PATHWAY TO C-CAT CERTIFICATION

AMA GUIDES CERTIFICATION – BACKGROUND

“The Guides Newsletter” November/December 2005 Edition

The author of the report must have qualifications in two areas:

i. Medical knowledge and/or training in the specific area or areas pertinent to the subject case.

ii. Experience, training, and preferably additional credentials in the area of Independent Medical Examination per se.

… treatment skills alone are not sufficient to produce a quality IME. A separate skill set is also needed. These IME skills are acquired by specialized training, experience and the certification process.

It is recommended that examiners have a special credential issued by a recognized disability or independent medical examiners national association. This is hereafter referred to as “special credential.”

Exactly who qualifies to perform an Independent Medical Examination will vary by jurisdiction.

It is strongly recommended that authors of IME’s understand the principles and style required in formal IME report writing. It is recommended that they take a formal course on report writing, such as a Writing Workshop, which specifically addresses IME report requirements. Such a workshop will help the author present material in a logical, understandable and organized fashion.

In addition to the qualifications above, it is imperative that the Examiner demonstrate the highest possible standards of ethics, objectivity and impartiality. Personal bias, prejudice, slanting or partiality cannot be tolerated. Indications of bias disqualify the Independent Medical Examination as a useful document.

A well-written report should reflect the dedication, skill and professionalism of the Examiner.

THE FSCO PERSPECTIVE

FSCO Superintendent’s Report on the Definition of Catastrophic Impairment in the Statutory Accident Benefits Schedule (December 2011):

“I have also reviewed the Expert Panel’s Phase II Report on the qualifications and experience for catastrophic impairment assessors, designed to standardize and maximize the quality of assessments. I have accepted the Panel’s recommendations in this area, with some modifications.”

Superintendent’s Recommendation (5.3): Evaluators conducting assessments of catastrophic impairments must have formal training in the use of the measurement tools that are directly relevant to their scope of practice.

The Panel recommends that all Evaluators involved in the assessment of catastrophic impairment have formal training in the use of the measurement tools that are directly relevant to their scope of practice. The measurement tools are: ASIA Scale; GOS-E; Spinal Cord Independence Measure; GAF; and the AMA Guides.

The Panel believes that proper training would improve the quality of assessments and standardize the way assessments are conducted. As a result, the system would be less prone to assessor bias and inconsistent use of measurement tools.

I accept the Expert Panel’s recommendation.

Superintendent’s Recommendation (5.4):

While I believe the university-based training advocated by the Panel would be an asset, I am not recommending this as a requirement to qualify as an Evaluator. I do however recommend that Evaluators who frequently conduct catastrophic impairment assessments should obtain this further education and thereby strengthen their knowledge and skills.

Superintendent’s Recommendation (5.6):

…. Phase II – One year after the new definition takes effect, all Evaluators must have completed training in the use of measurement tools described in the SABS definition of catastrophic impairment that are relevant to their scope of practice.

CSME-CAPDA CERTIFICATION PROGRAMS

C-CAT (Certification in Catastrophic Impairment Evaluation)

Specific to clinicians practicing within the Ontario SABS framework

Covers all aspects of pre/post June 2016 CAT legislation, specialized

assessment pathways/tests and case law review

2 day intensive training with formal examination and essay analyses

(psych)

Three streams to reflect the unique requirements/expectations of clinical

groups:

1. C-CAT(P) – Physical Medicine (Orthopaedics, Physiatry, Family Medicine,

Neurology, Internal Medicine, Rheumatology, Chiropractors, Physiotherapy

etc.)

2. C-CAT (MB) – Mental Behavioural (Psychology, Psychiatry, Neuropsychology

etc.)

3. C-CAT (FO) – Functional Observer (OT, SLP etc.)

CSME-CAPDA CERTIFICATION PROGRAMS

CMLE (Certification in Medico-Legal Expertise)

Purpose of the CMLE is to harmonize and improve quality standards for competent, independent practice as a medical expert in various domains of practice in Canada.

Intensive 2 day training program: Presents a review of a standardized set of core topics centered around evidence-based knowledge of core medicolegal principles as applied to all relevant clinical scenarios:

Clinical modules which focus on all areas of musculoskeletal conditions, trauma, chronic pain, mental behavioural conditions, TBI’s, internal/occupational medicine and an impairment and disability assessment framework. Designed to foster improved cross-functional integration and understanding

Legal context of personal injury claims including relevant case law review

Practical aspects assessment protocols and proper report structure. Participants must submit IME reports for review as a component of CMLE certification

Unique and specialized province-specific legislative framework review (SABS, Tort, WSIB etc.)

