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Guides to the Evaluation of Permanent Impairment; Moving from the Fifth to the Sixth Edition.

As you have probably noticed the AMA has made some major changes in the evaluation of permanent impairment. So far I have buried my head in the sand and continued to use the Fifth Edition although I don’t think this will be an effective coping strategy over the long term. The overarching change in the evaluation of permanent impairment is the shift to the ICF model, The International Classification of Functioning, Disability and Health. This is outlined in the first chapter of the Sixth Edition, “Conceptual Foundations and Philosophy”. This chapter is important reading for any person who is calculating permanent impairment ratings for patients. To quote from this chapter.

“In this edition there is a paradigm shift, which adopts a contemporary model of disablement: it is simplified, functionally based, and internally consistent to the fullest extent possible.”

“The vision…is articulated in terms of five specific new axioms.”

  1. The terminology and conceptual framework of the ICF are adopted.
  2. diagnosis and evidence based where possible
  3. simplicity and ease of application
  4. functionally based
  5. conceptual and methodological congruity between and within organ systems

The upper extremities are covered in Chapter 15 of the Sixth edition. For all surgeons measuring the permanent impairment rating it will be required to read the entire chapter from start to finish at least at the initiation of your use of the guides. Briefly the diagnosis is identified and a class of impairment is chosen based on the problems faced by the patient. Then grade modifiers are then applied and are based on the functional history, physical examination, and clinical studies. For some problems the range of motion can be used instead of this system.

On review, and for a concrete thinker, I find the new scheme to be complicated and more difficult to understand for hand problems. I have purchased a book from the AMA, “Transition to the AMA Guides Sixth” to get a handle on this new method. Working through the guide to the Guides, I was able to follow the examples and make some sense out of the ratings that followed.

Happily the impairment measurement method for digital nerve injuries and amputations has remained essentially the same as previous versions and we see the old familial diagrams in the new edition. Thank you. Thank you. A Rosetta Stone for Hand Surgeons. These have made me see things in an entirely new light. Adding the possibility of rating many conditions using ROM to the unchanged measures of digital nerve injuries and amputations gives me enough familiarity so that I have strange optimism that the Sixth edition will catch on and will be adopted by Hand Surgeons.

I suggest we take a deep breath, read over the Transition book, and the entire upper extremity chapter from the new Guides. Don’t make a snap judgment but come back to it a couple of times and try to go with the flow. Be calm and don’t try to use the new Guides cold turkey in the heat of the battle. Ease into it and I am sure it will eventually fit like a pair of old gloves. You might even enjoy this recent advance in measurement.