bluuebunny/crossref_metadata_2025 huggingface dataset:
Legal Update: Scheduled and Nonscheduled Injuries
Authors: Mangraviti James J.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition, includes two methods of evaluating low back impairment following injury, the Diagnosis-related estimates (DRE) method and the Range of Motion (ROM) method. The DRE method should be used first, and the ROM method should be used only when the patient's injury is difficult to categorize or when two examiners disagree about how to categorize a patient. The final rating always comes from the DRE category, never from the ROM method. Two groups of findings help determine into which DRE category to place the patient: First are structural inclusions (eg, fracture patterns on an x-ray) that are objective and automatically place a patient into a DRE category. Second are differentiators such as guarding, loss of reflexes, or loss of bowel or bladder control. In addition, unlisted objective findings may help categorize a patient but may require interpretation; examples include muscle spasm, nonverifiable root pain, anatomical numbness, anatomical weakness, and straight-leg raising. This article discusses the interpretation of sometimes partially subjective findings, thus objectifying them: guarding; muscle spasm; dysmetria; nonverifiable root pain; loss of reflexes; atrophy; straight-leg raising; anatomical numbness; weakness; EMG; loss of motion segment integrity; loss of bowel or bladder control, bladder studies; and range of motion.
Legal Update: Using the Guides for Permanent Partial Disability Determinations
Authors: Brigham Christopher R.
Published: December 2020

Rating the impairment related to various chronic painful conditions, including headaches, is challenging and is addressed in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in a section of the chapter on pain. Primary headache disorders include migraines, tension-type headaches, and cluster headaches caused by disturbances in the central nervous system. Headaches occur with varying intensities and frequencies but follow three broad patterns: 1) minimal, slight, moderate, and marked headache; 2) cycles or episodes that may last from moments to years; and 3) consistent and persistent pain that may last years, decades, or a lifetime. Physicians should estimate impairment related to headache pain according to the procedures discussed in section 15.8, including a multidimensional assessment of an individual's capabilities, including biological, psychological, and social aspects and excluding the existence of a separate comorbid pathologic process. The AMA Guides does not provide specific numeric values for impairment of headache or for pain itself. For patients who have a primary headache disorder, the physician should clearly understand the frequency and severity of the condition, the approach to treatment, and the effects of headaches on activities of daily living. The discussion of headaches in the AMA Guides emphasizes the importance of careful evaluation over merely assigning a numeric value to an impairment.
Clinical Update: Causality and Apportionment
Authors: Roth Henry J.
Published: December 2020

Assessing medical causality requires a clear understanding and discussion of causal relationships, and definitions of impairment may have special meaning in a legal context beyond their usual meanings in medical communications. In addition to assessing cause and effect and medical possibility vs medical probability, evaluating physicians must understand and carefully use terminology such as aggravation or exacerbation that have specific definitions and uses. Documentation of aggravation or causation depends on the acquisition, review, and analysis of medical documentation, including medical office and hospital records; available past medical records; results of tests or diagnostic procedures; results of permanent occupational or environmental surveys; medical information showing that an alleged factor could have caused or contributed to the effect; and occupational documentation of an alleged exposure or cause. Pitfalls during the assessments include the patient's aging, natural inherent limitations, self-abuse, and psychosocial factors that individually or collectively may confound medical causality and apportionment assessment. The evaluating physician alone is responsible for apportioning these factors and must provide the medical basis for all conclusions and opinions. Previous impairment of an organ system may be subtracted from the current impairment rating, and the written analysis should address separately a divergence between changes in impairment and disability.
The Challenge of Evaluating RSD Impairment and Disability (Part II)
Authors: Ensalada Leon H.
Published: December 2020

Part II of this two-part series continues the discussion of diagnostic and treatment issues related to reflex sympathetic dystrophy (RSD) and presents approaches to assessing pain and disability associated with complex regional pain syndrome (CRPS). CRPS encompasses CRPS Type I (RSD) and CRPS Type II (causalgia), but the approach of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition is problematic. The current approach may not account for the complete impairment, and RSD/CRPS I by definition does not involve a specific peripheral nerve disorder. Causalgia/CRPS II by definition involves a specific peripheral nerve disorder, and the physician can assess impairment due to pain and sensory deficit or loss of power and motor deficits by multiplying the graded percent deficit with the maximum allowable impairment for the specific peripheral nerve. RSD/CRPS I by definition does not involve disruption of a peripheral nerve, but the criteria recommended by the AMA Guides may be difficult to use. The fourth edition of the AMA Guides advises that, in general, only one evaluation method should be used to evaluate a specific impairment, and a table specifies which tests should not be used together, those that may be used in combination, if appropriate, and those for which combination is not specified.
Legal Update: Use of the Guides Down Under
Authors: Ranavaya Mohammed I. , Dowda Dwight K.
Published: December 2020

