bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Update: IME Report Standards: Independent Medical Evaluation Report Standards
Authors: Brigham Christopher R.
Published: December 2020

Independent medical examinations (IMEs) are performed by a physician or another health care provider who is not involved in the examinee's care and for the purpose of clarifying medical and case issues. Poor quality evaluations and reports are unfair to both the client and the examinee, and this article presents standards of a quality IME report. Evaluators should know the purpose of the IME so the length and detail of the examination are sufficient to address the questions posed with supportable conclusions. One table lists common issues in IMEs, another explains them, and a third divides the preparation of reports into three steps: clinical evaluation, calculation of the impairment rating, and discussion of how the impairment rating was calculated. A fourth table includes an extensive checklist that lists the components of most quality IME reports. The use of templates assists in ensuring a best-practices approach to the evaluation. Most experienced examiners use questionnaires, pain drawings, and inventories as an adjunct to the interview, and the process must be planned carefully to ensure all relevant history and subjective information are obtained. All reports should be completed as soon as possible following the evaluation to ensure efficiency and to generate a report of the highest quality.
Impairment Tutorial: Permanent Impairment Evaluation of the Temporomandibular Joint
Authors: Brown Chris
Published: December 2020

Temporomandibular joint dysfunction (TJD) is a term applied to a group of problems that affect the muscles of mastication, the temporomandibular joint, and their supporting structures. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, deals only briefly with TMD in Section 11.4b, noting that this dysfunction may impede mastication, affect speech, cause lower facial deformity, and produce pain. Objective criteria (disk displacement and radiographic evidence of joint degeneration, range of motion [ROM], and surgical intervention) have been used to diagnose TMD, but the AMA Guides, Fifth Edition, usually bases the diagnosis on dietary restrictions or problems with speech. A table in the article provides a description of disk displacement and joint degeneration; based on symptoms, clinical findings, and imaging results, examiners can place the patient in one of five stages. Evaluators should use generally accepted ROM measurement principles, and the reproducibility of active ROM is an important indicator of measurement accuracy. Surgical correction includes arthroscopy or arthroplasty. Challenges in developing a process for rating TMD impairment include what factors relate to impairment, what should be the range of impairment, and who should perform the rating. At present, the AMA Guides states that “permanent impairment requires a medical assessment performed by the physician.”
Longshore and Harbor Workers' Compensation Act: Use of AMA Guides
Authors: Brigham Christopher R.
Published: December 2020

The US Congress passed the Longshore and Harbor Workers’ Compensation Act (LHWCA) in 1927 to provide coverage to longshore laborers working on navigable waters of the United States when no state workers’ compensation law applied. After amendments that extended and standardized the Act, the Longshore Compensation Act provides more than $670 million in monetary, medical, and vocational rehabilitation benefits to more than 72,000 individuals annually. Under the LHWCA, ratings are performed for “scheduled injuries” (ie, a scheduled member of the body), including upper extremity injuries (excluding the shoulder), lower extremity injuries, and hearing loss. Impairment ratings typically are expressed in terms of whole person permanent impairment, but under the LHWCA impairment is expressed in the smallest applicable body part (eg, an injury of two digits is expressed as a hand rating). Definitions of terms such as injury, disability, and impairment are similar in the LHWCA and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Claims examiners are advised to require any physician selected to evaluate permanent medical impairment to use the AMA Guides, where applicable, to be detailed in their assessment report, and to rate and report permanent impairment according to the AMA Guides. Boxes in the article present portions of the LHWCA that address compensation for disability and the basic elements required to evaluate anatomical impairment.
Impairment Tutorial: Hearing Impairment
Authors: Mueller Kathryn , Brigham Christopher R.
Published: December 2020

A 1999 study of adults showed hearing loss was the fifth most common disability in the US population, and almost 50% of workers in carpentry, plumbing, and mining had hearing impairment. Determining hearing impairment according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 11.2a, Criteria for Rating Impairment Due to Hearing Loss, is straightforward, if limited. Examiners should be aware that hearing can be temporarily impaired by recent exposure to loud noise and should test only after an extended period without such exposure. Audiometers should be properly calibrated, and technicians must be appropriately trained to obtain accurate measurements. The evaluator should separately test both of the individual's ears at 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz (the representative or test frequencies) and then identify the total worst ear decibel level using the AMA Guides Table 11-1 or 11-2. The evaluator can use Tale 11-3 to convert hearing impairment to whole person loss. Tinnitus also can be rated if a hearing loss in that ear affects speech discrimination; in such instances, the tinnitus rating is limited to a 5% loss. The article includes a Hearing Impairment Rating Sheet that can be used to record data from the hearing impairment evaluation.
The Independent Medical Evaluation Relationship
Authors: Richman Jack
Published: December 2020

