AMA Guides ® to the Evaluation of Permanent Impairment, Sixth Edition, 2023

Summary of Updates to AMA Guides Sixth Edition 2023

• Chapter 11: No Changes to Impairment Ratings
• Chapter 13: Changes to Impairment Ratings
• Chapter 15: Minimal impact to Impairment Ratings; encourages use of the DBI method over ROM
• AMA Guides Sixth 2023 Errata (link)

Chapter 11: Ear, Nose, Throat, and Related Structures

• 11.2g Equilibrium
  • Inclusion of videonystagmography
  • Addition of Rotary Chair Testing
  • Text added: Dysphagia may be caused by structural, neuromuscular, neoplastic and other maladies. Oropharyngeal tumors must be ruled out and may occur even in young people, especially in association with human papilloma virus (HPV) infection
  • New dysphagia example

  Chapter 13: The Nervous System

  Content has been extensively re-written to better adhere to the principles of the AMA Guides, Sixth Edition by promoting the concept of Diagnosis Based Impairment. The structure of the chapter has changes and the way impairment ratings are performed has changed as well.

  Synopses of changes include, but are not limited to:

  • Change of chapter title from Central and Peripheral Nervous System to The Nervous System
  • Conformity of tables with all other Guides chapters
  • Identification of a Key Factor: Effect on ADLs consistent with known natural history of the diagnosis
  • Introduction of Grades within Classes along with Grade Modifiers
  • 3-Grade system with Grade A as the foundation
  • BOTC and adaptive measures can be used to Adjust Grade within Class
  • Update of the following Tables in conformity to the Guides Principle of Simplicity:
  • To maintain consistency with Chapter 14, The GAF has been incorporated into the MSCHIF as the MSCHIF-E; Aphasia has been incorporated into the Mental Status Examination within the MSCHIF-E; Modifies Episodic Disorders of Consciousness into Episodic Disorders; Consolidates 3 Tables on Pain into one (Neuropathic Pain); Defers Central Sleep Disorders to Chapter 14, consistent with the DSM-5
  • Creation of the QuickView Worksheet to improve Inter-Rater Reliability
  • Creation of a BOTC that is not burdensome on the evaluator

  Chapter 15: The Upper Extremities

  • Tables 15-2, 15-3, 15-4 and 15-5
    • The words “with normal motion” be removed from all sections in which it appears; elimination of the footnote from the DBI tables that says: “*If motion loss is present, this impairment may alternatively be assessed using Section 15.7, Range of Motion Impairment. A range of motion impairment stands alone and is not combined with diagnosis impairment.”
    • Edited to reinforce DBI as preferred method, but, when presented with decreased ROM, a rater can consider that as an alternative method when the impairment isn’t able to be rated with the DBI paradigm.

    This page is designed to provide you with easy access to the AMA Guides to the Evaluation of Permanent Impairment 6th Edition, 2023 tables.

    Jump to Chapter:

