bluuebunny/crossref_metadata_2025 huggingface dataset:
Malingering and Other Validity Considerations: With an Emphasis on Document Review
Authors: Patterson Chris Stewart , Barth Robert J. , Brigham Christopher R. , Talmage James B. , Leclair Steven , Coupland Michael
Published: December 2020

Many of the methods used to assess impairment rely on the completeness, accuracy, and reliability of patients’ self-presentations, and evaluators should be able to identify behavioral factors such as illness behavior and malingering; the latter is not ratable, but its presence complicates appropriate case management. This article focuses on the clinical data and the analysis that can be helpful in identifying malingering, as well as validity problems during document and medical file reviews. According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, examiners always should be aware of the possibility of malingering during impairment evaluations, and the possibility of avoiding responsibility and/or obtaining monetary awards increases the likelihood of exaggeration and/or malingering. Current methods for assessing malingering in general assess the probability of malingering based on comparisons to research statistics and free the evaluator from any reliance on expert opinion. Correlating multiple clinical sources is useful in assessing the validity of a clinical presentation and includes the individual's pre-existing status; information about the injury; the history of the presenting illness, past medical and social histories, physical examination, questionnaires and scales, functional capacity evaluations, and video surveillance. Coherence analysis is a method of clinical data review that uses multiple themes to determine if data provide an integrated presentation. Evaluators should highlight issues of discontinuity, inconsistencies, incongruencies, noncompliance, or poor effort.
Rating Distal Clavicle Resection
Authors: Books Charles N. , Talmage James B. , Melhorn J. Mark
Published: December 2020

Indications for excision of the distal clavicle include symptomatic degenerative arthritis of the acromioclavicular joint, impingement syndrome, and osteolysis of the distal clavicle if nonoperative treatment has failed. Distal clavicular resection (DCR), one could argue, is by definition an impairment because of the loss of a portion of a body part, the clavicle. Yet a competently performed and uncomplicated DCR generally results in improved function, not loss of use. DCR was first mentioned in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, which stated that a resection arthroplasty of the acromioclavicular joint warrants 10% upper extremity impairment (UEI). Rating DCR using the AMA Guides, Fifth Edition, is almost the same as using the fourth edition, but evaluators can use one of two approaches: The rating physician can select a 3% rating for DCR using the fifth edition and claim to be literally following the instructions and providing a sensible rating in view of the generally good results reported in the orthopedic literature following a DCR. Alternatively, a rating physician who is aware of the historical precedent underlying the 10% UEI in Table 16-27 could cite this and the absence of an instruction in the Arthroplasty section to justify a 10% impairment rating. In the sixth edition, DCR is a key factor in classifying an acromioclavicular joint injury or disease but is disregarded in the rating of rotator cuff or glenohumeral pathology.
Determining Normal for Upper and Lower Limb Motions
Authors: Brooks Charles N. , Brigham Christopher R.
Published: December 2020

Normal joint motions vary from one person to another and depend on multiple factors, which raises issues when evaluators attempt to address issues of causation and apportionment. Although the causation and apportionment of joint motion deficits were not addressed in the fourth and earlier editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), the fifth and sixth editions took three possibilities into consideration when they provided instructions about how to evaluate impairment due to diminished mobility of upper and lower limb joints. Evaluating physicians must consider whether: 1) the motion deficit existed before the injury or illness in question or if the deficit was caused by individual variation, aging, disease, trauma, and/or other cause; 2) the motion deficit was caused by the injury or illness that is at issue or is in question; and 3) a lesser, pre-existing motion deficit existed before the current injury or illness was aggravated (permanently increased). Because of variations in normal joint motions among individuals, examiners should measure the motions of the uninvolved as well as the involved joints, using the former to define normal. Any motion impairment of the uninvolved joint is subtracted from that for the involved joint to determine the net impairment. Examples from the fifth and sixth editions show applications of the AMA Guides to two sample cases.
Combining Values Chart
Authors: Brigham Christopher R.
Published: December 2020

Evaluating physicians may need to account for the effects of multiple impairments using a summary value. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, the Combined Values Chart provides a method to combine two or more impairment percentages based on the formula A + B(1 – A) = the combined value of A and B. Using the Combined Values Chart and this formula, physicians can combine multiple impairments so that the whole person impairment is equal to or less than the sum of all the individual impairment values. The AMA Guides, Sixth Edition, specifies that “impairments are successively combined by first combining the largest number with the next largest remaining number, and then further combining it with the next largest remaining number … until all given impairment numbers are combined.” Impairment values within a region generally are combined and converted to whole person permanent impairment before being combined with values from other regions. The article reviews the AMA Guides, Sixth Edition, approach to combining upper extremity impairments, lower extremity impairments, and combining spinal impairments.
Evaluating Causation for the Opposite Lower Limb
Authors: Brigham Christopher R. , Brooks Charles N. , Talmage James B.
Published: December 2020