A formalized Examination is designed to test core knowledge and application of all principles and establishes a minimum competence level expected from stakeholders

SABS CAT 2016 CHANGES

SABS CAT DEFINITION

2010-2016

GCS

GOS

Psych WPI approaches (Desbien AMA4 Ch. 4,

California GAF)

M/B Criteria 1x Class4

NEW 2016 SABS CAT DEFINITION

ASIA, GOS-E

SCIM, KOSCHI

AMA6: GAF, BPRS, PIRS

‘Bowel Routine’ ‘Radiological Findings’

SUMMARY OF NEW CAT DEFINITION (FOR ACCIDENTS AFTER JUNE 2016)

Current System New 2016 SABS Model

Paraplegia/Tetraplegia As outlined by generalized terms in Criterion 1 Relies on definitions as found in the ASIA Impairment Scale

Ambulatory Mobility As outlined by generalized terms in Criterion 2 Relies on more specific definitions of levels of amputation and on the Spinal Cord Independence Measure, Version III

Traumatic Brain Injuries

1. GCS criteria (<9)

2. GOS criteria

3. “Brain impairment” used

1. GCS Criteria discontinued , direct investigation and

imaging criteria introduced

2. Glasgow Outcome Scale Extended (GOS-E)

implemented

3. Language is now “traumatic brain impairment”

55% WPI criteria – Physical

Impairments Utilizes the AMA Guides 4th Edition Unchanged

Combining of Physical and

Mental Health Impairments

Based on case precedent (Desbien, Kuszniers)

in Ontario around the AMA 4th

Required to apply AMA 6th to obtain mental health

QPI and combine with physical findings from AMA 4th

Key tests include BPRS, GAF and PIRS

Mental Health Impairments

Criterion 8 – requires a class 4 or 5 rating as in

Ch. 14 of AMA 4th (Pastore – only in 1

category)

Revised to require 3 or more impairments at Class 4

level, or 1 at a Class 5 level (AMA 4th)

CAT DEFINITION: REVOKED ON JUNE 1 2016

All Subsections Including

3(2) Adult Definitions

3(3) and 3(4) Special Solutions for Children

3(5) Stability: unlikely to cease / 2 years

3(6) Unlisted: Analogy Solution

https://www.ontario.ca/laws/regulation/100034

2010 SABS CAT DEFINITION (3.2)

a) paraplegia or quadriplegia;

b) the amputation of an arm or leg or another impairment causing the total and permanent loss of use of an arm

or a leg;

c) the total loss of vision in both eyes;

d) subject to subsection (4), brain impairment that results in,

i. a score of 9 or less on the Glasgow Coma Scale, as published in Jennett, B. and Teasdale, G., Management

of Head Injuries, Contemporary Neurology Series, Volume 20, F.A. Davis Company, Philadelphia, 1981,

according to a test administered within a reasonable period of time after the accident by a person trained

for that purpose, or

ii. a score of 2 (vegetative) or 3 (severe disability) on the Glasgow Outcome Scale, as published in Jennett, B.

and Bond, M., Assessment of Outcome After Severe Brain Damage, Lancet i:480, 1975, according to a test

administered more than six months after the accident by a person trained for that purpose;

e) subject to subsections (4), (5) and (6), an impairment or combination of impairments that, in accordance with

the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993,

results in 55 per cent or more impairment of the whole person; or

f) subject to subsections (4), (5) and (6), an impairment that, in accordance with the American Medical

Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in a class 4

impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioural

disorder. O. Reg. 34/10, s. 3 (2).

2010 SABS CAT DEFINITION (3.3-3.5)

3. Subsection (4) applies if an insured person is under the age of 16 years at the time of the accident and none of the Glasgow Coma Scale, the Glasgow Outcome Scale or the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, referred to in clause (2) (d), (e) or (f) can be applied by reason of the age of the insured person. O. Reg. 34/10, s. 3 (3).

