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Assessment Guide " Seriously Flawed" Lump sum / IA assessments

#1 User is offline   ernie 

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Posted 22 October 2004 - 10:50 AM

Regulation 4 of the Injury Prevention, Rehabilitation and Compensation (Lump Sum and Independence Allowance) Regulations 2002 requires assessors to use the American Medical Association Guides to the Evaluation of Permanent Impairment (Fourth Edition) as the assessment tool in determining the degree of permanent impairment suffered by claimants.

Here's what research as long ago as 1999 revealed about the AMA Guides (Fourth Edition):

Dynamic Chiropractic
May 17, 1999, Volume 17, Issue 11

AMA Impairment Rating Guides Seriously Flawed

Spinal Range of Motion Guides Show Little Evidence of Reliability
Members of the American Medical Association were no doubt chagrined by a recent piece of research in Spine.1 A team of researchers reviewed the measurement recommendations of the AMA's Guides to the Evaluation of Permanent Impairment (AMA Guides) and found them lacking reliability.

The embarrassment is of international scope, as these spinal range-of-motion guides for impairment ratings are used not only in the United States, but in Australia, New Zealand and other countries.

According to the researchers, there are two editions of the AMA Guides that have reliability problems:

"The AMA Guides (2nd edition) recommend measurement of thoracolumbar spine range of motion with a long-arm goniometer (LAG), but fail to cite appropriate evidence of its reliability for use in the spine. In fact, no research was found that investigated the reliability of the LAG for measuring spinal range of motion as recommended in the AMA Guides (2nd edition).

"The current edition of the AMA Guides (4th edition, 1993) recommends the use of a dual inclinometer (DI) to measure lumbar spine range of motion, but several problems are associated with this method of measurement. Although the reliability of the DI has been extensively investigated in both normal subjects and patients with low back pain, broadly variable results have been obtained. Specifically, conflicting findings are evident regarding reliability for the DI in patients with low back pain. High interrater reliability has been reported for total flexion-extension range of motion, and high interrater reliability for flexion but not extension. Moderate to poor intra-rater reliability has been reported for both flexion and extension, with the intra-rater test-retest reliability reportedly better for lumbar flexion than for extension."

The researchers conducted their own measurement tests to see just how substantial the problem was. They used the LAG and DI equipment on 34 subjects with chronic low back or leg pain of at least six-months duration. They tested for interrater and intra-rater reliability.

The testing judged the measurement devices recommended in the AMA Guides as severely lacking:

"This study demonstrated that the methods recommended in both the second and fourth editions of the AMA Guides to measure low back range of motion have poor interrater and intra-rater reliability. Decisions about the amount of compensation entitlement for patients with chronic low back pain based on these measurements are clearly misinformed decisions. It is essential for all parties concerned (employer, employee, insurer) that adjudication of compensation awards be determined in a reproducible way that truly represents the subjects' impairment. The results of the current study show that these two methods of assessment do not achieve this. The implications of these flawed decisions for employers, employees, and insurers are far-reaching and indicate the extent of problems that can occur when unreliable measurements are used in the health sector.

"In summary, the findings indicate that a subject measured by two different examiners on the same day may be assessed as having (excluding the contribution from rotation) between 0% and 18% whole-body impairment. This must be considered a conservative estimate of variability because rotation contributes up to 12% of whole-body impairment and thus could further increase this estimate of the range of percentage impairment ratings. Similar findings can be demonstrated for second edition intra-rater reliability as well as fourth edition intra-rater and interrater reliability.

"In conclusion, the system of compensation for patients with chronic low back pain based on the AMA Guides to the Evaluation of Permanent Impairments (2nd edition) is not reliable. Results for the revised fourth edition of the AMA Guides reveal similar, perhaps slightly worse, reliability findings. The implications of these findings are important for the employers, employees, and insurers who use the AMA Guides' system of assessment because they indicate that these measures are not reproducible either between raters or by the same rater. The implications of the findings of the current study for the wider health care arena is that with the increased emphasis on measurable outcomes, it is vital that unreliable measures are not accepted as "good enough" or "near enough" because the information these measures provide may be inaccurate, and thus potentially harmful to all concerned."

