 19 – 30 is that these tables give a severity rating that is then multiplied by the impairment value of the joint in Table 18 to give the impairment for the appropriate unit. Table 18 gives the value for each joint relative to the unit, hand, upper extremity and whole person. For example the value for the CMC joint of the thumb is 75% of thumb function. Using Table 1 we see that this equates to a hand impairment of 30%, using table 2 this equates to an upper extremity impairment of 27% and using Table 3 to a whole person impairment of 16%. As you can see all these calculations are done for you in Table 18. Using table 19 as an example for Impairment from Joint Crepitation you will see that there are three possible severity grades, Mild 10%, Moderate 20% and Severe 30%. These severity grades are multiplied by the relative value of the joint from Table 18 to give the impairment value of join t crepitation to the unit, hand , upper extremity or whole person. i.e. a mild crepitation in the CMC joint of the thumb will give an impairment of the thumb of 8% (75% x 10% rounded up to the next whole figure). This equates to a hand impairment of 3% using Table 1. One could also use the 10% severity rating multiplied by the value of the thumb CMC joint to the hand of 30% as seen in Table 18 to get the same result. Tables 19, 20, 23, 24 and 25 all measure joint impairments whereas Tables 21, 22, 28, 29 and 30 all measure digit impairment so it is important to multiply the severity grade by the correct relative value from Table 18.

Another source of error occurs in the incorrect application of the other impairments. The use of Table, 19, 20, 23, 26, 28, 29 and 30 is only applicable if all other measurements are normal i.e. if the range of motion is normal. Impairments obtained from the use of Tables 21, 22, 24, 25 and 27 are to be combined with other impairments of the joint or unit. These impairments are to be calculated using the relevant severity Tables with Table 18 to give an impairment of the unit that is combined with other impairments of the unit prior to conversion to upper extremity and whole person impairments.

Table 27 gives impairments to the Upper Extremity for arthroplasty. It states that the impairment of a joint for resection arthroplasty is 40% and implant arthroplasty is 50% of the joint value. Any impairment of the joint due to loss of motion is to be combined with this impairment. It is important however to calculate the impairment of the joint due to arthroplasty and combine this with loss of motion impairments not to directly use the values in Table 27. Eg. An implant arthroplasty of the index metacarpophalangeal joint will result in an upper extremity impairment of 9% (Table 27) The metacarpophalangeal joint however represents 100% of the index finger function (Table 18) hence an implant arthroplasty of the index finger MCP joint equates to an impairment of the index finger of 50% (100% x 50%). 50% of index finger function is 10% of hand function (Table 1) and this equates to 9% of upper extremity function as noted in Table 27. If there is additional impairment of the index finger metacarpophalangeal joint then this is combined with the 50% index finger function before converting to hand and upper extremity impairment.

As with all Upper Extremity Impairments, if in doubt as to the order in which these calculations are to take place then it is best to refer to the Upper Extremity Impairment Evaluation Record on page 3/16 to see the order of calculation.

Terminology in the Lower Extremity
- what is a leg, what is a calf?

By Professor John AL Hart, Lower Extremity Reference Group

The AMA Guides to the Evaluation of Permanent Impairment of ( 4th edition) divides the musculoskeletal system into four units: spine, pelvis, upper extremity and lower extremity.

The Guides refer to the lower limb as the lower extremity (LEX) not the leg or lower limb.

The guides divide the lower extremity into six sections. The guides are not consistent; on page 15 units are described as regions and on page 75, sections are described as parts.

There are six sections: foot, hindfoot, ankle, leg, knee and hip. There is no section for the thigh.

The pelvis is designated as a separate unit. Despite that, pelvic fractures are also included in table 64 as diagnosis based injuries. Ischial bursitis is a specific condition in Table 64. When assessing pelvic impairments, reference should be made to both Table 64 and chapter 3.4, page 131 (Pelvis) and the most appropriate methodology selected. Only one methodology should be used to assess each impairment.

Leg and calf

The guides specify the leg as the section between the ankle and the knee. The calf is not specifically defined. In Gray’s Anatomy, the calf is described as the superficial muscle mass of the posterior compartment (gastrocnemius, soleus and plantaris).