According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, an independent medical evaluation (IME) is “an evaluation performed by an independent medical examiner, who evaluates—but does not provide care for—the individual.” In April 2002, the Work Fitness and Disability Evaluation Section of the American College of Occupational and Environmental Medicine (ACOEM) prepared a motion defining the rationale why there is no a priori establishment of a patient–physician relationship during an IME. A figure in the article includes the text of the resolution, which was proposed and debated at the House of Delegates but has not yet been adopted by ACOEM. A table prepared by the College of Physicians and Surgeons of Ontario (CPSO) enumerates differences between the usual doctor–patient relationship and IMEs in terms of duty to provide care, maintaining records, access to records, and fees. CPSO also clarifies that physicians who agree to conduct third-party examinations of individuals whom they are not currently treating have been hired by a third party to perform a particular task, typically to provide an opinion or answer specific questions about the individual. Clear and effective communication with the individual are particularly important because the individual's livelihood or compensation for injury, as well as the person's continuing health, are at stake.
Comparative Analysis of Third Edition, Revised; Fourth; and Fifth Edition Ratings: The State of Colorado Study
Authors: Brigham Christopher R. , Mueller Kathryn , Van Zet Douglas , Northrup Debra J. , Whitney Edward B. , McReynolds Martha M.
Published: December 2020

In 2002, the Department of Labor and Employment, the State of Colorado, performed a study to identify changes among the Third Edition, Revised (December 1990); the Fourth Edition (June 1993); and the Fifth Edition (November 2000) of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This three-part article summarizes the differences found. The study was based on a random sample of 250 cases identified by the Division of Workers’ Compensation of the State of Colorado and stratified into three broad categories: 40 upper extremity cases, 60 lower extremity cases, and 150 whole person cases. Only case records with adequate documented evidence to enable rating among all three editions of the AMA Guides were included. The average age of the examinee was 42.9 years (SD, 11.1 years, range, 18 to 71 years, 171 [68%] male); equal percentages of men and women were present in the upper extremity impairment ratings (20 men, 20 women), but lower extremity and whole person impairments occurred primarily among males (73% and 71% men, respectively). Interrater reliability was obtained from an independent expert medical review of 20% of the cases. Three figures show percentages of upper extremity, lower extremity, and whole person impairment according to the edition used; ratings generally are lower with more recent editions.
Clinical Update: Thoracic Outlet Syndrome
Authors: Brigham Christopher R. , Brooks Charles N. , Talmage James B.
Published: December 2020

The diagnosis, cause, and treatment of thoracic outlet syndrome (TOS) are challenging, and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) gives no specific instructions about rating impairments associated with this disorder. TOS is a group of symptoms and signs, including pain, weakness, paresthesias, numbness, swelling, and/or coldness arising at the base of the neck or superior chest but involving the upper limbs. Causes include compression of the brachial plexus (neurogenic TOS) or, less frequently, subclavian vein and/or artery (vascular TOS). Provocative tests for TOS attempt to induce symptoms and/or signs by compressing the subclavian artery or vein or brachial plexus, but palpitation of the radial pulse in various extremity positions is of limited diagnostic value. Diagnostic studies may include radiographs of the cervical spine, upper chest, and/or shoulder; MRI scans of the thoracic outlet; arteriography or venography, and electrodiagnostic testing. The differential diagnosis for TOS is broad and includes cervical radiculopathy, superior sulcus tumor, other peripheral nerve entrapment syndromes, complex regional pain syndrome, and psychiatric disease. The evaluator must determine if the symptoms, physical findings, and diagnostic study results support the diagnosis; the report should list the rating options considered, discuss the rationale for selecting the method(s) used, and explain how the percentage was calculated.
Impairment Tutorial: Cervical Fusions: A Paradox in the Fifth Edition
Authors: Haralson Robert H.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, presents an impairment paradox: Single-level fusions rating using the Diagnosis-related estimates (DRE) method often result in higher impairment values than do multilevel cervical spine fusions. In the AMA Guides, Chapter 15, The Spine, the definition of Cervical Category IV (alteration of motion segment integrity or bilateral or multilevel radiculopathy) changed from the definition in the fourth edition for Cervicothoracic Category IV (loss of motion segment integrity or multilevel neurological compromise) because of changes in the definition of “alteration of motion segment integrity,” which now also includes surgical arthrodesis. This applies only for single-level fusions because the AMA Guides, states the range-of-motion (ROM) method is used in situations when “there is alteration of motion segment integrity (eg, fusions).” The AMA Guides, Fourth Edition, rated impairment on the basis of the injury, not the surgical procedure, and the maximum whole person permanent impairment for a patient with a single-level, single-sided cervical radiculopathy who had a discectomy and fusion would be 15%, but the minimum award for a similar patient rated using the DRE method is 25%. The author reports that, for the reasons outlined, evaluators should rate all cervical fusions, including single-level fusions, using the ROM method.
Comparative Analysis: The State of Colorado Study, Part III
Authors: Brigham Christopher R. , Mueller Kathryn , Van Zet Douglas , Northrup Debra J. , Whitney Edward B. , McReynolds Martha M.
Published: December 2020

