bluuebunny/crossref_metadata_2025 huggingface dataset:
International Classification of Functioning, Disability, and Health: A Contemporary Model of Disablement
Authors: Bond Malcolm
Published: December 2020

This article begins with a consult of a patient using the International Classification of Functioning, Disability, and Health (ICF), published by the World Health Organization in 2001. The ICF framework serves as the conceptual model for the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. In contrast to the issues of morbidity-centric documentation schemas, the ICF platform provides a standardized nomenclature to chart functioning, specifically an integrative biopsychosocial model of functioning that defines the components of functioning. The ICF qualifier serves as the titratable dimension of function; the qualifier not only satisfies the need for charting progress but also, when aggregated, provides the possibility of identifying the quantitative metrics of a cohort (eg, service needs, length of hospitalization, level of care, functional outcomes, and return-to-work potential). Implementing ICF into routine documentation moves practitioners toward the concept of functioning not as a consequence of disease but rather toward the real-life dynamics among health condition, body function, body structure, and environmental factors that determine functioning. ICF will be an essential basis for the standardization of data concerning all aspects of human functioning and disability around the world. ICF will be useful for persons with all forms of disabilities, not only for identifying health care and rehabilitative needs but also in identifying and measuring the effect of the physical and social environments.
Practical Individual Resilience: A Neuroplastic Approach
Authors: Aurbach Robert
Published: December 2020

Resilience has been a disappointment in the context of understanding why some people bounce back from injury, illness, or other challenges, but others do not. Researchers have identified characteristics that are found in people they deem to be resilient, but these characteristics are too general to be used effectively and do not demonstrate how to build or reinforce resilience. Humans form habits of thought, feelings associated with particular stimuli, and behaviors in response to stimuli, a process known as neuroplasticity. Injured or ill individuals often are presented with additional stimuli that maintain the associations and expand the scope of illness. In the privacy of their own minds, individuals may repeat self-negating thoughts about economic pressure, loss of work identity, psychosocial issues, and others that lead to anger, frustration, worry, catastrophic thinking, and grief—creating a web of disability. In this context, resilience can be reframed as the ability of a person to change, quiet, or moderate self-talk in order to minimize their long-term reaction to stressors. To foster resilience, individual interventions can be undertaken as general life training, specific inoculation against anticipated situations, or in a remedial role to help those whose experience of challenges has been exacerbated by an inner voice that is out of control. Workplaces that enhance rather than diminish individual resilience allow productivity and wellness to coexist and reinforce one another.
Cervical Lordosis: The Significance of Decreased, Straightened, and Reversed Curves
Authors: Brooks Charles N. , Eskay-Auerbach Marjorie , Talmage James B. , Tencer Allan F.
Published: December 2020

The normal cervical spine is straight in the coronal plane and usually is lordotic (curved convex anteriorly) in the sagittal plane, and although cervical spine deformity occurs in the coronal plane (eg, scoliosis), sagittal plane deformities are more common. For example, cervical lordosis can be increased (hyperlordosis) within the normal range, decreased (hypolordosis), absent (a straight cervical spine with 0° of curvature on a lateral X ray), or reversed (kyphosis). Primary deformity of the cervical spine often is congenital (eg, wedge vertebra); secondary sagittal deformities may be due to disc degeneration accompanying aging, disease such as ankylosing spondylitis, or surgery (eg, for postlaminectomy kyphosis). Decreased, straightened, or reversed cervical lordosis (DSRCL) may be idiopathic and can be voluntary, and evaluators must differentiate DSRCL that does not change over time vs sagittal plane alignment that varies over time or with a change in posture or position. DSRCL usually is asymptomatic, but severe cervical kyphosis can cause neck pain, myelopathy, dysphagia, loss of horizontal gaze, and other symptoms that are sufficiently severe to result in disability and to require surgical correction. Reports of DSRCL due to spasm, particularly at times temporally remote to an injury, should be met with extreme skepticism. Kyphosis of sufficient severity to be symptomatic usually is a postoperative deformity, not an effect of whiplash.
Shoulder Impairment Ratings: Sixth Edition
Authors: Talmage James B. , Blaisdell Jay
Published: December 2020

