Guides to the Evaluation of Permanent Impairment

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 49

Page 587, Example 17-8: Intervertebral Disk Class 3 Example Calculation
Herniation or AOMSI at One or More Levels,
Physical Exam and Impairment Rating CDX GMFH GMPE GMCS

3 1 2 n/a

Physical Exam: Normal examination, including Net adjustment
neurological evaluation. He describes an occasional
sensation of numbness in a T1 distribution; however, no (GMFH Ϫ CDX) (1 Ϫ 3) ϭ Ϫ2
sensory deficits are documented.
ϩ (GMPE Ϫ CDX) ϩ (2 Ϫ 3) ϭ Ϫ1

Net adjustment ϭ Ϫ3

Impairment Rating: Regional Impairment: Diagnosis Result is class 3 with an adjustment of Ϫ3. An adjustment
is consistent with “Intervertebral disk herniation and/ ՅϪ2 moves the impairment to grade A; therefore, this
or documented AOMSI at a single or multiple levels impairment is class 3, grade A, which equals 12% WPI.
with medically documented findings; with or without
surgery, and with documented resolved Note: CDX indicates class of diagnosis; GMFH, grade modifier
for Functional History; GMPE, grade modifier for Physical
Examination; GMCS, grade modifier for Clinical Studies; WPI,
whole person impairment; and n/a, not applicable.

Class 1 Example Calculation Page 588, Example 17-10: Lumbar Sprain/
Strain, Impairment Rating and Comment
CDX GMFH GMPE GMCS
Impairment Rating: Regional Impairment: Diagnosis
1102 is consistent with “Documented history of sprain/strain
type injury, now resolved or occasional
Net adjustment

(GMFH Ϫ CDX) (1 Ϫ 1) ϭ 0

ϩ (GMPE Ϫ CDX) ϩ(0 Ϫ 1) ϭ Ϫ1

ϩ (GMCS Ϫ CDX) ϩ (2Ϫ 1) ϭ 1 Comment: Patient has a history of a single episode
of low back pain without objective findings on exam.
Net adjustment ϭ 0 Spina bifida occulta is a radiographic finding without
clinical significance. Without persistent axial pain
Result is class 1 with an adjustment 0 The adjustment documented on multiple occasions, IC is 0.
does not move the impairment; therefore, this impair-
ment is class 1, grade C which equals 4% impairment.

Note: CDX indicates class of diagnosis; GMFH, grade modifier Page 589, Example 17-12: Recurrent Low Back
for Functional History; GMPE, grade modifier for Physical Pain Without Objective Findings, Impairment
Examination; and GMCS, grade modifier for Clinical Studies. Rating

Page 588, Example 17-9: Vertebral Fractures and similar findings documented on multiple occasions
at Multiple Levels, Impairment Rating and present at the time of evaluation, and therefore
assigned to class 1. Functional History:
Lines 1-6:
Impairment Rating: Regional Impairment: Diagno- Page 590, Example 17-13: Intervertebral
sis consistent with “Single or multiple level fractures Disk Herniation or AOMSI at a Single Level
with >50% compression of one vertebral body; with (continued), Impairment Rating
or without moderate to severe bony retropulsion; with
or without pedicle and/or posterior element fracture Impairment Rating: Regional Impairment: Diagnosis
(>5mm displacement); is consistent with “Intervertebral disk herniation and/or
AOMSI at a single level with
Last two lines:
class is Ϫ3, resulting in class 3, grade A. Impairment is
12% WPI.

50 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 590, Example 17-14: Intervertebral Disk Page 592, Example 17-16: Lumbar Spinal
Herniation or AOMSI at a Single Level, Stenosis at Multiple Levels (continued),
Impairment Rating Impairment Rating