4. For the purposes of clauses (2) (d), (e) and (f), an impairment sustained in an accident by an insured person described in subsection (3) that can reasonably be believed to be a catastrophic impairment shall be deemed to be the impairment that is most analogous to the impairment referred to in clause (2) (d), (e) or (f), after taking into consideration the developmental implications of the impairment. O. Reg. 34/10, s. 3 (4).

5. Clauses (2) (e) and (f) do not apply in respect of an insured person who sustains an impairment as a result of an accident unless,

a) a physician or, in the case of an impairment that is only a brain impairment, either a physician or a neuropsychologist states in writing that the insured person’s condition is unlikely to cease to be a catastrophic impairment; or

b) two years have elapsed since the accident. O. Reg. 289/10, s. 1 (2).

6. For the purpose of clauses (2) (e) and (f), an impairment that is sustained by an insured person but is not listed in the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 is deemed to be the impairment that is listed in that document and that is most analogous to the impairment sustained by the insured person. O. Reg. 34/10, s. 3 (6).

DEFINITIONS AND INTERPRETATION 3.(1)

“accident” -directly causes an impairment…

“impairment” - loss or abnormality of a psychological, physiological or anatomical structure or function.

“physician” means a person authorized by law to practise medicine.

“psychologist” means a person authorized by law to practise psychology

“neuropsychologist” - registered to practice as a neuropsychologist in Canada for a minimum of five years.

REVISED DEFINITIONS AND ASSESSMENTS 45(1-2)

45. (1) An insured person who sustains an impairment as a result of an accident may apply to the insurer for a

determination of whether the impairment is a catastrophic impairment. O. Reg. 34/10, s. 45 (1).

(2) The following rules apply with respect to an application under subsection (1):

1. An assessment or examination in connection with a determination of catastrophic impairment shall be

conducted only by a physician but the physician may be assisted by such other regulated health

professionals as he or she may reasonably require.

2. Despite paragraph 1, if the impairment is a traumatic brain impairment only, the assessment or

examination may be conducted by a neuropsychologist who may be assisted by such other regulated

health professionals as he or she may reasonably require.

Note: On June 1, 2016, the definition of “neuropsychologist” in subsection 3 (1) of the Regulation is

amended by adding “who has been registered to practice as a neuropsychologist in Canada for a

minimum of five years” at the end. (See: O. Reg. 251/15, s. 2 (1))

(JUNE 2016) 45.1 If an insured person who is under 18 years of age at the time of the accident sustains a

traumatic brain injury that meets the criteria in subparagraph 5 i or 5 ii of subsection 3.1 (1) and that was

caused by an accident that occurs on or after June 1, 2016, the person may submit an application under

subsection 45 (1) and subsections 45 (2) to (5) do not apply, and the impairment is deemed to be a

catastrophic impairment for the purposes of subsection 45 (6). O. Reg. 251/15, s. 18.

2016 CAT CRITERIA: OVERVIEW

1) Spinal Cord

2) Limbs

3) Vision

4) Adult Brain

5) Child Brain

6) Physical WPI (AMA4)

7) M/B WPI (AMA6)

8) Pure M/B

CATASTROPHIC IMPAIRMENT DETERMINATION # 1 – 5: TIMELINES

Criterion Immediate 1 Month 3 Months 6 Months 9 mo – 12 mo

1) Spinal Cord Tetra/Quadra Paraplegia, Central

Cord Cauda Equina,

Brown-Sequard

2) Limbs Amputation Some complex

injuries

3) Vision Nerve damage Retinal damage

4) Adult Brain VS SD Lower MD

5) Child Brain Hospitalized Rehab Hosp / VS SD Supervision /

Assistance

CRITERION 1: SPINAL CORD / CAUDA EQUINA INJURY

3.1 (1) For the purposes of this Regulation, an impairment is a catastrophic impairment if an insured person

sustains the impairment in an accident that occurs on or after June 1, 2016 and the impairment

results in any of the following:

1) Paraplegia or tetraplegia that meets the following criteria:

i. The insured person’s neurological recovery is such that the person’s permanent grade on the ASIA

Impairment Scale, as published in Marino, R.J. et al, International Standards for Neurological

Classification of Spinal Cord Injury, Journal of Spinal Cord Medicine, Volume 26, Supplement 1,

Spring 2003, can be determined.

ii. The insured person’s permanent grade on the ASIA Impairment Scale is or will be,

A. A, B or C, or

B. D, and

1. the insured person’s score on the Spinal Cord Independence Measure, Version III, item 12 (Mobility

Indoors), as published in Catz, A., Itzkovich, M., Tesio L. et al, A multicentre international study on the

Spinal Cord Independence Measure, version III: Rasch psychometric validation, Spinal Cord (2007) 45,

275-291 and applied over a distance of up to 10 metres on an even indoor surface is 0 to 5,

2. the insured person requires urological surgical diversion, an implanted device, or intermittent or

constant catheterization in order to manage a residual neuro-urological impairment, or

3. the insured person has impaired voluntary control over anorectal function that requires a bowel

routine, a surgical diversion or an implanted device.

