bluuebunny/crossref_metadata_2025 huggingface dataset:
Letter to the Editor
Authors: Bohr Tom
Published: December 2020

The author of this letter responds to an article regarding fibromyalgia in the July/August 2001 issue of The Guides Newsletter and notes an error in the article's assertion that fibromyalgia patients are not more likely to have psychiatric disorders than are other patients with chronic pain (eg, rheumatoid arthritis) because of an error in a previous study (the Alabama fibromyalgia research group). The author of the letter asserts that 27 studies show excess psychopathology in fibromyalgia patients; the few articles that support a diagnosis of fibromyalgia are dated and somewhat weak in terms of methodology. In fact, the Alabama study suffered from referral bias at academic centers and has been refuted by at least two other groups that found that fibromyalgia patients do not seem to have excess psychopathology because the studies were conducted at academic medical centers and therefore suffer from the typical tertiary care referral bias associated with more severely affected patients. The letter writer also highlights the original article's assertion that 14% to 23% of fibromyalgia patients receive a formal diagnosis of somatization. This is a large group of patients, the writer suggests, and a less restrictive diagnosis of “undifferentiated somatoform disorder” or “pain disorder” would increase the incidence. Finally, further discussions of fibromyalgia should address the excess incidence of abuse (sexual, physical, and emotional) during the early life of these patients.
Clinical Update: Motivation and Impairment Evaluation of Mental and Behavioral Disorders
Authors: Leclair Norma J. , Steven W. Leclair , Brigham Christopher R.
Published: December 2020

According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), motivation is a need or desire that causes a person to act and may be a key factor in an individual's physical or mental impairment. Poor motivation can cause poor functioning, and personality characteristics and underlying character are important determinants of an individual's motivation to benefit from rehabilitation. Particularly because of the subjective and highly sensitive nature of most mental and behavioral disorders, examinees have multiple self-interests, and, when one party engages in activities that are inconsistent with the other's expectations, resolution may depend on the employee's and employer's shared perceptions that the return to work is positive and consistent with each party's self-interests, particularly if both believe this step will succeed. Participants are motivated by the real or imagined costs associated with the return to work, and examinees may have concerns about facing coworkers, losing benefits or wages, dealing with labor relations, or simply making a change. When determining an individual's degree of motivation to return to work, the physician should consider the following: the value or usefulness of returning to work; employer's and employee's perceptions of the potential for successful return to work; and the real and perceived costs of work return (functional renewal) for the individual.
Rating Peripheral Neuropathy
Authors: Brigham Christopher R.
Published: December 2020

This article discusses the evaluation of peripheral nerve impairment and focuses on assessing peripheral polyneuropathies. Although peripheral neuropathy is a common neurological disorder, no uniform criteria exist for either evaluation or diagnosis, and 30% of cases remain idiopathic. The patient must be at maximum medical improvement (MMI) before permanent impairment is rated, but determining MMI is challenging, particularly if neuropathy is secondary to an underlying medical condition such as hypothyroid or diabetic neuropathy or toxic exposure. A table in this article directs readers to specific tables from the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) for determining maximum motor and sensory loss. Sensory dysfunction is evaluated by whether it interferes with performance of daily functions, and another table compares sensory gradings according to the AMA Guides, Fifth Edition (Tables 16-10 and 13-23) and the Fourth Edition (Table 11). When using these tables, evaluators should be aware of differences in terminology: sensation is the acceptance and activation of impulses in the afferent nerve fibers of the nervous system, and sensibility is the conscious appreciation and interpretation of the stimulus. In addition, a box discusses two-point discrimination testing and steps the examiner can take to minimize the variability of this procedure. Grading a sensory deficit requires considerable judgment and interpretation, which makes the findings less objective than findings that are independently verifiable.
Determining Impairment and Disability for Mental and Behavioral Disorders
Authors: Leclair Norma J. , Leclair Steven W. , Brigham Christopher R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 14, Mental and Behavioral Disorders, focuses on the particularly challenging process of evaluating a person with a mental or behavioral disorder. This chapter is unique: It does not include numeric impairment ratings because no precise methods exist for assessing impairment in mental disorders. This article focuses on the process of gathering qualitative data and relevant information to substantiate the behavioral impairment assessment, for which the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition–Text Revised (DSM-IV-TR) is used. Impairment ratings in the AMA Guides reflect “consensus-derived estimates that reflect the severity of the impairment and the degree to which the impairment decreases an individual's ability to perform common activities of daily living [ADL]” and designates four relevant areas to consider: ADL; social functioning; concentration, persistence, and pacing; and deterioration or decompensation in complex or work-like settings. The validity of an impairment classification depends on the process used to collect and analyze the data, including clinical treatment records, hospital discharge summaries, community mental health program activity reports, patient and family interviews, reports from work evaluation or rehabilitation centers, supported employment records, and workplace evaluations. Defining maximum medical improvement in patients with mental and behavioral disorders is difficult and, in some instances, may be impossible.
Impairment Tutorial: Rating Spondylolisthesis
Authors: Brigham Christopher R. , Haralson Robert H.
Published: December 2020