This article concludes the three-part discussion of differences among the editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): Third Edition Revised, Fourth, and Fifth Editions. The discussion begins with a comparison of different editions of the AMA Guides for evaluating lower extremity impairment and spinal impairment. The AMA Guides, Fourth Edition, introduced the Diagnosis related estimates (DRE) model, and in this edition the range-of-motion (ROM) model has only a limited role (ie, primarily as a differentiator). A table summarizes the criteria of spinal impairment criteria by edition of the AMA Guides. The authors summarize differences in the impairment ratings of various body systems based on the use of different editions of the AMA Guides, including differences in ratings of the cardiovascular, pulmonary, digestive, and other systems. Critiquing the AMA Guides, the authors call for improvements, including the following: add a system to rate permanent impairments, including functional limitations; base impairment ratings on scientific evidence and a valid whole person impairment scale; make the AMA Guides reliable, comprehensive, internally consistent, comprehensible, accessible (ie, the AMA Guides are complex and difficult to use, and not all physicians are capable of rating impairment), and acceptable. Despite the shortcomings, no other widely accepted basis to assess impairment is available, and future editions of the AMA Guides will improve the process of providing fair assessments of functional loss.
Chapter 14 or 18 for Pain Complaints? Avoiding the Common but Mistaken Dichotomy of Psychological vs Organic
Authors: Barth Robert J. , Brigham Christopher R.
Published: December 2020

In accordance with the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 18, Pain, pain that is attributable to mental illness does not also qualify for an additional pain-related evaluation. Evaluators must discriminate between presentations of pain that represent mental illness vs those that do not and must decide whether to rate using Chapter 18 or 14. Dichotomous thinking often opposes the notion of psychological vs physiological-organic presentations, but all presentations of pain include psychological aspects, and all mental illnesses include physiological aspects. One type of illustrative mental illness involves conditions that are overtly mental but have been found via extensive scientific study to have a physiological basis (eg, schizophrenia and Alzheimer's disease). Another presentation that is claimed to be of a medical nature actually overlaps with psychological issues (eg, complex regional pain syndrome, type 1 [CRPS-1] and fibromyalgia). Further, the AMA Guides summarizes the lack of a strong correlation between tissue damage or physiology and pain: Pain can exist without tissue damage, and tissue damage can exist without pain. Pain, chronic pain, and impairment from pain are largely, even primarily, psychological phenomena. Accordingly, the determination whether to rely on the pain chapter or the mental/behavioral chapter in the evaluation of a pain presentation cannot be reduced to a misleading dichotomy of psychological vs organic pain.
Special Feature: Referral Letter for the Performance of an Independent Medical Evaluation
Authors: Brigham Christopher R. , Walker Phil
Published: December 2020

Clients who request an independent medical or impairment evaluation are more likely to obtain a quality report from an evaluating provider if they request the appropriate evaluator, provide needed information, and clarify the specifics of their referral. The referral should identify the information needed for the assessment, define the standards for the evaluation, and provide detailed questions to be answered. Failure to provide this information often will result in a poor outcome. The article includes a sample generic referral letter to an impairment evaluator; this example letter can be modified based on the specifics of a case. For example, a workers’ compensation case in California could include the question, What is the overall percentage of permanent disability caused by the industrial injury, and what is the percentage of permanent disability due to all other factors, including prior injuries? The generic referral letter instructs the evaluator to use the standards in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition and refers the evaluator to Chapter 2, Philosophy, Purpose, and Appropriate Use of the AMA Guides. The article includes a sample paragraph that could be included in the generic referral letter and includes specific questions that address statutory requirements under California law, along with instructions about apportionment decisions and documentation.
Impairment Tutorial: Billing for Impairment Ratings
Authors: Colledge Allan , Krohm Greg
Published: December 2020