Causation analysis always should be based on current scientific evidence and the facts of a specific case rather than common opinions or beliefs, eg, the myth that “favoring” one lower extremity often results in injury or illness of the opposite lower limb. Temporal sequence does not prove causation, and in causation analysis one also must consider temporal disparity: Was an injury or exposure likely to cause the condition in question, or is there another, more probable, cause? To conclude that a given cause and effect are etiologically associated with a reasonable degree of medical probability or certainty (ie, more than 50% probability), all three of the following criteria must be met: the cause is medically probably; the effect is medially probably; and the cause and effect probably are etiologically related. That is, causation analysis must be based on an analytical approach and not patient history alone. The medical literature reveals no generally accepted studies that support a causal relationship based on an individual's “favoring” one extremity. Rather, evaluators must base conclusions on scientific evidence and facts of the case at hand rather than relying solely on patient history or false logic such as the post hoc propter hoc fallacy.
“Double-Dipping”
Authors: Demeter Stephen L.
Published: December 2020

The goal of impairment assessment is to accurately estimate the loss of structure and/or function due to an injury or illness. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) sometimes provides two or more methods for rating a given condition, or, in the case of two or more impairing conditions, it may be inappropriate to rate less significant conditions if the rating for the primary impairment already takes into account the deficit(s). Either scenario offers opportunities for “double-dipping” or rating the same impairment more than once. Duplicative ratings commonly occur when two or more impairing conditions are present in a single organ system and even more often if multiple organ systems are involved. Because of methodological changes, ratings using the AMA Guides, Sixth Edition, are less susceptible to double-dipping than those from earlier editions, especially musculoskeletal ratings. To avoid duplication, the rater must look closely at all elements included in the impairment classes and determine if any similarity exists in the other organ systems or conditions rated (eg, is the patient's coronary artery disease responsible for the diminished exercise capacity, or is it the cardiomyopathy, or is it chronic obstructive pulmonary disease). When two or more conditions are present, evaluators should rate the higher or highest impairment and then eliminate, as much as possible, the influence of similar symptoms, signs, or diagnostic test abnormalities when rating the lower impairments.
American Medical Association Impairment Ratings and Earnings Losses Due to Disability
Authors: Seabury Seth A. , Neuhauser Frank , Nuckols Teryl
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) has been criticized because it was designed to measure the severity of impairment (loss of function of a body part) rather than disability (eg, inability to work), and the AMA Guides uses whole person impairment that accords higher priority to body regions that are deemed more important to functionality even though no objective evidence supports the relative importance of different body regions. This article reports on a study funded by the California Commission on Health and Safety and Workers’ Compensation (CHSWC) to address these concerns. The study found that the AMA Guides, Fifth Edition, is an effective tool for ranking the effect of physical impairments on the ability to work; people with higher physical impairment ratings, measured using the AMA Guides, consistently had higher earnings losses. The authors conclude that ratings based on the AMA Guides, Fifth Edition, probably are more accurate and consistent than ratings conducted under the previous system in California, the system used by the Veterans Administration, or systems used by Wisconsin and Florida in the 1960s. The authors also identified significant challenges to using ratings based on the AMA Guides to determine financial compensation, particularly across body regions, and some evidence suggests that the relationship between impairment ratings and losses was attenuated at higher ratings.
To Combine or Not to Combine
Authors: Ranavaya Mohammed I , Rondinelli Robert
Published: December 2020

Physicians must account for the effects of multiple impairments using a summary value. Sometimes, when dealing with multiple impairments in a single case, the evaluating physician may be confused about whether specific impairments are added or combined, particularly during the assessment of hand or limb injuries. Combining is accomplished by using the Combined Values Chart presented in the Appendix of each edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). With a few exceptions, the general rule is that all impairments should be combined. The combining must occur at the same hierarchal level (eg, upper extremity impairment can be combined only with another upper extremity impairment from the same limb), and whole person impairment (WPI) can be combined only with another WPI impairment. In case of impairments from a different limb (either from both upper or lower limbs) even though they may be expressed at the same hierarchal limb (eg, upper extremity or lower extremity), they should be combined at the WPI level only after the individual limb is fully rated and the final impairment for that limb is expressed at the WPI level. Evaluators should remember that impairing factors (sensory, motor, vascular, and so on) are combined at the smallest common unit (ie, digit < hand < upper extremity < whole person).
Evidence-Based Medicine: Determining Quality of Randomized Controlled Trials
Authors: Cheng Melissa
Published: December 2020