Spondylolisthesis generally is defined as an anterior or posterior slipping or displacement of one vertebra on another. A unilateral or bilateral defect of the pars interarticularis without displacement of the vertebra is known as spondylolysis or, less frequently, spondyloschisis. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes that the two common types of spondylolisthesis are isthmic (related to the presence of spondylolysis and occurring in the immature spine) and degenerative spondylolisthesis (usually found in older individuals with degenerative changes, usually at the fourth or fifth lumbar vertebra). The AMA Guides classifies spondylolisthesis based on the etiology of the slip: congenital, isthmic, degenerative, traumatic, pathologic, and iatrogenic/postsurgical. In addition, grades ranging from I to V are assessed based on the severity of the displacement of the vertebra above on the vertebra below. Some of the confusion concerning terminology used in the AMA Guides regarding alteration of motion segment integrity arises because multiple different but similar terms exist, eg, those from the American Academy of Orthopaedic Surgeons vs the AMA Guides. The AMA Guides specifies that an x-ray finding of spondylolisthesis alone does not equal alteration of motion segment integrity, and a Diagnosis-related estimate (DRE) is the appropriate method for assessing spondylolisthesis (except in rare occurrences of multilevel spinal involvement, when the range-of-motion method is recommended).
Legal Update: Use of the AMA Guides: 2003 Update
Authors: Brigham Cathy V. , Brigham Christopher R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is widely used in federal workers’ compensation, Longshore and Harbor Workers’ Act, and automobile casualty (personal injury) cases. The AMA Guides, Fifth Edition, is widely used, but not all state workers’ compensation systems make use of the current edition; in fact, relevant state statutes may or may not specify which edition of the AMA Guides to use and how to do so. Thirty-six states make use of the AMA Guides within their workers’ compensation systems, and 23 states use the Fifth Edition. Eleven states use the AMA Guides, Fourth Edition: Alabama, Arkansas, Connecticut, Delaware, Indiana (both Fourth and Fifth Editions), Kansas, Maine, Maryland, South Dakota, Texas, and West Virginia. Two states use the Third Edition, Revised: Colorado and Oregon. Some states do not use the AMA Guides and instead rely on state specific guidelines, and these include California, Florida, Illinois, Minnesota, New York, North Carolina, Utah, and Wisconsin. Other states may use their own guidelines for specific issues and use the AMA Guides for other issues (eg, state of Washington). Some states do not specify the use of any specific guidelines, including Michigan, Mississippi, Missouri, Nebraska, New Jersey, South Carolina, and Virginia. A table summarizes state statutes dealing with rating impairment in workers’ compensation cases, including AMA Guides edition most used, statute/code, comments, and relevant websites.
Clinical Update: Grip Strength: An Uncommon Impairment
Authors: Brigham Christopher R.
Published: December 2020

Upper extremity impairment rarely is assessed using grip strength, according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), because results can be influenced by subjective factors that are difficult to control, including sex, age, comorbidities, fatigue, handedness, time of day, pain, and the individual's cooperation. The AMA Guides, Section 16.5b, Impairment Evaluation Methods, discusses the approach used for rating peripheral nerve injuries, but this section applies only to specific nerve lesions with resulting weakness of the muscles supplied or sensory changes. Strength correlates only poorly with performance of the activities of daily living, and grip strength testing using a dynamometer or other types of isometric strength testing has not been shown to reliably discriminate between submaximal and maximal efforts. Grip strength usually is not used in the presence of decreased motion, painful conditions, deformities, or absence of body parts (eg, missing digit), nor is it used to rate weakness from a peripheral nerve lesion. In rare cases, the AMA Guides allows the use of loss of strength (eg, due to a severe muscle tear that healed leaving a palpable muscle defect). Impairment ratings based on objective anatomic findings take precedence, and loss of strength is rarely combined and only if based on unrelated etiologic or pathomechanical causes.
Impairment Tutorial: Convert, Add, or Combine?
Authors: Fries Ian Blair , Brooks Charles N.
Published: December 2020