Reference

1. Nitschke JE, Nattrass CL, Disler PB, Chou MC, Ooi KT. Reliability of the American Medical Association Guides' model for measuring spinal range of motion. Spine 1999;24:262-268


So why are ACC still using the AMA Fourth Edition Guides? Another good question for the Minister.
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#2 User is offline   ernie 

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Posted 22 October 2004 - 12:41 PM

And the response from John J. Gerhardt, M.D., Contributing Author to the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition, 1993 -

Dear Editor:

This letter is in response to the article Reliability of the American Medical Association Guides’ model for measuring spinal range of motion appearing in Spine; 1999, 24-262-268 by Nitschke, J.E., et al.

Nitschke, et al, used patients’ reports of pain as a criterion to assess the validity of spinal range of motion. Although this may sound reasonable, it is extremely problematic. Observers have noted for years that pain complaints of patients often do not correlate well with objective measures of organ function and structure (Osterweis, et al, 1987; Robinson, in press).

At one extreme research has demonstrated that abnormalities on diagnostic tests of the lumbar spine including myelograms, CT scans and MRI scans are often found among individuals with no complaints of back pain (Jensen, et al, 1994). At the opposite extreme patients with fibromyalgia often report incapacitating pain in the absence of any objective markers of organ dysfunction.

Pain is not a diagnosis; it is a symptom. Pain cannot be measured or rated by either the range of motion model nor the diagnosis or injury based models and in this lies the fallacy of trying to discriminate between measurements and the AMA Guides to the Evaluation of Permanent Impairment. The AMA guides do not even pretend to use range of motion per se for rating of pain or evaluation of impairment.

Even in the First and Second Editions of the Guides, which still advocate the use of two-arm goniometers for measuring spinal motion, describe in detail steps to be taken in impairment rating, namely:

1. To make thorough medical evaluation.
2. To review history of medical conditions.
3. To make a thorough physical examination supported by tests and diagnostic procedures including laboratory tests.
4. To analyze the findings critically which are supported by complete and valid data.
5. To compare the results of the analysis with the criteria of the Guides for particular body parts, systems, which include anatomical and physiological factors underlying the function of joints and the ability to compare.
6. To then use the tables to modify the findings and relate them to impairment of the whole person.

The Third Edition of the Guides mandates use of inclinometers in measurement of the spine, as they are much more accurate than two-arm goniometers, which were proven to be inaccurate by many investigators (Waddle, et al). The range of motion model is not simply a rating model for impairment. It includes special tables for assessing impairment caused by specific disorders of the spine, such as impairment due to neurological deficiencies like radicular and peripheral neurological disorders. All of these numerical values are added as indicated for each particular patient and combined using the combined values chart.

For assessment of radiculopathy the guides recommended new technologies for relevant, valid and reproducible measurements of other elements of human performance such as isolated trunk strengths, lifting, and task performance capabilities, but no specific details are offered.

The Fourth Edition of the Guides is problematic because the scientific panel debated the appropriateness of range of motion measurements in the assessment of impairment in association with disorders of the spine. As a result two different systems are described and recommended: 1) The “Range of Motion Model” includes spinal range of motion as one of the factors in determining impairment. 2) The “Injury Model” which completely eliminates range of motion in impairment ratings. The duality of the AMA’s present approach to spine impairment rating reflects lack of consensus among experts about the reliability with which spinal motion can be measured.

The Fourth Edition of the Guides also includes a chapter on impairment rating for patients with chronic pain. However, this issue lacks correspondence between a patient’s report of pain and objective measures of organ function. There is no valid biological test to substantiate assessment or rating of pain.

The range of motion and strength testing, however, can give excellent assessment of functional capacity if these tests are done objectively. Function is crucial for objective and fair rating.

Unfortunately, there is a tendency to rely more on subjective, patient-generated questionnaires than striving to achieve truly objective tests that include range of motion, muscle strength testing and surface EMG. Objective range of motion can determine the onset of pain at certain positions and comparisons can be made in subsequent tests whether the pain-free range increases or decreases.