    Chapter 1: Conceptual Foundations and Philosophy
    Tables
    Table 1-1: Self-Care
    Table 1-2: Hierarchy of Study Types
    Table 1-3: ICF Codes and Functional Levels
    Table 1-4: Sample Impairment Function Classification
    Table 1-5: Generic Template for Impairment Classification Grids
    Table 1-6: General Principles for Calculating Impairment
    Chapter 2: Practical Application of the Guides
    Tables
    Table 2-1: Fundamental Principles of the Guides
    Chapter 3: Pain-Related Impairment
    Tables
    Table 3-1: Pain-Related Impairment and Whole Person Impairment Based on Pain Disability Questionnaire
    Chapter 4: The Cardiovascular System
    Tables
    Table 4-1: NYHA Functional Classification of Cardiac Disease
    Table 4-2: Relationship of METs and Functional Class According to 5 Treadmill Protocols
    Table 4-3: Energy Expenditure in METs During Bicycle Ergometry
    Table 4-4: Methodology for Determining the Grade in an Impairment Class
    Table 4-5: Criteria for Rating Permanent Impairment due to Valvular Heart Disease
    Table 4-6: Criteria for Rating Impairment due to Coronary Artery Disease
    Table 4-7: Criteria for Rating Impairment due to Cardiomyopathies
    Table 4-8: Criteria for Rating Impairment due to Pericardial Heart Disease
    Table 4-9: Criteria for Rating Impairment due to Dysrhythmias
    Table 4-10: Classification of Blood Pressure for Adults
    Table 4-11: Criteria for Rating impairment due to Hypertensive Cardiovascular Disease
    Table 4-12: Criteria for Rating Impairment due to Peripheral Vascular Disease – Lower Extremity
    Table 4-13: Criteria for Rating Impairment due to Peripheral Vascular Disease – Upper Extremity
    Table 4-14: Criteria for Rating Impairment due to Diseases of the Pulmonary Artery
    Table 4-15: Cardiac Impairment Evaluation Summary
    Chapter 5: The Pulmonary System
    Tables
    Table 5-1: Impairment Classification of Dyspnea (Adapted)
    Table 5-2: Impairment Classification for Prolonged Physical Work Intensity by Oxygen Consumption
    Table 5-3: Methodology for Determining the Grade in an Impairment Class
    Table 5-4: Criteria for Rating Permanent Impairment due to Pulmonary Dysfunction
    Table 5-5: Criteria for Rating Permanent Impairment due to Asthma
    Table 5-6: Scale for Judging Capabilities of Subjects With Cancer
    Table 5-7: Pulmonary Impairment Evaluation Summary
    Chapter 6: The Digestive System
    Tables
    Table 6-1: Desirable Weights for Men by Height and Body Build
    Table 6-2: Desirable Weights for Women by Height and Body Build
    Table 6-3: Methodology for Determining the Grade in an Impairment Class
    Table 6-4: Criteria for Rating Permanent Impairment due to Upper Digestive Tract (Esophagus, Stomach and Duodenum, Small Intestine, and Pancreas) Disease
    Table 6-5: Criteria for Rating Permanent Impairment due to Colonic and Rectal Disorders
    Table 6-6: Criteria for Rating Permanent Impairment due to Anal Disease
    Table 6-7: Impairments From Surgically Created Stomas
    Table 6-8: Criteria for Rating Permanent Impairment due to Liver Disease
    Table 6-9: Criteria for Rating Permanent Impairment due to Biliary Tract Disease
    Table 6-10: Criteria for Rating Permanent Impairment due to Herniation
    Table 6-11: Digestive System Impairment Evaluation Summary
    Chapter 7: The Urinary and Reproductive Systems
    Tables
    Table 7-1: Methodology for Determining the Grade in an Impairment Class
    Table 7-2: Criteria for Rating Permanent Impairment due to Upper Urinary Tract Disease
    Table 7-3: Criteria for Rating Permanent Impairment due to Urinary Diversion Disorders
    Table 7-4: Criteria for Rating Permanent Impairment due to Bladder Disease
    Table 7-5: Criteria for Rating Permanent Impairment due to Urethral Disease
    Table 7-6: Criteria for Rating Permanent Impairment due to Penile Disease
    Table 7-7: Criteria for Rating Permanent Impairment due to Scrotal Disease
