bluuebunny/crossref_metadata_2025 huggingface dataset:
Psychiatric Assessment in Injury and Disability
Authors: Scott Marcia
Published: December 2020

Chapter 14 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) discusses diagnosis, mental impairment, impairment severity assessment, special impairment categories, report format, and psychiatric impairment evaluation. The chapter differs from others in the AMA Guides insofar as it does not provide percentages for estimates of mental impairment because such usage suggests a certainty that does not exist. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, is a widely accepted classification system for mental disorders, but it omits context. Few clinically standardized tests can identify functional or structural effects, and neuropsychological testing is not the standard for documenting subtle impairment. How individuals manage their illness and cope with life demands are better measures of impairment than diagnostic labels or numbers and kinds of symptoms. Further, assessment requires an evaluation of the context in which the illness unfolds, including premorbid function and previous response to treatment; details about the individual's life course; review of developmental and functional deficits; character style and comorbidities such as anxiety and substance abuse; severity of precipitants, current stage of the episode, and current effectiveness of treatment; and external supports that can moderate impairment. A table lists areas of functional impairment, symptoms to consider, and patient history relevant to symptoms.
Clinical Update: Subjective Illness and Disability
Authors: Scott Marcia
Published: December 2020

Symptoms are the body's major signaling device, but symptoms often are frustratingly vague, subjective, and ill reported. In addition, challenges attend making decisions about an individual's ability to function based solely on the medical diagnosis, particularly when impairment is subtle or subjective. Chronic fatigue syndrome (CFS) is a model for understanding the limits of the medical approach to determining impairment and disability. A protocol from the Center for Disease Control and Prevention (CDC) is used to define CFS. This protocol is not a list of diagnostic criteria, and some patients with chronic fatigue may not meet the CDC definition. The syndrome reflects dysfunction in the neuroendocrine system similar in some ways to that seen with depressive illness, and most patients seen for this condition fulfill the criteria for depression, which is another illness characterized by fatigue and somatic complaints. Physicians who evaluate and treat patients with subtle persistent illness know that employers and coworkers respond less positively to an employee's needs when illness is subtle than when impairment is obvious. Physicians must be clear about the family, job, and employment risks patients take when they stay out of work for medical reasons; they also must recognize the risk these patients take when they continue to work despite impaired performance.
Evaluating Shoulder Impairment
Authors: Katz Richard T. , Perraraju Sankar
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, offers several categories to describe impairment in the shoulder, including shoulder amputation, abnormal shoulder motion, peripheral nerve disorders, subluxation/dislocation, and joint arthroplasty. This article clarifies appropriate methods for rating shoulder impairment in a specific patient, particularly with reference to the AMA Guides, Section 3.1j, Shoulder, Section 3.1k, Impairment of the Upper Extremity Due to Peripheral Nerve Disorders, and Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. A table shows shoulder motions and associated degrees of motion and can be used in assessing abnormal range of motion. Assessments of shoulder impairment due to peripheral nerve lesion also requires assessment of sensory loss (or presence of nerve pain) or motor deficits, and these may be categorized to the level of the spinal nerves (C5 to T1). Table 23 is useful regarding impairment from persistent joint subluxation or dislocation, and Table 27 can be helpful in assessing impairment of the upper extremity after arthroplasty of specific bones of joints. Although inter-rater reliability has been reasonably good, the validity of the upper extremity impairment rating has been questioned, and further research in industrial medicine and physical disability is required.
Lower Extremity Impairments—Knee and Hip
Authors: Shaw William S. , Brooks Charles N.
Published: December 2020

The process of assessing lower extremity impairment described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, differs from that in previous editions. This article addresses common questions that arise in knee and hip impairment rating according to the new edition. Anatomic, diagnostic, or functional methods can be used to estimate lower extremity impairments. Functional methods include ratings based on diminished range of motion, weakness, or gait derangement. In general, only one method should be used to rate impairment associated with an injury or illness. Section 3.2i, Diagnosis-related Estimates, in the AMA Guides lists impairment ratings for many knee conditions and operative procedures. Decreased range of motion, ankylosis, diminished muscle function, and joint space narrowing are some rating methods for the knee. Similar anatomic, diagnostic, and functional methods may be used to rate impairment due to hip pathology, but most hip impairments are estimated by range-of-motion deficits. Assessing lower extremity impairments requires a thorough medical evaluation, careful analysis, experience, and clear judgment; evaluators must determine the applicable rating methods, use the methods to rate the impairment, and then decide which method or combination best describes the impairment, without overlooking or duplicating ratings. [A related Lower Extremity Impairment Checklist and Worksheet appears on page 4 of this issue of The Guides Newsletter. A related Quick Reference, Motion at the Wrist, Elbow, and Shoulder, appears on page 5.]
Legal Update: North Dakota Supreme Court: Third Edition of Guides is “Most Current”
Authors: Mangraviti James J.
Published: December 2020