Impairment Rating: Regional Impairment: Diagnosis Impairment Rating: Regional Impairment: Diagnosis
is consistent with “Intervertebral disk herniation and/or is consistent with “Lumbar stenosis at multiple levels
AOMSI at a single level with with or without AOMSI with medically documented
findings; with or without surgery and may have docu-
Physical Examination: Grade modifier is 2 based on mented signs of bilateral or multiple-level radiculopathy
both positive SLR test and sensory loss. Clinical testing: at clinically appropriate levels at the time of exam or
Not applicable (AOMSI). The net adjustment is +1 and severe neurogenic claudication and inability to ambulate
the impairment is class 2, grade D. Impairment is 13% without assistive devices, and therefore, assigned to class
WPI. 4 with default impairment of 29% WPI. Adjustment
Grids: Functional Assessment: Grade modifier 4,
Class 2 Example Calculation based on limited activity. Since functional assessment
is 2 or more than physical exam grade modifier, it is
CDX GMFH GMPE GMCS not included. Physical Examination: Grade modifier 2
based on decreased motor strength (3/5). Clinical stud-
2 3 2 n/a ies are not included because they were used to make the
diagnosis. Because this is a class 4 impairment, the net
Net adjustment adjustment calculation requires that +1 be added to each
adjustment calculation. Therefore, the net adjustment is
(GMFH Ϫ CDX) (3 Ϫ 2) ϭ 1 Ϫ1, and the impairment is class 4, grade B. Impairment
rating is 27%.
ϩ (GMPE Ϫ CDX) (2 Ϫ 2) ϭ 0

Net adjustment ϭ ϩ1

Result is class 2 with a net adjustment of ϩ1; therefore,
this impairment is class 2, grade D, which equals 13%

impairment.

Note: CDX indicates class of diagnosis; GMFH, grade modifier Class 4 Example Calculation
for Functional History; GMPE, grade modifier for Physical
Examination; and GMCS, grade modifier for Clinical Studies. CDX GMFH GMPE GMCS

4 4(ϩ1)ϭ5 2(ϩ1)ϭ3 n/a

Page 591, Example 17-15: Intervertebral Net adjustment
Disk Herniation or AOMSI at Multiple Levels,
Impairment Rating (GMFH Ϫ CDX) (5 Ϫ 4) ϭ n/a

Impairment Rating: Regional Impairment: Diagnosis ϩ (GMPE Ϫ CDX) ϩ (3 Ϫ 4) ϭ Ϫ1
is consistent with “Intervertebral disk herniations and/
or AOMSI at multiple levels with medically docu- Net adjustment ϭ Ϫ1
mented findings; with or without surgery; AND with
or without documented residual radiculopathy at a Result is class 4 with an adjustment of Ϫ1. Therefore,
single clinically appropriate level present at the time of the result is class 4, grade B ϭ 27% impairment.
examination,” and therefore, assigned to class 3.

Page 591, Example 17-16: Lumbar Spinal
Stenosis at Multiple Levels, Physical Exam

Physical Exam: Persistent severe back pain and pal-
pable spasm with persistent L5 sensory deficit and 3/5
ankle dorsiflexion weakness, absent patellar tendon
flex. SLR test was negative, and walking in the hall-
way outside the office provoked bilateral buttock and
leg pain, which was relieved with rest.

Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications 51

Page 593, Table 17-11, Diagnosis-Based Impairment Grid: Pelvis, Row 4, Columns 1, 4, 5, and 6

Fractures of 0 12233 45566 7 8 9 10 11 12 13 14 15 16
the pubic
rami; fractures Nondisplaced, Nondisplaced or Displaced fractures Fractures dis- SI joint dislocations,
of the ilium, healed fractures minimally dis- (Ͼ1 cm and Ͻ2 placed Ն2cm or fracture-
ischium, and/ without residual placed fractures, cm) of the ilium, of the ilium, dislocations with
or sacrum structural defor- with or without ischium, sacrum, or ischium, sacrum, rupture of the
mity; no residual surgery coccyx or coccyx SI ligaments;
*Instability is symptoms transverse sacral
defined as a healed and healed, with or healed, with or fractures with
position shift or stable, including without surgery without surgery spinopelvic
that occurs minor separa- dissociation
when compar- healed fracture tion of the pubic or and
ing supine and with or without symphysis (Ͼ1 or
weight-bear- surgery with no cm and Ͻ3 cm; traumatic separa- with deformity
ing X rays. residual symp- unrelated to tion of the pubic and instabil- severe
toms related to childbirth); with symphysis (Ն3 cm) ity; traumatic complications after
fracture residual signs with residual signs separation of the surgery, including
and symptoms but no instability* pubic symphysis pseudarthrosis,
Ն3 cm with or osteomyelitis,
without surgery or documented
with residual instability*
deformity and
instability*