    Table 7-8: Criteria for Rating Impairment due to Testicular, Epididymal, and Spermatic Cord Disease
    Table 7-9: Criteria for Rating Impairment due to Prostate Disease
    Table 7-10: Criteria for Rating Permanent Impairment due to Vulval and Vaginal Disease
    Table 7-11: Criteria for Rating Permanent Impairment due to Cervical and Uterine Disease
    Table 7-12: Criteria for Rating Permanent Impairment due to Fallopian Tube and Ovarian Disease
    Table 7-13: Urinary and Reproductive Systems Impairment Evaluation Summary
    Chapter 8: The Skin
    Tables
    Table 8-1: Structure, Functions, and Disorders of the Skin
    Table 8-2: Criteria for Rating Permanent Impairment due to Skin Disorders
    Table 8-3: Skin Impairment Evaluation Summary
    Chapter 9: The Hematopoietic System
    Tables
    Table 9-1: Karnofsky Performance Status Scale Definitions Rating (%) Criteria
    Table 9-2: Eastern Cooperative Oncology Group Performance Status Scale (ECOG-PSS)
    Table 9-3: Burden of Treatment Compliance
    Table 9-4: Methodology for Determining the Grade in an Impairment Class
    Table 9-5: Criteria for Rating Permanent Impairment due to Anemia
    Table 9-6: Criteria for Rating Permanent Impairment due to Neutropenia
    Table 9-7: Criteria for Rating Permanent Impairment due to the Leukemias
    Table 9-8: Criteria for Rating Permanent Impairment due to HIV Disease
    Table 9-9: Criteria for Rating Impairment due to Platelet Disorders
    Table 9-10: Criteria for Rating Impairment due to the Hemophilias
    Table 9-11: Criteria for Rating Impairment due to Other Bleeding Disorders
    Table 9-12: Criteria for Rating Impairment due to Thrombotic Disorders
    Table 9-13: Criteria for Rating Impairment due to Lymphoma and Metastatic Disease
    Table 9-14: Hematologic Impairment Evaluation Summary
    Chapter 10: The Endocrine System
    Tables
    Table 10-1: Methodology for Determining the Grade in an Impairment Class
    Table 10-2a: Enteral, Intranasal, and Topical Medications
    Table 10-2b: Parenteral Medications
    Table 10-3: Points Assigned for Dietary Modification
    Table 10-4: Procedure-Based Points
    Table 10-5: Criteria for Rating Impairment due to Disorders of the Hypothalamic-Pituitary Axis
    Table 10-6: Criteria for Rating Impairment due to Thyroid Abnormalities
    Table 10-7: Criteria for Rating Impairment due to Disorders of the Parathyroids
    Table 10-8: Criteria for Rating Impairment due to Disorders of the Adrenal Cortex
    Table 10-9: Criteria for Rating Impairment due to Disorders of the Adrenal Medulla
    Table 10-10: Criteria for Rating Impairment due to Diabetes Mellitus
    Table 10-11: Criteria for Rating Impairment due to Hypoglycemia
    Table 10-12: Criteria for Rating Impairment due to Gonadal Disorders
    Table 10-13: Criteria for Rating Impairment due to Mammary Disorders
    Table 10-14: Criteria for Rating Impairment due to Metabolic Bone Disease
    Table 10-15: Endocrine System Impairment Evaluation Summary
    Chapter 11: Ear, Nose, Throat, and Related Structures
    Tables
    Table 11-1: Monaural Hearing Loss and Impairment
    Table 11-2: Computation of Binaural Hearing Impairment
    Table 11-3: Relationship of Binaural Hearing Impairment to Impairment of the Whole Person
    Table 11-4: Criteria for Rating Impairments due to Vestibular Disorders
    Table 11-5: Criteria for Rating Impairment due to Facial Disorders and/or Disfigurement
    Table 11-6: Criteria for Rating Impairment due to Air Passage Deficits
    Table 11-7: Impairments of Mastication and Deglutition: Relationship of Dietary Restrictions to Permanent Impairment
    Table 11-8: Criteria for Rating Voice and Speech Impairment
    Chapter 12: The Visual System
    Tables
    Table 12-1: Calculation Steps for the Visual System
    Table 12-2: Impairment of Visual Acuity
    Table 12-3: Calculation of the Acuity-Related Impairment Rating
