bluuebunny/crossref_metadata_2025 huggingface dataset:
Impairment Rating Insights
Authors: Brigham Christopher R. , Uehlein W. Frederick , Uejo Craig , Dilbeck Leslie
Published: December 2020

This article addresses a number of issues regarding impairment evaluation and the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). First, impairment is not synonymous with disability, and, as noted in the sixth and previous editions of the AMA Guides, no direct correlation exists between impairment and work restrictions or loss of earning capacity. An impairment rating does not directly equate to a permanent disability rating and does not solely determine compensation. The AMA Guides creates the opportunity for consistency of impairment ratings among physicians, but impairment ratings must be performed according to standards defined in the AMA Guides. Impairment rating values and methods in the AMA Guides can change between editions based on medical reasons. It is too early to determine the effects of changes in the sixth edition of the AMA Guides pending the accumulation of adequate experience using this edition, until impairment ratings associated with specific diagnoses can be compared, and until an adequate sample of cases can be evaluated and compared using the fifth and sixth editions. Use of the sixth edition may result in some lower impairment ratings, but this edition also expands the number of ratable conditions compared to previous versions. Finally, impairment determination is a medical issue, and more reasonable approaches should be developed to translate impairment into financial rewards.
Pain Disorders, Part II: Evaluating the Difficult Pain Patient
Authors: Katz Richard T. , Smith Stacey Lee
Published: December 2020

In the conclusion of this two-part article, the authors present the notion of psychiatric confounders to assist non–psychiatric physicians in assessing the “difficult pain patient.” Non–psychiatric physicians need not have a detailed understanding of all psychiatric diagnoses, but an understanding of certain diagnoses will assist in evaluating patients with enduring pain complaints. Psychosocial factors have important effects on the relationship between pain and disability. In one study, job satisfaction was a predictor of future disability in low back pain patients; in another study, psychiatric morbidity in a pain-free population predicted the development of back pain over a defined period. In many patients with persistent somatic and/or pain complaints, unrecognized psychiatric diagnoses drive or complicate symptoms and may precede the onset of low back pain. Mood, anxiety, and substance abuse disorders are common and can be associated with physical and pain complaints. Somatic symptoms often are the core feature of the depressed patient who presents to a primary care physician. Somatoform disorders are a spectrum of psychiatric disorders in which physical complaints are driven or aggravated by psychological factors; somatizing patients have chronic problems, many of which are pain-related and involve recurrent physical symptoms, often in different bodily systems, that wax and wane over time. Physicians who evaluate patients with pain complaints must understand the complexity of the challenge, including the probability that pain complaints indicate underlying psychopathology.
A Biopsychosocial Model of Sickness and Disability
Authors: Waddell Gordon , Burton A. Kim , Aylward Mansel
Published: December 2020

Despite improvements in objective measures of impairment, health, and working conditions, long-term incapacity and ill-health retirement are major problems in all western societies. This article explores three models that address disability: the medical, social, and biopsychosocial models. The medical model identifies the sequence from disease that causes an impairment to a disability that leads to incapacity; this model works best when identifiable pathology permits objective diagnosis and assessment but is inappropriate for many common health problems, particularly those that are subjective or when treatment is symptomatic and often ineffective. The social model is widely accepted as the basis for social inclusion and antidiscrimination policies but cannot be operationalized as the basis for individual entitlement for incapacity benefits. The biopsychosocial model attempts to tack account of biological, psychological, and social dimensions of health and is reflected in the International Classification of Functioning, Disability, and Health (ICF), which is the contemporary model of disablement used in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Powerful links exist among poor health, disability, social and regional disadvantage, worklessness, and poverty. Vocational rehabilitation, in the biopsychosocial model, reverses the question of why people develop long-term incapacity and instead asks why people with common health problems do not recover as expected. The answer involves addressing the biopsychosocial obstacles that delay or prevent expected recovery and requires a fundamental cultural shift in how we perceive and manage common health problems.
Commentary
Authors: Katz Richard T.
Published: December 2020

The author, who is the editor of the Mental and Behavioral Disorders chapter of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, comments on the previous article, Assessing Mental and Behavioral Disorder Impairment: Overview of Sixth Edition Approaches in this issue of The Guides Newsletter. The new Mental and Behavioral Disorders (M&BD) chapter, like others in the AMA Guides, is a consensus opinion of many authors and thus reflects diverse points of view. Psychiatrists and psychologists continue to struggle with diagnostic taxonomies within the Diagnostic and Statistical Manual of Mental Disorders, but anxiety, depression, and psychosis are three unequivocal areas of mental illness for which the sixth edition of the AMA Guides provides M&BD impairment rating. Two particular challenges faced the authors of the chapter: how could M&BD disorders be rated (and yet avoid an onslaught of attorney requests for an M&BD rating in conjunction with every physical impairment), and what should be the maximal impairment rating for a mental illness. The sixth edition uses three scales—the Psychiatric Impairment Rating Scale, the Global Assessment of Function, and the Brief Psychiatric Rating Scale—after careful review of a wide variety of indices. The AMA Guides remains a work in progress, but the authors of the M&BD chapter have taken an important step toward providing a reasonable method for estimating impairment.
Relevance of the Social Security Listings in the Assessment of Severity of Mental and Behavioral Impairments per the Fourth and Fifth Editions
Authors: Leclair Steven W. , Leclair Norma J.
Published: December 2020