Evidence-based medicine is based on evidence gathered by randomized controlled trials (RCTs), which are considered the “gold standard” of research studies. Users of the medial literature must be able to read critically and evaluate RCTs. The present article uses the standards of the American College of Occupational and Environmental Medicine (ACOEM) practice guidelines in evaluating RCTs according to 11 criteria; these criteria follow those used by the Cochrane Collaboration in their evidence-based reviews. Well-written articles present their randomization schemes to create comparable groups, and studies must be controlled for co-interventions; in a double-blind trial, the co-interventions would be used equally in both groups, and treatment allocations should be concealed. Readers should ask if the study had acceptable compliance; that is, were patients doing what they were asked, and was the dropout rate acceptable (typically, less than 20%)? RCTs should be analyzed by an intention-to-treat analysis that includes all study subjects who were randomized, not just those who completed the study. Having high internal validity ensures a more accurate study that can be reproduced by others, so readers may ask if results are likely to be affected by observational bias, confounding, or chance variation. Readers can determine external validity by assessing study participants according to inclusion and exclusion criteria and baseline characteristics.
Cardiopulmonary Exercise Stress Testing – an Update
Authors: Demeter Stephen L.
Published: December 2020

This article updates one published in The Guides Newsletter in January/February 1998 and reflects changing legislation in the workers’ compensation area and also in motor accident compensation. In the various Australian state and federal jurisdictions, impairment rating has become an important component of independent medical examinations, and in many areas, impairment guides have been adopted as a mandatory tool for assessing permanent impairment. For example, in the mid-1990s the state of Victoria established use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, as the sole tool for evaluating impairment and continues to use this edition to the present time. Despite the publication of the AMA Guides, Fifth Edition, in 2000, the Motor Accidents Authority in New South Wales (NSW) continues to use the fourth edition, supplemented with the NSW Motor Accidents Authority Guidelines. In November 2001, Tasmania adopted the same guidelines that were being used by the NSW Motor Accidents Authority. Despite publication of the AMA Guides, Sixth Edition, in 2007, there has remained a general reticence in Australia to progress to use of this latest edition either as stand-alone impairment rating tools or an underpinning of the purpose-developed impairment guidelines already in place. A large number of Australian medical assessors have become used to the model based on the NSW WorkCover Guides for the Evaluation of Permanent Impairment, which interprets the AMA Guides, Fifth Edition.
Impairment Rating for Non-Specific Back Pain Under the AMA Guides, Sixth Edition: Medical Perspective
Authors: Talmage James B. , Blaisdell Jay , Eskay-Auerbach Marjorie , Brigham Christopher R.
Published: December 2020

Low back pain and disability are common and evaluating a patient with non-specific spinal pain may be challenging, including determining impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, provides ratable impairment for the diagnosis of “non-specific chronic, or chronic recurrent low back pain (also known as chronic sprain/strain, symptomatic degenerative disc disease, facet joint pain,” and others. The evaluator should consider the diagnosis of non-specific chronic back pain only when no category of specific diagnosis fits the case (eg, no fracture, no spinal stenosis) or when “no reliable physical examination or imaging findings” but the patient's history of pain is felt to be reliable. According to the AMA Guides, primary determinant between a class 0 and class 1 rating for non-specific chronic back pain is whether the evaluator gives credibility to the patient's subjective reports of pain and interference with activities of daily living (ADLs). An evaluator may choose to use the Pain Disability Questionnaire (reproduced in the article) and Table 17-6, Functional History Adjustment, Spine, to determine the Functional History Grade Modifier (GMFH). The diagnosis of non-specific chronic or chronic recurrent low back pain yields a positive impairment only when the evaluator feels the patient's pain, as quantified by the GMFH, is reliably reported. Because there are no diagnostic objective findings on physical examination or clinical studies, these modifiers are excluded.
Electrodiagnosis of the Peripheral Nervous System: An Introduction
Authors: Katz Richard T.
Published: December 2020