Evaluations of the cervical and the lumbar spine are similar with the major exception that injury in the cervical spine may cause spinal cord damage that results in long-tract signs (weakness, numbness, or paralysis). The AMA Guides to the Evaluation of Permanent Impairment recognizes eight categories of cervical spine injury, and the first five are similar to those used for the lumbar spine. Category I involves no objective findings. Category II includes objective findings such as true muscle spasm, dysmetria, or nonverifiable radicular symptoms. Category III is radiculopathy and is assessed when the patient shows signs such as the loss of relevant reflexes or unilateral atrophy with a greater than 2-cm decrease in circumference compared with the unaffected side. Category IV is loss of motion segment integrity or multilevel neurologic compromise and indicates 3.5 mm or more translation of one vertebra on another on flexion and extension x-rays. Category V is severe upper extremity neurologic compromise that requires the use of upper extremity external functional or adaptive devices. Categories VI, VII, and VIII reflect a significant change in evaluating method and include long-tract signs in addition to upper extremity involvement. Category VI includes cauda equina–like symptoms without bowel or bladder involvement. Category VII is the same as Category VI but with bowel or bladder involvement. Category VIII is paraplegia, defined as complete or near-complete loss of function in the lower extremities.
Impairment Update: Illness Behavior
Authors: Ensalada Leon H.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes that many methods used to report medical impairments rely on the completeness, accuracy, and honesty of the patient's self-presentations. Symptom exaggeration is best understood in the context of clinical phenomena that lie along a continuum from unconscious and unintentional to conscious and intentional. Illness behavior refers to the ways in which given symptoms may be perceived, evaluated, and acted upon by different persons, and such behavior can be appropriate or inappropriate, depending on context, and can be learned and reinforced. Further, certain illness behaviors potentially confound the association between illness or injury, on the one hand, and impairment or disability, on the other hand. For example, any deficit can be exaggerated, including neuropsychological deficits, pain, and loss of sensation. Specialized assessments include symptom validity testing to assess memory or sensory deficits, and maximum voluntary effort testing assesses strength deficits. In their assessment of illness behavior, physicians should employ the same degree of thoroughness as they would with any condition. Written reports should include not only the conclusion that symptom exaggeration is present but also the basis for this determination. A table shows the characteristics of symptom magnification syndromes and other related conditions vs the presence of symptoms such as seeking gain or deception.
Assessing Mild Traumatic Brain Injury
Authors: Zasler Nathan D. , Martelli Michael F.
Published: December 2020

Mild traumatic brain injury (MTBI) accounts for approximately 80% of the estimated 373000 traumatic brain injuries that occur annually in the United States. MTBI typically occurs in males 15 to 24 years of age, and postconcussional sequelae may impede physical, emotional, social, marital, vocational, and avocational functioning. Usually the severity of the initial neurologic injury is defined according to the Glasgow Coma Score, the presence and duration of amnesia (retrograde and anterograde), and the alteration of loss of consciousness and its duration. MTBI is a traumatically induced physiological disruption of cerebral function manifested by at least one of the following: loss of consciousness no longer than 20 minutes; any loss of memory; any alteration in mental status at the time of the accident; physical symptoms that potentially are related to the brain; and development of posttraumatic cognitive deficits not accounted for by emotional factors. When a patient presents with multisystem trauma, impairments may involve several parts of the body, including the nervous system. Individual impairments of other systems should be calculated separately and their whole person values combined using the Combined Values Chart in AMA Guides to the Evaluation of Permanent Impairment. At present, no ideal system can rate impairment following MTBI, and physicians must thoroughly understand both the underlying disease process and the associated injuries.
Clinical Update: Tinnitus
Authors: Sataloff Robert Thayer , Sataloff Joseph , Mandel Steven
Published: December 2020