Establishing a valid and reliable impairment rating for persons with mental and behavioral disorders is particularly challenging. This article focuses on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, Chapter 14, Mental and Behavioral Disorders; because of similarities between the fourth and fifth editions, most comments here apply as well to the fifth edition. The section regarding mental and behavioral disorders is based in the US Social Security Administration (SSA) disability determination. The AMA Guides measures impairment in the same four areas of functioning designated by SSA: activities of daily living; social functioning; concentration, persistence, and pace (ie, focused attention); and deterioration or decompensation in work-like settings (“adaptation”). The assessment of severity of impairment is based on the five-level SSA approach and is applied to each of the four areas of functioning. The authors define and interpret the practical meanings of terminology in the AMA Guides associated with classes of severity: no impairment (self-explanatory); mild impairment (compatible with most useful functioning); moderate impairment (compatible with some but not all useful functioning); marked impairment (significantly impedes useful functioning); and extreme impairment (not compatible with useful functioning). Impairment ratings are truly applicable only when clinicians can approach the process in a consistent manner using consistent terminology and methodology; the latter two will improve both the understanding of the rating process and its reliability and validity.
Impairment Tutorial: Lower Extremities Impairment Evaluation: Overview of Sixth Edition Approaches
Authors: Brigham Christopher R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, takes approaches to the lower extremities that are consistent with Chapter 15, Upper Extremities (reviewed in the March/April 2008 issue of The Guides Newsletter). Because there is a comparatively smaller spectrum of diagnoses in the lower extremities, Chapter 16 is less complex and is shorter than Chapter 15. The purposes of the lower extremity are transfer and mobility, and, in comparison to the upper extremity, the lower extremity provides greater stability than flexibility. This chapter's principles of assessment define the standards for interpreting symptoms and signs, functional history, physical examination, and clinical studies. Examiners may use the Lower Limb Instrument developed by the American Academy of Orthopaedic Surgery as an adjunct to defining functional ability, but values are not provided to define a specific grade modifier. Most lower extremity impairments are based on Diagnosis-related impairments, and an impairment example case demonstrates the use of the Knee Regional Grid to asses a partial meniscus repair. An associated table illustrates the resulting whole person impairment values associated with these examples and gives the probable impairments based on the fifth edition. The article also discusses impairments of the peripheral nerves, amputation, and range of motion. Mastery of one chapter of the AMA Guides facilitates performing ratings using other chapters.
Impairment Tutorial: Headache Impairment
Authors: Subin Kenneth , Brigham Christopher R.
Published: December 2020

The approach to assessing impairment for headaches differs among the fourth, fifth, and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In summary, the fourth edition provides only a qualitative, nonnumeric rating. In the fifth edition, an examiner can give up to 3% whole person permanent impairment. Using the sixth edition of the AMA Guides, an examiner may determine up to 5% whole person permanent impairment for migraine headaches for Chapter 13 and up to 3% whole person impairment for other headaches according to Chapter 3. With respect to the AMA Guides, Fourth Edition, unless other objective features can be rated according to specific organ dysfunction, headache impairment is a qualitative, nonnumeric rating, and “The vast majority of patients with headache[s] will not have permanent impairments.” In some defined cases, the fifth edition facilitates calculation of a pain related impairment score (that specifically is not an impairment rating) that is used to describe the severity of the pain, for which up to 3% whole person impairment may be provided. The sixth edition of the AMA Guides provides a quantitative whole person impairment rating up to 5% whole person impairment for migrainous headaches and 3% whole person impairment for nonmigrainous headaches.
Spine Impairment Evaluation: Sixth Edition Approaches
Authors: Uejo Craig , Eskay-Auerbach Marjorie , Brigham Christopher R.
Published: December 2020