The presence of multiple ratable entities, including symptoms, physical findings, test results, diagnoses, and/or procedures, complicates impairment evaluation; further, patients may have several findings in the same anatomic area and/or findings unrelated to the condition being rated. In complex cases involving a final extremity or whole person impairment (WPI), the examining physician must consider all possible ratable impairments, discarding duplicative or mutually exclusive ratings and converting, adding, or combining to obtain the final rating. Failure to follow the instructions detailed in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is a common source of error in impairment rating. The AMA Guides provides multipliers and, for the upper extremity, tables to convert a body part impairment to an extremity and then to a whole person rating. Jurisdictional requirements vary, but rating physicians commonly are asked to provide a single impairment percentage for the limb or whole person; when two or more impairments are involved, the rater must add or combine the percentages, carefully following the specific instructions in the AMA Guides. Adding two ratings is no different than deriving any other arithmetic sum, but impairment percentages much more commonly are combined than added to ensure that, no matter how many impairments are present, the total is never greater than 100% loss of an extremity or 100% WPI.
Motion Analysis of the Cervical Spine
Authors: Luers Patrick R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, defines a motion segment as “two adjacent vertebrae, the intervertebral disk, the apophyseal or facet joints, and ligamentous structures between the vertebrae.” The range of motion from segment to segment varies, and loss of motion segment integrity is defined as “an anteroposterior motion of one vertebra over another that is greater than 3.5 mm in the cervical spine, greater than 2.5 mm in the thoracic spine, and greater than 4.5 mm in the lumbar spine.” Multiple etiologies are associated with increased motion in the cervical spine; some are physiologic or compensatory and others are pathologic. The standard radiographic evaluation of instability and ligamentous injury in the cervical spine consists of lateral flexion and extension x-ray views, but no single pattern of injury is identified in whiplash injuries. Fluoroscopy or cineradiographic techniques may be more sensitive than other methods for evaluating subtle abnormal motion in the cervical spine. The increased motion thus detected then must be evaluated to determine whether it represents normal physiologic motion, normal compensatory motion, motion related to underlying degenerative disk and/or facet disease, or increased motion related to ligamentous injury. Imaging studies should be performed and interpreted as instructed in the AMA Guides.
Clinical Update: Assessing Common Issues in Electrophysiologic Studies
Authors: Ross Mitchell K.
Published: December 2020

Electrodiagnosis is a quantitative electrophysiologic test that may identify and localize the site of neurologic dysfunction and detect subclinical changes and compensatory processes. Electrodiagnostic (EDX) studies useful in evaluating the peripheral nervous system and spinal cord include electromyography (EMG), nerve conduction studies, and somatosensory evoked potentials. The primary uses of these tests are to evaluate radiculopathy, entrapment neuropathy, or other peripheral nerve study, and results must be presented completely, concisely, and in a standardized format understandable to nonelectromyographers (who may include adjusters, attorneys, hearing officers, and judges with varying degrees of knowledge about clinical neurology). Needle EMG remains the most sensitive electrophysiologic test for determining radiculopathy. Any EDX report should contain the fundamental test results and a summary of the findings and should make clear when facts other than neurophysiological data are included. Reports must be internally consistent to avoid compromising the report's integrity. Errors of fact and technique, incomplete or irrelevant data, and over-, mis-, and underinterpretation of data are too frequent in EMG reports. EDX studies objectively define peripheral nerve injuries, entrapment neuropathies, and radiculopathies; the findings must be clearly presented with supportable conclusions. Carpal tunnel syndrome practice parameters from the American Academy of Neurology and the American Academy of Physical Medicine and Rehabilitation are provided.
Legal Update: Apportionment and California Workers’ Compensation Reform
Authors: Walker Phil
Published: December 2020

In April 2004, California implemented workers’ compensation reforms to reduce workers’ compensation premiums for California employers while speeding medical treatment for injured workers. The new law requires the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, particularly regarding apportionment analysis for impairment; the AMA Guides does not directly evaluate disability. Under the new California law, the following are clear: apportionment of permanent disability is based on a) causation and requires both the overall percentage of permanent disability caused by the industrial injury, and b) the percentage of permanent disability due to all other factors, including previous injuries. Less clear about the new law are the following: does apportionment to “causation” mean the physician should apportion out preexisting “pathology” even if it was not disabling prior to aggravation; what happens if a worker fails to disclose a prior injury; and are the standards of the AMA Guides on apportionment similar to those in California's new Labor Code? In the AMA Guides, the discussion of causation, apportionment analysis, and aggravation is different from the legal precedent for disability in California. New in the law is the explicit statement that the employer shall be liable only for the percentage of permanent disability directly caused by the industrial injury. Legal decisions are expected to clarify the interpretation of apportionment.
Clinical Update: The Impairment Impact Inventory: Comparison of Responses by Treatment-seekers and Claimants Undergoing Independent Medical Examinations
Authors: Turk Dennis C. , Robinson James P. , Aulet Mary
Published: December 2020