Momentary or intermittent tinnitus—perceived sounds that originate within a person's head rather than in the outside world—is common; continuous tinnitus is abnormal but not unusual. According to the National Center for Health Statistics, 32% of US adults acknowledge having experienced tinnitus at some time; 6.4% characterize the condition as debilitating or severe; and prevalence increases with age to approximately 70 years and declines thereafter. A patient with tinnitus is assessed initially using a comprehensive otologic and neurotologic history, a physical examination, and selected tests of otologic function. Current tests can evaluate hearing and balance, but no good, comprehensive, objective methods exist to determine the presence of tinnitus, quantify the symptoms, or assess its severity. For these reasons, there are no scientific data on which to base a judgment regarding impairment or disability, and tinnitus alone generally is not considered compensable. The AMA Guides to the Evaluation of Permanent Impairment allows some adjustment for unilateral, but not bilateral, tinnitus that may impair speech discrimination. No scientific justification supports this policy, and there is no defensible basis for this disparity. Thus, additional research is necessary before this subjective symptom can be used reliably in impairment and disability determinations.
Impairment Tutorial: Dermatological Impairment Assessment
Authors: Welch Laura
Published: December 2020

The main function of the skin is to protect the body that it encloses. Anatomically and physiologically, the skin's regions differ to the extent that skin is not one organ but a combination of multiple systems. The skin has a limited range of reaction patterns, but these may express a wide range of clinical syndromes. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) states that the morphology of the lesion and the pattern of distribution suggest the differential diagnosis. Skin lesions can be characterized as macule, papule, change in pigmentation, plaque, erythema, or eczema. The evaluating physician should consider relevant characteristics, including: Is the condition localized or generalized? Does in involve the face or spare it? Does the condition involve or spare the palms and soles? Approximately 95% of occupational skin disease involves contact dermatitis from irritation, contact allergy, or both. The remaining instances usually arise from biological, physical, mechanical, or other miscellaneous causes. The AMA Guides directs the evaluating physician to complete a detailed work description and conduct a physical examination with biopsy or patch testing as needed. Because most cases of occupational contact dermatitis involve irritants, a systematic approach to examination of the skin and use of good dermatology tests can pinpoint the diagnosis in the majority of cases.
Questions and Answers
Authors: Talmage James B.
Published: December 2020

The authors respond to the two-part article by Ensalada in the November/December 1997 and January/February 1998 issues of The Guides Newsletter. Disability determination in the AMA Guides to the Evaluation of Permanent Impairment often is based on formulations that use a scaled ranking of the impaired function(s) that approximates the impact on the individual's ability to perform specific tasks. The method, although imperfect, generates a percentage impairment score for rating the disability. This method breaks down when applied to disorders with far-reaching effects, such as reflex sympathetic dystrophy (RSD), because it tends to focus only on the affected extremity. The AMA Guides also identifies five factors can affect disability in individuals with RSD: First, RSD spreads in an unpredictable temporal manner. Second, RSD is associated with global effects on cognitive processes (eg, constant pain leads to impairment of sleep, decreased alertness, and altered attention). Third, depression often is a reactive consequence to impaired function. Fourth, RSD may change over time yet may remain quite disabling. Fifth, RSD can significantly affect remote systems (eg, bladder disturbance). For these reasons, during the evaluation of people affected by RSD, physicians should be aware of additional issues besides the percentage loss of function of the affected injured extremity.
Quotables from the Guides on General Principles
Authors: Mueller Kathryn
Published: December 2020

This article reviews portions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) that are useful to evaluators making individual case decisions in various legal systems. The first step is a determination of permanency, and evaluators should know that many state laws have unique definitions of “maximum medical improvement.” Next, the evaluator should establish a definitive diagnosis that identifies the existence of an abnormality and impairment of the activities of daily living. Based on his or her judgment and expertise, training, skill, and thoroughness, the evaluating physician must use clinical judgment regarding whether or not the results of tests or impairment measurements are reasonable for a particular patient and the impairment under evaluation. The AMA Guides notes that an evaluator may increase an impairment rating after determining that the estimate for the anatomic impairment does not sufficiently reflect the severity of the patient's condition. When findings between two physicians differ, then the stability of the medical issue may be in question, and the involved physicians should be in communication and should have access to all prior physician reports and test results. Evaluators may need to educate patients about the difference between impairment and disability. Clear report writing is the key to successful impairment evaluations.
Upper Extremity Impairment Scenarios–Challenges in Rating
Authors: Jones Frank , Talmage James B.
Published: December 2020