The accurate measurement of hip motion is critical when one rates impairments of this joint, makes an initial diagnosis, assesses progression over time, and evaluates treatment outcome. The hip permits all motions typical of a ball-and-socket joint. The hip sacrifices some motion but gains stability and strength. Figures 52 to 54 in AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, illustrate techniques for measuring hip flexion, loss of extension, abduction, adduction, and external and internal rotation. Figure 53 in the AMA Guides, Fourth Edition, illustrates neutral, abducted, and adducted positions of the hip and proper alignment of the goniometer arms, and Figure 52 illustrates use of a goniometer to measure flexion of the right hip. In terms of impairment rating, hip extension (at least any beyond neutral) is irrelevant, and the AMA Guides contains no figures describing its measurement. Figure 54, Measuring Internal and External Hip Rotation, demonstrates proper positioning and measurement techniques for rotary movements of this joint. The difference between measured and actual hip rotation probably is minimal and is irrelevant for impairment rating. The normal internal rotation varies from 30° to 40°, and the external rotation ranges from 40° to 60°.
Clinical Update: Evaluating the Allergic Patient: Practical Techniques
Authors: Bascom Rebecca , Craig Timothy J. , Schuler Diane
Published: December 2020

Despite rapid advances in understanding of the biology of allergic disorders, practical techniques for evaluating the allergic patient remain fairly constant. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) requires appropriate assessment before an examiner diagnoses the disorder, determines causation, evaluates whether the patient has reached maximal medical improvement, and rates permanent impairment, if any. A careful history includes both occupational and environmental assessment. Patients with allergic occupational asthma typically must be removed from exposure to the allergen. The environmental assessment should determine the nature of the patient's dwelling, its construction material, heating and ventilation, and the presence or absence of a damp basement, pets, rodents or cockroaches, or hobbies performed in the home. A physical examination should focus on the eyes, nose, lungs, and skin and should exclude obstructive sleep apnea. A thorough medical evaluation always is required, and assessment of immunologic sensitization involves diagnostic allergy skin testing or laboratory assessment. Although the allergens used in such tests are purified and the tests themselves increasingly are standardized, concerns remain regarding nonstandardized laboratories and remote testing. Spirometry is an essential element in objectively defining the nature and severity of respiratory complaints; rhinolaryngoscopy helps differentiate asthma from laryngeal dysfunction and can evaluate sinus disease; and limited cut CT of the sinuses is more cost effective than plain sinus films.
Tools and Resources: Cautions in Using the Guides
Authors: Brigham Christopher R.
Published: December 2020

The approach to evaluation of lower extremity impairments in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) differs from that given in previous editions. This article uses case studies to illustrate practical applications of current approaches to ankle impairment and to foot and toe impairment. Anatomic methods for rating ankle impairments include evaluations of muscle atrophy and limb length discrepancy. The Diagnosis-related estimates section provides ratings for ligamentous laxity and displaced fractures of the ankle. The arthritis section contains ratings for radiographically determined and graded diagnosis. Methods for rating ankle impairments include assessing gait derangement, range of motion, joint ankylosis, and manual muscle testing. The methods used for rating lower extremity impairments also are applicable for the foot and toes, and examiners may deploy less commonly used rating techniques such as those employed for amputations, skin loss, causalgia and reflex sympathetic dystrophy, and vascular disorders. The examiner must understand the applicable rating methods used, estimate percentages via each, and decide which methods best describe the impairment(s) without overlooking or duplicating ratings. The examiner also should report the rating options considered, the reasons for selecting the method(s) used, the method by which the percentage was calculated, and the rationale for any variance from the AMA Guides. [A companion Quick Reference, Measuring Impairments of the Hand and Digits, appears on pp 5-6 of this issue of The Guides Newsletter.]
Clinical Update: Overview of Work-Capacity Restrictions
Authors: Bleecker Margit L.
Published: December 2020