In the adversarial setting of an independent medical evaluation (IME), claimants may be incentivized to exaggerate the severity of their problems. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) describes a protocol for assessing impairment associated with chronic pain, including the Impairment Impact Inventory (I3) that consists of 26 items that assess the burden of illness in three domains: pain intensity, interference with activities of daily living, and emotional distress. A study was performed to establish preliminary norms for the I3 and to compare responses of claimants undergoing IMEs with those of treatment-seeking chronic pain patients: 183 patients completed the I3, including fibromyalgia syndrome patients (FMS group), 35 multidisciplinary pain center patients (PC group), and 72 claimants undergoing IMEs. Patients in the latter two groups had a variety of chronic pain problems (and hypothetically may be more likely to exaggerate their problems). The three groups had similar mean scores on the total I3 and for each of the FMS, PC, and IME groups. Results support the hypothesis that participants, in aggregate, do not exaggerate their pain when they undergo IMEs, although some quite possibly do. These results are a step toward establishing a scientific basis for the impairment rating system described in the AMA Guides from consensus-based rules to an evidence-based system for making decisions about impairment.
Impairment Tutorial: Chapter 14 or 18 for Pain Complaints? Guidance From Chapter 14 and Other Mental Health Resources
Authors: Barth Robert J.
Published: December 2020

This is the second in a series of articles that address pain complaints and mental illness. The AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, should not be used if the pain presentation is attributable to mental illness, and the evaluator must distinguish between presentations that should be evaluated using Chapter 18, Pain, and those that should be evaluated using Chapter 14, Mental and Behavioral Disorders. Chapter 14 is unique in its avoidance of numerical impairment ratings but has been praised for its internal consistency and emphasis on following the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The only section of Chapter 14 that discusses pain complaints is somatoform pain disorders, which presents several problems, including nomenclature (the phrase somatoform pain disorder is antiquated and disappeared from DSM in 1994, and other forms of mental illness are not somatoform disorders). The DSM is the foundation of the evaluation process, and its discussion of any given mental illness is the gold standard definition of that illness; therefore, any attempt to evaluate pain complaints as a possible manifestation of mental illness must use DSM protocols. The article concludes with a discussion of the components of the evaluation process: awareness of the most prominent diagnostic possibilities; presenting complaints; health history; social history; review of records; family history; collateral interviews; and psychological testing.
Chapter 14 or 18 for Pain Complaints? Guidance From Chapter 18 and Other Pain Resources
Authors: Barth Robert J.
Published: December 2020

This article is part three of a four-part series that examines the rating of pain complaints and mental illness using the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides). Chapter 18 provides physicians with a method for evaluating impairment associated with “chronic pain states” for which there may be “no demonstrable active disease or unhealed injury,” and Chapter 14 should be considered when symptoms are out of proportion to physical findings. This article focuses on the directions from Chapter 18 and other pain resources. The authors note that Chapter 18 specifically addresses the issue of distinguishing between uses of Chapters 18 and 14, but the directions are contradictory with respect to the key question, Do “psychological factors” play a “major role” in the presentation of pain? Resources such as Bonica's Management of Pain point out that “[t]issue damage and nociception are neither necessary nor sufficient for pain,” suggesting that psychological factors are nearly always present and obviating the use of Chapter 18. A potential solution would be to ask, “Is the presentation of pain consistent with any mental illness as defined in the American Psychiatric Association's Diagnostic and Statistical Manual?” The decision rule then would be if the presentation of pain is consistent with any mental illness, then the mental and behavior chapter should be used.
Left Page: Rating Total Ankle Replacement
Authors: Brooks Charles N.
Published: December 2020

Total ankle replacement (TAR), also known as total ankle arthroplasty, has been used since the early 1970s, but, because of improvements in both techniques and materials, the procedure is used more frequently, and examiners are asked to rate permanent impairment resulting from TAR. The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) is silent about rating ankle impairment following arthroplasty but does provide a two-step method to rate the results of total hip and knee replacements. Using tables in the AMA Guides, examiners can rate disability associated with TAR. To provide a standard method for reporting the clinical status of the ankle and foot, the American Orthopaedic Foot and Ankle Society (AOFAS) published rating scales for four anatomic regions, one of which (the ankle-hindfoot scale), can be used to rate the clinical status of ankle, subtalar, talonavicular, and calcaneocuboid joints before and after treatment. The AOFAS scale includes neither patient satisfaction nor many other functional, physical, and radiographic findings, and the AOFAS ankle-hindfoot scale is not and never was intended to be comprehensive. Examiners can follow the same procedures for rating hip and knee replacements, substituting the AOFAS scale for rating clinical outcomes. [Two Quick References in this issue of The Guides Newsletter provide tables and figures relevant to rating upper extremity sensory and motor deficits and to measuring impairments of the hand and digits.]
Standards for Independent Medical Examinations
Authors: Nierenberg Chet , Brigham Christopher , Direnfeld Lorne K. , Burket Clarissa
Published: December 2020

