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IN THIS EDITION:  
AMA 4 Guides Impairment Assessment Training E-Newsletter
Issue date: Thursday 23 July 2009
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Chairman's Message

Scar Impairment Assessment

Hearing Loss Assessors & Review of Guidelines

MODULES IN DETAIL

2009 Program

  CHAIRMAN'S MESSAGE  

As you can see from the following newsletter, a number of "meaty" topics relating to AMA 4 have been considered by the Management Committee and reference groups. There is still a great deal of work to be done to elucidate these and other problems. Our impression is that there is less division of opinion in Victoria in the interpretation of AMA 4 than there is in other jurisdictions. We are keen to have your feedback to iatvic@amavic.com.au.

Tony Buzzard
Chairman
Impairment Assessment Training Management Committee

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  AMA 4 NEWS  


Scar Impairment Assessment

Following the last round of training for the Dermatology and Scaring module a number of discussion points and questions arose which may be helpful information to pass on here.

“It should be understood that the Guides does not and cannot provide answers about every type and degree of impairment.” - AMA Guides 4th Edition 1/3

To assist in using Table 2 in Chapter 13, in assessing scars there are important guidelines to apply which will enhance both intra and inter-rater reliability of assessments.

1. What is being assessed?

Table 2 applies as a global measure to assess impairment arising from disorders of the skin as one organ system. It should not be applied for each individual scar or disorder arising out of the accepted injury, injury claimed or transport accident.

On page 279 the Guides indicate that behavioural changes as a result of disfigurement of the skin are evaluated in accordance with Chapter 14 – Mental and Behavioural Disorders. In Victoria this chapter has been substituted with “Guidelines to the Evaluation of Psychiatric Impairment for Clinicians” and subject to assessment of non-secondary psychiatric impairment only, in accordance with the relevant legislation.

2. Establishing the impairment class

The impact of the skin disorder on daily activities should be the primary consideration in determining the class of impairment. Activities of daily living are listed on page 317 of the Guides. The gradations applied by Table 2 are; no limitations, limitation in the performance of few activities, limitation in the performance of some activities, limitation in the performance of many activities and limitation in the performance of most activities. The Guides however do not specifically define “few, some, many and most which may lead to inconsistency in the application of the appropriate class.

The examples in the Guides indicate that it is the physiologic impact on activities of daily living as a result of skin disorders are assessed as opposed to limitation of activities of daily living as a result of a behavioural reaction to cosmetic changes to the skin. On page 280 the Guides indicates that “If a scar involves the loss of sweat gland function, hair growth, nail growth or pigment formation, the effect of such a loss on the performance of daily living activities should be evaluated.”

3. Impairment percentage within a class

The frequency and intensity of the signs and symptoms and the frequency and complexity of medical treatment guide the selection of an appropriate impairment within any of the five classes.

The Guides on page 279 state the scars should be described by giving their dimensions in centimeters and by describing their shape, color and anatomic location, and any evidence of ulceration, depression or elevation, which relates to whether they are “atrophic” or “hypertrophic”; texture, which relates to whether they are soft and pliable or hard and indurated, thin or thick, smooth or rough; and attachment to any underlying bone, joints, muscles or other tissue. Color photographs with multiple views of the defect enhance the description of scars. The glossary on page 316 provides definitions for ‘intermittent’, ‘occasional’, ‘frequent’, and ‘constant’ in respect of signs and symptoms.

The frequency and complexity in terms of medical treatment and medical treatment itself lacks specific definition in the Guides. However, some examples of medical treatment in referred to in chapter 13 are:

  • Application of sun screen required to protect hypo pigmentation areas
  • Regular use of moisturizer
  • Intermittent or regular use of prescribed topical medicationIntermittent or constant use of topical steroids
  • Bandaging with use of petroleum jelly
  • Antibiotics
  • Intermittent hospitalisation
  • Skin grafts

An injured person with no limitation on ADL can still be in Class 1 and have some impairment depending on the intensity of Signs and Symptoms and frequency and complexity of medical treatment.

4. Overall approach

Impairment estimates for the skin generally should be expressed in whole numbers ending in 0 or 5; except for Class 1, for which smaller increments may be justified.

In addition to a description of the physical characteristics of the scar, a history detailing the physiologic impact of any scarring on the individual is necessary. In this respect, the age, gender, cultural factors are important.

As is stated in Chapter 1 of the Guides, assessment depends on the physician’s judgment to decide on the percentage of impairment: "The physician’s judgment and his or her experience, training, skill and thoroughness in examining the patient and applying the findings to Guides criteria will be factors in estimating the degree of the patient’s impairment."

Although there is a lack of a clear definition of some of the terms utilised in the Guides, the application of the Guidelines as noted above will assist in improving consistency in the scar impairment assessment.

 

Ministerially approved Hearing Loss Assessors & Review of Guidelines for the assessment of Noise Induced Hearing Loss

Within the WorkSafe jurisdiction, the Minister for Finance, WorkCover and the TAC (the Minister) approves those persons able to assess the percentage of diminution of hearing and total loss of hearing for the purpose of determining whole person impairment in accordance with the Accident Compensation Act 1986 (ACA). The ACA allows that an approval by the Minister continues in force for a period not exceeding three years, unless revoked by the Minister.

Therefore, in order for an Ear Nose and Throat (ENT) specialist to accept a hearing loss claim referral from an agent of WorkSafe or a Self Insurer, they must have:

  • successfully completed the Ministerially approved Impairment Assessment Training Course ENT elective; and
  • be a Ministerially approved Hearing Loss Assessor.

Both the ACA and the Transport Accident Act 1986 require that the percentage of diminution of hearing shall be determined in accordance with the Improved Procedure for Determination of Percentage Loss of Hearing published by the National Acoustic Laboratory. The approved manner, applicable to the ACA, requires the application of the Guidelines for the assessment of noise induced hearing loss (guidelines) authored by the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) (www.asohns.org.au) Victorian Audiological Subcommittee in 2000.

In 2008, the Subcommittee and the Impairment Assessment Training ENT Reference Group recommended a review of the manner and guidelines to ensure compliance with contemporaneous clinical and impairment assessment practice.

The review is currently underway and a comprehensive stakeholder consultation process will commence in due course. Recommendations will then be made to the Minister and if endorsed, training in the revised ASOHNS guidelines and manner will be presented to Hearing Loss Assessors as part of the Impairment Assessment Training Course.


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  MODULES IN DETAIL  

2009 Program

Core (Stream 2)

Tues 6/10/09

7:00 PM

9:00 PM

Ear, Nose & Throat (Stream 1 & 2)

Tues 8/09/09

6:30 PM

9:30 PM

Hand & Upper Extremities (Stream 1)

Tues 4/08/09

6:00 PM

10:00 PM

Hand & Upper Extremities (Stream 2)

Tues 8/09/09

7:00 PM

9:00 PM

Nervous System (Stream 1)

Tues 18/08/09

6:00 PM

10:00 PM

Psychiatry (Stream 1)

Tues 1/09/09

7:00 PM

10:00 PM

Spine (Stream 2)

Tues 4/08/09

7:00 PM

9:00 PM

Urology (Stream 1 & 2) Tues 13/10/09 7:00 PM

9:00 PM

Visual System (Stream 1 & 2)

Thurs 27/08/09

7:00 PM

9:00 PM

Click here to register

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