This article is an introduction to electrodiagnosis of the peripheral nervous system, including electromyography, electroneurography (nerve conduction studies), and somatosensory evoked potentials. Electromyography involves the introduction of a special recording needle into a muscle body in search of spontaneous activity (electrical potentials that occur while the muscle is at rest). Three types of spontaneous activity are of greatest relevance: positive sharp waves, fibrillation potentials, and fasciculations. Electromyography can help assess the status of nerve fibers indirectly, but the integrity of large myelinated sensory and motor neurons can be evaluated directly by nerve conduction studies (NCS), also known as electroneurography. NCS involves the introduction of an electrical stimulus, either by surface electrode or needle, and recording an evoked response. NCS can assess motor neurons, sensory neurons, or mixed nerve trunks, depending on the strategy employed. Somatosensory evoked potentials (SSEP) sometimes are useful as an adjunct to EMG and NCS in the diagnosis of peripheral nervous system pathology and are obtained by stimulating a peripheral mixed nerve at a frequency of approximately 2-5 Hz. Several manufacturers have created automated, hand-held units for performing nerve conduction studies, and neuromuscular ultrasound is noninvasive and painless, and ultrasound of nerve entrapment has identified nerve enlargement just proximal to the site of entrapment. Physicians should know or learn the qualifications of the physician to whom they refer their patients for electrodiagnostic assessment.
Two-Point Discrimination in the Use of Upper Extremity Nerve Function in the AMA Guides
Authors: Katz Richard
Published: December 2020

This article presents a case report regarding a 34-year-old obese male who works as a chipper and grinder at a steel manufacturing mill and uses high-frequency vibratory power tools. He presents with typical complaints of carpal tunnel syndrome, including numbness in all five digits, wrist pain, nocturnal awakening/numbness, and others. Two-point discrimination (2PD) using a caliper was tested in the digits of the upper extremities and was 5 mm throughout. 2PD first appeared in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, and the Sixth Edition states, “sensory deficits can be challenging to grade, since the clinical examination is based on subjective reports by the patient. Grading is based on the results of sensibility testing and two-point discrimination, to improve inter-rater reliability.” The discussion of “sensibility” involves a concept of sensory perception that is more appropriate in surgery literature than neurological literature, and the discussion of the case report in this article reflects the recent literature regarding 2PD as a measure of sensibility. The authors report that sensibility is not a simple recovery of sensory function following nerve injury but rather is a complex interaction between nerve recovery and modulation of central nervous system function in spinal cord, subcortical, and cortical structures. The authors ask if the value of 2PD in the clinical assessment of impairment has been overrated within the AMA Guides, as was range of motion in the assessment of spine impairment.
In Recent Literature
Authors: Brigham Christopher R.
Published: December 2020

This column presents abstracts, as published in PudMed.gov (U.S. National Library of Medicine, National Institutes of Health) that are pertinent to the evaluation of patients who are injured or ill.
Apportionment of Medical Illness
Authors: Demeter Stephen L. , Hoo E. Randolph Soo
Published: December 2020

Apportionment sometimes is necessary when a person had a prior injury that affected the same organ system or when there was evidence of a pre-existing disorder that was similar to the injury that will be rated. The past three editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) include subtle differences in the way that apportionment is defined. In addition to the information provided in the appropriate edition, certain philosophical and mechanistic considerations should be assessed before any apportionment and then should be used consistently in any subsequent cases that require apportionment. The first step in apportionment is a scientifically based causation analysis. Evaluators must avoid arbitrary, opinion-based unscientific apportionment estimates that are little more than speculations. In a situation that involves multiple injuries, if the impairment assessment has reached a defensible position with respect to causation then the rating for the first injury is determined using the edition of the AMA Guides that was used to rate the second injury. For example, if the rating for a second injury will be determined using the sixth edition, then the data for the first injury should be reworked using the sixth edition rules, irrespective of the rating for the first injury and the edition that was used.
Range of Motion: AMA Guides, Sixth Edition
Authors: Talmage James B. , Blaisdell Jay
Published: December 2020

In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, range of motion (ROM) is used to calculate the physical examination modifier when the diagnosis-based impairment (DBI) method is used, ie, Table 15-8, Physical Examination Adjustment: Upper Extremities, and Table 16-7, Physical Examination Adjustment: Lower Extremities. The DBI method is preferable for calculating upper and lower extremity ratings, but in instances specified by the regional grid, the evaluator may choose to use the ROM method, typically because it yields a higher impairment rating. The article outlines the steps for measuring ROM. Invalid results on the day of testing are declared after three consecutive efforts if the three measurements for a given plane of motion vary by more than 10 degrees from the average (mean) of these three measurements. The process can be tried again another day, or the DBI method can be used. All ROM measurements should be rounded to the nearest number ending in zero, and a figure provides examples of suitable annotations. Adjustments for functional history can be made if ROM is the only method used for rating, if results are deemed reliable and consistent with results from an activities of daily living questionnaire or other valid functional report, and if the current ROM impairment does not adequately capture the full impairment.
Social Security Disability and the AMA Guides
Authors: Hoo E. Randolph Soo
Published: December 2020