In many workers’ compensation systems, shoulder injuries are among the most common reasons for filing a claim, and greater familiarity with the significant differences in rating processes between the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions will help physicians avoid common pitfalls and improve the reliability of impairment ratings. One source of confusion associated with rating a shoulder is determining whether to use the range-of-motion (ROM) method or the diagnosis-based impairment (DBI) method. The AMA Guides, Sixth Edition, clearly states that DBI is the primary method of evaluation for the upper limb and that range of motion is used primarily as a physical examination adjustment factor and only when a grid permits its use as an option. An impairment rating that is calculated using ROM may not be combined with a DBI-based impairment rating; DBI is the primary method, and ROM should be used “only under specific circumstances.” When measuring ROM, evaluators should record all six measurements of shoulder motion for each arm and use the injured arm as a baseline. If two or more diagnoses are possible under the DBI method, evaluators should choose the highest causally related impairment rating from the shoulder grid and modify the clinical studies grade modifier.
Assessing Impairment and Disability in the Pain Patient
Authors: Feinberg Steven D. , Brigham Christopher R. , Ensalada Lee
Published: December 2020

Assessing impairment and/or disability in the pain patient often is difficult due to both administrative and clinical issues; in addition, the terms impairment and disability are misunderstood. Chronic pain complaints may be associated with significant disability, but typically the physician defines clinical issues, functional deficits, and, when requested, impairment; disability most often is an administrative determination. The biopsychosocial approach currently is viewed as most appropriate perspective for understanding, assessing, and treating chronic pain disorders and acknowledges a complex and dynamic interaction among biological, psychological, and social factors. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, discusses the assessment of pain and eligibility requirements for pain-related impairment (PRI). Some physicians feel that the AMA Guides’ approach to PRI does not adequately address the “disability” and functional loss caused by some chronic pain states, but the AMA Guides is limited, mostly, to describing measurable objective changes or impairment. The AMA Guides is not intended to be used for direct estimates of loss of work capacity (disability), and impairment percentages derived according to the AMA Guides criteria do not measure work disability. Impairment ratings in the AMA Guides already have accounted for impairment-associated pain, including that experienced in areas distant to the specific site of pathology.
A Review of the Evaluation, Treatment, and Rating of Lateral Epicondylitis
Authors: Arnett Justin J. , Mandel Steven , Aydin Steve M. , Brigham Christopher R.
Published: December 2020

Lateral epicondylitis, often called “tennis elbow,” is a musculoskeletal condition characterized by pain around the lateral elbow and adjacent forearm with resisted wrist extension or passive terminal wrist flexion with the elbow in full extension, plus tenderness over and/or just distal to the lateral epicondyle. The name is a misnomer because the pathology is neither inflammatory nor located in the lateral epicondyle but rather represents a chronic tendinosis with disorganized tissue and neovessels of the tendon originating from the extensor carpi radialis brevis muscle and less commonly the extensor digitorum communis muscle, which originate on the lateral epicondyle. Clinical assessment involves understanding the chronology, precipitating activities, current symptoms, and interference with activities of daily living. Physical examination is performed bilaterally and includes palpitation provocative testing, measuring elbow and wrist motions, and neurological evaluation. Many treatments have been proposed, but little quality evidence supports any specific approach; more than 90% of cases are managed nonoperatively. Severe cases that have failed at least months of nonoperative management may warrant surgical assessment, but studies of surgical results for treatment of lateral epicondylitis are limited. Impairment rating may be necessary in a minority of cases and involves using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, based on diagnosis-based impairment and using Table 15-4, Elbow Regional Grid: Upper Extremity Impairments.
Hernia Impairment Ratings and the AMA Guides, Sixth Edition
Authors: Jay Blaisdell , Talmage James
Published: December 2020

Of the many types of abdominal wall hernias, inguinal hernias are, by far, the most common type and typically present in males in workers’ compensation cases who report the cause as heavy lifting. The AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, indicates that genetics (family history) is the strongest risk factor. Conditions that chronically increase intra-abdominal pressure (eg, obesity, ascites, or pregnancy) and smoking are statistically associated with abdominal wall hernias, but no good studies show an increased risk of hernia formation in laborers. Abdominal hernias with palpable defects or protrusions usually are corrected with surgery, and the outcome typically warrants an impairment of 0%. In the AMA Guides, Sixth Edition, Section 6.6, Hernias, and Table 6-10, Criteria for Rating Permanent Impairment Due to Hernias, are used for ratings. The rating scheme in the internal medicine chapters differs from that found in the musculoskeletal chapters because the rater uses a key factor of two of three potential variables—history, physical findings, and objective findings—to select the impairment class. Like the grade modifiers in the musculoskeletal chapters, the other variables (other than the key factors) then are used to modify the impairment rating within the impairment class. Most hernias are not due to injury and result in 0% whole person permanent impairment after repair.
Assessing Sexual Dysfunction, Part 1: Male Sexual Dysfunction
Authors: Cohen Seth D. , Mandel Steven , Samadi David B.
Published: December 2020