Early return to work is fundamental in the treatment of occupational injuries, but the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) may require temporary or permanent work restrictions. The US Department of Labor Physical Demand Characteristics of work classifies jobs by exertional level (sedentary, light, medium, heavy, and very heavy). The Workplace Functional Ability Guidelines (WFAGs) consist of 21 categories of health impairment and emphasize what the worker can do, ie, the “functional ability.” Musculoskeletal symptoms and signs such as strength, range of motion, or radiographic findings are not good predictors of functional abilities, nor does standardizing the method for work-capacity determination. Measures of physical work performance, even when conducted by highly trained individuals, have low interrater reliability when used for complex tasks. Any discrepancy in expectations between the physician and worker about capabilities and anticipated progress should be resolved. This may be best done if the physician is familiar with the requirements of the job and can offer suggestions about, for example, reducing the stress on an injured body part by using a different model of a tool. Individual differences in motivation, pain tolerance, conditioning, and so on make it difficult to determine work restrictions, but physicians should attempt to return the worker to gainful employment as early as possible.
Somatization
Authors: Ensalada Leon H , Brigham Christopher R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fourth Edition, notes that individuals may consciously exaggerate the symptoms of a disorder in the clinical or impairment evaluation setting, an activity that is associated with the process of somatization. This article reviews the phenomena of somatization, its magnitude, factors that contribute, and somatizing disorders themselves. Somatization is characterized by the propensity to experience and report somatic symptoms that have no pathophysiologic explanation, to misattribute them to disease, and to seek medical attention for them. Reported symptoms could result from organic disease—which is precisely the point because somatizing patients choose symptoms, consciously or not, that will be taken as evidence of real, physical disease. The prevalence of somatization reportedly ranges from 5% to 60% and varies with the medical specialty and the clinical setting. Studies have reported that in 25% to 50% of all primary care encounters, physicians found no significant objective cause to explain the presenting symptoms. The somatization process contributes to somatoform disorders, which are mental disorders and are not intentionally produced or feigned. A table compares three types of somatizing disorders: somatoform disorders, factitious disorders, and malingering. The presence of somatization distorts symptom presentation and can confound assessment methodologies, but the AMA Guides instructs that impairment is rated on the basis of objective findings, not solely on subjective complaints.
Tools and Resources: Nonorganic Findings
Authors: Brigham Christopher R. , Ensalada Leon H.
Published: December 2020

Experienced medical examiners perform detailed physical examinations that document negative, positive, and nonorganic findings. The latter are observations or subjective reports that cannot be readily explained on an anatomical basis. Nonorganic findings have been described since the early part of the 20th century, and nonorganic physical signs in low back pain were defined in 1979. Cervical nonorganic signs also have been developed, standardized, and proven reliable. Nonorganic symptoms and signs may indicate symptom magnification behavior or malingering, particularly if multiple findings are noted and are closely correlated with psychological distress and abnormal illness behavior. The presence of these findings does not necessarily preclude organic pathology. Table 1 extensively lists some of the tests commonly used by independent medical examiners to determine whether findings are nonorganic. Columns in the table list the area for which the test is used (eg, back pain, muscle spasm, or muscle weakness), the name of the test or maneuver (eg, log rolling, pinch test, or others), and a description with notes and recommendations.
Impairment Tutorial: Rating Sensory and Motor Deficits of the Upper Extremity
Authors: Brooks Charles N.
Published: December 2020

The three components of electrodiagnosis useful in evaluation of the peripheral nervous system and spinal cord include electromyography (EMG), electroneurography (nerve conduction studies), and somatosensory evoked potentials. EMG examination involves introduction of a special recording needle into a muscle belly. Electrical potentials located within a few millimeters of the needle are picked up by an electrode and are transmitted from the muscle to amplifiers that filter and display results visually for the electromyographer. Three types of spontaneous activity in electrical potentials are of the greatest relevance: positive sharp waves, fibrillation potentials, and fasciculations (fasciculation potentials on the EMG result from irregular firing of motor units). 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 can assess motor neurons, sensory neurons, or mixed nerve trunks. Sensory nerve conduction velocity can be studied in a manner analogous to motor conduction velocity: sensory fibers can be directly stimulated, and the evoked response can be measured at the wrist and elbow. Somatosensory evoked potentials occasionally are useful as an adjunct to EMG and NCS in the diagnosis of peripheral nervous system pathology. These tests also are useful when it is unclear whether an individual has a true radiculopathy.
Impairment Tutorial: Rating Sensory and Motor Deficits of the Lower Extremities
Authors: Brooks Charles N.
Published: December 2020