Two disability programs are administered by the US Social Security Administration (SSA): Disability under Title II of the Social Security Act is referred to as SDI, which is funded via contributions made by the individual worker, and disability under Title XVI of the Act commonly is referred to as SSI, which is funded through general funds from the US Treasury. Both SDI and SSI disability adjudication use the same five-step sequential evaluation process to determine if a claimant fulfills SSA's disability definition. The foundation for determining disability under SSA is medical evidence that establishes a medically determinable impairment based on defined evidentiary criteria. SSA determines disability, does not rate disability, and awards disability benefits only for total disability. Unlike SSA, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not determine (or rate) disability. The AMA Guides, Sixth Edition, emphasizes the use of evidence-based diagnosis for determining whole person impairments and contrasts with SSA disability for which a diagnosis is not a requirement and the focus is placed on determining «impairment» based on symptoms, clinical signs, and laboratory/diagnostic findings. SSA determines disability, does not rate disability, and awards disability benefits only for total disability. An impairment rating using the AMA Guides should not be equated to an SSA disability determination.
Cardiovascular Impairment Evaluation: Sixth Edition
Authors: Talmage James B. , Blaisdell Jay
Published: December 2020

To assess medical impairments, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) divides cardiovascular diseases into the following eight groups, each of which has its own grid: valvular heart disease; coronary artery disease; cardiomyopathies, pericardial heart disease, dysrhythmias, hypertensive cardiovascular disease, vascular diseases affecting the extremities, and diseases of the pulmonary artery. An accompanying table shows the criteria for rating permanent impairment due to valvular heart disease. Within the grids, the rows are divided into three main impairment variables: history, physical findings, and objective test results. The latter are essential in assigning cardiovascular impairment ratings. The AMA Guides names the objective test results variable as the key factor to underscore its role in assigning the impairment class in the cardiovascular chapter. For cardiovascular impairments, objective test results are always used to place the injury in its impairment class; therefore, objective test results are never used to modify the rating once the evaluator chooses the impairment class. Not all internal medicine chapters designate objective test results as the key factor, but all use one key factor that is clearly indicated in a footnote and one or two non-key factors. This rating scheme emphasizes objective test results, history, and physical findings and avoids incorporating variables twice.
Sex-Specific Conditions, Gender, and Evaluation Using the AMA Guides
Authors: Cocchiarella Linda , Mueller Kathryn
Published: December 2020

Concerns about potential sex and gender bias during impairment and disability evaluations have been raised; this article reviews ways in which sex and gender contribute to the unique presentation, manifestations, treatment, and functional outcome of medical conditions and how these differences can be appropriately addressed using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Sex differences are objective and are based on biochemical and biological factors; gender refers to cultural attitudes that are learned and vary by culture, history, and ethnicity. The AMA Guides acknowledges individual variations and advocates a flexible approach: Physicians can choose among sections of the AMA Guides those best suited to account for individual and sex differences. The AMA Guides does not advocate different evaluation of medical conditions based on sex, except for sex-specific disorders (eg, unique male or female reproductive organs). The health care system is striving to eliminate gender and sex bias, and impairment and disability are following by attempting to eliminate bias by offering individualized assessments of how impairment affects the injured organ, use of unique rating methods to fully characterize the impairment, use of rating ranges to account for individual variability and sex, and by ascribing equal values to gender-ascribed activities of daily living.
Impairment Assessment of Male Sexual Dysfunction
Authors: Brigham Christopher R. , Soo Hoo Randy
Published: December 2020

Impairment assessment of male sexual dysfunction using both the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions, must be done with appropriate evaluation and objective findings in order to support ratable sexual dysfunction. The fifth edition specified that the absence of sexual functioning results in a maximum rating of 20% whole person impairment (WPI); in the sixth edition, the maximum is 15%. In the AMA Guides, Fifth and Sixth Editions, sexual dysfunction is discussed in Chapter 7, The Urinary and Reproductive Systems, and in Chapter 13, The Central and Peripheral Nervous System. In the fifth edition, Section 7.7, Male Reproductive Organs, provides guidance for impairment percentages for male reproductive organs for men aged 40–65 years; age adjustment is made for males younger than 40 (WPI is increased 50%) and older than 65 (WPI is decreased 50%). Section 13.7d, Sexual System Neurologic Impairments, in the fifth edition of the AMA Guides directs evaluators to use Table 13-21, Criteria for Rating Neurologic Sexual Impairments. In the sixth edition, Section 7.7 similarly offers guidance for impairment percentages for male reproductive organs for men aged 40–65 years but, unlike the fifth edition, allows a 10% upward or downward adjustment at the evaluator's discretion based on the individual's age and level of premorbid sexual functioning. In the sixth edition, Table 7-6, Criteria for Rating Permanent Impairment Due to Penile Disease, presents four classes and three grades.
Case Study: Use of Electrodiagnostic Evaluation to Assess Lumbar Radiculopathy
Authors: Dagher Edward , Talmage James B. , Direnfeld Lorne , Brigham Christopher R.
Published: December 2020