To properly assess men and women with sexual dysfunction, evaluators should take a biopsychosocial approach that may require consultation with multiple health care professionals from various fields in order to get to the root of the sexual dysfunction; this multidisciplinary methodology offers the best chance of successful treatment. For males, this article focuses on erectile dysfunction (ED) and hypogonadism. The initial evaluation of ED involves a thorough case history, preferably taken from the patient and partner, physical examination, and proper laboratory and diagnostic tests, including an acknowledgment of the subjective complaint. The diagnosis is established on the basis of an individual's report of the consistent inability to attain and maintain an erection sufficient to permit satisfactory sexual intercourse. Initial workups for ED should entail a detailed history that can be obtained from a validated questionnaire such as the International Index of Erectile Function and the Sexual Health Inventory for Men. Hypogonadism is evaluated using the validated Androgen Deficiency in the Aging Male questionnaire and laboratory testing for testosterone deficiency. Treatments logically can begin with the least invasive and then progress to more invasive strategies after appropriate counseling. The last and most important treatment component when caring for men with sexual dysfunction—and, arguably, the least practiced—is close follow-up.
Compensability of Common Upper Extremity Conditions When Work Activities Are Repetitive
Authors: Melhorn J. Mark , Haley LuAnn , Brooks Charles N.
Published: December 2020

Repetitive illness sometimes is wrongly called repetitive injury or cumulative trauma, but the latter are misnomers because the employee cannot identify a specific injury as a cause of the symptoms. In workers’ compensation, such gradual illness claims may be compensable if the condition arises during the course of employment, which requires that it be caused by occupational duties, exposures, or equipment used on the employer's premises. Expert impairment evaluators face three requirements: they must know the best scientific evidence currently available regarding causation of the condition(s) in question, ie, generic causation; the facts of the individual case, ie, specific causation; and the legal threshold in the applicable jurisdiction for acceptance of a condition as work related. The AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, is an excellent resource and provides the physician a blueprint for the assessment of causation in occupational injury and illness claims. The book adopts the methodology developed by the National Institute for Occupational Safety and Health and the American College of Occupational and Environmental Medicine. When asked to render opinions regarding causation, a physician is wise to consider this methodology in determining the work relatedness of the condition. Medical opinions based on an accepted methodology and the best scientific evidence will result in better patient outcomes.
Imprecision in the Evaluation of Workers’ Compensation Psychological Injury Claims
Authors: Warren Pamela A.
Published: December 2020

Psychological conditions with severe symptoms can result in considerable impairment in functioning, and psychological disability claims, also called behavioral health disability, have increased during the past two decades. A review of states’ workers’ compensation (WC) systems shows no overlap between systems; that is, all states and federal WC systems have unique terminology, rules, and laws. In order to thoroughly evaluate the individual, evaluators must use a biopsychosocial approach that combines aspects of biological, psychological, and psychosocial issues. Studies consistently demonstrate a high degree of comorbidity between physical and psychological conditions, but frequently only the former are identified and treated. Current disability systems use byzantine definitions of disability and require professional opinions and documentation that do not comport with current psychological standards of care, introducing imprecision. Many issues relating to WC terminology and laws can be addressed if the Daubert standard is incorporated into any amendment of WC state and federal laws. The Daubert standard requires that currently accepted scientific methods be used when a professional offers testimony as an expert or is submitting professional treatment records (eg, in a WC determination). Compliance with the Daubert standard requires more consistent, objective professional documentation and testimony to ensure even-handed decisions that align with standards of psychological care. One observer has suggested that the Daubert standard is a mechanism by which junk science is kept out of legal proceedings.
Do Imaging Findings Predict the Need for Work Restrictions?
Authors: Eskay-Auerbach Marjorie , Talmage James B.
Published: December 2020

Physicians frequently are asked to assess work ability in individuals with low back pain (LBP) who also require an impairment rating. Physicians may be tempted to base their decisions about the individual's work ability on spinal anatomy/diagnosis as established by imaging, because that may seem objective. However, a review of the current medical literature consistently demonstrates that anatomical abnormalities identified on imaging do not predict functional ability. Rather, recent studies have demonstrated a strong association between the number of symptoms and functional status, on the one hand, and the lack of correlation between findings on imaging and symptoms, on the other hand. For example, a systematic review by Mayo Clinic physicians of 33 published studies in which 3110 asymptomatic adults were imaged using magnetic resonance imaging (MRI) showed that, in middle age when most problematic back pain problems present, roughly half of asymptomatic adults had disc bulges, roughly one-third had disc protrusions, and roughly one-quarter had annular fissures. The authors of the present study also review related studies regarding low back pain and conclude that current scientific knowledge suggests that imaging alone is not useful in predicting function or in assessing future risk. Degenerative changes on imaging are not a sound basis for work restrictions because they do not correlate with risk or capacity.
Colorectal Cancer: Case Example
Authors: Brigham Christopher R. , Talmage James B. , Demeter Stephen L.
Published: December 2020