Previous issues of The Guides Newsletter have presented overviews of electrodiagnostic evaluation, including electromyography, nerve conduction studies, and somatosensory-evoked responses. This article contains suggestions for nonelectromyographers who read reports and identify questionable uses of electrodiagnosis, specifically for the evaluation of radiculopathy and focal neuropathy (eg, nerve entrapments), the two most common presentations. Some subtle abnormalities (eg, changes in motor unit recruitment pattern, changes in firing rate, or reduction in motor units recruited) often are overinterpreted by poorly trained or inexperienced electromyographers. Nerve conduction studies often are overused and may accompany the electromyogram without apparent indication, but they are nearly useless in diagnosing radiculopathy and should be included only for nerve entrapment or differential diagnosis of plexus injury. Nerve conduction studies often are accompanied by F waves and H reflexes. The F wave helps assess proximal portions of nerves and is used primarily in the diagnosis of Landry-Guillain-Barré syndrome but has poor sensitivity and specificity in evaluation of radiculopathy or entrapment neuropathy. The H reflex is used primarily in S1 radiculopathy evaluation. The article includes six questions a clinician should bear in mind while interpreting the electrodiagnostic report. Improperly trained physicians may report false positive or negative results, so examiners should be aware of the qualifications of physicians to whom they refer their patients.
Fifth Edition: the New Standard
Authors: Brigham Christopher R. , Talmage James B. , Ensalada Leon H.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, is available and includes numerous changes that will affect both evaluators who and systems that use the AMA Guides. The Fifth Edition is nearly twice the size of its predecessor (613 pages vs 339 pages) and contains three additional chapters (the musculoskeletal system now is split into three chapters and the cardiovascular system into two). Table 1 shows how chapters in the Fifth Edition were reorganized from the Fourth Edition. In addition, each of the chapters is presented in a consistent format, as shown in Table 2. This article and subsequent issues of The Guides Newsletter will examine these changes, and the present discussion focuses on major revisions, particularly those in the first two chapters. (See Table 3 for a summary of the revisions to the musculoskeletal and pain chapters.) Chapter 1, Philosophy, Purpose, and Appropriate Use of the AMA Guides, emphasizes objective assessment necessitating a medical evaluation. Most impairment percentages in the Fifth Edition are unchanged from the Fourth because the majority of ratings currently are accepted, there is limited scientific data to support changes, and ratings should not be changed arbitrarily. Chapter 2, Practical Application of the AMA Guides, describes how to use the AMA Guides for consistent and reliable acquisition, analysis, communication, and utilization of medical information through a single set of standards.
Case Studies: Spinal Impairment Evaluation: Comparison of the Third Edition Revised, Fourth, and Fifth Editions
Authors: Brigham Christopher R.
Published: December 2020

Significant differences exist regarding spinal impairment rating among the Third Edition Revised, and the Fourth and Fifth Editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Table 1 summarizes the rating criteria used in these three editions. The AMA Guides, Third Edition Revised used only the method that was subsequently labeled the Range of Motion (ROM) Model or Method to assess impairment. The AMA Guides, Fourth Edition, introduced the Injury or Diagnosis-related estimates (DRE) Method, but it had a limited role, primarily as a differentiator, when a patient's final category of disability was in doubt. The AMA Guides, Fifth Edition retains both ROM and DRE, but they are termed methods rather than models. The DRE Method remains the principal means to evaluate an individual who has an injury, but changes were made regarding when and how it is used. In specified cases, the ROM Method is used to assess impairment not caused by an injury (eg, multilevel involvement, recurrent radiculopathy, or multiple pathologic episodes that produce alteration of motion segment integrity or radiculopathy). Table 2 presents seven exemplar cases that demonstrate the differences in impairment ratings among the three editions, and the text discusses the ratings and differences among the outcomes according to edition used.
Fifth Edition: Causalgia, RSD, CRPS Impairment Evalaution
Authors: Ensalada Leon H.
Published: December 2020

In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the methods for rating impairment to causalgia, reflex sympathetic dystrophy (RSD), and complex regional pain syndromes (CRPS) differ from the approaches found in previous editions. Methods for evaluating impairment due to causalgia, RSD, and CRPS can be described as having anatomic or functional bases. The physical evaluation determines the anatomic impairment and is based on history and a detailed examination; the functional evaluation measures the individual's performance of the activities of daily living (ADL). Chapter 13 of the AMA Guides, Fifth Edition, considers causalgia and RSD in Section 13.8, Criteria for Rating Impairments Related to Chronic Pain, and defines chronic pain as the diagnoses of causalgia, posttraumatic neuralgia, and reflex sympathetic dystrophy. In contradistinction to Chapters 16 and 17 and the Glossary, the new term CRPS is not used here. Chapter 16 considers CRPS, RSD (now CRPS I), and causalgia (now CRPS II) and notes that, “contrary to previous suggestions, regional sympathetic blockade has no role in the diagnosis of CRPS.” Chapter 17 uses a functional approach for assessing impairment due to causalgia, RSD, and CRPS. Pending further guidance, evaluators should ensure that their methods for rating lower extremity impairments due to causalgia, RSE, and CRPS are internally consistent.
Clinical Update: Fibromyalgia Syndrome: Impairment and Disability Issues
Authors: Brigham Christopher R. , Leclair Norma J.
Published: December 2020