The electrodiagnostic examination is an important diagnostic tool that defines the location, pathophysiology, severity, and chronicity of a wide array of neuromuscular disorders. The test comprises two parts, a nerve conduction study (NCS) and needle electromyography (EMG), and is an extension of the neuromuscular portion of the physical examination. Together, NCS and EMG provide complementary information about the integrity of the peripheral nervous system. The article presents a case example that is evaluated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. The case describes a 52-year-old woman who had a back injury that was managed conservatively for fifteen months and then underwent a three-level lumbosacral instrumented posterolateral fusion (the rationale is unclear from the records). Her pain persisted and treatment has included chronic narcotics; she reported multiple physical and psychological complaints and difficulties, and illness behavior and unreliable self-reports failed to corroborate her reports. Needle EMG must be performed on the patient's paraspinal muscles for proper evaluation of radiculopathy, and in this case there was no evidence of involvement of any ventral ramus and thus no evidence was documented of nerve root abnormality involving two or more limb muscles that receive innervation from the same nerve root. For this individual, the changes seen in paraspinal EMGs were unlikely to be due to a true lumbar radiculopathy, which was not convincingly established.
Assessing Sexual Dysfunction Part 2: Female Sexual Dysfunction
Authors: Cohen Seth D. , Mandel Steven , Samadi David B.
Published: December 2020

Sexual dysfunction is more common in women (43%) than men (31%), and the evaluating physician must consider the individual's chronological and physiologic age, personal and interpersonal sexual experiences, life events, and relationship issues that may have an effect on female sexual health. The medical history should include focused questions about medical and/or surgical illnesses, use of medications, and urogynecological history. Validated, reliable, standardized questionnaires are useful to identify the presence or absence of various domains of female sexuality such as sexual desire, sexual arousal, orgasm, and/or sexual pain (eg, the Female Sexual Function Index). Serum hormone testing should be dictated by clinical suspicion, and the physician also may assess multiple androgen and estrogen values, as well as pituitary function and levels of thyroid stimulating hormone. Systemic androgens (eg, systemic dehydroepiandrosterone and/or systemic testosterone) may improve mood, energy, stimulation, sensation, arousal, and orgasm in women with sexual health concerns. Combining a biomedical and psychosocial approach to any kind of sexual dysfunction helps to optimize patient outcomes. In the case of hypoactive sexual desire disorder (HSDD), individual or couples-based therapy with a sexual health therapist should be part of the consultation. If the biologic basis of the sexual health concern can be diagnosed by history, physical examination, laboratory testing, and directed imaging studies, then management can be directed to evidence-based management strategies.
Impairment Assessment of Female Sexual Dysfunction
Authors: Brigham Christopher R. , Soo Hoo Randolph
Published: December 2020

Impairment assessment of female sexual dysfunction using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth or Sixth Edition, must be performed using appropriate evaluation and objective findings to support ratable sexual dysfunction. In both editions, sexual dysfunction is discussed in Chapter 7, The Urinary and Reproductive Systems, and Chapter 13, The Central and Peripheral Nervous System. In the fifth edition, the maximum impairment rating for female sexual functioning is 35% whole person impairment; in the sixth edition, the maximum is 20%. In terms of rating female reproductive organ impairment, the fifth edition gives consideration to the differences between premenopausal and postmenopausal women. Table 7-9, Criteria for Rating Permanent Impairment Due to Vulval and Vaginal Disease in the fifth edition is used to rate female sexual dysfunction; three classes are identified, and, although age is not a specific consideration, this edition discusses differences between premenopausal and postmenopausal women. In the AMA Guides, Sixth Edition, Table 7-10, Criteria for Rating Permanent Impairment Due to Vulval and Vaginal Disease, is used and provides four classes, two of which have severity grades. Each class addresses historical signs and symptoms of vulvar or vaginal diseases, vulval and vaginal physical alterations, and potential effect of altered vaginal anatomy for vaginal delivery (if premenopausal). Neurogenic sexual dysfunction is combined with other related impairments using the Combined Values Chart.
Putting Job Loss in the Spotlight as a Poor (and Often Preventable) Health Outcome
Authors: Christian Jennifer
Published: December 2020