CRITERION 1: SPINAL CORD / CAUDA EQUINA INJURY

CAT

ASIA A/B/C

Non-ambulatory

Limited to recreational/exercise walking

ASIA D SCIM 0-5 with 10 meters AND

Neuro-urological OR Anorectal compromise and intervention required

ANATOMY OF THE SPINE

ASIA IMPAIRMENT SCALE (AIS)

ASIA IMPAIRMENT SCALE (AIS)

ASIA IMPAIRMENT SCALE (AIS)

AIS Descriptor Qualifier Functional Status

A Complete No sensory or motor function at S4/5 Non-ambulatory

B Sensory Incomplete Sensory, but no motor function at S4/5 Non-ambulatory

C Motor Incomplete

More than half of the key muscles below the neurological level of injury

have a grade less than 3

Recreational/Exercise Walking

D Motor Incomplete

Half or more of the key muscles below the neurological level of injury have a

grade greater than or equal to 3

Supported Stand/Walk

<-> Unassisted Gait

E Normal All components of International

standards exam are normal Fully Recovered

Motor Level

Neurological Level of Injury (NLI)

SPINAL CORD INDEPENDENCE MEASURE (SCIM): MOBILITY SCORES (INDOORS AND OUTDOORS ON EVEN SURFACE)

12. Mobility Indoors (0-10 meters)

0 - Requires total assistance

1 - Needs electric wheelchair or partial assistance to operate manual wheelchair

2 - Moves independently in manual wheelchair

3 - Requires supervision while walking (with or without devices)

4 - Walks with a walking frame or crutches (swing)

5 - Walks with crutches or two canes (reciprocal walking)

6 - Walks with one cane

7 - Needs leg orthosis only

8 - Walks without walking aids

Catz, A., Itzkovich, M., Tesio L. et al, A multicentre international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation, Spinal Cord (2007) 45, 275-291)

13. Mobility for Moderate Distances (10-100 meters)

0 - Requires total assistance

1 - Needs electric wheelchair or partial assistance to operate manual wheelchair

2 - Moves independently in manual wheelchair

3 - Requires supervision while walking (with or without devices)

4 - Walks with a walking frame or crutches (swing)

5 - Walks with crutches or two canes (reciprocal walking)

6 - Walks with one cane

7 - Needs leg orthosis only

8 - Walks without walking aids

SPINAL CORD DETERMINATION VIA AMA4

AMA4 Ch. 3.3

DRE (Diagnosis Related Estimates) – require musculoskeletal spinal trauma

AMA4 Ch. 4.3: Spinal cord

Upper Extremity, Gait, Bowel, Bladder, Sexual

+/- Table 6 (Sleep Apnea)

+/- Chapter 2 (pain, medication side effects);

especially for Brown-Sequard or Central Cord Syndrome

CRITERION 2: UPPER/LOWER EXTREMITY FUNCTION/AMPUTATION

2. Severe impairment of ambulatory mobility or use of an arm, or amputation that meets the following criteria:

ii. Trans-tibial or higher amputation of a leg.

iii. Amputation of an arm or another impairment causing the total and permanent loss of use of an arm.

iv. Severe and permanent alteration of prior structure and function involving one or both legs as a result of which the insured person’s score on the Spinal Cord Independence Measure, Version III, item 12 (Mobility Indoors), as published in Catz, A., Itzkovich, M., Tesio L. et al, A multicentre international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation, Spinal Cord (2007) 45, 275-291 and applied over a distance of up to 10 metres on an even indoor surface is 0 to 5.