Fibromyalgia is a perplexing, controversial syndrome with many unanswered questions regarding both etiology and manifestations and impairment and disability issues. This article reviews controversies attending this diagnosis, examines the debates concern etiology, explains why this diagnosis is unratable by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, and explore issues of disability. Health care professionals debate whether the diagnostic criteria actually define a distinct clinical disorder, but the American College of Rheumatology published, for research purposes, classification criteria for Fibromyalgia Syndrome (FMS) that since have been widely used: FMS has been defined as a complex, chronic condition characterized by widespread noninflammatory musculoskeletal pain, severe fatigue, and sleep disturbances. Many health care professionals maintain that FMS is best understood from a biopyschosocial perspective because of the absence of visible clinical signs and inability to confirm the condition by laboratory tests. FMS may affect between 3 and 6 million people in the United States, with a 10:1 predominance in women, most between 35 and 60 years of age. Section 18.3b, When This Chapter Should Not Be Used to Rate Pain-Related Impairment, advises that “the pain of individuals with ambiguous or controversial pain syndromes is considered unratable” and provides three discriminatory questions.
Impairment Tutorial: Respiratory System: Fifth Edition Redefines Normal
Authors: Talmage James B. , Ranavaya Mohammed
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, changes the definition of “normal” (ie, the process of differentiating between an individual whose lung function is “normal” as opposed to an individual with Class 2 respiratory impairment) because the definition has changed over time. For example, the AMA Guides, First Edition (1971), used from the VA-Army 1961 Cooperative Study to construct tables of “normal” or “predicted” values during spirometry. Regression equations were used to calculate the predicted forced vital capacity, forced expiratory volume in the first second, and mandatory minute ventilation for men and women, by age and height. The Second Edition (1984) used data from a pulmonary function study in 251 healthy white individuals who lived 1400 meters above sea level (Utah), more than 90% of whom were members of the Mormon church (a very narrow segment of the American population). The AMA Guides, Third and Fourth Editions, continued to rely on the study just cited and made a distinction between “normal” and “mildly impaired.” The AMA Guides, Fifth Edition, uses the four classes of respiratory impairment and the same whole person impairment ratings for each class, unchanged from the Fourth Edition. The Fifth Edition has reverted to using the 95% confidence interval to determine “normal,” so that the same individual who, under the Fourth Edition guidelines was up to 25% impaired, would become normal under the pulmonary impairment guides of the Fifth Edition.
Objectifying the Spinal Impairment Examination: Fifth Edition Approaches
Authors: Haralson Robert H. , Brigham Christopher R.
Published: December 2020

A careful and thorough physical examination is a critical component of the spinal impairment evaluation. Two methods have been used for this evaluation, the Diagnosis-related estimates (DRE) method and the Range of Motion (ROM) method, but the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, states that “the DRE method is the principal methodology used to evaluate an individual who has had a distinct injury.” The DRE rating is based on objective findings at the time of evaluation and includes the following clinical findings: muscle spasm; muscle guarding; asymmetric spinal motion (previously called dysmetria); nonverifiable radicular pain; reflexes, neurological changes such as weakness or loss of sensation, atrophy, radiculopathy, and electrodiagnostic changes; alteration of motion segment integrity; cauda equina–like syndrome; and urodynamic tests. This article examines the definitions of the findings and discusses their use in the DRE method. For example, the AMA Guides, Fifth Edition, defines muscle spasm as a sudden, involuntary contraction of a muscle or group of muscles, and muscle spasm must be present at the time of a DRE-based evaluation; in the Fourth Edition, examiners used only a history of spasm. The AMA Guides, Fifth Edition also has different parameters, compared with the Fourth Edition, for determining atrophy.
Legal Update: State-Specific Use of the AMA Guides
Authors: Brigham Christopher R.
Published: December 2020