The AMA Current Procedural Terminology (CPT) codebook lists specific codes that can be used for impairment ratings, and in some industrial cases insurance carriers require an impairment rating determination at medical stability for which a CPT code is needed. For billing purposes, an impairment rating performed by the treating physician usually is considered an extension of the treatment process (office visit, medical records review, diagnostic studies, current physical findings, and a written report). A table in this issue of The Guides Newsletter shows current nonspecific CPT procedure codes; if the report does not conform to the established criteria as outlined in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), the evaluating physician may not be entitled to reimbursement. A work-related or medical disability examination involves taking a medical history commensurate with the patient's condition, examination, diagnosis, assessment of capabilities and stability, calculation of impairment, development of a treatment plan, and completion of documentation or certificates and report. Treating physicians who perform the examination can bill this work using CPT code 9455; CPT code 99456 applies if a nontreating physician performed the work (the code is used for each 30-minute increment). AMA recommends tht payment for these codes be dependent on the complexity of the case, the time required in the evaluation and report writing, and the value of the examiner's time.
Special Features: Workers' Compensation Benefits
Authors: Colledge Alan , Krohm Greg
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) specifies that impairment evaluation may be conducted by a treating or nontreating physician. A treating physician who is knowledgeable about the use of the AMA Guides may be the appropriate professional to evaluate impairment, but in cases that involve pain, disability, and medicolegal (forensic) issues, a truly independent medical examiner typically is most appropriate. All specialties share the same elevated risk of iatrogenesis when treating and evaluating/forensic roles are mixed because mixing compromises the quality of care and threatens the viability of the therapeutic relationship. Further, all treating specialties share the same bias toward offering treatment for most complaints—rather than engaging in the type of cautious skepticism that is required for competent impairment evaluation and other forensic duties. Finally, no treating clinician, regardless of specialty, can offer allegiance to judicial and administrative decision-makers. Treating clinicians often find themselves in a position in which they would be cutting off a source of their own income if they were to offer opinions that the clinical presentation is not valid, work related, or injury related, nor is the patient in need of further treatment. Such a financial conflict of interest can be eliminated only by referral to independent examiners and restricting treating clinicians from becoming involved in such decisions.
Carpal Tunnel Syndrome: Impairment Rating by the AMA Guides, Fifth Edition
Authors: Talmage James B. , Brigham Christopher R. , Brooks Charles N.
Published: December 2020

The pain, numbness, and paresthesias of carpal tunnel syndrome generally are intermittent and are felt in the wrist, hand, thumb, and fingers, often in a distribution approximating that of the median nerve. No specific physical examination exists for carpal tunnel syndrome, and, in the impairment rating assessment, the physical examination focuses on detecting signs of permanent nerve damage (decreased sensation and thenar weakness on opposition). According to the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), provocative tests have no role in impairment rating. The AMA Guides, Fifth Edition, requires nerve conduction testing (NCT), even in “believable” instances, but no uniform definition of an abnormal NCT exists and examiners should realize the uses and limits of NCT. For example, if the NCT is normal, the symptoms, even if believable, do not rise to the level of an impairment. Impairment assessment must take place when the patient is at maximum medical improvement. If the NCT is grossly abnormal (axon loss) and/or degenerative changes are present on needle electromyography, and if physical exam shows sensory and/or thenar weakness, the examiner can use tables in the AMA Guides to rate the disability, combining sensory and motor impairments as appropriate. A one-page sidebar in this issue of The Guides Newsletter addresses the causes of carpal tunnel syndrome.
Erroneous Impairment Ratings Companion: Impairment Rating Critique and the Longshore and Harbor Workers’ Compensation Act
Authors: Uejo Craig , Walker Phil
Published: December 2020

A 2005 Benefits Review Board decision by the US Department of Labor, Peter J. Desjardins vs Bath Iron Works Corporation affirmed a decision and order (2004-LHC-1364) regarding the utility of impairment rating critique. The administrative law judge credited the rating opinion of an expert physician reviewer (who had not seen the claimant) over that of the treating physician. The claimant's physician was awarded 20% upper extremity impairment, but, following the review and opinion of an expert reviewer, the award was reduced to 4%. The claimant appealed, largely on the argument that the expert reviewer had reviewed the report by the patient's physician, not the claimant himself and that the expert's opinion properly relied on the correct use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The appeals judges noted that the administrative judge properly noted that the AMA Guides was suitable for use (and was the basis of the treating physician's award). The administrative law judge found that the expert reviewer's opinion was based on the specifics of the present case and on his knowledge and application of the AMA Guides, which together warranted determinative weight, based on the expert reviewer's credentials, experience, and well-reasoned opinion. This decision confirms that expert reviewers can provide evidence for the fact finder to evaluate the treating physician's opinion to determine if it is well reasoned and documented.
Challenges in the Diagnostic Conceptualization of CRPS-1 (Formerly Conceptualized as RSD)
Authors: Barth Robert J. , Bohr Tom W.
Published: December 2020