CRITERION 2: UPPER/LOWER EXTREMITY FUNCTION/AMPUTATION

CAT

Lower extremity

amputation (1)

Upper extremity

loss of function (1)

Lower extremity

loss of function

(1/2)

At level of tibia or higher

Generally requires prosthesis

Severe and permanent alteration of prior structure and function involving one or both legs AND

SCIM Indoor Mobility score 0-5

Amputation of an arm or another impairment causing the total and permanent loss of use of an arm.

CRITERION 3: LOSS OF VISION

3. Loss of vision of both eyes that meets the following criteria:

i. Even with the use of corrective lenses or medication,

A. visual acuity in both eyes is 20/200 (6/60) or less as measured by the Snellen Chart or an equivalent chart, or

B. the greatest diameter of the field of vision in both eyes is 20 degrees or less.

ii. The loss of vision is not attributable to non-organic causes.

CRITERION 4: TRAUMATIC BRAIN INJURY (ADULT)

4. If the insured person was 18 years of age or older at the time of the accident, a traumatic brain

injury that meets the following criteria:

I. The injury shows positive findings on a computerized axial tomography scan, a magnetic

resonance imaging or any other medically recognized brain diagnostic technology

indicating intracranial pathology that is a result of the accident, including, but not limited

to, intracranial contusions or haemorrhages, diffuse axonal injury, cerebral edema, midline

shift or pneumocephaly.

II. When assessed in accordance with Wilson, J., Pettigrew, L. and Teasdale, G., Structured

Interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale:

Guidelines for Their Use, Journal of Neurotrauma, Volume 15, Number 8, 1998, the injury

results in a rating of,

A. Vegetative State (VS or VS*), one month or more after the accident,

B. Upper Severe Disability (Upper SD or Upper SD*) or Lower Severe Disability (Lower SD

or Lower SD*), six months or more after the accident, or

C. Lower Moderate Disability (Lower MD or Lower MD*), one year or more after the

accident.

CRITERION 5: TRAUMATIC BRAIN INJURY (CHILD)

5. If the insured person was under 18 years of age at the time of the accident, a traumatic brain injury that meets one of

the following criteria:

i. The insured person is accepted for admission, on an in-patient basis, to a public hospital named in a Guideline

with positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other

medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the

accident, including, but not limited to, intracranial contusions or haemorrhages, diffuse axonal injury, cerebral

edema, midline shift or pneumocephaly.

ii. The insured person is accepted for admission, on an in-patient basis, to a program of neurological rehabilitation

in a paediatric rehabilitation facility that is a member of the Ontario Association of Children’s Rehabilitation

Services.

iii. One month or more after the accident, the insured person’s level of neurological function does not exceed

category 2 (Vegetative) on the King’s Outcome Scale for Childhood Head Injury as published in Crouchman, M.

et al, A practical outcome scale for paediatric head injury, Archives of Disease in Childhood, 2001: 84: 120-124.

iv. Six months or more after the accident, the insured person’s level of neurological function does not exceed

category 3 (Severe disability) on the King’s Outcome Scale for Childhood Head Injury as published in

Crouchman, M. et al, A practical outcome scale for paediatric head injury, Archives of Disease in Childhood,

2001: 84: 120-124.

v. Nine months or more after the accident, the insured person’s level of function remains seriously impaired such

that the insured person is not age-appropriately independent and requires in-person supervision or assistance

for physical, cognitive or behavioural impairments for the majority of the insured person’s waking day.

CRITERION 4/5: TRAUMATIC BRAIN INJURY (ADULT/CHILD)

4. Subsection (5) applies to an insured

person who was under the age of 18 at

the time of the accident and whose

impairment is not a catastrophic

impairment within the meaning of

subsection (1). O. Reg. 251/15, s. 3.

5. If the insured person’s impairment can

reasonably be believed to be a

catastrophic impairment for the purposes

of paragraph 6, 7 or 8 of subsection (1),

the impairment shall be deemed to be

the impairment referred to in paragraph

6, 7 or 8 of subsection (1) that is most

analogous to the impairment, after taking

into consideration the developmental

implications of the impairment. O. Reg.

251/15, s. 3.