Atrophy of the calf is therefore wasting due to a specific neurological lesion affecting those muscles, as a result of a direct injury to the muscles or loss of plantar flexion of the ankle. Atrophy related to joint ankylosis or disuse will affect all muscle compartments and therefore the atrophy should be described as leg atrophy and not calf atrophy.

Combining Impairments in the Lower Extremity

Malunited Fractures By Professor John AL Hart, Lower Extremity Reference Group

Malunion of diaphyseal fractures can occur in three planes and may have associated shortening. Each deformity can provide a specific impairment of function. The AMA Guides to the Evaluation of Permanent Impairment (4 th edition) quotes an example of a malunited tibial fracture with shortening and an angulation deformity (3.2i,3/84).

The Guides recommend that the impairments for the two components of the deformity be combined as lower extremity impairments. In Victoria, following the judgment in Elworthy v TAC (7/3/07), lower extremity impairments are estimated as whole person impairments.

Thus if a patient had a malunion of a fractured tibia and fibula with 15° of varus, 10° of internal rotation and 3 cm of shortening, the impairment would be 12% C 8% = 19% C 4% = 22% WPI.

QUICK TIPS FOR IMPAIRMENT ASSESSMENT

Provided by Dr John Malios, Member, Impairment Assessment Training Management Committee

When using the goniometer to measure a range of motion it is useful to begin the examination without the goniometer and establish some physical examination contact with the patient (eg gentle palpation and passive movement of the joint) before introducing the goniometer for measurement of active motion.

Careful documentation of medication that the patient is using including dosages and frequency of intake including correlation with frequency of doctor visits is important information for establishing severity of some impairments and selecting a class of impairment.(eg Chap 10 assessments)

 

Impairment Assessment Training Program 2008

Stream 1

Date Time Module
Sat 1 Mar 8.30-11am Core *
Wed 19 Mar 7-9pm Endocrinology #
Wed 19 Mar 7-10pm Lower Extremities
Tue 15 Apr 7-9pm Cardiovascular #
Tue 15 Apr 7-9pm Respiratory
Tue 29 Apr 7-9pm Digestive #
Tue 29 Apr 7-9pm Gynaecology #
Wed 30 Apr 7-10pm Spine
Tue 13 May 7-10pm Ear, Nose and Throat #
Tue 3 Jun 6-10pm Hand & Upper Extremities
Tue 22 Jul 6-10pm Neurology
Tue 2 Sep 7-9pm Dermatology
Tue 14 Oct 7-9pm Visual System
Tue 14 Oct 7-9pm Urology #
Tue 21 Oct 7-10pm Psychiatry
Tue 21 Oct 7-9.30pm Industrial/Haematology #

Stream 2

Date Time Module
Wed 19 Mar 7-9pm Endocrinology #
Tue 15 Apr 7-9pm Cardiovascular #
Tue 29 Apr 7-9pm Digestive #
Tue 29 Apr 7-9pm Gynaecology #
Sat 3 May 8.30-10.30am Core
Sat 3 May 11-1pm Hand & Upper Extremities
Sat 3 May 2-5pm Lower Extremities
Wed 7 May 7-9pm Spine
Wed 7 May 7-9pm Visual System
Tue 13 May 7-10pm Ear, Nose and Throat #
Tue 27 May 7-9pm Respiratory
Tue 22 July 7-9pm Psychiatry
Tue 26 Aug 6.30-8.30pm Neurology
Tue 14 Oct 7-9pm Urology #
Tue 21 Oct 7-9.30pm Industrial/Haematology #

Registrations are essential and close 10 days prior to each individual workshop, or sooner if fully subscribed.

Participants are encouraged to register early to avoid disappointment.

A registration form is enclosed with this newsletter for your use. Registration enquiries should be directed to Dorothy Fulgueras on
(03) 9280 8764.

* Stream 1 participants must successfully complete a core module prior to any elective modules being undertaken.

# Combined Stream 1 & 2 modules with stream specific group work.

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