From the previous issue, this article continues a discussion of the potentially confusing aspects of the diagnostic formulation for complex regional pain syndrome type 1 (CRPS-1) proposed by the International Association for the Study of Pain (IASP), the relevance of these issues for a proposed future protocol, and recommendations for clinical practice. IASP is working to resolve the contradictions in its approach to CRPS-1 diagnosis, but it continues to include the following criterion: “[c]ontinuing pain, which is disproportionate to any inciting event.” This language only perpetuates existing issues with current definitions, specifically the overlap between the IASP criteria for CRPS-1 and somatoform disorders, overlap with the guidelines for malingering, and self-contradiction with respect to the suggestion of injury-relatedness. The authors propose to overcome the last of these by revising the criterion: “[c]omplaints of pain in the absence of any identifiable injury that could credibly account for the complaints.” Similarly, the overlap with somatoform disorders could be reworded: “The possibility of a somatoform disorder has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a somatoform scenario.” The overlap with malingering could be addressed in this manner: “The possibility of malingering has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a malingering scenario.” The article concludes with six recommendations, and a sidebar discusses rating impairment for CRPS-1 (with explicit instructions not to use the pain chapter for this purpose).
Special Feature: Use of the AMA Guides–2006 Update
Authors: Brigham Christopher R. , Walker Jenny
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition, is the most widely used basis for determining impairment and is used in state workers’ compensation systems, federal systems, automobile casualty cases, and personal injury cases. The AMA Guides is used in most state workers’ compensation jurisdictions: 25 states use the fifth edition; 10 use the fourth edition, 1 state uses a hybrid of the fourth and fifth editions, and 2 states use the third edition, revised; 6 states use their own state-specific guidelines, and 6 do not indicate a specific guideline. Statutes may or may not specify which edition of the AMA Guides to use nor how to use them. In addition, many states use a statutory schedule for amputations, hearing loss, visual loss, hernias, and disfigurement, and other states use the AMA Guides for nonscheduled injuries. The AMA Guides often is used to quantify the extent of injuries resulting from an automobile casualty or personal injury. Insurers may use an impairment rating as a factor in setting reserves and determining the settlement value of a claim, and attorneys may use this information to quantify the effects of an injury. A four-page table displays uses of the AMA Guides in state workers’ compensation plans, including the edition most commonly used, the statute/code, comments, and relevant websites.
Impairment Tutorial: Rating Tears of the Acetabular Labrum
Authors: Brooks Charles N. , Strain Richard E. , Talmage James B.
Published: December 2020

The primary function of the acetabular labrum, like that of the glenoid, is to deepen the socket and improve joint stability. Tears of the acetabular labrum are common in older adults but occur in all age groups and with equal frequency in males and females. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, is silent about rating tears, partial or complete excision, or repair of the acetabular labrum. Provocative tests to detect acetabular labrum tears involve hip flexion and rotation; all rely on production of pain in the groin (typically), clicking, and/or locking with passive or active hip motions. Diagnostic tests or procedures rely on x-rays, conventional arthrography, computerized tomography, magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and hip arthroscopy. Hip arthroscopy is the gold standard for diagnosis but is the most invasive and most likely to result in complications, and MRA is about three times more sensitive and accurate in detecting acetabular labral tears than MRI alone. Surgical treatment for acetabular labrum tears usually consists of arthroscopic debridement; results tend to be better in younger patients. In general, an acetabular labral tear, partial labrectomy, or labral repair warrants a rating of 2% lower extremity impairment. Evaluators should avoid double dipping (eg, using both a Diagnosis-related estimates and limited range-of-motion tests).
Case Exercise: Toxic Exposure-Related Illness: Causation, Diagnosis, and Permanent Impairment
Authors: Fung Frederick
Published: December 2020

A diagnosis of toxic-related injury/illness requires a consideration of the illness related to the toxic exposure, including diagnosis, causation, and permanent impairment; these are best performed by a physician who is certified by a specialty board certified by the American Board of Preventive Medicine. The patient must have a history of symptoms consistent with the exposure and disease at issue. In order to diagnose the presence of a specific disease, the examiner must find subjective complaints that are consistent with the objective findings, and both the subjective complaints and objective findings must be consistent with the disease that is postulated. Exposure to a specific potentially causative agent at a defined concentration level must be documented and must be sufficient to induce a particular pathology in order to establish a diagnosis. Differential diagnoses must be entertained in order to rule out other potential causes, including psychological etiology. Furthermore, the identified exposure at the defined concentration level must be capable of causing the diagnosis being postulated before the examiner can conclude that there has been a cause-and-effect relationship between the exposure and the disease (dose-response relationship). The evaluator's opinion should make biological and epidemiological sense. The treatment plan and prognosis should be consistent with evidence-based medicine, and the rating of impairment must be based on objective findings in involved systems.
Impairment Evaluation: Use of the Guides in Ontario for Defining “Catastrophic Impairment”: Challenges and Controversies
Authors: Ameis Arthur , Brigham Christopher , Barth Robert J. , Leclair Norma , Leclair Steven
Published: December 2020