Page 595, Left Column, Paragraph 2 Page 596, Example 17-17: Ischiopubic Stress
Fracture, Clinical Tests
Instability for the purposes of pelvis-related impair-
ment is defined as a position shift that occurs when Clinical Tests: Pelvic X rays show a slightly displaced
comparing supine and weight-bearing X rays. In cases fracture of inferior pubic ramus; there is already callus
when the abnormalities discussed earlier are present on development in the area.
imaging studies and are known (or assumed) to have
preexisted an injury being rated, evaluators should Class 1 Example Calculation
acknowledge these antecedent conditions in the report
(see Table 17-14). CDX GMFH GMPE GMCS

Page 595, Example 17-17: Ischiopubic Stress 1 2 1 n/a
Fracture, History
Net adjustment
History: The patient participated in military intensive
training involving running with a backpack weighing (GMFH Ϫ CDX) (2 Ϫ 1) ϭ 1
27 kg (60 lb) over an extended time and distance. He
fell jumping from a boulder and had difficulty stand- ϩ (GMPE Ϫ CDX) (1 Ϫ 1) ϭ 0
ing up due to pain in the pelvis and right upper thigh,
which increased with walking and running. Pain was Net adjustment ϭ 1
initially felt while jumping over a boulder two weeks
before the time of the medical exam. Result is class 1 with an adjustment 1; therefore,
this impairment is class 1, grade D, which equals 3%
impairment

Note: CDX indicates class of diagnosis; GMFH, grade modifier
for Functional History; GMPE, grade modifier for Physical
Examination; GMCS, grade modifier for Clinical Studies; and
n/a, not applicable.

52 Guides to the Evaluation of Permanent Impairment, Sixth Edition, Corrections and Clarifications

Page 596, Example 17-18: Traumatic Separa- Page 599, 17.6 Appendix 17-A: Pain Disability
tion of the Symphysis Pubis, Clinical Tests Questionnaire, Left Column, Paragraph 1

Clinical Tests: Initial X rays reveal separation of The Pain Disability Questionnaire (PDQ) was specifi-
symphysis by approximately 3.5 cm. Follow-up X rays cally developed for evaluating clinical out-comes in a
6 months later reveal persistent displacement, but no population of patients with disabling musculoskeletal
instability. disorders, primarily involving the spine. It yields a total
functional disability score ranging from 0 (perfect func-
Page 597, Example 17-19: Complex Pelvic Ring tion) to 150 (total disability).
Fracture Dislocation, Physical Exam and
Diagnosis Page 599, Right Column, Number 3
3. The evaluating doctor or an assistant will
Physical Exam: The patient is able to rise from a sit- score the PDQ by adding together the
ting position and walks with a walker. He has residual marked integer in each question.
partial loss of bladder control due to a left S3 nerve
root involvement, with sensory loss estimated at 80% Page 600
affecting the left S3 dermatome. Note: See PDQ on page 4 of this document.

Diagnosis: Complex pelvic ring fracture disloca-
tion, surgically treated, reduced and stabilized, with
persistent deformity, with residual left S3 nerve root
involvement.

Page 597, Summary

5. Determine the DBI for each ratable diagnosis,
using the regional grids, as explained in Sections
17.2 and 17.4. This includes selection of the
appropriate impairment class for that diagnosis.

Page 599, Table 17-A, PDQ Scoring

Pain Disability Questionnaire Score Grade Modifer
0 No disablity 0
Mild disability 1
1–70 Moderate disability 2
71–100 Severe disability 3
101–130 Extreme disability 4
131–150

Glossary Page 612, Independent Medical Examiner (IME)

Page 611, Impairment Evaluation Independent medical examination (IME) A usu-
ally one-time evaluation performed by an indepen-
Impairment evaluation Acquisition, recording, dent medical examiner who is not treating the patient
assessment, and reporting of medical evidence, or claimant, to answer questions posed by the party
performed by a licensed medical doctor or surgeon, requesting the IME.