    Table 12-4: Classification of Impairment of Visual Acuity
    Table 12-5: Impairment of Visual Field
    Table 12-6: Conversion of Field Radius to Field Score
    Table 12-7: Calculation of the Visual Field–Related Impairment Rating
    Table 12-8: Classification of Impairment of Visual Field
    Table 12-9: Correction for Central Scotomata
    Table 12-10: Classification of Impairment of the Visual System and of the Whole Person
    Table 12-11: Determination of Reading Acuity and Impairment Rating, Using Letter Size and Viewing Distance
    Chapter 13: The Nervous System
    Tables
    Table 13-1A: Summary of Chapters Used to Rate Various Neurologic Disorders
    Table 13-1B: Activities of Daily Living
    Table 13-1C: Summary of Impairment Rating Tables
    Table 13-1D: Burden of Treatment Compliance
    Table 13-2A: Nervous System Rating Tables
    Table 13-2B: Rating the Effects of a Neurologic Disease
    Table 13-2C: Methods for Rating Neurologic-Based Impairment
    Table 13-2D: Framework for Rating Tables Within This Chapter
    Table 13-3A: Method Specific to Rating Cognitive Cerebral Impairments
    Table 13-3B: Progression of the MSCHIF-E Into Disorders of Consciousness
    Table 13-4 QuickView Worksheet (Master): Summary of Rating Impairment Table
    Table 13-5A: Disorders of Consciousness
    Table 13-5B: Episodic Disorders (Epilepsy and Autonomic Disorders)
    Table 13-5C: Mental Status, Cognition, Highest Integrative Function, and Emotion (MSCHIF-E)
    Table 13-5D Upper Extremity CNS Dysfunction
    Table 13-5E Station and Gait Disorders
    Table 13-5F Neurogenic Respiratory Dysfunction
    Table 13-5G Neurogenic Bowel
    Table 13-5H Neurogenic Bladder
    Table 13-5I Neurogenic Sexual Dysfunction
    Table 13-5J Neuropathic Pain (Peripheral Neuropathy and Craniofacial)
    Table 13-5K Migraine
    Chapter 14: Mental and Behavioral Disorders
    Tables
    Table 14-1: Mental Status Examination
    Table 14-2: Selected Psychological Assessment Tools in Adults
    Table 14-3: Suggestions for the Mental and Behavioral Disorders Independent Medical Examination
    Table 14-4: Functional Impairment Scales for Patients With Mental and Behavioral Disorders (M&BDs)
    Table 14-5: Factors That May Affect Motivation
    Table 14-6: Characteristics Suggestive of the Need to Evaluate for Malingering
    Table 14-7: Brief Psychiatric Rating Scale Form
    Table 14-8: Impairment Score of Brief Psychiatric Rating Scale
    Table 14-9: Self-Care, Personal Hygiene, and Activities of Daily Living
    Table 14-10: Role Functioning, Social and Recreational Activities
    Table 14-11: Travel
    Table 14-12: Interpersonal Relationships
    Table 14-13: Concentration, Persistence, and Pace
    Table 14-14: Resilience and Employability
    Table 14-15: Impairment Score of Psychiatric Impairment Rating Scale
    Chapter 15: The Upper Extremities
    Tables
    Table 15-1: Definition of Impairment Classes
    Table 15-2: Digit Regional Grid: Digit Impairments
    Table 15-3: Wrist Regional Grid: Upper Extremity Impairments
    Table 15-4: Elbow Regional Grid: Upper Extremity Impairments
    Table 15-5: Shoulder Regional Grid: Upper Extremity Impairments
    Table 15-6: Adjustment Grid: Summary
    Table 15-7: Functional History Adjustment: Upper Extremities
    Table 15-8: Physical Examination Adjustment: Upper Extremities
    Table 15-9: Clinical Studies Adjustment: Upper Extremities
    Table 15-10: Methodology for Determining the Grade in an Impairment Class
    Table 15-11: Impairment Values Calculated From Upper Extremity Impairment
    Table 15-12: Impairment Values Calculated From Digit Impairment
    Table 15-13: Monofilament Test Criteria
    Table 15-14: Sensory and Motor Severity
    Table 15-15: Sensory Quality Impairment Classification
    Table 15-16: Digit Impairment for Transverse and Longitudinal Sensory Losses in Thumb and Little Finger Based on Percent of Digital Length Involved