Evaluators who use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, should understand the significant changes that have occurred (as well as the Clarifications and Corrections) in impairment ratings for disorders of the cervical spine, thoracic spine, lumbar spine, and pelvis. The new methodology is an expansion of the Diagnosis-related estimates (DRE) method used in the fifth edition, but the criteria for defining impairment are revised, and the impairment value within a class is refined by information related to functional status, physical examination findings, and the results of clinical testing. Because current medical evidence does not support range-of-motion (ROM) measurements of the spine as a reliable indicator of specific pathology or permanent functional status, ROM is no longer used as a basis for defining impairment. The DRE method should standardize and simplify the rating process, improve validity, and provide a more uniform methodology. Table 1 shows examples of spinal injury impairment rating (according to region of the spine and category, with comments about the diagnosis and the resulting class assignment); Table 2 shows examples of spine impairment by region of the spine, class, diagnosis, and associated whole person impairment ratings form the sixth and fifth editions of the AMA Guides.
Rating Spinal Nerve Extremity Impairment Using the Sixth Edition (Authoritative Article*)
Authors: Brigham Christopher R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, does not provide a separate mechanism for rating spinal nerve injuries as extremity impairment; radiculopathy was reflected in the spinal rating process in Chapter 17, The Spine and Pelvis. Certain jurisdictions, such as the Federal Employee Compensation Act (FECA), rate nerve root injury as impairment involving the extremities rather than as part of the spine. This article presents an approach to rate spinal nerve impairments consistent with the AMA Guides, Sixth Edition, methodology. This approach should be used only when a jurisdiction requires ratings for extremities and precludes rating for the spine. A table in this article compares sensory and motor deficits according to the AMA Guides, Sixth and Fifth Editions; evaluators should be aware of changes between editions in methodology used to assign the final impairment. The authors present two tables regarding spinal nerve impairment: one for the upper extremities and one for the lower extremities. Both tables were developed using the methodology defined in the sixth edition. Using these tables and the process defined in the AMA Guides, Sixth Edition, evaluators can rate spinal nerve impairments for jurisdictions that do not permit rating for the spine and require rating for radiculopathy as an extremity impairment.
Impairment Rating in California: Analysis of the Almaraz and Guzman Decision and Impact on the Use of the AMA Guides, Fifth Edition
Authors: Brigham Christopher R. , Uehlein W. Frederick
Published: December 2020

The Sate of California Workers’ Compensation Appeals Board (WCAB) in a February 3, 2009, decision in the consolidated cases of Almaraz vs SCIF et al. and Guzman vs Milpitas Unified School District (Almaraz/Guzman) concluded that the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, portion of the 2005 Permanent Disability Rating Schedule is rebuttable. The effects of this decision are significant for California and could catalyze challenges regarding use of the AMA Guides in other jurisdictions. Unavoidable consequences of this decision include increased confusion in the assessment of permanent impairment and disability, far more litigation, increased medical and legal costs, and delayed case closure. The consequence of the WCAB's interpretation is significant financial and human costs, including inaccurate expectations by employees regarding the amount of benefits they may reasonably expect, delays in obtaining these benefits, and perceptions of being significantly permanently disabled. Further, the WCAB decision confuses the concepts of “work impairment” and “disability” and presents misleading information about the AMA Guides and its role in assessing impairment. The WCAB decision will be appealed to the Supreme Court, and it likely will be overturned. In the interim, stakeholders must continue to ensure that impairment ratings and resulting disability ratings are accurate. The article reports on and comments in depth regarding the WCAB Decision and highlights errors in the decision.
Obstacles to Claiming Permanence and Injury-Relatedness for “Posttraumatic” Headache
Authors: Barth Robert J.
Published: December 2020

“Posttraumatic” headaches claims are controversial because they are subjective reports often provided in the complex of litigation, and the underlying pathogenesis is not defined. This article reviews principles and scientific considerations in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) that should be noted by evaluators who examine such cases. Some examples in the AMA Guides, Sixth Edition, may seem to imply that mild head trauma can cause permanent impairment due to headache. The author examines scientific findings that present obstacles to claiming that concussion or mild traumatic brain injury is a cause of permanent headache. The World Health Organization, for example, found a favorable prognosis for posttraumatic headache, and complete recovery over a short period of time was the norm. Other studies have highlighted the lack of a dose-response correlation between trauma and prolonged headache complaints, both in terms of the frequency and the severity of trauma. On the one hand, scientific studies have failed to support the hypothesis of a causative relationship between trauma and permanent or prolonged headaches; on the other hand, non–trauma-related factors are strongly associated with complaints of prolonged headache.
Commentary
Authors: Katz Richard T.
Published: December 2020