The Australian Study has flaws because it uses two-arm goniometers to assess range of motion of the spine, a method that was proven to be no better than visual assessment with an error of 20-40 degrees, and therefore abandoned in all editions of the AMA Guides after the Second Edition.

The use of goniometers, which do not indicate gravity (a constant which never changes) and which cannot be properly stabilized on the body, have inherent errors in application, and cannot render reproducible readings in either intra-tester or inter-tester studies. An electronic inclinometer might be much more accurate than the two-arm goniometer in bench measurements, but not necessarily so when used on the living body.

The proper training of investigators in the use of instruments is also questionable as most training sessions are directed towards optimization in techniques of calculating ratings rather than placing emphasis on generating objective data. This aspect of continued medical education courses and seminars dealing with evaluation of impairment is practically nonexistent. There is a wide spread assumption that investigators, physicians and therapists alike know how to measure correctly. Nothing is farther away from the truth. In addition, the techniques of measurement using two-arm goniometers and inclinometers are different, and there is no close correlation or standardization of the measuring techniques necessary for achieving reproducible, comparable and therefore objective measurements.

To establish reliable, comparable and objective measurements in humans and animals for recording body characteristics, acceptance of a standardized measuring system is necessary.

Objectivity depends on accuracy, precision and comparability.

Properly designed instrumentation and hands-on training of investigators and practitioners in its proper application and use can accomplish accuracy and precision.

Comparability, on the other hand, depends on standardization of:

1. Terminology.
2. Measuring method.
3. Numerical documentation of measured values in meaningful numbers.
4. Properly designed instrumentation.
5. Measuring techniques including starting positions related to gravity and anatomical landmarks.

I have developed, during 45 years of observation, research and application of various measuring devices, a system which satisfies the criteria of objectivity in measuring range of motion.
1. Terminology: based on the international Nomina Anatomica.
2. Measuring method: Modified Neutral Zero Measuring Method of Cave and Roberts, which has been already accepted as standard worldwide.
3. Documentation: Numerical SFTR recording system, based on documentation in two basic planes and rotation of Johannes Schlaaff and adapted to the Neutral Zero Measuring method by J. Gerhardt. It allows accurate, fast and simple documentation in meaningful numbers, eliminating confusion related to terminology and language. It is already mandatory in some countries in Europe and gaining momentum in the United States and other countries.
4. Instrumentation: The UNI-LEVEL inclinometer, which is a further development of the UCLA (University of California Los Angeles) Devil Level (level indicator), Dr. Jules Rippstein’s gravity-indicating PLURIMETER, and other designs with various unique new attachments.
5. Standardized measuring techniques: Protocols for use in medicine are available and satisfy the criteria of objectivity. Special attention is given to stabilization of the measured body or the proximal component of the joint, and stabilization of the instrument on the body or distal component of the joint. Standardized anatomical landmarks and the gravity related starting positions are also crucial for comparable measurements.
6. Additional information regarding conditions affecting ranges of motion such as date, time of the day, age, gender, injuries, physical workout, and medication taken prior to the evaluation and measurements must be documented to allow proper interpretation of the measurements.
7. Gabriel Sella, M.D. has proven in his many studies that surface EMG is an excellent tool to assure objectivity in range of motion as well as muscle strength testing, and this test should be used in addition to the measurements of range of motion and strength if there is any question of effort and validity.

At present there is chaos in measurements because of the paucity of generally accepted guidelines, no universal rules and no global agreements in the standardization of measurements. The use of multiple systems with no cross- correlation precludes comparability, which is necessary in research, is vital for establishment of normative data and for every-day practice application of measurements for a variety of reasons -- such as baseline data, monitoring progress of disease, response to treatment, outcome assessment, evaluation of impairment and disability, and in forensic or legal medicine.

Only by revision of present practices, including standardization of method and training, can we achieve objectivity in measurements and get closer to objective and fair rating of impairment and disability. Hopefully, these revisions will be reflected in the forthcoming Fifth Edition of the AMA Guides.