Many states require use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in their workers’ compensation systems; state statutes may or may not specify which edition of the AMA Guides to use and how to use them. Thirty-five states make use of the AMA Guides, and 60% (21) of them use the Fifth Edition. Eleven states use the Fourth Edition (Alabama, Arkansas, Delaware, Kansas, Maine, Maryland, Nevada, Ohio, South Dakota, Texas, and West Virginia). One state uses the Third Edition–Revised (Colorado), and one state uses the Second Edition (Louisiana). Some states use their own guidelines for specific issues and use the AMA Guides for other issues (eg, Washington State rates spinal impairment using the state's own guidelines but rates extremity disorders using the AMA Guides). Many states use a statutory schedule to assess amputations, hearing loss, visual loss, hernias, and disfigurement; some states may use a statutory schedule and use the AMA Guides for nonscheduled injuries. Physicians who practice in a state that does not make use of the AMA Guides in state workers’ compensation cases may need to assess impairment using the “latest edition” of the AMA Guides. The article includes a tabular summary of state statutes that deal with rating impairment in workers’ compensation cases.
Pain Evaluation: Fifth Edition Approaches
Authors: Robinson James , Turk Dennis C. , Loeser John D.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, stresses that impairment assessment should be based on objective evidence of organ dysfunction. Using this model, pain-related impairment (PRI) such as migraine headache not associated with definable organ dysfunction is difficult to reconcile with patients’ reports of limitations in their activities of daily living (ADL). Chapter 18 of the AMA Guides, Fifth Edition, systematically addresses PRI and differs from previous editions by allowing examiners to award both quantitative and qualitative impairments. PRI is challenging to integrate with other chapters of the AMA Guides, which provide conventional impairment ratings (CIR) based on objectively measurable organ dysfunction. Examining physicians should consider PRI when performing an impairment evaluation on an individual who has a condition associated with pain, including almost any orthopedic condition and most neurological conditions. The examiner must determine if an individual's PRI should be considered as incorporated in the CIR or if the PRI increases the burden of illness above that acknowledged in the CIR—and only in the latter case should the physician use Chapter 18. This chapter distinguishes ratable vs unratable PRI, but better terminology may be uncontroversial and controversial PRI, respectively. Ten steps are involved in a PRI assessment and require the examining physician to use a multiaxial approach, synthesize information from multiple sources, and carefully assess the individual's credibility and pain behavior.
Clinical Update: Chronic Fatigue Syndrome
Authors: Ensalada Leon H. , Brigham Christopher R.
Published: December 2020

Chronic fatigue syndrome (CFS) is a term applied to individuals who report severe chronic fatigue out of proportion to their efforts, but the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth and Fifth Editions, are clear that no ratable impairment is linked to CFS. Chronic fatigue is not synonymous with CFS; only a small fraction of persons who present with chronic fatigue symptoms meet the criteria for CFS; and CFS, like fibromyalgia and multiple chemical sensitivity, is poorly understood. CFS may be associated with disability but primarily is based on psychological rather than physical symptoms. No tests confirm the diagnosis of CFS, and routine laboratory testing is reserved for excluding other medical conditions. CFS is an illness without a disease and often is characterized by illness behavior expressed as somatization. To date, no convincing evidence supports the notion that CFS is an infectious, neuroendocrine, or immunologic disorder. Thus, sophisticated behavioral assessment is critical and may include a fatigue rating scale, a depression scale, and psychological and personality inventories. No specific treatment has been recommended for CFS treatment, but cognitive and behavioral interventions may be useful to address psychological symptoms; medication is reserved for specific symptoms indicative of depression or anxiety.
Impairment Tutorial: Rating After IDET Procedures: Rating Permanent Impairment in Patients Who Have Already Had Intra-discal Electrothermal Annuloplasty (IDET) Procedures
Authors: Talmage James B. , Haralson Robert H.
Published: December 2020

Intra-discal electrothermal annuloplasty (IDET) is a relatively recently described surgical procedure for chronic low back pain that is caused by degenerative discs is unresponsive to nonoperative treatment. IDET involves percutaneously inserting a catheter into a disc(s) and then heating the catheter to 90 °C for 17 minutes. Randomized controlled trials are in progress but not yet reported, so the proper role of IDET in the care of chronic back pain is not yet known. Neither the Fourth nor the Fifth Edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) specifically addresses IDET. Evaluators who use the AMA Guides, Fifth Edition, apply the Diagnosis-related estimates (DRE) method to assess impairment when the patient is at maximum medical improvement (MMI). Because the long-term effects of IDET are not known and the patient's disc probably has been permanently changed by the procedure, evaluators should consult the AMA Guides, Fifth Edition, regarding categorization. This is because the injury and surgery have not resulted in a normal disc but rather one that may be prone to future problem episodes. If the evaluator chooses to use the range-of-motion method from the AMA Guides, Fourth Edition, in some scenarios the authors recommend considering IDET as if it were “surgical treatment” of the disc.
Legal Update: Use of Impairment as a Threshold Determinate for Disability
Authors: Brigham Christopher R.
Published: December 2020