Patients may complain of daytime drowsiness associated with a painful musculoskeletal disorder, but these complaints regard an activity of daily living (ADL) and do not result in a separate sleep impairment rating. This article focuses on sleep impairment resulting from documented nervous system dysfunction or sleep apnea. Because the accuracy and reliability of sleep testing are critical for the proper diagnosis and impairment rating of a sleep disorder, sleep testing should be completed at a center certified by the American Academy of Sleep Medicine. In both the fifth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), neurologically based sleep disorders are rated using Chapter 13, and sleep apnea is rated using Chapter 5. The AMA Guides, Sixth Edition, does provide a rating value of up to 3% whole person impairment for sleep apnea related impairment, but the fifth edition does not provide any numerical rating value. A sleep disturbance not related to neurologically based dysfunction or apnea should be considered according to its effects on ADLs for the primary pathology identified or diagnosed. Expert understanding of sleep disorders is crucial, as is the specialized experience of a credentialed sleep laboratory. Subjective questionnaires can be used to screen for sleep disorders or excessive daytime sleepiness, but formal sleep studies are necessary to confirm any diagnosis and to provide an objective basis to assess permanent impairment.
A Historical Review of Complex Regional Pain Syndrome in the “Guides Library”
Authors: Barth Robert J.
Published: December 2020

Complex regional pain syndrome (CRPS) is a controversial, ambiguous, unreliable, and unvalidated concept that, for these very reasons, has been justifiably ignored in the “AMA Guides Library” that includes the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), the AMA Guides Newsletter, and other publications in this suite. But because of the surge of CRPS-related medicolegal claims and the mission of the AMA Guides to assist those who adjudicate such claims, a discussion of CRPS is warranted, especially because of what some believe to be confusing recommendations regarding causation. In 1994, the International Association for the Study of Pain (IASP) introduced a newly invented concept, CRPS, to replace the concepts of reflex sympathetic dystrophy (replaced by CRPS I) and causalgia (replaced by CRPS II). An article in the November/December 1997 issue of The Guides Newsletter introduced CRPS and presciently recommended that evaluators avoid the IASP protocol in favor of extensive differential diagnosis based on objective findings. A series of articles in The Guides Newsletter in 2006 extensively discussed the shortcomings of CRPS. The AMA Guides, Sixth Edition, notes that the inherent lack of injury-relatedness for the nonvalidated concept of CRPS creates a dilemma for impairment evaluators. Focusing on impairment evaluation and not on injury-relatedness would greatly simplify use of the AMA Guides.
Guides Question and Answer
Authors: Talmage James B.
Published: December 2020

Sun-related skin disorders are rated, along with all dermatological disorders, using Chapter 8, The Skin, in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) and are based on three factors: the presence of a skin disorder (signs and symptoms); need for treatment; and interference with activities of daily living (ADL). This Case Presentation illustrates some of the challenges that an evaluator new to the rating process may encounter and clarifies that precautionary guidance to reduce sun exposure is not equivalent to interference in ADL and the assignment of impairment. The patient has been a firefighter since 1986, previously worked in construction, lives in Southern California, and surfed recreationally until six or seven years ago. He presents with new lesions of his skin following sun exposure and has been followed by his primary care physician and his dermatologist regarding his basal cell carcinoma and cryosurgeries to treat actinic keratoses. The evaluator determines class 3, 25% impairment, which precludes ADL in the midday sun. The authors note two immediate red flags: Misnaming the AMA Guides is a typical beginner's error, and the evaluation provides no reference to specific criteria or tables even though the State of California uses the fifth edition to rate workers’ compensation cases.
Impairment Rating and Spinal Cord Injuries: Revisiting the Guides
Authors: Katz Richard T.
Published: December 2020

This article addresses some criticisms of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) by comparing previously published outcome data from a group of complete spinal cord injury (SCI) persons with impairment ratings for a corresponding level of injury calculated using the AMA Guides, Sixth Edition. Results of the comparison show that impairment ratings using the sixth edition scale poorly with the level of impairments of activities of daily living (ADL) in SCI patients as assessed by the Functional Independence Measure (FIM) motor scale and the extended FIM motor scale. Because of the combinations of multiple impairments, the AMA Guides potentially overrates the impairment of paraplegics compared with that of quadriplegics. The use and applicability of the Combined Values formula should be further investigated, and complete loss of function of two upper extremities seems consistent with levels of quadriplegia using the SCI model. Some aspects of the AMA Guides contain inconsistencies. The concept of diminishing impairment values is not easily translated between specific losses of function per organ system and “overall” loss of ADLs involving multiple organ systems, and the notion of “catastrophic thresholds” involving multiple organ systems may support the understanding that variations in rating may exist in higher rating cases such as those that involve an SCI.
Dispute Resolution as a Creator of Needless Disability
Authors: Aurbach Robert
Published: December 2020