This article discusses situations in which an evaluating physician may find rating according the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) cumbersome, including fingertip injuries, transection of flexor digitorum sublimis tendon, medial and lateral epicondylitis, upper extremity amputations, and recurrent shoulder dislocation. On finding decreased motion at a finger distal interphalangeal joint (DIP) or thumb interphalangeal (IP) joint, the examiner should carefully assess the functional consequences and ensure the rating adequately addresses the impairment but does not rate the same problem twice. Laceration of the distal palm or proximal phalanx of a finger resulting in isolated transection of the flexor digitorum sublimis tendon (flexor digitorum profundus tendon remains intact) is a challenging scenario. Medial and lateral epicondylitis are not mentioned in the AMA Guides because usually they resolve with time. Grip strength loss usually is not an appropriate way to rate epicondylitis because pain limits grasp in this condition. Impairment ratings for upper extremity amputations may not be consistent in terms of the location where the procedure is used. Recurrent shoulder dislocation may complicate an initial traumatic dislocation, particularly in younger patients and must be medically documented rather than anecdotally reported. When faced with a situation that is not covered in the AMA Guides, the rating physician should consider analogous situations, consult other manuals or guidelines, or discuss the case with other experienced evaluators.
Tools and Resources: Instrumentation for Upper Extremity Impairment Assessment
Authors: Talmage James B.
Published: December 2020

The primary methods of evaluating impairment in the upper extremity are range of motion testing and neurological examination. For certain conditions that do not cause motion or neurological deficits yet leave the extremity significantly impaired, the editors of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, provided Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. The AMA Guides emphasizes that the criteria described in these “other disorders” should be applied only when the other criteria have not adequately encompassed the extent of the impairments. The evaluator must carefully read the criteria for rating each derangement to ensure the rating is correct and not duplicative. Table 26, Upper Extremity Impairment Due to Carpal Instability Patterns, includes values based on radiographic findings, and Table 27, Impairment of the Upper Extremity after Arthroplasty of Specific Bones or Joints, features ratings for resection arthroplasty and implant arthroplasty. Tables 28, 29, and 30 for musculotendinous impairments require that the percent of digit impairment be multiplied by the relative value of the digit according to Table 18. The AMA Guides does not assign a large role to functional measurements such as pinch and grip strength tests because they are influenced by subjective factors that are difficult to control.
Impairment Tutorial: Evaluating Impairment Due to Other Disorders of the Upper Extremity
Authors: Haralson Robert , Brigham Christopher R.
Published: December 2020

Because grip and pinch strength are highly correlated and most literature deals with the former, this article focuses on grip strength, which is controversial because, as a functional test, it can be influenced by subjective factors that are difficult to control and include effort, pain, time of day, and fatigue. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) identifies additional factors that influence grip and include sex, age, sensation, comorbidities, age, nutritional status, and, perhaps, handedness. Although grip strength is considered a measure of hand function, its correlation with activities of daily living is poor. Grip strength measurements must be performed in a standard manner because altering wrist, forearm, or elbow position can change the results. Impaired hand strength is compared to that of the opposite extremity, which usually is normal; if both extremities are involved, the strength measurements are compared to the average normal strengths. The AMA Guides specifies that grip measurements are regarded as reliable if there is less than 20% variation in the readings, but subjective factors may result in higher-than-normal variance between measurements of grip. Because pain interferes with maximal effort and, if present, may invalidate grip strength measurement, the latter generally is inappropriate to rate tendonitis or other painful conditions. Generally, grip strength is not used to rate neurological deficits.
Minimizing Impairment Evaluation Difficulties and Risks
Authors: Brigham Christopher R.
Published: December 2020