Workers’ compensation jurisdictions use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), in various ways, including as a proxy for disability, either as a direct correlate or as a threshold indicator. The AMA Guides clearly states that it should not be used for direct estimates of work ability: “it is inappropriate to use the Guides’ criteria or rating to make direct estimates of work disability.” The Maine Supreme Court ruled on two cases in which the resolution depended on the critical question of what impairment was being rated—that due to the injury or to all impairment. The court found that statutory language regarding personal injury may include a pre-existing condition when the work injury aggravates, accelerates, or combines with the pre-existing condition in a significant manner. The Commonwealth of Pennsylvania also uses impairment as a threshold to determine if an employee is totally disabled: Act 57 requires employees who have received total disability benefits for 104 weeks to submit to an impairment rating evaluation. The actions in both states raise questions about the reasonableness of using impairment to determine disability: What is the average extent of impairment among the working population? How can multisystem impairment be rated effectively? Few physicians have been trained in the use of the AMA Guides, and fewer understand the complexities of multisystem rating.
Multiaxial Diagnosis of Mental and Behavioral Disorders
Authors: Leclair Norma J. , Leclair Steven W. , Brigham Christopher R.
Published: December 2020

Most health care professionals who diagnose and treat mental disorders use the diagnostic criteria outlined in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition–Text Revised (DSM-IV-TR), which uses a multiaxial system to ensure a comprehensive assessment and evaluation of the patient's presenting symptoms, general medical condition, psychosocial and environmental problems, and level of function. The five axes are mental disorders; personality and mental disorders; general medical conditions; psychosocial and environmental problems, and global assessment of functioning (GAF) scale. Psychosocial and environmental problems may affect diagnosis, treatment, and prognosis of mental disorders; the problems or stressors can contribute to the development of a mental disorder or can be the result of a mental disorder. The multiaxial assessment process should result in the following; documentation of the primary and any secondary mental and behavioral disorders; definition of physical disorders that may be present and indication if they are related to or influence the mental and behavioral disorders; identification of environmental stressors that may affect, contribute to, complicate, or exacerbate the mental and behavioral disorder; and a rating of the person's psychological, social, and occupational functioning. A table shows the GAF scale (ratings by deciles from 1 to 100; higher numbers indicate fewer problems) and does not include impairments that result from physical or environmental limitations.
Common Tips for IMEs: Musculoskeletal Conversions: Musculoskeletal Conversions
Authors: Brigham Christopher R.
Published: December 2020

Most impairments are expressed ultimately as a whole person impairment, and the musculoskeletal chapters of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) include instructions for converting regional impairments to whole person impairments using a percentage relationship. This article presents an extensive table that incorporates the conversion factors for extremity and spinal impairments. Occasionally evaluators need to convert spinal impairments from whole person to impairment of the spine, a process that is explained in the AMA Guides, Section 15.13. The conversion factors differ depending on whether the impairment was obtained using the Diagnosis-related estimate (DRE) method or the range-of-motion (ROM) method. For example, a 5% whole person impairment is an 8% upper extremity impairment, a 9% hand impairment, 23% thumb impairment, 46% index/middle finger impairment, or 93% ring/little finger impairment. The same 5% whole person impairment would convert to a cervical spine impairment of 14% cervical spine if the DRE method were used and 6% if the ROM method were used. For the lumbar spine, this would convert to 7% lumbar spine impairment if the DRE method were used and 6% if the ROM method were used. The table in this article provides values for converting foot to lower extremity impairment and for converting whole person impairment to regional spinal impairment.
Impairment Tutorial: The Lower Extremities: Challenges with Chapter 17, The Lower Extremities
Authors: Brooks Charles N. , Talmage James B.
Published: December 2020

Like all multi-authored texts, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) presents some challenges and inconsistencies, and in March 2002 AMA published an errata. The latter has only one correction for Chapter 17, The Lower Extremities, and this article reviews some additional problems and inconsistencies in Chapter 17. For example, the AMA Guides, Fifth Edition, gives inconsistent instructions about measurements of muscle atrophy, and this article recommends simple, unambiguous directions such as measuring thigh and leg circumferences 15 cm superior and inferior to the medial joint line of the knee, respectively. One could argue that no goniometer should be included in Figure 17-1a, Using a Goniometer to Measure Flexion of the Right Hip; in Figure 17-1b, the goniometer should be placed with its axis at the center of rotation of the right hip. In Figure 17-1c, the limb of the goniometer overlying the left femur should instead be parallel to the tabletop. Additional sections of the article discuss joint ankylosis; peripheral nerve injuries; causalgia, complex regional pain syndrome, and reflex sympathetic dystrophy. A careful reading of Chapter 17 uncovers some problems, none of which is critical, but all should be noted by frequent users of the AMA Guides.
Clinical Update: Pain and Suffering
Authors: Wendler Sheila
Published: December 2020