Under California Labor Code Section 3212.1, firefighters, forestry and fire protection workers, peace officers, and first responders receive a potentially rebuttable presumption of compensability for certain conditions, including cancer and leukemia. This case example illustrates the need for accurate clinical, causation, apportionment, and impairment assessments that are based on the facts, current science, and appropriate use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). A retired California firefighter in his mid-sixties presented for an impairment evaluation for the sequelae of his colon cancer; six years earlier, he was diagnosed with stage 1 colorectal cancer and received neoadjuvant chemotherapy and radiation therapy, followed by surgical resection with a diverting colostomy and take-down surgery. He is morbidly obese (body mass index, 45) and has hypertension. He reported fecal frequency, urgency, and incontinence and stated he had problems with erectile dysfunction (ED) before his diagnosis of colon cancer, but after diagnosis and treatment the problem worsened to impotence. The author presents impairment assessments of this case example according to the AMA Guides, Fifth Edition vs the Sixth Edition. According to the fifth edition, this individual's impairment for lower gastrointestinal tract impairment is 17% whole person impairment (WPI), and this is combined with 5% WPI for ED, resulting in 21% WPI. According to the sixth edition, the lower gastrointestinal tract impairment of 14% is combined with 5% WPI for ED, leading to an 18% WPI.
AMA Guides, Sixth Edition: Skin Impairment, An Overview
Authors: Blaisdell Jay , Talmage James B.
Published: December 2020

The most common source of occupational skin disease is contact dermatitis, an inflammation caused by exposure to an allergen. Whenever possible, the evaluating physician should rely on objective evidence such as lichenification, excoriation, and hyperpigmentation rather than subjective complaints. Patch testing, biopsy, and sensory discrimination tests are reliable tools at the evaluating physician's disposal. Disfigurements of the face are rated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 11.3, The Face, and Chapter 8, The Skin, is used for all other skin impairments. The evaluating physician records the history of the injury, evaluates the patient, and, in consultation with Table 8-3, notes any objective clinical studies to diagnose the pathology. The functional history, physical examination findings, and diagnostic test findings values then are assigned using Table 8-2; the functional history acts as the key factor and determines the patient's impairment class, physical examination, and diagnostic test findings, each acting as non-key factors, or modifiers. Finally, the non-key factors are used to modify the impairment rating from its default value within its impairment class, and the result is the final skin impairment rating expressed as whole person impairment. Chapter 8 is used only rarely in impairment rating in workers’ compensation cases, and examiners should study the chapter carefully before using it.
Reliability of Cervical Spine Palpation
Authors: Dagher Edward I.
Published: December 2020

Palpitation is an important component of a comprehensive musculoskeletal and neurologic examination of the cervical spine in individuals with neck pain, but examiners should not base diagnostic conclusions (eg, facetogenic pain) and interventional procedures on palpatory findings alone. A methodological approach to palpation of the posterior neck includes evaluation of the paraspinal musculature, the tissues that overlie the facet (zygapophyseal) joints, and the midline spinous processes. Although studies have shown low interexaminer reliability, palpation is an important component of the physical examination for determining general anatomic regions of symptoms and in establishing rapport with the examinee. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the diagnosis-related estimate (DRE) or injury method lists both muscle spasm and muscle guarding as potential physical exam findings by palpation. In this edition, the range-of-motion method for rating spinal impairment states that an examiner cannot find muscle spasm on exam and rate the individual's impairment on the same day because, by definition, the individual is not at maximum medial improvement. Despite acceptance by the AMA Guides, Fifth Edition, neither spasm nor guarding appears to be a reliable finding on palpation. The AMA Guides, Sixth Edition, provides a different method for determining spinal impairment, and the authors recommend limiting physical examination findings used in impairment rating to those with acceptable interrater reliability.
Maximum Medical Improvement: Jurisdictional Perspectives
Authors: Brooks Charles N. , Brigham Christopher R.
Published: December 2020