Several Canadian provinces use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) to adjudicate workers’ compensation claims, and the Province of Ontario uses the AMA Guides, Fourth Edition, to adjudicate motor vehicle accident personal injury claims. This article focuses on controversies that have arisen in Ontario regarding how the AMA Guides is applied and shows some of the challenges that occur in quantifying psychological impairment. In 2004, the Ontario Superior Court found in the Desbiens v. Mordini trial that the AMA Guides did not provide any direct methodology for estimating percentage impairment in this unique circumstance that involved pre-existing paraplegia and subsequent dramatic loss of residual functions. The judge found that, using the information available, a whole person impairment (WPI) score of 40% could be derived, but Ontario requires a minimum 55% WPI before an individual qualifies for catastrophic impairment benefits. In view of the individual's circumstances and a psychologist's recommendation, the judge awarded an additional 25% WPI. The Ontario model has been interpreted to allow subjective complaints (symptoms) to be included in the impairment evaluation process, but this approach eliminates any expectation of objectivity. If a judicial system aims to force impairment percentages onto a situation that in fact does not warrant such ratings, it should not do so by an inappropriate application of the AMA Guides.
Sixth Edition: the New Standard
Authors: Brigham Christopher R. , Rondinelli Robert D. , Genovese Elizabeth , Uejo Craig , Eskay-Auerbach Marjorie
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, was published in December 2007 and is the result of efforts to enhance the relevance of impairment ratings, improve internal consistency, promote precision, and simplify the rating process. The revision process was designed to address shortcomings and issues in previous editions and featured an open, well-defined, and tiered peer review process. The principles underlying the AMA Guides have not changed, but the sixth edition uses a modified conceptual framework based on the International Classification of Functioning, Disability, and Health (ICF), a comprehensive model of disablement developed by the World Health Organization. The ICF classifies domains that describe body functions and structures, activities, and participation; because an individual's functioning and disability occur in a context, the ICF includes a list of environmental factors to consider. The ICF classification uses five impairment classes that, in the sixth edition, were developed into diagnosis-based grids for each organ system. The grids use commonly accepted consensus-based criteria to classify most diagnoses into five classes of impairment severity (normal to very severe). A figure presents the structure of a typical diagnosis-based grid, which includes ranges of impairment ratings and greater clarity about choosing a discreet numerical value that reflects the impairment.
Evaluating the Difficult Pain Patient
Authors: Katz Richard T. , Smith Stacey Lee
Published: December 2020

One of the most difficult aspects of performing independent medical examinations (IME) is the assessment of individuals with pain complaints (eg, neck or low back pain) for which no clear and objective basis can be determined. This two-part article critiques chronic pain models and presents a useful construct based on well-validated psychiatric diagnoses. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) attempts to evaluate pain in the context of the underlying, objectively defined impairment and considers pain to be of secondary importance. Physicians differ sharply concerning the contributions of neurophysiological vs behavioral/psychological factors when pain is present without general medical findings (eg, fibromyalgia). Chronic pain syndrome diagnosed by the “Eight Ds in Chronic Pain” is superficially attractive but seriously inadequate. Evaluators are challenged by poorly validated criteria for certain diagnoses and questions about the accuracy of patient self-reports. The AMA Guides, Sixth Edition, does not use range of motion to determine spinal impairment, and in most cases electrodiagnosis has little to add. Impairment and disability assessment of individuals with pain complaints is one of the greatest challenges encountered by IMEs, and future challenges will involve taking into account both the subjective factors and the difficulties inherent in evaluating another person's subjective experiences.
Degenerative Disc Disease: The Myth of Work-Related “Cumulative Trauma”
Authors: Brigham Christopher R. , Talmage James B. , Brooks Charles , Andersson Gunnar , Uejo Craig
Published: December 2020