An independent medical evaluation (IME) may be more comprehensive and may contain more elements than an impairment evaluation, but to date no standards have defined a high-quality IME. The authors, a group of experienced IME physicians, note the variability of requirements in individual IME cases, but they have identified standards that generally apply to IME reports and include the following: definition of IME and key concepts; examiner qualifications; methodology and procedures; the physical examination; suggested generalized report format; and quality assurance. An IMR is a specialized examination and report, ideally performed by a medical physician with special training and experience in IMEs; an IME is not a medical consultation and report but rather an opportunity to determine diagnosis and document the clinical course over time. Examiners should be qualified by experience and qualifications and ideally should have a special credential from an independent medical examiners association and must be knowledgeable about IME report writing. A section of the article describes the structure of the IME report, which may vary from examiner to examiner but should include careful attention to descriptive data, history, record review, oral history, physical examination, records of other objective data, and an opinion section (with diagnoses, discussion, past medical treatment, maximum medical improvement, future medical treatment, causation and apportionment, disability/functional status, prognosis, answers to specific questions, and references.
Questions and Answers: Pain-Related Impairment Questions
Authors: Brigham Christopher R.
Published: December 2020

Physicians who perform impairment evaluations should base their ratings on the objective condition of the patient, along with credible subjective findings. In making interpretations and judgments, examiners have obligations that are distinct from the duty of care as a treating physician. An experienced attending clinician, for example, may be unfamiliar with the correct process of rating impairment or may not feel unbiased in performing the rating. If significant new diagnoses are discovered, the physician has a medical obligation to inform the requesting party and individual about the condition and to recommend or refer for further medical assessment. When the physician is uncertain about which method to use to calculate an impairment rating or if more than one method can accurately be used, the physician should calculate the impairment rating using different alternatives and choose the method or combination of methods that best represents the functional impairment of the individual. The attending physician often is the person most knowledgeable about the injured employee and is encouraged to render the final impairment rating, when possible. Depending on the jurisdiction, examiners may be required to comply with specific constraints and duties regarding the rating. Examiners should not question an individual's integrity but can appropriately comment on the person's credibility.
Special Features: Duties of the Examining Physician
Authors: Colledge Alan
Published: December 2020

Workers’ compensation systems provided $25.3 billion of compensation benefits in 1999, and nearly $19 billion of this was compensation for permanent injury. Under workers’ compensation, when injured worker have missed a predetermined amount of work time, they are eligible for wage indemnification (the amount is determined by the jurisdiction). Benefits continue until the disabling condition either permits a return to work or reaches a plateau at which healing ends and no significant improvement is likely (maximum medical improvement or a permanent and stationary condition). How the award is calculated differs from jurisdiction to jurisdiction: In some jurisdictions, permanent injury benefits are awarded only on the direct physical loss; other jurisdictions compensate to some degree for expected wage loss, loss of employment options, expenses for accommodating the disability, and, perhaps, an implicit award for psychological loss and pain. Some jurisdictions require all impairments to be combined as a single whole person impairment, but others use individual impairments expressed as a regional impairment. In some jurisdictions, the permanent benefit is statutory and has no medical or clinical basis (eg, some statutes limit or disallow awards for conditions such as tinnitus or certain psychological conditions). Evaluators must be aware of statutes, administrative rules, and case law that apply to the evaluation.
Diagnostic Conceptualization for CRPS-1: Challenges in the IASP's Diagnostic Conceptualization for CRPS-1 (Formerly Conceptualized as RSD)
Authors: Barth Robert J. , Bohr Tom W.
Published: December 2020

Complex regional pain syndrome-type 1 (CRPS-1) is a problematic diagnosis of a characteristic burning pain that is present without stimulation or movement, occurs beyond the territory of a single peripheral nerve, and is disproportionate to the inciting event. This article highlights some challenging aspects of the diagnostic formulation for CRPS-1 by the International Association for the Study of Pain (IASP) and provides recommendations to address the issues. First, the terminology, CRPS-1, was created specifically to replace the previous term, “reflex sympathetic dystrophy.” Unfortunately, no gold standard diagnostic tests exist for CRPS-1, and the concept itself has a long and continuing history of controversy, not the least factor of which is the lack of reliable diagnostic schemes. Next, IASP's criteria for CRPS-1 do not standardize the diagnostic process and depart from epidemiologic guidelines, particularly regarding continuing pain, allodynia, or hyperalgesia disproportionate to any inciting event. Further, the IASP protocol overlaps diagnostic criteria for somatoform disorders, eg, those in the American Psychiatric Association's diagnostic manual, DSM-IV-TR. Finally, according to the IASP protocol, the majority of CRPS-1 patients present with symptoms that are indistinguishable from those in the DSM-IV-TR guidelines, and the majority of CRPS-1 cases are indistinguishable from the formal definition of malingering.
Erroneous Impairment Ratings
Authors: Brigham Christopher R.
Published: December 2020