When injured persons feel pain and a physician tells them that they have a permanent condition, the feeling of pain can become associated over time with the diagnosis, the emotional response to the diagnosis, and factors associated with the diagnosis (including helplessness, fear, anger and overwhelming stress). Even the language associated with the process can be misleading: To some, the phrase “maximum medical improvement” may have the ominous ring of a life sentence with a judgment that they have reached the highest potential for recovery, even if this is not the case. The US legal system often contributes to needless disabling, to the extent that the author coins the term “attorneyogenic disability.” Delaying dispute resolution following disputes in the case causes harm by creating a period when injured workers may obsess about their condition, the people who have wronged them, and the unfairness of the system in failing to compensate them. As delays stretch on, the individual's perception of physical symptoms may become habitual in a complex association of thoughts, feelings, and emotions that affect the worker's neural network. Finally, the legal system stops when the claim is resolved, and the patient's advocate has no systemic motivation to assist after the claim is completed. Planning for functional adaptation and treatment after the dispute resolution often is lacking, especially after the individual has been exposed both to catastrophic thinking in the courtroom and multiple medical evaluations and treatment protocols.
Behavioral Factors Impact Impairment and Disability Evaluation
Authors: Ensalada Lee
Published: December 2020

Illness behavior refers to the ways in which symptoms are perceived, understood, acted upon, and communicated and include facial grimacing, holding or supporting the affected body part, limping, using a cane, and stooping while walking. Illness behavior can be unconscious or conscious: In the former, the person is unaware of the mental processes and content that are significant in determining behavior; conscious illness behavior may be voluntary and conscious (the two are not necessarily associated). The first broad category of inappropriate illness behavior is defensiveness, which is characterized by denial or minimization of symptoms. The second category includes somatoform disorders, factitious disorders, and malingering and is characterized by exaggerating, fabricating, or denying symptoms; minimizing capabilities or positive traits; or misattributing actual deficits to a false cause. Evaluators can detect the presence of inappropriate illness behaviors based on evidence of consistency in the history or examination; the likelihood that the reported symptoms make medical sense and fit a reasonable disease pattern; understanding of the patient's current situation, personal and social history, and emotional predispositions; emotional reactions to symptoms; evaluation of nonphysiological findings; results obtained using standardized test instruments; and tests of dissimulation, such as symptom validity testing. Unsupported and insupportable conclusions regarding inappropriate illness behavior represent substandard practice in view of the importance of these conclusions for the assessment of impairment or disability.
Evaluating Causation for the Opposite Upper Limb
Authors: Melhorn J. Mark , Talmage James B. , Brooks Charles N. , Brigham Christopher R.
Published: December 2020

Workers’ compensation and personal injury claims often become embroiled in debates about the cause of the clinical presentation. When the primary claim involves an extremity, affected individuals sometimes report subsequent symptoms in the contralateral, previously “normal” limb and often attribute its onset to overuse while favoring the initially involved extremity; such an overuse hypothesis seems plausible, and perhaps intuitively obvious, to some. The concept that favoring one upper limb can result in injury to or illness in the other is not based on scientific evidence and instead is an unsupportable myth. Determining relationships between risk factors or exposures and medical conditions is a complex process that is outlined in the Guides to the Evaluation of Disease and Injury Causation (Causation). A search on PubMed and MEDLARS using the key phrases “opposite uninjured arm” and “uninjured arm” returned only six relevant articles, and the authors report that claims of serious or persisting painful syndromes in the arm or hand opposite the injured one are seldom adequately supported by clinical evidence. Similarly, the literature does not support “favoring” as a reasonable cause for development of symptoms in the contralateral shoulder or elbow. Epidemiological studies can provide general information regarding risk; this information must be filtered by specific steps to assess causal association for a disorder and determine if the injury is work related. Findings then can be applied to the specific individual.
Determining Injury-Relatedness, Work-Relatedness, and Claim-Relatedness
Authors: Barth Robert J
Published: December 2020