In summary, the Australian article should be reviewed as to the validity of its conclusions because of its use of inappropriate tools and techniques, and its use of two measuring methods which lack accuracy, precision and comparability. This article’s conclusions should be summarily rejected as the authors unjustly criticize the AMA Guides and the range of motion model, showing their complete lack of understanding of this model and coming up with nothing better to replace it.

Sincerely,

John J. Gerhardt, M.D.
Contributing Author to the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition, 1993.
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#3 User is offline   ernie 

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Posted 22 October 2004 - 12:54 PM

Quote

The Fourth Edition of the Guides also includes a chapter on impairment rating for patients with chronic pain.
- John J. Gerhardt, M.D. - Contributing Author to the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition

So why does an independence allowance assessor who assessed a claimant I'm working with recently report: "XXXX has a problem of pain and muscle fatigue on performance of tasks. This disability interferes with her life. The consensus of medical opinion is that this is a pain syndrome. The guides have no rating per se for a pain syndrome... This assessment is based on the fourth edition of the American Medical Association guides to the evaluation of permanent impairment..." and report zero whole person impairment?

I smell a rather large rodent.
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#4 User is offline   Kiwee 

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Posted 22 October 2004 - 02:45 PM

Exactly what happened to me in 98. I applied for disability allowance and was examanied and found to have only a chronic pain problem, 0% impairment. However recently i have discovered i have a problem where the original injury cannot heal, so will hopefully be able to get this taken into consideration when I re-apply for disability allowance under ama 4.
kiwee
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#5 User is offline   Tomcat 

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Posted 04 October 2007 - 08:18 PM

BUMP... ;)

WAY PAST TIME ACC STOPPED USING THE 4th Ed. AND MOVED ON TO THE 5th Ed...
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#6 User is offline   doppelganger 

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Posted 04 October 2007 - 09:23 PM

Pain has a chaper all of its own. So there is a lying assessor
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#7 User is offline   Tomcat 

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Posted 05 October 2007 - 09:25 AM

GREETINGS,
PAIN... =CHRONIC PAIN...


THIS IS COVERED .... NO B... S... ;)
It comes under, "MENTAL CAUSED BY PHYSICAL"...
I, as others have, been given cover for this...
= "CHRONIC PAIN, with DEPRESSION as a COMPONANT"...
I have had the Psych assessment, and the I.A. assessment,
and now it is at "Peer Review"...
= PERCIVAL at Takapuna.... NA !!!! <_<
Now it is being recalled and send to another in the South Island... ;)

SO, as I have already stated elsewhere... If you feel that you fit the Critiria,
DO IT... Apply for assessment for "MENTAL CAUSED BY PHYSICAL". Under I.A....
I can advise as to how I went about this... "Privately".
Wont reveal that here...
= Pm or email or phone... 09-4018821

Stress / Anxiety / Depression, due to INJURY, and how it effects life in general,
In many cases most deal with it... BUT, ACC makes that somewhat impossible...
FACT...

AND... If I am not "Happy with the result of peer review" it will be reviewed.
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#8 User is offline   Tomcat 

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Posted 13 June 2008 - 10:23 PM

I have to BUMP this again... Its way past time ACC up graded to a later edition of the AMA guide.

"The implications of the findings of the current study for the wider health care arena is that with the increased emphasis on measurable outcomes, it is vital that unreliable measures are not accepted as "good enough" or "near enough" because the information these measures provide may be inaccurate, and thus potentially harmful to all concerned."



View Posternie, on Oct 22 2004, 10:50 AM, said:

Regulation 4 of the Injury Prevention, Rehabilitation and Compensation (Lump Sum and Independence Allowance) Regulations 2002 requires assessors to use the American Medical Association Guides to the Evaluation of Permanent Impairment (Fourth Edition) as the assessment tool in determining the degree of permanent impairment suffered by claimants.

Here's what research as long ago as 1999 revealed about the AMA Guides (Fourth Edition):

Dynamic Chiropractic
May 17, 1999, Volume 17, Issue 11

<span style='font-size:14pt;line-height:100%'>AMA Impairment Rating Guides Seriously Flawed</span>

Spinal Range of Motion Guides Show Little Evidence of Reliability
Members of the American Medical Association were no doubt chagrined by a recent piece of research in Spine.1 A team of researchers reviewed the measurement recommendations of the AMA's Guides to the Evaluation of Permanent Impairment (AMA Guides) and found them lacking reliability.