This article continues a discussion of the results of a nationwide study that reviewed 2100 impairment ratings and found a large number of errors (see the May/June issue of The Guides Newsletter). Spinal impairment ratings, for example, often are erroneous. Although the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) clearly specifies use of the Diagnosis related estimates (DRE) method, evaluators sometimes incorrectly use the range-of-motion (ROM) method, which is fraught with potential error and typically results in higher impairment ratings. The most common problem associated with rating the lower extremities is combining multiple duplicative impairments. Multiple impairments typically are combined rather than added because the latter usually results in overrating impairments. A sidebar highlights red flags to erroneous AMA Guides ratings, and evaluators can take a number of steps to ensure accurate ratings. The first of these is to ensure an unbiased rating, preferably by a board-certified physician who, ideally, also has certification in the performance of independent medical and impairment examinations. The client requesting the evaluation should provide a cover letter describing the specifics of the evaluation, and the evaluator's report should comply with standards defined in the AMA Guides. All submitted reports should be reviewed by a physician experienced in the use of the AMA Guides; this cannot be accomplished by a nonphysician reviewer.
Erroneous Impairment Ratings
Authors: Brigham Christopher R.
Published: December 2020

A nationwide study in 2005 of 2100 cases referred for impairment rating review found 80% to be erroneous, and 89% of these erroneous ratings were higher than appropriate. Among whole person erroneous ratings (839 of 1037 cases critiqued), the original physician's rating averaged 15.5% whole person permanent impairment, but following rerating by physician experts, the corrected rating averaged 5.6%; only 7% of the cases were underrated. All ratings were based on the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition. Tables and figures show error rates according to portion of the body affected, expert vs original rating, and other explanatory variables. Two physicians who use the AMA Guides should arrive at similar conclusions about impairment ratings, but most physicians have not received instruction about assessing impairment, disability, or causation and lack an adequate ability to assess these issues. Causation requires a given cause and a given effect that are associated with a reasonable degree of medical probability and also requires documentation with appropriate scientific evidence (not self-reports or historical time frames). Those who prepare and review assessments of impairment should ensure that clinical causation assessments were accurate, that the rating was performed at maximal medical improvement, that examination findings were consistent, and that the individual's normal state was determined.
Impairment Tutorial: Rating Permanent Impairment for Artificial Disc Replacements
Authors: Talmage James B. , Brooks Charles N. , Brigham Christopher R.
Published: December 2020

In 2005, the Food and Drug Administration (FDA) approved an artificial disc replacement (ADR), and physicians likely will be called on to evaluate permanent impairment in some patients who have been treated using an ADR. The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition, was published in 2000, before the approval of ADRs, and thus is silent about evaluating ADR-associated impairment. FDA based its approval on the results of a study in which the indications were tightly limited and for which the list of relative contraindications was quite long. One review of 100 consecutive lumbar spine surgery patients found that 95% had at least 1 contraindication to ADR. The AMA Guides recommends using the Diagnosis-related estimates (DRE) method, but some situations (eg, multilevel involvement in the same spinal region) warrant use of the range-of-motion (ROM) method. Assuming a single injury and one level of loss of the activities of daily living, the DRE is the correct method to rate the permanent impairment, and the authors recommend that ADR be accepted as the equivalent to loss of motion segment integrity, warranting a rating from CRE Category IV. ADR is in its infancy, and until the AMA Guides, Sixth Edition, is available, evaluators can rate one level ADR from DRE Category IV.
Ulnar Neuropathy at the Elbow Due to Repetition: Myth or Reality?
Authors: Katz Richard T.
Published: December 2020

Repetitive strain injury (RSI), also known as cumulative trauma disorder, implies that an injury exists and was caused by repetitive strain, but both implications are debatable. Ulnar neuropathy at the elbow (UNE), also known as cubital tunnel syndrome, is the second most common upper extremity compression neuropathy (after carpal tunnel syndrome). This article examines one particular aspect of the RSI debate: Is there scientific evidence to support a causal relationship between UNE and repetitive elbow flexion and extension in the workplace? The authors extensively searched published articles, books, and federal task force publications to look for evidence supporting a causal relationship between UNE and RSI. This included a literature review followed by a study of pertinent review articles, bibliographies, national task force reports related to musculoskeletal problems in the workplace, and relevant case reports. In brief, after extensive searches the authors found no credible medical literature to support a causal relationship between RSI and UNE. Case reports and cadaver studies provide tenuous support for causation of UNE by high-force activities such as pitching in baseball. The only prospective study that systematically assessed any causal relationship between RSI and UNE showed there is none. This article includes a three-page Feature Companion, “Rating Guidance: Ulnar Neuropathy,” that identifies common errors and provides an example rating report.
The Challenge of Hand Arm Vibration Syndrome (HAVS)
Authors: Katz Richard T.
Published: December 2020