The American Medical Association's Guides to the Evaluation of Disease and Injury Causation (Causation) is an important component of the AMA Guides library and delineates a type of evaluation that is distinctly different from a diagnostic evaluation, a treatment planning evaluation, a prognosis evaluation, or an impairment evaluation. Causation provides a protocol for determining whether a clinical presentation, in the context of a legal or administrative claim, may be credibly attributed to a claimed cause. This article presents the evaluation protocol from Causation, provides self-assessment questions (so users can check how well they complied with the protocol), highlights the protocol's value as a model for scientifically credible practice in general, and clarifies that the protocol is relevant to claims that involve issues related to forensic causation. Courts and administrative systems have an extremely unfortunate emphasis on opinions from experts rather than on facts. The protocol from Causation is a good example of how clinicians can focus on facts and avoid surrendering to the court or administrative system's emphasis on opinions. The protocol is standardized, objective, fact-based, and scientifically credible and involves the following: establish a diagnosis; apply relevant findings; obtain and assess evidence of exposure; consider other relevant factors; scrutinize the validity of the evidence; and evaluate results and generate conclusions.
AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition: A Response to the NCCI Study
Authors: Rondinelli Robert D. , Eskay-Auerbach Marjorie , Ranavaya Mohammed I. , Brigham Christopher R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Sixth Edition, is the recognized international standard for assessing impairment. The National Council on Compensation Insurance (NCCI) conducted a comparative study to examine the effects on impairment ratings in three states that have switched from the fifth to the sixth edition. The purpose and objectives of this article are as follows: 1) to provide a brief review of the conceptual framework and terminology of disablement and of the current model of disability in the AMA Guides and also to underscore the importance of the construct of medical impairment to compensation schemes within workers' compensation and other disability systems; 2) to examine the AMA Guides in terms of its origin, purpose, distribution, applications, and misapplications; 3) to examine the changes in the sixth edition in terms of efforts to direct change and improve upon the AMA Guides; 4) to examine the merits and shortcomings of the NCCI study and its conclusions within a broader context of inherent sources of variance in impairment ratings, as well as the content validity, reliability, and reproducibility of the ratings themselves; 5) to provide recommendations regarding the implications of this study for the use of the sixth and earlier editions of the AMA Guides, and to suggest new directions for much needed critical research.
Question and Answer
Authors: Brigham Christopher R. , Melhorn J. Mark , Talmage James B.
Published: December 2020

Following successful surgical treatment of an inguinal hernia (ie, preparing the defect), there should be no ratable impairment unless there is clearly recognized nerve injury or a complication such as infection. The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth and Sixth Editions, provide guides to the rating of permanent impairment for hernias. Both stress that impairment evaluation is predicated on the existence of a causal relationship between the individual's condition and an event or exposure. If a patient has an appropriate repair, then the defect should be resolved; that is, there should be no physical examination findings of a palpable deficit nor of a protrusion. If a palpable defect is present and the hernia is causally related to an injury, then the hernia is ratable. As with all ratings, the underlying basis must be reliable; that is, the history, including reported activities of daily living (ADL), must be supportable. In the AMA Guides, Fifth Edition, three examples show ratings, all of which depend on objective findings of palpable defects (protrusions). The sixth edition outlines the assignment of one of four classes of findings and interferences with ADLs. Impairment is based on objective findings when the individual is at maximum medical improvement.
A Trial Consultant's View of the Medical Expert Witness
Authors: Rutt Deborah , Mueller Kathyrn
Published: December 2020

Physicians who use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) often serve as medical expert witnesses. In workers’ compensation cases, the expert may appear in front of a judge or hearing officer; in personal injury and other cases, the physician may testify by deposition or in court before a judge with or without a jury. This article discusses why medical expert witnesses are needed, what they do, and how they can help or hurt a case. Whether it is rendered by a judge or jury, the final opinions rely on laypersons’ understanding of medical issues. Medical expert testimony extracts from the intricacies of the medical literature those facts the trier of fact needs to understand; highlights the medical facts pertinent to decision making; and explains both these in terms that are understandable to a layperson, thereby enabling the judge or jury to render well-informed opinions. For expert witnesses, communication is everything, including nonverbal communication that critically determines if judges and, particularly, jurors believe a witness. To these ends, an expert medical witnesses should know the case; be objective; be a good teacher; state opinions clearly; testify with appropriate professional demeanor; communicate well, both verbally and nonverbally; in verbal communications, explain medical terms and procedures so listeners can understand the case; and avoid medical jargon, finding fault or blaming, becoming argumentative, or appearing arrogant.
Impairment Related to Diseases of the Aorta
Authors: Demeter Stephen L.
Published: December 2020

Aneurysms may result in ratable permanent impairment, and this article provides a basic understanding of aneurysms and how to rate them using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. An aneurysm is a bulge in a blood vessel, commonly in the arterial circulation and in the cerebral and renal vasculature or in the aorta. Because ruptured aneurysms frequently are lethal, generally they are treated prophylactically once they have reached a certain size. Endovascular repair is associated with an increased risk of all-cause mortality and abdominal aortic aneurysm mortality. The AMA Guides, Fifth Edition, rated aneurysms solely on the risk of rupture (ie, a future impairment, one of the few exceptions to their general proscription in the AMA Guides), and the impairment percentages can be quite large. These impairments are rated using the rating systems for the affected organ system when the individual is at maximum medical improvement (MMI). In addition, the risk of future impairment should be assessed when the individual is at MMI, and that rating should be combined with the rating for organ system vascular compromise. The justification for rating the risk of future events should be clarified in the report, which should cite the method reported in the present article because the AMA Guides, Sixth Edition, does not provide a methodology for rating this disease process.
Apportionment of Impairment from Meniscal Tears and Knee Arthritis
Authors: Brooks Charles N. , Talmage James B.
Published: December 2020