The author considers the hypothetical case of a worker disabled by an accident and spine fusion surgery that did not relieve the pain; he is offered opioids and spends his time in a recliner grieving the loss of his self-respect as a good husband, provider, and father. This outcome need not have been a foregone conclusion. Research has shown that, for adults, worklessness is harmful to both physical and mental health, as well as to marital, family, social, and economic well-being. Gaps in social fabric are creating job loss and work disability because none of the professionals who typically respond to workers with job disruption due to illness or injury specifically feels responsible for avoiding job loss. Besides being a personal catastrophe, health-related withdrawal from work (work disability) negatively effects society; the lost productivity of workers in the local and national economy, which accounts for the majority of the approximately $400 billion that federal and state governments spend to support working-age people with disabilities. All Americans deserve timely assistance to maintain their economic independence and enjoy the dignity that comes with having a job. Improved public policy, governmental efforts, and support from the private sector is needed to prevent needless disability.
Life Care Plans
Authors: Katz Richard T.
Published: December 2020

In catastrophic injury cases, attorneys may request that a budget, often called a life care plan (LCP), be created to estimate expenses that a client will have in the future. The LCP is a budgeting process that requires a thorough understanding of a patient's condition, rehabilitation, and future needs to estimate what services and costs are likely to be needed in the future. The physician determines the extent and sequelae of the patient's physical and cognitive impairments; estimates a prognosis; estimates the need for and benefit of further medical and rehabilitative interventions; and then calculates the costs of future personal needs. Such a model first requires an accurate prognostication of the patient's life expectancy. Various costs projections are evaluated to estimate costs related to supplies, medications, physician and therapist services, and home and transportation modifications. Finally, such costs must be placed in an economic model in order to determine how the costs of inflation will modify the LCP. A competently formulated LCP can be a useful tool in estimating the future costs in catastrophic patient care. The article also presents a case example using a spinal cord injury to demonstrate how an LCP can be constructed.
Two Faulty Beliefs about Independent Medical Evaluators and Impartial Physicians
Authors: Christian Jennifer
Published: December 2020

Patients and their advocates tend to be skeptical about reports produced by independent medical evaluators (IMEs) and file reviewers. There are legitimate reasons for this skepticism, but the author points out two common but erroneous beliefs that create unnecessary distrust in disability benefits and workers’ compensation claim management systems. First, despite patients’ faith in their own doctors, treating physicians as a group are not a reliable source of accurate and unbiased information. Second, although justice attempts to be even-handed, impartial physicians should not find for both sides equally (ie, should not attempt to achieve parity in outcomes), particularly because any case sent for review has some feature that raised questions in the mind of an experienced observer. This experienced observer requires an impartial, expert physician advisor who can confirm that the treating physician is doing the right thing or validate the claims manager's concerns. When claims or case managers are doing a good job of selecting cases for referral, one should expect that most of their decisions will favor the insurer/defense. The more expert the claims/case managers are, the more likely the independent physicians will agree because the claims/case managers are accurately detecting real problems and concerns. In counseling their patients, physicians should not discredit the work of independent experts; doing so increases distrust, resentment, and anger and encourages passivity rather than problem-solving.
Flawed Approaches to Determining the “Most Accurate Impairment Rating”: The California Experience
Authors: Brigham Christopher R. , Talmage James B. , Eskay-Auerbach Marjorie
Published: December 2020

Socioeconomic factors influence all aspects of workers’ compensation, personal injury, and disability systems, but the best financial interest of certain stakeholders may not be aligned with the ultimate best interests of those who are injured or ill. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, was introduced in California in 2005 to improve the reliability of permanent disability award ratings, which previously were based primarily on subjective factors. The result was a reduction in the dollar value of disability rewards, and, in response, certain stakeholders took steps to reduce this impact, including instructing physicians to ignore instructions in the AMA Guides. The AMA Guides, Sixth Edition, addresses many of the potential misapplications of the criteria in the fifth edition. Despite efforts to improve the validity and reliability of impairment assessment, some stakeholders continue to resist use of the more current edition. In California, impairment currently is rated by agreed medical evaluators; this should be changed to ensure that evaluations are performed by unbiased physicians who are educated with respect to evidence-based medicine and causation. Injured workers must be fairly and appropriately compensated for losses associated with an injury, but not at the cost of inappropriate inflation of impairment and disability ratings because the latter contribute to needless disability and impede living a productive and joyous life.
Rating Cognitive Impairment, Part 2: Objective and Evidence-Based Integration of Neuropsychology Testing
Authors: Barth Robert J. , Meyers John E.
Published: December 2020