Maximum medical improvement (MMI) and its multiple synonyms are important terms to understand because one cannot determine permanent impairment until a condition has resolved or reached a stable plateau with respect to improvement. Further, in many jurisdictions MMI represents the date beyond which temporary or all benefits cease or time-loss compensation (temporary disability benefits) may be terminated. Because each arena is to some extent unique, evaluating physicians should become familiar with MMI or the term used and its definition in the applicable federal, state, or provincial law or insurance policy. A table shows the terminology used by various US workers’ compensation jurisdictions, but there is no universal definition for MMI. The fourth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) says only that “an impairment should not be considered ‘permanent’ until the clinical findings, determined during a period of months, indicate that the medical condition is static and well stabilized. The AMA Guides, Fifth Edition, defines MMI as “a condition or state that is well stabilized and unlikely to change substantially in the next year, with or without medical treatment” but acknowledges the possibility of “some change.” Similarly the sixth edition states that MMI is the “point at which a condition has stabilized and is unlikely to change (improve or worsen) substantially in the next year, with or without treatment”; signs and symptoms may wax and wane, but further recovery or deterioration is not anticipated.
Do Low-Speed Vehicle Collisions Cause Intervertebral Disc Degeneration or Herniation?
Authors: Wood Rawson L. , Greenston Mathew J. , Bain Charles E. , Brooks Charles N.
Published: December 2020

Complaints of spinal pain are common after motor vehicle collisions (MVCs), and evaluators may be asked whether the collision caused permanent injury to the spine, including aggravating intervertebral disc degeneration (IDD) and/or causing a disc herniation. To determine causality, evaluators can use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) to understand if a low-speed collision caused IDD. Injury causation analysis (ICA) is the scientific method used to analyze the mechanism and magnitude of injury for people who experience an MVC. ICA involves comparing the mechanical forces involved in the incident with the body's injury tolerance. Low back pain (LBP) is a common complaint following MVCs, but the literature regarding automobile collision testing has been compared to the body of evidence regarding real-world collision data and shows that, for low-speed impacts, any injuries are minor and self-limiting. Further, disability due to LBP was predicted by an abnormal baseline psychological test profile or a previously disputed compensation claim. The motions, forces, and accelerations generated in low-speed collisions are less than those encountered in activities of everyday living. ICA suggests that disc degeneration and disc herniations are pre-existing and are not caused by low-speed MVCs. Although the pain caused by a muscle sprain associated with a low-speed collision may prompt imaging studies that show disc pathology, these are coincidental and are not causally related.
Effects of Aging on Impairment Ratings: Part 2: Internal Medicine Issues
Authors: Demeter Stephen L.
Published: December 2020

This is the second of four articles that explore the effects of age-related changed in impairment evaluations according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions; specifically, this article completes the review of the internal medicine sections. With respect to the digestive system, the normal aging process affects gastrointestinal impairment ratings as found in the AMA Guides, Fifth and Sixth Editions, for gastroesophageal reflux disease, peptic ulcer disease, pancreatitis, diverticulitis, irritable bowel syndrome, fecal incontinence, and hemorrhoids. Cancers of the digestive system and infectious hepatitis were reviewed by the National Institutes of Health in The Burden of Digestive Diseases in the United States (2008), which should be reviewed when an impairment rating or apportionment is needed or for an individual with these conditions alleged to be the result of a compensable injury or illness. The normal aging process does not significantly affect the impairment ratings for renal disease (upper urinary tract disease), but, for individuals over 70, an age adjustment should be incorporated into the impairment rating. The AMA Guides, Fifth and Sixth Editions, also do not provide age-related modifications for urinary incontinence, but a rating physician may apply a discretionary apportionment. For diseases of the scrotum, testicles, epididymis, and spermatic cord, as well as for prostatic hypertrophy, neither edition of the AMA Guides makes age-related modifications; neither are modifications because of aging are made for the female reproductive tract, although raters are told to consider the physiological differences.
Symptom Validity Testing
Authors: Ensalada Lee H.
Published: December 2020

Symptom validity testing (SVT), also known as forced-choice testing, is a means of assessing the validity of sensory and memory deficits, including tactile anesthesias, paresthesias, blindness, color blindness, tunnel vision, blurry vision, and deafness. The common feature among these symptoms is a claimed inability to perceive or remember a sensory signal. SVT comprises two elements: a specific ability is assessed by presenting a large number of items in a multiple-choice format, and then the examinee's performance is compared to the statistical likelihood of success based on chance alone. These tests usually present two alternatives; thus the probability of simply guessing the correct response (equivalent to having no ability at all) is 50%. Thus, scores significantly below chance performance indicate that the sensory cues must have been perceived, but the examinee chose not to report the correct answer—alternative explanations are not apparent. SVT also has the capacity to demonstrate that the examinee performed below the probabilities of chance. Scoring below a norm can be explained by fatigue, evaluation anxiety, inattention, or limited intelligence. Scoring below the probabilities of chance alone most likely indicates deliberate deceptions and is evidence of malingering because it provides strong evidence that the examinee received the sensory cues and denied the perception. Even so, malingering must be evaluated from the total clinical context.
Effects of Aging on Impairment Ratings: Part 1: Internal Medicine Issues
Authors: Demeter Stephen L.
Published: December 2020