The primary cause of degenerative disc disease (DDD) is nonoccupational factors such as genetics and aging, and attributing DDD to “cumulative trauma” at work is a myth that is not supported by current scientific evidence. Some authors have suggested that DDD is a misnomer because the condition is not a disease but rather an inevitable component of the aging process that occurs at variable rates in different persons. Causation analysis requires a link between a cause and an effect, and reference to “cumulative trauma” without identification of a specific accident is incomplete. Physicians appear sometimes to opine “to a reasonable degree of medical certainty” that certain work events caused or aggravated a condition solely on the basis of a temporal relationship. Further, DDD usually is not the cause of neck or back pain but rather is an incidental finding on x-rays or advanced imaging studies. A dominant view of disc degeneration has been that disc structures are damaged by occasional excessive forces and the cumulative effects of repeated loading—but modern science contradicts this view. The authors examine current publications regarding DDD (including four full abstracts from recent articles) and conclude that current scientific evidence does not support the premise that “cumulative trauma” results in or aggravates degenerative disc disease. “Repetitive strain injury” of the spine is a mythical medicolegal concept, not a clinical or pathologic reality.
Carpal tunnel syndrome – Occupationally Related or Not?
Authors: Uejo Craig
Published: December 2020

Carpal tunnel syndrome (CTS), the most common peripheral entrapment neuropathy, is caused by compression of the median nerve at the wrist, and annual costs of CTS treatment in the United States total $2 billion. Although CTS often is attributed to repetitive motions at work, recent reports have questioned the relationship of CTS and occupational activities. This article reviews recent publications and provides insights into the causation of this common problem. Despite ergonomic workplace modifications aimed at reducing perceived risk factors, rates of imputedly work-related musculoskeletal disorders such as CTS have not decreased during the past ten years. One study found a prevalence of electrodiagnostically confirmed CTS of 3.5% in frequent computer users, but the authors also note that affected and unaffected employees had similar occupations, years using a computer, and usage rates. Another group concluded that computer use does not pose a severe occupational hazard for developing symptoms of CTS. Recent publications have suggested other risk factors such as age, obesity, hand dominance, reduced physical fitness, lifetime alcohol intake, and smoking; others have correlated weight and body mass index with prolonged median nerve latency. A relatively small number of jobs may be associated with CTS, primarily those that involve high force and repetition. The etiology of CTS usually is multifactorial, and risk factors include genetics, age, female sex, and obesity; its relationship with occupational injury is questioned.
Examinee-Reported History Is Not a Credible Basis for Clinical or Administrative Decision Making
Authors: Barth Robert J.
Published: December 2020

If a patient reports not having back pain before lifting an object at work but having chronic disabling pain thereafter, an examiner may conclude without further questioning that an injury took place when the object was lifted and therefore is work related. This article reviews relevant scientific findings and provides recommendations for making disability determinations in a manner that is more credible than basing conclusions on an examinee's reports. The author specifically recommends that future editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) should emphasize that clinical and forensic conclusions cannot be based on reports from an examinee and instead must be based on more credible sources of information. Research has shown that, among individuals who believe that a specific event (eg, an accident) caused the current complaints, the individual is likely to underreport their health history for the time preceding that event and to overstate the extent of their problems following the event. Other researchers found that claimants systematically underreported every preclaim health issue that might have provided a non–injury-related explanation for their complaints. Any basis for a conclusion of injury should be based on objective and scientifically credible findings that would have indicated that an injury had occurred even in the absence of any information having been reported by the patient.
Spine Ratings: Guides, Sixth Edition vs Guides, Fifth Edition
Authors: Eskay-Auerbach Marjorie
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, caused controversy with respect to changes in rating percentages. Impairment ratings in this edition are more specific than in previous editions and are intended to reflect lesser impairment in cases when symptomatology has improved with appropriate treatment. Grids in the AMA Guides, Sixth Edition, include impairment ratings for multiple-level conditions, so an alternative rating system (such as the range-of-motion method in the fifth edition) are not needed. The Diagnosis-related estimate (DRE) categories described in the fifth edition have been modified and expanded by the creation of regional grids that are used in the sixth edition to rate spinal impairments. The grids provide clearer categorization of many conditions and are consistent with clinical outcomes; ratings in the sixth edition reflect the results of treatment rather than the method of treatment. A significant difference in impairment ratings occurs between the fifth and sixth editions of the AMA Guides with respect to the classification of diagnoses of Alteration of Motion Segment Integrity, which includes fusion and, in the sixth edition, motion preserving technologies. A table compares the fifth and sixth editions for single-level spinal disease with or without radiculopathy and with or without surgery, including fusion.
Case Example: Rating Upper Extremity Injuries Involving Multiple Conditions in Same Extremity Using the AMA Guides, Sixth
Authors: Uejo Craig
Published: December 2020