Hearing impairment rating determination is described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 11.2a, Criteria for Rating Impairment Due to Hearing Loss. A hearing impairment evaluation for adults who have acquired language skills is derived from a pure-tone audiogram and always is based on the functioning of both ears even though hearing loss may be present in only one ear. Audiometers should be properly calibrated, and technicians should be appropriately trained to obtain accurate measurements. Audiograms typically are obtained at four frequencies (test frequencies): 500, 1000, 2000, and 3000 Hz, which are considered to be representative of everyday auditory speech ranges. The evaluator tests the individual's right and left ears at the test frequencies and adds the decibel levels for each of these frequencies for each ear separately; consults Table 11-2, Computation of Binaural Hearing Impairment; and finally consults Table 11-3, Relationship of Binaural Hearing Impairment to Impairment of the Whole Person. Tinnitus can be rated if the individual experiences hearing loss in the ear and this loss affects speech discrimination; loss is limited to a maximum of 5% loss. The AMA Guides provides no correction in the hearing section for age-related loss of hearing, although the latter may be apportionable. A table presents a model hearing impairment report.
Commonly Misused Musculoskeletal and Medicolegal Terms
Authors: Brooks Charles N.
Published: December 2020

The misuse of medical and legal terminology can be confusing and frustrating and also introduces the potential for errors; this article focuses on some of the most often misused terms applicable to injury and illness. A common example of anatomical imprecision involves the shoulder, and patients who complain of “shoulder pain” sometimes localize their discomfort in the trapezius or scapula rather than on the shoulder per se. The distinction between shoulder and upper back or shoulder girdle pain is not merely terminological nitpicking but rather is of clinical significance. Similarly, no terms are more commonly misused than “arm” and “leg.” The most misused terms in musculoskeletal pathology are those related to disc lesions, and one commonly hears that a magnetic resonance image (MRI) scan was ordered “to rule out a disc,” but having a disc is neither an indication for MRI nor surgery. Further imprecise terminology leads to semantic imprecision when terminology is incorrectly used, including intervertebral disc, bulge, protrusion, extrusion, sequestered fragment, hernia, rupture, and even fracture. Physician evaluators and health care providers must understand that—by virtue of the authority vested in them and the weight given to their opinions by claims personnel, attorneys, judges, and others—errors and injustices may occur if they do not understand or correctly use medicolegal terms.
Central Nerve System Impairment, AMA Guides, Sixth Edition: An Overview
Authors: Talmage James B. , Blaisdell Jay
Published: December 2020

Injuries that affect the central nervous system (CNS) can be catastrophic because they involve the brain or spinal cord, and determining the underlying clinical cause of impairment is essential in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), in part because the AMA Guides addresses neurological impairment in several chapters. Unlike the musculoskeletal chapters, Chapter 13, The Central and Peripheral Nervous System, does not use grades, grade modifiers, and a net adjustment formula; rather the chapter uses an approach that is similar to that in prior editions of the AMA Guides. The following steps can be used to perform a CNS rating: 1) evaluate all four major categories of cerebral impairment, and choose the one that is most severe; 2) rate the single most severe cerebral impairment of the four major categories; 3) rate all other impairments that are due to neurogenic problems; and 4) combine the rating of the single most severe category of cerebral impairment with the ratings of all other impairments. Because some neurological dysfunctions are rated elsewhere in the AMA Guides, Sixth Edition, the evaluator may consult Table 13-1 to verify the appropriate chapter to use.
Rating Knee Impairments
Authors: Blaisdell Jay , Talmage James
Published: December 2020

Workers who kneel for major portions of their workday (eg, floor and roof installers) may be prone to inflammation of the knee bursae and patellofemoral pain. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), range-of-motion (ROM) and diagnosis-based impairment (DBI) are the two possible stand-alone methods for rating knee impairment. The ROM method was widely used in previous editions of the AMA Guides, but at present DBI is the method of choice for calculating impairment. To rate knee impairment using the DBI method, the physician first chooses the appropriate diagnosis from the Knee Regional Grid in the AMA Guides, Sixth Edition. Next, the physician chooses the appropriate impairment class for the diagnosis and then selects the appropriate grade modifiers. The physician applies the net adjustment formula to determine lower extremity impairment and finally converts the final lower extremity impairment to whole person impairment. Two or more conditions often are found in the knees and require causation analysis in which the physician should choose the single causally related diagnosis that will yield the highest impairment rating. Modifiers should be chosen based on reliable findings that have not been used previously to assign either the diagnosis or impairment class. The ROM method can be used to select the physical examination grade modifier or as a stand-alone rating if the physician offers a rationale that is supported by the AMA Guides.