PROVISIONS FOR EXCEPTIONS IN CHILDREN 3.1 (4) (5)

45.1 DETERMINATION OF CATASTROPHIC IMPAIRMENT — CERTAIN TRAUMATIC BRAIN INJURIES

45.1 If an insured person who is under 18 years of age at the time of the

accident sustains a traumatic brain injury that meets the criteria in

subparagraph 5 i or 5 ii of subsection 3.1 (1) and that was caused by an

accident that occurs on or after June 1, 2016, the person may submit an

application under subsection 45 (1) and subsections 45 (2) to (5) do not apply,

and the impairment is deemed to be a catastrophic impairment for the

purposes of subsection 45 (6). O. Reg. 251/15, s. 18.

GOS-E

Glasgow Outcome Scale Extended*

The Glasgow Outcome Scale (GOS) is a global scale for functional outcome that rates an patient status into one of five categories: Dead, Vegetative State, Severe Disability, Moderate Disability or Good Recovery. The extended GOS (GOSE) provides more detailed categorization into eight categories by subdividing the categories into lower and upper categories.

Category GOSE Descriptor Key Features

1 Dead D

2 Vegetative State VS Unable to obey commands or say words

3 Severe Disability - Lower SD- Needs frequent help or someone to be around most of the time

4 Severe Disability - Upper SD+

Does not need frequent help to be alone at home for up to 8 hrs.

Not able to shop without assistance

Not able to travel locally without assistance

5 Moderate Disability - Lower MD-

Not able to work, or, only in a sheltered or non-competitive position

Unable to participate (or, rarely if ever) in regular social and leisure activates outside home

Constant and intolerable (daily disruption of family relationships or friendships due to psychological

problems

6 Moderate Disability - Upper MD+

Able to work or study but at a reduced capacity

Participates much less (less than half as often) in regular social and leisure activities outside home

Frequent but tolerable (once per week) disruption of family relationships or friendships due to

psychological problems

7 Good Recovery - Lower GR-

Participates at least half as often as before in regular social and leisure activities outside home

Occasional disruption of family relationships or friendships due to psychological problems

Other problems relating to the injury (headache, dizziness, tiredness, sensory sensitivity, slowness,

memory failures, concentration problems) affect daily life

8 Good Recover - Upper GR+

Able to work to previous capacity

Able to resume regular social and leisure activities outside home

No psychological problems resulting in ongoing family disruption or disruption to friendships

KING’S OUTCOME SCALE FOR CHILDHOOD HEAD INJURY (KOSCHI)

Category Definition

1. Death

2. Vegetative Breathes spontaneously; no evidence of verbal or non-verbal communication; no response to commands.

3. Severe disability Conscious, totally dependent; may be able to communicate; requires special educational/rehabilitation setting.

4A. Moderate disability Limited self-care abilities, predominantly dependent; may have meaningful communication; requires specialized educational/rehabilitation setting.

4B. Moderate disability

Mostly independent for daily living, but needs a degree of supervision/help for physical or behavioral problems; has overt problems; may be in special ed/rehab or mainstream school with special needs assistance; behavioral problems may have caused patient to be excluded from school.

5A. Good recovery Age appropriately independent for daily living; but neurologic sequelae affects daily life including behavioral and learning difficulties; may have frequent headaches; likely to be in mainstream school with/without special needs assistance.

5B. Good recovery Appears to have made a full functional recovery, but has residual pathology attributable to TBI; may suffer headaches that do not affect school or social life.

Mild** Moderate** Severe**

Normal structural imaging Normal or abnormal structural imaging

Normal or abnormal

structural imaging

LOC = 0 – 30 min LOC > 30 min and < 24 hours LOC > 24 hours

PTA = 0 – 1 day PTA > 1 and < 7 days PTA > 7 days

GCS = 13 – 15 GCS = 9 – 12 GCS = 3 – 8

TRAUMATIC BRAIN INJURY BY SEVERITY

* Kay, T., Harrington, D.E., Adams, R., Anderson, T., Berrol, S., Cicerone, K.,…Malec, J. (1993). Definition of mild traumatic brain injury. Journal

of Head Trauma Rehabilitation, 8(3), 86-87.

**Bryant, R.A., O’Donnell, M.L., Creamer, M., McFarlane, A.C., Clark, C.R., & Silove, D. (2010). The psychiatric sequelae of traumatic injury.

American Journal of Psychiatry, 167, 312-320.

CRITERION 6 & 7: WPI AND COMBINING

6. Subject to subsections (2) and (5), a physical impairment or combination of physical impairments that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 per cent or more physical impairment of the whole person.