Some injuries to the extremities can be associated with multiple injuries or diagnoses, and, in such cases, evaluators should recall that the functional history adjustment can be considered only for the single highest rated condition. This Case Example illustrates the proper rating methodology using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition section on The Upper Extremities. A 58-year-old male automotive mechanic fell at work on an oil-slickened floor and landed directly on his left outstretched hand and wrist, as well as the lateral part of his left elbow. At maximum medical improvement (MMI), the individual complained of moderate pain at rest and severe pain with repetitive forceful gripping and grasping. Radiographs taken at MMI showed a healed distal radius fracture in anatomic position with no posttraumatic arthritis and no carpal instability. The AMA Guides, Sixth Edition, allows use of only one of two methodologies: the Diagnosis-based impairment (DBI) methodology or the range-of-motion (ROM) method. Because ROM findings at the left elbow and wrist were recorded as normal and because the greater impairment that is causally related to the injury is used to rate the impairment, the DBI methodology is appropriate here. Only a single diagnosis is rated per region, and a case that involves more than a single region in the same extremity can be rated for separate impairments based on the separate regional conditions or diagnoses.
Rating Visual System Impairment using the Sixth Edition: Technical Aspects
Authors: Blais Bernard R.
Published: December 2020

Use of The Visual System section of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, requires knowledge and skills in ophthalmology and assessing impairment. Visual acuity usually is measured using symbols (letters, numbers, pictures, or other symbols) presented in a letter chart format. The Visual Acuity Scale (VAS) is a linear scale with fixed increments and provides a reasonable estimate of acuity-related visual abilities; the associated impairment rating is a reasonable estimate of acuity-related performance loss. This article shows how to perform visual acuity calculations and how to assess impairment of visual fields, including visual field test procedures and calculations. Additional factors can lead to a loss of functional vision and can limit the individual's ability to perform activities of daily living and include contrast sensitivity, glare sensitivity, color vision defects, and binocularity, stereopsis, suppression, and diplopia. If functional vision is affected and is not accounted for by visual acuity or visual field loss, the impairment rating of the visual system can be adjusted but should be limited to an increase of the impairment rating of the visual system by, at most, 15 points (ie, less severe than the total loss of one eye). The ability to rate visual impairment requires significant knowledge and education, and therefore a physician trained in ophthalmology should perform the visual examination and visual system impairment rating.
Thrombotic and Hemorrhagic Disorders
Authors: Demeter Stephen L.
Published: December 2020

The fourth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) devoted only a single page to the rating of thrombotic and hemorrhagic disorders, based primarily on analogous impairments from other organ systems and impairments in the activities of daily living (ADLs). The AMA Guides, Fifth Edition, rated thrombotic disorders by the effects on the organ system; criteria for rating hemorrhagic and platelet disorders were based on the treatment required and interferences in ADLs. The sixth edition introduced significant changes, among which are the following: The ratings for hematological disorders were deliberately reduced, especially the highest ratings, because of the inevitable involvement of other organ systems. The goal is for evaluators to rate each organ system based on its defined criteria rather than combining multiple organ system difficulties into a single organ system rating. Also in the AMA Guides, Sixth Edition, separate tables are used to rate hemorrhagic conditions caused by platelet disorders, hemophilia, and clotting disorders. Further, major changes were required because of global methodological changes in this edition, including a significant expansion of the methodology used in rating clotting defects. Finally, the rating for the use of warfarin was altered, and thrombotic disorders are rated using the specific coagulation defect.
Carpometacarpal (CMC) Joint Subluxation: Causation Analysis and Impairment Evaluation
Authors: Melhorn J. Mark , Brigham Christopher R. , Talmage James B.
Published: December 2020

Carpometacarpal (CMC) joint subluxation refers to the changes that occur in the CMC joint as seen on x-rays and observed during physical examination. The CMC joint is the most commonly involved arthritic joint in the hand, and arthritis may appear in localized or systemic forms. A diagnosis of thumb-CMC arthritis is based on symptoms of localized pain, tenderness, and instability on physical examination and radiographic evaluation. The AMA Guides to the Evaluation of Disease and Injury Causation provides a protocol for assessing causation and requires that all three of the following criteria must be met: 1) the patient has an illness compatible with a disease-producing agent or an injury; 2) the worker's exposure in the occupational environment potentially caused the disease or is a plausible mechanism of injury of sufficient magnitude to cause the condition; and 3) the preponderance of evidence supports the disease or injury as occupational in origin. If any one of the three is possible but not probable, causation has not been established. The authors review several published articles and conclude that, based on the clinical facts and current science, CMC joint subluxation is unrelated to work and instead is reflective of aging. The article concludes with a comparison of impairment ratings of CMC-related disability using the fifth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment, both of which lead to identical impairment ratings but by different means.