• IMPAIRMENT /DISABILTY and EXACERBATION/AGGRAVATION ARE DIFFERENT-ABIME BY A CIME.

    5 October at 20:42 from atlas

    The terms impairment and disability are often used interchangeably by medical and case management staff, but they are different.

    Impairment is a loss, loss of use , or derangement of any body part, organ system, or organ function (page 2 AMA 5).Impairment in AMA 5 and 6 no longer is defined as a condition which interferes with an individual's ability to perform ADLs; this concept reflects an impairment rating.Not all impairments interfere with ADL.However, an impairment that interferes with an individual's ability to perform a listed ADL (AMA 5 table 1-2) , generally is of sufficient severity to meet an impairment rating.Only impairments that interfere with ADL qualify for an impairment based on the AMA Guides.

    ADLs include(i):Self-care& personal hygiene(ii);Communication,(iii)Physical Activity of standing, sitting, walking, climbing stairs;(v) Sensory function;(vi)Nonspecialised hand activities,(vii)Travel, (viii)Sexual function & (ix)Sleep.

    Only impairments that interfere with ADL qualify for an impairment rating based on the AMA Guides.

    Impairment assessment includes both anatomic and functional loss, with some body systems emphasising one area.

    Impairments do NOT necessarily lead to disability or functional limitations;the relationships between these terms are not linear but bidirectional.

    Disabilty is an alteration of an individual's capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment.Impairment ratings should NOT be used as direct estimates of disability UNLESS the impairment results in no more interference with personal, social or occupational demands than is already considered in the anatomic or functional loss implicit in the impairment rating. 

    IMPAIRMENT ASSESSMENT IS A NECESSARY FIRST STEP FOR DETERMINING DISABILITY.

    In worker's compensation schemes , disability traditionally refers to the loss of income-earning capacity caused by an impairment.If an impairment is not rateable, it usually means that no disability exists, since a ratable impairment is usually a legal requirement for calculating disability.

    Despite limitations, WPI %es estimate the impact of the impairment on the individual's ability to perform ADL.%es are Combined from multiple regional body impairments using the Combined values Chart(not arithmetically!).all regional impairments are converted to a WPI rating. A 0% impairment rating indicates that an impairment MAy be present , but that impairment does NOT impact on he ability to perform ADL.A 90-100% WPI indicates a very severe organ or body system impairment requiring the individual to be fully dependent on others for self-care, approaching death(page 5 AMA 5).

    Assessors who assess disability need to understand the impairment , its impact on ADL, and the interaction with the environment (work or social) for which the referrer has requested as the setting for the disability determination.

    Under AMA 5 ,some disability claims will be nullified because of AMA 5's non-ratable impairments(those that are recognisable anatomical losses that do NOT interfere with ANY ADL.

    The concept of EXCLUDING work or complex social or recreational activities was developed during the initial creation of The Guides and its impairment ratings in 1958."Evaluation (rating) of permanent impairment is an appraisal of the nature and extent of the patient's illness or injury as it affects his personal efficiency in the activities of daily living.These activities are self-care,normal living postures, ambulation, elevation, travelling and non-specialised hand activities.It is not and never can be the duty of physicians to evaluate the social and economic effects of permanent impairment."

    It is very complex indeed.A disability award also accounts for the anatomic or functional loss measured by the impairment.Common phrases used in worker's compensation are" disability in excess of impairment" and "disability inclusive of impairment."

    Aggravation refers to a factor(s) that ALTERS the course or progression of the medical impairment. (AMA 5 page 599).Aggravation is a legal concept as well as a medical one.Aggravation may be a form of subsequent causation that also requires apportionment.Aggravation is associated with a permanent change in anatomical structure and the individual does NOT return to their pre-aggravation status.

    Exacerbation is a transient worsening of a prior condition by an injury or illness, with the expectation that the situation will eventually return to baseline or pre-worsening level.

    various insurers will have Guidelines in their Spinal protocols that determine whether surgical intervention will be covered by the insurer and this may involve current concepts (AMA 6) of aggravation and exacerbation with reference often to whether the proposed surgery is to treat structural changes cause by the event or injury , or whether the proposed surgery is operating on changes pre-existent to the incident that may have been exacerbated by the incident. different jurisdictions have differing Spinal Surgical Approval guidelines ,which may , or may not rely on what the surgeon is operating ion and what caused it-the injury OR pre-existing degeneration.

    The terms aggravation and exacerbation may not always be used interchangeably-certainly AMA 6 makes the differences crystal clear.In Texas, for example, an aggravation that leads to a permanent worsening of an underlying or pre-exisyting condition may be a compensable, work-related injury.An exacerbation , however, is interpreted as a temporary worsening of symptoms, such as pain, that does not change an individual's underlying medical condition.An exacerbation alone may not always be compensable , even if it caused by work.This is the situation in AMA 4 &5.When giving opinions around the issue of causation, it is important for physicians to be aware of such jurisdictional nuances.

    It is incumbent on the insurer  in a particular jurisdiction ( not the assessor or the AMA Guides)to document a set of Guidelines for assessors to use in respect of approving or disapproving the separate matter (rather than MMI or PI) requests for surgery in Workman injury cases-having regard to the current concepts of aggravation being a permanent change and exacerbation temporary OR using  the 'test 'of whether the changes being operated on were caused by the injury(essentially either a new injury OR an aggravation of pre-existing change causing a new structural permanent change or alteration of structure that will likely be permanent OR a different set of criteria , in writing.

    DR MICHAEL CORONEOS CIME MASE

    HONORARY ADJUNCT ASSISTANT PROFESSOR: BOND UNIVERSITY MEDICAL SCHOOL ADJUNCT ACADEMIC APPOINTMENT

    SENIOR NEUROSURGEON

    FAIM FRACS FRCSI FACS FRCS(EDIN)SN MB BS(1ST CLASS HONOURS) MASE CIME MNSA MNSQ MAPS MANZSOM

    NATIONAL RACS EXAMINER

    RACS MORTALITY ASSESSOR (QASM)

    TRIPLE EXAM PI CERTIFIED PI ASSESSOR

    MEMBER of ACADEMY of SURGICAL EDUCATORS.

    Always follow your treating doctor's advice.