    Table 15-17: Digit Impairment for Transverse and Longitudinal Sensory Losses in Index, Middle, and Ring Fingers Based on Percent of Digital Length Involved
    Table 15-18: Impairment for Sensory Only Peripheral Nerve Injury
    Table 15-19: Origins and Functions of Peripheral Nerves of Upper Extremity Emanating From Brachial Plexus
    Table 15-20: Brachial Plexus Impairment: Upper Extremity Impairments
    Table 15-21: Peripheral Nerve Impairment: Upper Extremity Impairments
    Table 15-22: Activities of Daily Living (ADLs)
    Table 15-23: Entrapment/Compression Neuropathy Impairment
    Table 15-24: Diagnostic Criteria for Complex Regional Pain Syndrome
    Table 15-25: Objective Diagnostic Criteria Points for Complex Regional Pain Syndrome
    Table 15-26: Complex Regional Pain Syndrome (Type I): Upper Extremity Impairments
    Table 15-27: Level of Amputation
    Table 15-28: Impairment for Upper Limb Amputation at Various Levels
    Table 15-29: Amputation Impairment
    Table 15-30: Thumb Range of Motion
    Table 15-31: Finger Range of Motion
    Table 15-32: Wrist Range of Motion
    Table 15-33: Elbow/Forearm Range of Motion
    Table 15-34: Shoulder Range of Motion
    Table 15-35: Range of Motion Grade Modifiers
    Table 15-36: Functional History Grade Adjustment: Range of Motion
    Table 15-37: Activities of Daily Living Questionnaire
    Table 15-38: ADLs Questionnaire Evaluation
    Table 15-39: Comparison Between QuickDASH and ADL Questionnaires
    Table 15-40: Self-Report Functional Assessment Measures
    Chapter 16: The Lower Extremities
    Tables
    Table 16-1: Definition of Impairment Classes
    Table 16-2: Foot and Ankle Regional Grid – Lower Extremity Impairments
    Table 16-3: Knee Regional Grid – Lower Extremity Impairments
    Table 16-4: Hip Regional Grid – Lower Extremity Impairments
    Table 16-5: Adjustment Grid: Summary
    Table 16-6: Functional History Adjustment – Lower Extremities
    Table 16-7: Physical Examination Adjustment – Lower Extremities
    Table 16-8: Clinical Studies Adjustment – Lower Extremities
    Table 16-9: Methodology for Determining the Grade in an Impairment Class
    Table 16-10: Impairment Values Calculated From Lower Extremity Impairment
    Table 16-11: Sensory and Motor Severity
    Table 16-12: Peripheral Nerve Impairment – Lower Extremity Impairments
    Table 16-13: Diagnostic Criteria for Complex Regional Pain Syndrome
    Table 16-14: Objective Diagnostic Criteria Points for Complex Regional Pain Syndrome
    Table 16-15: Complex Regional Pain Syndrome (Type I) – Lower Extremity Impairments
    Table 16-16: Amputation Impairment
    Table 16-17: Functional History Net Modifier
    Table 16-18: Lesser Toe Impairments
    Table 16-19: Greater Toe Impairments
    Table 16-20: Hindfoot Motion Impairments
    Table 16-21: Ankle or Hindfoot Deformity Impairments
    Table 16-22: Ankle Motion Impairments
    Table 16-23: Knee Motion Impairments
    Table 16-24: Hip Motion Impairments – Lower Extremity Impairment
    Table 16-25: Range of Motion ICF Classification
    Chapter 17: The Spine and Pelvis
    Tables
    Table 17-1: Definition of Impairment Classes and Impairment Ranges
    Table 17-2: Cervical Spine Regional Grid: Spine Impairments
    Table 17-3: Thoracic Spine Regional Grid: Spine Impairments
    Table 17-4: Lumbar Spine Regional Grid: Spine Impairments
    Table 17-5: Adjustment Grid: Summary
    Table 17-6: Functional History Adjustment: Spine
    Table 17-7: Physical Examination Adjustment: Spine
    Table 17-8: Common Radicular Syndromes
    Table 17-9: Clinical Studies Adjustment: Spine
    Table 17-10: Methodology for Determining the Grade in an Impairment Class
    Table 17-11: Diagnosis-Based Impairment Grid: Pelvis
    Table 17-12: Functional History Adjustment: Pelvis
    Table 17-13: Physical Examination Adjustment: Pelvis
    Table 17-14: Clinical Studies Adjustment: Pelvis
    Table 17-A: PDQ Scoring