Meniscal tears and osteoarthritis (osteoarthrosis, degenerative arthritis, or degenerative joint disease) are two of the most common conditions involving the knee. This article includes definitions of apportionment and causes; presents a case report of initial and recurrent tears of the medial meniscus plus osteoarthritis (OA) in the medial compartment of the knee; and addresses questions regarding apportionment. The authors, experienced impairment raters who are knowledgeable regarding the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), show that, when instructions on impairment rating are incomplete, unclear, or inconsistent, interrater reliability diminishes (different physicians may derive different impairment estimates). Accurate apportionment of impairment is a demanding task that requires detailed knowledge of causation for the conditions in question; the mechanisms of injury or extent of exposures; prior and current symptoms, functional status, physical findings, and clinical study results; and use of the appropriate edition of the AMA Guides. Sometimes the available data are incomplete, requiring the rating physician to make assumptions. However, if those assumptions are reasonable and consistent with the medical literature and facts of the case, if the causation analysis is plausible, and if the examiner follows impairment rating instructions in the AMA Guides (or at least uses a rational and hence defensible method when instructions are suboptimal), the resulting apportionment should be credible.
Do Rear-End Motor Vehicle Collisions Cause Rotator Cuff Tears?
Authors: Brooks Charles N. , Funk James R. , Mark Melhorn J. , Talmage James B. , Brigham Christopher R.
Published: December 2020

The rotator cuff comprises four muscles and their tendons, the supraspinatus, infraspinatus, teres minor, and subscapularis. Rotator cuff tears (RCTs) are common and most frequently involve the supraspinatus, and usually occur through tendon rather than muscle. Clinical manifestations vary depending on the size and age of the tear, the individual's physical demands, psychosocial factors, and other variables; tears may range from the asymptomatic to large, full-thickness, and retracted tears that cause pain, weakness, and at least partial disability. Individuals involved in rear-end motor vehicle collisions (MVCs) may complain of “shoulder” pain, and magnetic resonance imaging may reveal the presence of shoulder cuff tears, high-energy trauma can cause rotator cuff tears, but the tensile forces encountered in rear-end MVCs almost certainly do not cause rotator cuff tears de novo. Because rear-end collisions and RCTs are common and often involve claims or lawsuits, physicians may be asked to assess the causation of the RCTs. Treatment should be based on clinical findings and not the results of imaging; the same applies to causation analysis: Involvement in a rear-end MVC does not establish causality for a rotator cuff tear. The medical literature is devoid of evidence indicating that rear-end collisions cause RCTs, but compelling evidence in the biomechanical literature shows that low-speed rear-end MVCs do not cause RCTs.
Clinical Assessment of Cervical Myelopathy
Authors: Eskay-Auerbach Marjorie , Brooks Charles N.
Published: December 2020

Myelopathy literally indicates any pathology of the spinal cord, but the term most commonly is used when the cord pathology results from degenerative disease. Specific names usually are used if the disorder is traumatic (spinal cord injury), infectious (myelitis), or neoplastic (the name of the tumor is used). Cervical myelopathy (CM) may result in symptoms such as clumsiness, loss of dexterity, imbalance or poor coordination; muscle weakness; pain; and, in severe cases, bowel, bladder, or sexual dysfunction. When impairment is rated, if the evaluator finds objective evidence of myelopathy when the individual is at maximum medical improvement, neurological impairment is combined with that for the spine. A detailed and thorough neurologic examination is the current standard for the diagnosis of CM, but diagnosis is challenging in the early stages. Correlation of patient symptoms and imaging studies, both plain radiographs and magnetic resonance imaging scans, is essential for correct diagnosis. When imaging studies are equivocal or insensitive, other studies such as electrodiagnostic testing and cerebrospinal fluid analysis may be considered. When CM is defined as the presence of more than one long-tract sign, spinal cord compression in isolation did not cause myelopathy, and up to 20% of those with cord compression did not exhibit CM.
Evidence-Based Medicine, Treatment Guidelines, and Literature Search Web Resources
Authors: Brigham Christopher R.
Published: December 2020