This article is the first of four to explore the effects of age-related changes in impairment evaluations as defined by the fifth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). With respect to the cardiovascular system, impairment ratings for the following conditions commonly are affected by the aging process: coronary artery disease, valvular heart disease, arrhythmias/dysrhythmias, hypertension, and peripheral vascular disease. Impairment ratings in the fifth and sixth editions of the AMA Guides for the pulmonary system apply corrections for age with respect to certain measurements such as forced vital capacity. The normal aging process does not significantly affect impairment ratings for either hematological impairments or the endocrine system, nor does normal aging significantly affect the impairment ratings for mammary glands. With careful attention to the diagnosis and causative factors, evaluators may find that the normal aging process can affect impairment ratings associated with metabolic bone disease. Evaluating physician typically must determine impairment secondary to a specific cause (eg, injury or exposure) and therefore must consider if other factors are contributing to the impairment.
Effects of Aging on Impairment Ratings: Part 3: Neurological and Associated Issues
Authors: Demeter Stephen L.
Published: December 2020

This article is the third in a series of four that explore the effects of age-related changes in impairments as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. Specifically, this article focuses on evaluation of disturbances of the nervous system, divided for discussion here into four parts—the central nervous system (CNS), the peripheral nervous system, vision, and hearing—and offers guidance in using the AMA Guides, Fifth and Sixth Editions, in a variety of specific disorders within each group. For example, the CNS discussions address disorders of consciousness and awareness; sleep and arousal disorders; alterations in metal status, cognition, and highest integrative function; aphasia or dysphagia; emotional or behavioral disorders resulting from CNS causation (fifth edition only); chronic pain; and others. One of the most challenging issues in evaluating peripheral neuropathy regards carpal tunnel syndrome, and rating physicians should provide references in their reports to justify their position. Rating visual problems usually requires attention to the medical records to document preinjury visual status. The AMA Guides, Fifth and Sixth Editions, do not use age-adjusted corrections in assessing age-related diminished hearing, but local jurisdictions and circumstances may apply apportionment. In apportioning impairment due to aging, the examiner must understand both the science and the specific legal processes involved.
Amputation Evaluation: Sixth Edition Approaches
Authors: Blaisdell Jay , Talmage James B.
Published: December 2020

Upper extremity amputations are rated in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, Section 15.6, Amputation Impairment, where text, tables, and figures guide evaluators in combining proximal diagnosis-based impairments (DBIs) and proximal range-of-motion impairments. The AMA Guides provides impairment grids for lower and upper extremity amputations, which are divided into five impairment classes (0 through 4), and each impairment class is further divided (except class 0) into five grades (A through E), each with its respective impairment rating that is expressed as a percentage of the extremity. Determining impairment class, and thus the default value of impairment, is straightforward if the amputation occurred directly at one of the points in the relevant grid; if the amputation occurred at another point, the evaluator should consult the appropriate figure to assess how the specific level of amputation corresponds with impairment percentages. An individual's proximal problems may lead to an increase in the impairment value because of the application of grade modifiers. Except in rare instances of bilateral upper extremity amputation or when the patient is unable to wear a prosthesis for a lower extremity amputation, the evaluator usually uses the default rating value within the selected impairment class as the final percentage rating. Evaluators are advised to re-read the amputation section in the AMA Guides before conducting an amputation evaluation.
Part I: Psychological Factors in Delayed and Failed Recovery and Unnecessary Disability
Authors: Caruso Garson , Kertay Les
Published: December 2020

The first part of this two-part series discusses psychological influences in delayed and failed recovery and resulting unnecessary work disability; the second part discusses theoretical and practical aspects of the issue, including evaluation and treatment. Delayed and failed recovery and unnecessary disability (DFRUD) refers to a lag in, or lack of, expected recovery from a medical condition and/or unnecessary resultant disability. Causation is complex, and we are not doing well at managing this group of workers using a biomedical model. The traditional biomedical model posits that disease or injury produces symptoms and signs that cause impairment and result in disability. This approach too strictly separates mental phenomena and bodily function (Cartesian dualism) and leads to scientific reductionism when actually six domains are active in worker disability: medical, personal, psychological, sociocultural, systematic (including compensation and insurance), and workplace elements. Medically unexplained physical symptoms (MUPS) should be understood as a disturbance of normal neurological and/or psychological processes underlying symptom production, perception, and experience and cannot be better explained by another physical or psychiatric illness. Within this system of evaluation, administrative and medical iatrogenicity are associated with unnecessary medical care and poor outcomes for individuals. In addition to determining industrial causality and apportionment, if evaluators accept some psychological factors, MUPS, and central sensitization, they must explain to what extent these are compensable. Part two of this article will discuss theoretical and practical approaches, including specific evaluation and treatment methods.
Range of Motion Extremity Evaluation: Sixth Edition Approaches
Authors: Blaisdell Jay , Talmage James B.
Published: December 2020