Attorneys use the term pain and suffering to indicate the subjective, intangible effects of an individual's injury, and plaintiffs may seek compensation for “pain and suffering” as part of a personal injury case although it is not usually an element of a workers’ compensation case. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, provides guidance for rating pain qualitatively or quantitatively in certain cases, but, because of the subjectivity and privateness of the patient's experience, the AMA Guides offers no quantitative approach to assessing “pain and suffering.” The AMA Guides also cautions that confounders of pain behaviors and perception of pain include beliefs, expectations, rewards, attention, and training. “Pain and suffering” is challenging for all parties to value, particularly in terms of financial damages, and using an individual's medical expenses as an indicator of “pain and suffering” simply encourages excessive diagnostic and treatment interventions. The affective component, ie, the uniqueness of this subjective experience, makes it difficult for others, including evaluators, to grasp its meaning. Experienced evaluators recognize that a myriad of factors play a role in the experience of suffering associated with pain, including its intensity and location, the individual's ability to conceptualize pain, the meaning ascribed to pain, the accompanying injury or illness, and the social understanding of suffering.
Clinical Update: Assessing Maximum Medical Improvement in Carpal Tunnel Syndrome
Authors: Brigham Christopher R. , Talmage James B.
Published: December 2020

Permanent impairment cannot be assessed until the patient is at maximum medical improvement (MMI), but the proper time to test following carpal tunnel release often is not clear. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) states: “Factors affecting nerve recovery in compression lesions include nerve fiber pathology, level of injury, duration of injury, and status of end organs,” but age is not prognostic. The AMA Guides clarifies: “High axonotmesis lesions may take 1 to 2 years for maximum recovery, whereas even lesions at the wrist may take 6 to 9 months for maximal recovery of nerve function.” The authors review 3 studies that followed patients’ long-term recovery of hand function after open carpal tunnel release surgery and found that estimates of MMI ranged from 25 weeks to 24 months (for “significant improvement”) to 18 to 24 months. The authors suggest that if the early results of surgery suggest a patient's improvement in the activities of daily living (ADL) and an examination shows few or no symptoms, the result can be assessed early. If major symptoms and ADL problems persist, the examiner should wait at least 6 to 12 months, until symptoms appear to stop improving. A patient with carpal tunnel syndrome who declines a release can be rated for impairment, and, as appropriate, the physician may wish to make a written note of this in the medical evaluation report.
Legal Update: Social Security Disability Insurance
Authors: Pransky Glenn , Wasiak Radoslaw , Himmelstein Jay
Published: December 2020

The US Social Security Disability Insurance (SSDI) system does not use the AMA Guides to the Evaluation of Permanent Impairment, but examinees who are evaluated for permanent impairment frequently also are receiving SSDI benefits. The latter are restricted to workers who have long-term impairments that are so severe they preclude any type of gainful compensable activity, and the impairment must be medically determinable and expected to last at least a year or result in death. Both SSDI and the Supplemental Security Income plan (primarily for workers who have insufficient past work contributions) require the examining physician to provide specific medical information such as the medical history, physical examination, laboratory findings, and impairment, often using standardized forms. Examiners should know that the observations of the treating physician have legal significance, especially in areas of controversy. Social Security may approve additional diagnostic testing in order to conclusively establish the extent and severity of an illness. Based on the patient's history and observations during the examination, physicians also are asked to report any impairments in daily functioning, but examiners are advised not to address work-relatedness and are discouraged from discussing ability to work, which is determined by the state disability agency. Infrequent follow-up reports may be requested because most accepted claims are reviewed on a periodic (yearly) basis.
Legal Update: Cross-Examination: Fifth Edition Examples
Authors: Brigham Christopher R.
Published: December 2020

Physicians may need to defend their impairment evaluation opinions during cross-examination, and, in contrast to direct examination during which leading questions cannot be asked, during cross-examination the laws of evidence allow the questioning attorney to pose leading questions that are designed to elicit more information than a “yes” or “no” answer. A witness being cross-examined with leading questions typically may respond “yes,” “no,” or “I don't know,” but physicians should not volunteer information during examination because this may disclose inappropriate information. Similarly, physicians should avoid vague terms such as “I guess,” “I believe,” or “It's possible.” If the witness does not know the answer, the proper response is “I don't know,” or “I don't remember.” The expert's professional qualifications, expert opinion, and reasoning in forming that opinion are all subject to challenge, and the expert must be qualified to perform permanent impairment evaluations and prepare a report with supportable conclusions. The article includes examples of cross-examinations based on principles from the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapters 1 and 2. For example, evaluators may be criticized for erroneously using the terms guidelines instead of guides and disability instead of impairment; physicians who use impairment and disability interchangeably should expect close cross-examination. Evaluating physicians also may be challenged regarding their status as “independent and unbiased” examiners based on having seen the patient only once or, as a treating physician, on numerous occasions.