Hand arm vibration syndrome (HAVS) has been defined as a constellation of vascular, neurological, and musculoskeletal signs and symptoms in workers who use hand-held vibrating tools (eg, drills, grinders, saws, or jackhammers); pathological features affect primarily vascular, neurological, and muscle tissues. Researchers have hypothesized changes in central nervous system processing, but no significant somatotopic cortical changes have been found using functional magnetic resonance imaging. Differential diagnosis of HAVS includes a variety of anatomical, circulatory, and vasospastic disorders and was standardized in the Stockholm Workshop classification scale (1987). Available laboratory tests generally are incapable of grading the severity of individual cases, and no protocol reliably distinguishes between psychogenic and organic abnormalities. Some proposed tests are impractical, and multimodality testing is confounded by statistical fallacies. Vascular tests, including the cold provocation tests, correlate poorly with disease staging according to the Stockholm Scale, and plethysmography before and after cold provocation, were found to be unsatisfactory. Job tasks that involve vibrating machines are associated with musculoskeletal symptoms but sorting out the roles and latency periods of vibration, repetitive movements, grip and push factors, and worker postures is imprecise. The AMA Guides to the Evaluation of Permanent Impairment, does not provide directions about rating impairment associated with HAVS, but evaluators can use Chapter 16 The Upper Extremities, basing the rating on motion, neurological, and/or vascular deficits.
Observation Compromises the Credibility of an Evaluation
Authors: Barth Robert J
Published: December 2020

Impairment evaluations often occur within an adversarial context that involves a claimant or plaintiff vs a defense or benefits system; this adversarial context may precipitate proposals for observations of a clinical evaluation (eg, by an attorney or attorneys for one or both parties, a court reporter, a clinical expert, other consultant; audio or video also may be recorded). Evaluators, judges, and state workers’ compensation systems sometimes allow such observation, but a century of scientific research has reliably demonstrated that any observation changes an examinee's presentation in ways that are not themselves predictable. Such contamination leaves the evaluation results without a scientifically credible analysis, rendering observed evaluations futile exercises at best and sources of misinformation at worst. This article reviews the research in social psychology regarding “social facilitation and inhibition,” which has identified an extensive list of factors that are affected by observation (eg, complexity or novelty of the issue being evaluated, perceptions of the observer as an evaluator, stranger, or ally, number of observers, and other factors). No mechanism allows an evaluator to systematically account for the effects of all such variables for any given evaluation. When observation is mandatory, the evaluator should clearly document and communicate that a credible direct evaluation was rendered impossible, to the detriment of the referring party and the system as a whole.
Resources: Internet Resources for the Independent Medical Evaluator – 2007
Authors: Brigham Christopher R. , Walker Jenny
Published: December 2020

Rating patients with head trauma and multiple neurological injuries can be challenging. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 13.2, Criteria for Rating Impairment Due to Central Nervous System Disorders, outlines the process to rate impairment due to head trauma. This article summarizes the case of a 57-year-old male security guard who presents with headache, decreased sensation on the left cheek, loss of sense of smell, and problems with memory, among other symptoms. One year ago the patient was assaulted while on the job: his Glasgow Coma Score was 14; he had left periorbital ecchymosis and a 2.5 cm laceration over the left eyelid; a small right temporoparietal acute subdural hematoma; left inferior and medial orbital wall fractures; and, four hours after admission to the hospital, he experienced a generalized tonic-clonic seizure. This patient's impairment must include the following components: single seizure, orbital fracture, infraorbital neuropathy, anosmia, headache, and memory complaints. The article shows how the ratable impairments are combined using the Combining Impairment Ratings section. Because this patient has not experienced any seizures since the first occurrence, according to the AMA Guides he is not experiencing the “episodic neurological impairments” required for disability. Complex cases such as the one presented here highlight the need to use the criteria and estimates that are located in several sections of the AMA Guides.
Spinal Alteration of Motion Segment Integrity
Authors: Luers Patrick
Published: December 2020