Significant professional and legal difficulties and risks may be associated with the performance of impairment evaluations, particularly in the context of an independent medical evaluation (IME). Many IMEs occur in legal arenas and may involve individuals with challenging personalities, and the circumstances of performing an IME are unique because there exists no physician-patient relationship. The best defense against professional or legal difficulties is prevention, including establishing a well-thought-out process for performing these evaluations, being consistent with directives provided in the AMA Guides to the Evaluation of Permanent Impairment, and, if a problem arises, dealing with it directly and documenting the circumstances. If an examinee is uncooperative, the examining physician may need to explain his or her role, and, if the examinee remains uncooperative or is disruptive, the examiner may stop the examination, notify the client, contact the police as appropriate, and document what occurred. Injury claims against an examiner may be forestalled by preventive strategies such as obtaining written informed consent from the patient to perform the evaluation, having a member of the examiner's staff present during the evaluation, and, after the examination, using a patient satisfaction survey to document “no difficulties with the evaluation.” IMEs require examiners to be familiar with legal aspects of confidentiality, libel and slander, negligence, and other issues. Examiners should ensure their medical malpractice insurance is suitable for this work.
Clinical Update: Functional Capacity Evaluations—An Update
Authors: Welch Laura
Published: December 2020

Functional capacity evaluations (FCEs) have become an important component of disability evaluation during the past 10 years to assess an individual's ability to perform the essential or specific functions of a job, both preplacement and during rehabilitation. Evaluating both job performance and physical ability is a complex assessment, and some practitioners are not yet certain that an FCE can achieve these goals. An FCE is useful only if it predicts job performance, and factors that should be assessed include overall performance; consistency of performance across similar areas of the FCE; consistency between observed behaviors during the FCE and limitations or abilities reported by the worker; objective changes (eg, blood pressure and pulse) that are appropriate relative to performance; external factors (illness, lack of sleep, or medication); and a coefficient of variation that can be measured and assessed. FCEs can identify specific movement patterns or weaknesses; measure improvement during rehabilitation; identify a specific limitation that is amenable to accommodation; and identify a worker who appears to be providing a submaximal effort. FCEs are less reliable at predicting injury risk; they cannot tell us much about endurance over a time period longer than the time required for the FCE; and the FCE may measure simple muscular functions when the job requires more complex ones.
Cauda Equina Syndrome
Authors: Ensalada Leon H.
Published: December 2020

The cauda equina is a collection of peripheral nerves in the common dural sheath within the lumbar spinal canal. Cauda equina syndrome, also known as bilateral acute radicular syndrome, usually is caused by a large, sequestered acute disc rupture at L3-4, L4-5, or L5-S1 that produces partial or complete lesions of the cauda equina–lower motor neuron lesions associated with flaccid paralysis, atrophy, and other conditions. Patients usually present with a history of back symptoms that have worsened precipitously. The syndrome includes back pain, bilateral leg pain, saddle anesthesia, bilateral lower extremity weakness, urinary bladder retention, and lax rectal tone. Cauda equina syndrome is rated using Diagnosis-related estimates (DRE) lumbosacral categories VI or VII. Category VI, Cauda Equina–like Syndrome Without Bowel or Bladder Signs, is used when there is permanent bilateral partial loss of lower extremity function but no bowel or bladder impairment. Category VII, Cauda Equina Syndrome with Bowel or Bladder Impairment, is similar to Category VI but also includes bowel or bladder impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) uses the term cauda equina syndrome with reference to both the thoracolumbar and cervicothoracic spine regions; this usage is unique to the AMA Guides but maintains the internal consistency of the Injury Model, which is the best approach to date for assessing spine impairment.
Clinical Update: Causality in Workers'Compensation
Authors: Mueller Kathryn , Brooks Charles N
Published: December 2020

Because of their education and training, treating physicians often address causality only in terms of differential diagnosis (ie, what is causing the individual's symptoms and signs). Etiology also can be considered from a prophylactic or therapeutic standpoint (ie, how to prevent recurrent injury or eliminate the cause of an illness). In workers’ compensation, causation analysis extends beyond diagnosis, prophylaxis, and treatment and must consider whether the condition is attributable to the workplace. The terms cause, effect, exacerbation, and aggravation have specific meanings in the AMA Guides to the Evaluation of Permanent Impairment and are defined, with discussion. Three criteria must be met before causation is established in workers’ compensation: the cause is medically probable; the effect is medically probable; and the cause and effect probably are etiologically related (ie, the occupational trauma likely caused the injury, or the exposure caused the illness). A table presents the steps in a causation analysis in workers’ compensation: 1) define the injury, activity, or exposure (cause); 2) establish the diagnosis; 3) determine generic causation; specifically, determine if the reported mechanism, activity, or exposure ever causes the patient injury or disease; 4) determine specific causation in this instance and determine if another (more probably) nonoccupational cause was involved.
Rating Upper Extremity Entrapment Neuropathies
Authors: Talmage James B.
Published: December 2020