Cardiopulmonary exercise stress testing (CPET) provides objective data to assess cardiac and pulmonary impairment. This article discusses changes in the CPET section of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The explanation of CPET in the AMA Guides, Sixth Edition, adds a single word, “static,” that significantly effects how this test should be conducted. Routine pulmonary function tests (PFTs) provide information about a person's ability to breathe, eg chronic obstructive pulmonary disease or asthma can stratify the severity of these diseases; they do not measure the ability of the lungs or heart to provide adequate oxygenation to metabolizing tissues. Static tests of lung function are the norm when diagnosing asbestosis, and the typical abnormalities seen are restriction, some airflow obstruction, and a diminished diffusing capacity. These abnormalities correlate linearly with the degree of abnormality found radiographically. In individuals with unexplained shortness of breath with exertion or fatigue that is not easily explained in the medical records, a CPET will allow secure diagnosis of causation. Thus CPET is a powerful tool to explain shortness of breath with exertion or fatigue, and CPET has a role in the impairment rating process of all individuals with interstitial lung diseases and in selected individuals with unexplained symptoms.
Sacroiliac Joint Pain: Clinical and Impairment Rating Issues
Authors: Eskay-Auerbach Marjorie , Talmage James B.
Published: December 2020

The sacroiliac joint (SIJ) is an accepted source of pain in patients with ankylosing spondylitis and other spondyloarthropathies, osteoarthritis, infections, and tumors, but the occurrence of isolated SIJ pain in the absence of such diseases is controversial. The term, sacroiliac joint dysfunction, which is used widely, describes pain from an SIJ that has no identifiable lesion but is presumed to have some mechanical etiology. Practitioners currently have no universally accepted gold standard for identifying a disc, facet joint, of SIJ as the pain generator. Treatment options for SIJ pain include medications, physical therapy, bracing, manual therapy, injections, radiofrequency neurotomy, and arthrodesis. Optimal management of patients with SIJ pain remains controversial. In the AMA Guides, Sixth Edition, a clinically established and causally related diagnosis of SIJ dysfunction is rated using the first row in Table 17-4. Surgery does not change the diagnosis or rating: The SIJ is not a motion segment of the lumbar spine, and SIJ fusion is not an alteration of motion segment integrity. Clinically, pain presumed to be from SIJ dysfunction is low back pain, so if this is the clinical diagnosis, the spine chapter in the AMA Guides, Fifth Edition, should be used. In such cases, the first step is to determine whether to use the diagnosis-related estimate or the range-of-motion method, and the article provides guidance about situations in which the use of each is appropriate.
Fit Vs Faint: Assessing Work Causation in “Idiopathic Fall” Cases
Authors: Direnfeld Lorne , Torrey David B. , Black Jim , Haley LuAnn , Brigham Christopher R.
Published: December 2020

When an individual falls due to a nonwork-related episode of dizziness, hits their head and sustains injury, do workers’ compensation laws consider such injuries to be compensable? Bearing in mind that each state makes its own laws, the answer depends on what caused the loss of consciousness, and the second asks specifically what happened in the fall that caused the injury? The first question speaks to medical causation, which applies scientific analysis to determine the cause of the problem. The second question addresses legal causation: Under what factual circumstances are injuries of this type potentially covered under the law? Much nuance attends this analysis. The authors discuss idiopathic falls, which in this context means “unique to the individual” as opposed to “of unknown cause,” which is the familiar medical terminology. The article presents three detailed case studies that describe falls that had their genesis in episodes of loss of consciousness, followed by analyses by lawyer or judge authors who address the issue of compensability, including three scenarios from Arizona, California, and Pennsylvania. A medical (scientific) analysis must be thorough and must determine the facts regarding the fall and what occurred: Was the fall due to a fit (eg, a seizure with loss of consciousness attributable to anormal brain electrical activity) or a faint (eg, loss of consciousness attributable to a decrease in blood flow to the brain? The evaluator should be able to fully explain the basis for the conclusions, including references to current science.
Peripheral Nerve Entrapment Impairments Revisited: Part I
Authors: Melhorn J. Mark , Talmage James B. , Brooks Charles N.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, introduced the concept of diagnosis-based impairments (DBI), and a modified version of this method can be used in rating peripheral nerve injury in general (Section 5.4) and upper limb entrapment syndromes (Section 15.4f). The first portion of this article reviews the evaluation of upper extremity nerve impairment and summarizes inclusion criteria and causation correlation for carpal tunnel syndrome, Guyon's canal syndrome, cubital tunnel syndrome, anterior interosseous, Wartenberg's syndrome, and radial tunnel syndrome. Very mild nerve entrapments do exist and may fail to meet the AMA Guides criteria for impairment related to a diagnosis of nerve entrapment. Electrodiagnostic examination includes nerve conduction studies that assess the largest, most heavily myelinated axons, and needle electromyelography, which detects muscle membrane instability but not the sensory function of nerves. A case example from the AMA Guides, Sixth Edition, shows the process of permanent impairment rating in a case of carpal tunnel syndrome. Determination of impairment for peripheral nerve entrapments can be easily accomplished once one understands how to determine if the nerve under consideration from the electrodiagnostic evaluation demonstrates a conduction delay, a conduction block, or an axon loss. This establishes the test findings that usually are the only objective findings present.