Examiners use range-of-motion (ROM) testing to help calculate the physical examination modifier when they use the diagnosis-based impairment (DBI) method in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. DBI is the preferred method for calculating upper and lower extremity ratings, but, in instances specified by the regional grid, the evaluator may choose to use the ROM method, typically because it yields a higher impairment rating relative to the DBI method. In rare lower-limb cases when the injury is not fully articulated by the regional grid (eg, severe crushes, burns, and scarring), ROM may be used instead of diagnosis. In cases of amputation, ROM may be used for the remaining portion of the limb and combined with amputation rating as explained in sections of Chapter 15. Note that, in the AMA Guides, the extended anatomic position is 0° rather than 180°, and evaluators can consult the detailed diagrams of the planes of the thumbs, fingers, wrists, elbows, and shoulders. Invalid results are declared if, after three consecutive efforts, the three measurements for a given plane of motion vary more than 10° from the mean (average) of these three measurements. The article also discusses adjustments for functional history when the ROM method does not adequately capture the full impairment.
Effects of Aging on Impairment Ratings: Part 4: Musculoskeletal Issues
Authors: Demeter Stephen L. , Brooks Charles N. , Melhorn J. Mark
Published: December 2020

This article is the fourth of five in a series on the effects of age-related changes in impairment evaluations as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. The present article addresses the musculoskeletal system and differs from the first three articles, which focused on apportionment of an impairment rating between aging and other causes. The medical literature supports the notion that age-related osteoarthritis (OA) changes in the hand and digits frequently are associated with injury and/or repetitive motion. Thus, apportionment is indicated, but deciding which came first, the imaging abnormality or the injury, requires consummate skill on behalf of the rating physician. OA also occurs in the knees and hips of older individuals. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory disorder characterized by calcification and ossification of spinal ligaments and entheses and is unique, in the authors’ opinion, because of a positive correlation between aging and back pain caused by this condition. The article also addresses the association—or the lack thereof—between pathology and aging, as well as degenerative changes and symptoms, to facilitate causation analysis. For a fuller discussion of causation analysis for the spine, readers can consult the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition.
Entrapment Neuropathies: Electrodiagnostic Criteria
Authors: Blaisdell Jay , Talmage James B.
Published: December 2020

Like the diagnosis-based impairment (DBI) method and the range-of-motion (ROM) method for rating permanent impairment, the approach for rating compression or entrapment neuropathy in the upper extremity (eg, carpal tunnel syndrome [CTS]) is a separate and distinct methodology in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Rating entrapment neuropathies is similar to the DBI method because the evaluator uses three grade modifiers (ie, test findings, functional history, and physical evaluation findings), but the way these modifiers are applied is different from that in the DBI method. Notably, the evaluator must have valid nerve conduction test results and cannot diagnose or rate nerve entrapment or compression without them; postoperative nerve conduction studies are not necessary for impairment rating purposes. The AMA Guides, Sixth Edition, uses criteria that match those established by the Normative Data Task Force and endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM); evaluators should be aware of updated definitions of normal from AANEM. It is possible that some patients may be diagnosed with carpal or cubital tunnel syndrome for treatment but will not qualify for that diagnosis for impairment rating; evaluating physicians must be familiar with electrodiagnostic test results to interpret them and determine if they confirm to the criteria for conduction delay, conduction block, or axon loss; if this is not the case, the evaluator may use the DBI method with the diagnosis of nonspecific pain.
Comorbid Conditions in Workers' Compensation
Authors: Iglesias Marcos
Published: December 2020