The Diagnosis-related estimate (DRE) method is the principal methodology to evaluate spinal impairment, and alteration of motion segment integrity results at least in a DRE Category IV rating, based on a single-level fusion. Multilevel fusions are rated using the range-of-motion (ROM) method. Detailed examination of the medical literature identifies definitions of loss of motion segment integrity that differ from those in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fourth and Fifth Editions. Evaluators should note that the descriptions of certain figures were revised in the Errata to the Fifth Edition of the AMA Guides. Evaluators should note three key points from the AMA Guides: permanent impairment is based on findings at maximal medical improvement (MMI); motion in the spite must be abnormal to qualify for permanent impairment; and imaging results, by themselves, cannot be used to establish a DRE impairment rating. Overall, evaluators should consider flexion/extension radiographs that are technically adequate and taken at MMI; read and understand the Errata for Figures 15-3a, 15-3b, and 15-3c; and apply only normal translation and angular motion thresholds that are consistent with the scientific literature.
Cervical Whiplash: Assessment, Treatment, and Impairment Rating
Authors: Colledge Alan L. , Pack Roger , Brigham Christopher R. , Brooks Charles N.
Published: December 2020

Whiplash-associated disorder (WAD) refers to complaints attributed to a shear-hyperextension then hyperflexion cervical injury, typically following a rear-end motor vehicle collision. Research suggests that chronic whiplash symptoms should be the exception rather than the rule, and the surge of chronic whiplash symptoms probably reflects the focus on biological treatment of WAD, ignoring the cultural, psychological, and sociological influences. The physician evaluating and/or treating a whiplash patient needs to have a solid understanding of the complexities and controversies associated with this disorder. Evaluation should be prompt and thorough, but, unless indicated, evaluators should avoid sophisticated diagnostic studies (eg, magnetic resonance imaging studies correlate poorly with whiplash symptoms). Treatment generally should be simple and consists primarily of reassurance and home exercise. Disability, both occupational and avocational, should be avoided or minimized. As with other impairment evaluations, the clinical assessment (history, physical examination, and review of diagnostic studies) must be thorough. If there are ratable findings, examiners must determine their reliability and whether the examinee has achieved maximal medical improvement. Most cases of WAD do not result in permanent impairment, but when there is ratable impairment it usually falls in DRE Cervical Category II, with a rating of 5% to 8% whole person permanent impairment. Managing patients’ beliefs and expectations following motor vehicle injury can help guide them to continue or promptly return to normal activities. {223}
Clinical Update: Understanding Causation: An Example Using Carpal Tunnel Syndrome
Authors: Melhorn J. Mark
Published: December 2020

Medical evidence is drawn from observation, is multifactorial, and relies on the laws of probability rather than a single cause, but, in law, finding causation between a wrongful act and harm is essential to the attribution of legal responsibility. These different perspectives often result in dissatisfaction for litigants, uncertainty for judges, and friction between health care and legal professionals. Carpal tunnel syndrome (CTS) provides an example: Popular notions suggest that CTS results from occupational arm or hand use, but medical factors range from congenital or acquired anatomic structure, age, sex, and body mass index, and perhaps also involving hormonal disorders, diabetes, pregnancy, and others. The law separately considers two separate components of causation: cause in fact (a cause-and-effect relationship exists) and proximate or legal cause (two events are so closely related that liability can be attached to the first event). Workers’ compensation systems are a genuine, no-fault form of insurance, and evaluators should be aware of the relevant thresholds and legal definitions for the jurisdiction in which they provide an opinion. The AMA Guides to the Evaluation of Permanent Impairment contains a large number of specific references and outlines the methodology to evaluate CTS, including both occupational and nonoccupational risk factors and assigning one of four levels of evidence that supports the conclusion.
Differential Diagnosis for Complex Regional Pain Syndrome
Authors: Barth Robert J. , Haralson Robert
Published: December 2020

Complex regional pain syndrome (CRPS) is a controversial, ambiguous, and often unreliable concept that presents significant clinical and rating challenges, to the extent that, for any individual case, many of the differential diagnostic issues provide a far more probable explanation of symptoms than does CRPS. The International Association for the Study of Pain (IASP) introduced CRPS in 1994 specifically to replace “reflex sympathetic dystrophy” [RSD] and “causalgia.” The IASP diagnostic protocol for assessing CRPS has led to overdiagnosis, as well as questions regarding the protocol's reliability, validity, and high error rate during field trials. Using the IASP protocol and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the authors discuss the mental health and general medical evaluations that are part of the differential diagnosis of CRPS, which involves both psychological and general medical components. Finally, examiners should be aware that the probability rates for a diagnosis of CRPS following a thorough and extensive differential diagnosis is very small and is further limited by the general lack of scientific credibility for the concept of CRPS. A diagnosis of CRPS in the absence of ruling out all potential differentials is not credible. A sidebar discusses several chapters that are relevant to rating impairment due to causalgia, RSD, and CRPS.