7. Subject to subsections (2) and (5) a mental or behavioural impairment, excluding traumatic brain injury, determined in accordance with the rating methodology in Chapter 14, Section 14.6 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 6th edition, 2008, that, when the impairment score is combined with a physical impairment described in paragraph 6 in accordance with the combining requirements set out in the Combined Values Table of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 percent or more impairment of the whole person.

CRITERION 6 & 7: WPI AND COMBINING

3.1 (2) Paragraphs 6 and 7 of subsection (1) do not apply in respect of an insured person who sustains an impairment as a result of an accident unless,

A. two years have elapsed since the accident; or

B. an assessment conducted by a physician three months or more after the accident determines that,

i. the insured person has a physical impairment or combination of physical impairments determined in accordance with paragraph 6 of subsection (1), or a combination of a mental or behavioural impairment and a physical impairment determined in accordance with paragraph 7 of subsection (1) that results in 55 per cent or more impairment of the whole person, and

ii. the insured person’s condition is unlikely to improve to less than 55 per cent impairment of the whole person. O. Reg. 251/15, s. 3.

2016 CRITERION 6 & 7: WPI AND COMBINING

PHYSICAL MENTAL/BEHAVIOURAL

2016 SABS M/B WPI APPROACH: AMA6

1. Utilize three different scales to arrive

at three scores:

Brief Psychiatric Rating Scale

(BPRS)

The Global Assessment of

Functioning Scale (GAF)

The Psychiatric Impairment Rating

Scale (PIRS)

2. Rank order the scores

3. Choose the Middle (Median) of the

three scores.

4. This score is then used to combine

with the physical ratings to arrive at a

Final WPI which in turn must reach

55%.

THE GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALE: WPI SCORING

Table 14-10

Impairment Score of Global Assessment of Functioning Scale (GAF)

GAF Description GAF Impairment

Score

91-100 No symptoms; superior functioning in a wide rang of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities

0%

81-90 Absent or minimal symptoms (e.g. mild anxiety before an exam); good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (eg. an occasional argument with family members)

0%

71-80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (eg. difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (eg. temporarily falling behind in school work)

0%

61-70 Some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g. occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships

5%

51-60 Moderate symptoms (e.g. flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g. few friends, conflicts with coworkers)

10%

41-50 Serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job)

15%

31-40

Some impairment in reality testing or communication (e.g. speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (eg. depressed adult avoids friends, neglects family , and is unable to work; child frequently beats up younger children, is defiant at home and is failing at school)

20%

21-30 Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (eg. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (eg. stays in bed all day; no job, home, or friends)

30%

11-20 Some danger of hurting self or others (e.g. suicide attempts without clear expectation of death, frequently violent, manic excitement) or occasionally fails to maintain minimal personal hygiene (e. smears feces) or gross impairment in communication (largely incoherent or mute)

40%

1-10 Persistent danger of severely hurting self or others (e.g. recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death

50%

2016 SABS COMBINING DEFINITION: DISCUSSION POINTS

AMA6 Chapter 14 says only rate

Mood Disorders, Anxiety Disorders,

and Psychotic Disorders.

The 2016 SABS refers only to 14.6 so

it could be argued that the exclusion

instructions do not apply

Pain Disorders/Somatic Symptom

Disorders - To rate or not to rate –

that is the question

CRITERION 8: M/B CLASS SCORING

8. Subject to subsections (3) and (5), an impairment that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 results in a class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning or a class 5 impairment (extreme impairment) in one or more areas of function that precludes useful functioning, due to mental or behavioural disorder. O. Reg. 251/15, s. 3.

3(3) Paragraph 8 of subsection (1) does not apply in respect of an insured person who sustains an impairment as a result of the accident unless,

a) two years have elapsed since the accident; or

b) a physician states in writing that the insured person’s impairment is unlikely to improve to less than a class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning, due to mental or behavioural disorder. O. Reg. 251/15, s. 3.

AMA4 CHAPTER 14 ANALYSIS

Rate permanent impairments and not impairments expected to resolve

Exclude physical impairments

Provide separate ratings for each of:

• Activities of Daily Living

• Concentration, Persistence and Pace

• Social Functioning

• Adaptation to Work or Work-Like Stressors

Determine the extent to which functional impairment can be attributable

to psychological/mental disorders

THE AMA4 CHAPTER 14 METHOD