A comorbidity is a concomitant but unrelated pathological or disease process, and comorbid conditions are coexisting medical conditions that are not necessarily compensable in a work-related injury but may affect the individual's treatment and recovery. Many comorbid conditions also are chronic health conditions that may interact with the sequelae of a compensable injury or illness and/or may affect the individual's health and abilities. In addition to the normal physiological changes of age, advancing age increases the number and severity of comorbid conditions, and this article examines three: obesity, diabetes, and heart disease. Obesity is associated with increasing workers’ compensation claims, medical and indemnity claim costs, and lost workdays; it is also a risk factor for type 2 diabetes, cancer, heart disease, and numerous other chronic and serious diseases. Hypoglycemia associated with diabetes can lead to falls and accidents, and diabetes may delay healing, predispose to infection, and cause peripheral neuropathies. Uncontrolled hypertension may be present in half of people with hypertension, leading to increased cardiac risk, especially if procedures or operations are needed. Claimants with comorbid conditions should be identified early in the claims process so claim handlers can use available comorbidity calculators to better plan for higher costs, longer disability, and more complex medical management. Nurse case managers can help the injured worker navigate the health system and act as a liaison between claims staff and medial providers.
Nonspecific Chronic Back Pain: Sixth Edition Approaches
Authors: Blaisdell Jay , Talmage James B.
Published: December 2020

Ratings for “non-specific chronic, or chronic reoccurring, back pain” are based on the diagnosis-based impairment method whereby an impairment class, usually representing a range of impairment values within a cell of a grid, is selected by diagnosis and “specific criteria” (key factors). Within the impairment class, the default impairment value then can be modified using non-key factors or “grade modifiers” such as functional history, physical examination, and clinical studies using the net adjustment formula. The diagnosis of “nonspecific chronic, or chronic reoccurring, back pain” can be rated in class 0 and 1; the former has a default value of 0%, and the latter has a default value of 2% before any modifications. The key concept here is that the physician believes that the patient is experiencing pain, yet there are no related objective findings, most notably radiculopathy as distinguished from “nonverifiable radicular complaints.” If the individual is found not to have radiculopathy and the medical record shows that the patient has never had clinically verifiable radiculopathy, then the diagnosis of “intervertebral disk herniation and/or AOMSI [alteration of motion segment integrity] cannot be used.” If the patient is asymptomatic at maximum medical improvement, then impairment Class 0 should be chosen, not Class 1; a final whole person impairment rating of 1% indicates incorrect use of the methodology.
The Medical Benefits of Work and the Health “Cost” of Unemployment
Authors: Talmage James B.
Published: December 2020

In 2011, the American Medical Association published the AMA Guides to the Evaluation of Work Ability and Return to Work (AMA's Return to Work), Second Edition, which began with a review of consensus statements attesting that, in general, work is good for a person's health and well-being. Since publication of AMA's Return to Work, the Australian Royal College of Physicians has issued a consensus statement about the negative health consequences of becoming unemployed and the health benefits of returning to work. Key points include: for most individuals, working improves general health and well-being and reduces psychological distress; even musculoskeletal and mental health conditions attributed to work can benefit from activity-based rehabilitation and an early return to suitable work; long-term work absence is harmful to physical and mental health and well-being; the negative effects of remaining away from work include stress on the worker's families, including children. Of the potential consequences of unemployment in mid-adult life, the worst is premature death. In causation research, unlike medical treatment studies, individuals cannot be randomly assigned to a group that is forced to remain at work and a group that is forced to be unemployed. Even so, causation research has found strong evidence for a protective effect of employment on depression and general mental health. In performing evaluations, physicians must accurately assess work ability and recognize the healthy benefits of work.
The AMA Guides in Pennsylvania “Post-Protz”: Act 111 and Case Law Update
Authors: Beck Justin D. , Torrey Judge David B.
Published: December 2020

Medical evaluators must understand the context for the impairment assessments they perform. This article exemplifies issues that arise based on the role of impairment ratings and what edition of the AMA Guides to the Impairment of Permanent Impairment (AMA Guides) is used. This discussion also raises interesting legal questions related to retroactivity, applicability of prior precedent, and delegation. On June 20, 2017, the Supreme Court of Pennsylvania handed down its decision, Protz v. WCAB (Derry Area Sch. Dist.), which disallows use of the “most recent edition” of the AMA Guides when determining partial disability entitlement under the Pennsylvania Workers’ Compensation Act. An attempted solution was passed by the Pennsylvania General Assembly and was signed into law Act 111 on October 24, 2018. Although it affirms that the AMA Guides, Sixth Edition, must be used for impairment ratings, the law reduces the threshold for total disability benefits from 50% to 35% impairment. This legislative adjustment benefited injured workers but sparked additional litigation about whether, when, and how the adjustment should be applied (excerpts from the laws and decisions discussed by the authors are included at the end of the article). In using impairment as a threshold for permanent disability benefits, evaluators must distinguish between impairment and disability and determine an appropriate threshold; they also must be aware of the compensation and adjudication process and of the jurisdictions in which they practice.