The embarrassment is of international scope, as these spinal range-of-motion guides for impairment ratings are used not only in the United States, but in Australia, New Zealand and other countries.

According to the researchers, there are two editions of the AMA Guides that have reliability problems:

"The AMA Guides (2nd edition) recommend measurement of thoracolumbar spine range of motion with a long-arm goniometer (LAG), but fail to cite appropriate evidence of its reliability for use in the spine. In fact, no research was found that investigated the reliability of the LAG for measuring spinal range of motion as recommended in the AMA Guides (2nd edition).

"The current edition of the AMA Guides (4th edition, 1993) recommends the use of a dual inclinometer (DI) to measure lumbar spine range of motion, but several problems are associated with this method of measurement. Although the reliability of the DI has been extensively investigated in both normal subjects and patients with low back pain, broadly variable results have been obtained. Specifically, conflicting findings are evident regarding reliability for the DI in patients with low back pain. High interrater reliability has been reported for total flexion-extension range of motion, and high interrater reliability for flexion but not extension. Moderate to poor intra-rater reliability has been reported for both flexion and extension, with the intra-rater test-retest reliability reportedly better for lumbar flexion than for extension."

The researchers conducted their own measurement tests to see just how substantial the problem was. They used the LAG and DI equipment on 34 subjects with chronic low back or leg pain of at least six-months duration. They tested for interrater and intra-rater reliability.

The testing judged the measurement devices recommended in the AMA Guides as severely lacking:

"This study demonstrated that the methods recommended in both the second and fourth editions of the AMA Guides to measure low back range of motion have poor interrater and intra-rater reliability. Decisions about the amount of compensation entitlement for patients with chronic low back pain based on these measurements are clearly misinformed decisions. It is essential for all parties concerned (employer, employee, insurer) that adjudication of compensation awards be determined in a reproducible way that truly represents the subjects' impairment. The results of the current study show that these two methods of assessment do not achieve this. The implications of these flawed decisions for employers, employees, and insurers are far-reaching and indicate the extent of problems that can occur when unreliable measurements are used in the health sector.

"In summary, the findings indicate that a subject measured by two different examiners on the same day may be assessed as having (excluding the contribution from rotation) between 0% and 18% whole-body impairment. This must be considered a conservative estimate of variability because rotation contributes up to 12% of whole-body impairment and thus could further increase this estimate of the range of percentage impairment ratings. Similar findings can be demonstrated for second edition intra-rater reliability as well as fourth edition intra-rater and interrater reliability.

"In conclusion, the system of compensation for patients with chronic low back pain based on the AMA Guides to the Evaluation of Permanent Impairments (2nd edition) is not reliable. Results for the revised fourth edition of the AMA Guides reveal similar, perhaps slightly worse, reliability findings. The implications of these findings are important for the employers, employees, and insurers who use the AMA Guides' system of assessment because they indicate that these measures are not reproducible either between raters or by the same rater. The implications of the findings of the current study for the wider health care arena is that with the increased emphasis on measurable outcomes, it is vital that unreliable measures are not accepted as "good enough" or "near enough" because the information these measures provide may be inaccurate, and thus potentially harmful to all concerned."

Reference

1. Nitschke JE, Nattrass CL, Disler PB, Chou MC, Ooi KT. Reliability of the American Medical Association Guides' model for measuring spinal range of motion. Spine 1999;24:262-268


So why are ACC still using the AMA Fourth Edition Guides? Another good question for the Minister.

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#9 User is offline   MINI 

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Posted 14 June 2008 - 11:02 AM

TC

Dont forget they have their own handbook for the past few years, and as they say, if in doubt the Act rules.

It doesnt matter what literture they use. While the people at IA Dunedin and Hamilton are flawed, they will still try and keep the minimum of %, so they dont have to pay the maximum of dollars.

everybody go for your backdating of IA. Get as much off them as you can. Their object is to give us as little as possible so lets reverse the trend.

Cheers
Mini
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