Upper extremity entrapment neuropathies are chronic injuries to peripheral nerves, presumably from sustained pressure on the nerve in question. These conditions are controversial, and physicians disagree, unfortunately too often, about whether a neuropathy is present, what caused the neuropathy, and what the proper impairment rating should be. Carpal tunnel syndrome is the most common entrapment or “pressure neuropathy” and must be differentiated from other causes of nerve dysfunction such as viral illness, toxins (eg, heavy metals), and systemic diseases such as diabetes or vasculitis. Each of the upper extremity nerves has many potential sites of entrapment, which most frequently occurs secondary to a congenital anomaly such as anomalous fibrous band, muscle bellies, or arteries. Ganglion cysts, lipomas, tumors, and fracture callus or nonunion also have been reported as a cause of these rare neuropathies. Diagnosis of entrapment is challenging because entrapments are uncommon to rare, but arm pain is common in individuals who move their arms repetitively at work, avocation, or sport, and establishing causation also is controversial. Severe entrapment essentially is total destruction of the nerve involved, but, in a lifetime of practice, most physicians will not see a nerve entrapment that progresses to complete loss of all motor and sensory function.
Questions and Answers
Authors: Brigham Christopher R. , Talmage James B.
Published: December 2020

Lesions of the peripheral nervous system (PNS), whether due to injury or illness, commonly result in residual symptoms and signs and, hence, permanent impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) describes procedures for rating upper extremity neural deficits in Chapter 3, The Musculoskeletal System, section 3.1k; Chapter 4, The Nervous System, section 4.4 provides additional information and an example. The AMA Guides also divides PNS deficits into sensory and motor and includes pain within the former. The impairment estimates take into account typical manifestations such as limited motion, atrophy, and reflex, trophic, and vasomotor deficits. Lesions of the peripheral nervous system may result in diminished sensation (anesthesia or hypesthesia), abnormal sensation (dysesthesia or paresthesia), or increased sensation (hyperesthesia). Lesions of motor nerves can result in weakness or paralysis of the muscles innervated. Spinal nerve deficits are identified by sensory loss or pain in the dermatome or weakness in the myotome supplied. The steps in estimating brachial plexus impairment are similar to those for spinal and peripheral nerves. Evaluators should take care not to rate the same impairment twice, eg, rating weakness resulting from a peripheral nerve injury and the joss of joint motion due to that weakness.
Impairment Tutorial: Rating Less Common Meniscal and Articular Cartilage Scenarios
Authors: Talmage James B. , Haralson Robert H.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, provides methods to rate knee injuries treated by partial or total menisectomy and also provides methods to rate knee injuries treated by partial or total menisectomy. Although accompanying tables permit impairment rating of most knee injuries, arthroscopy and new surgical procedures have permitted early diagnosis of osteochondral fracture defects that are not easily rated. A peripheral meniscal tear in the fascular part of the meniscus potentially is repairable, but impairment rating after treatment is challenging. If the only surgical procedure was meniscal transplantation and if preoperative radiographs demonstrate joint space narrowing that is sufficiently significant to rate as an impairment, the knee probably can be rated using the joint space narrowing measurement and Table 62. The AMA Guides is silent about rating the impairment when an osteochondral fracture has occurred. If, after time for healing and rehabilitation, the joint has limited motion, atrophy in supporting muscles, or joint space narrowing on radiographs, the rating for those problems probably will adequately describe the impairment. Long-term results of operations that attempt to repair the meniscal or articular cartilage are not known, and impairment rating after one of these procedures may change with time and the publication of additional studies.
Maximum Medical Improvement
Authors: Brooks Charles N
Published: December 2020

The term maximum medical improvement (MMI) is important to understand because an evaluator cannot determine permanent impairment until a condition is permanent and stationary. In addition, in many jurisdictions MMI represents the date beyond which at least some benefits cease or when an impairment award is made or a pension is awarded. Before rendering an opinion, the evaluating physician should become familiar with the terminology used and the definitions in the applicable federal, state, or provincial law or insurance policy. The AMA Guides to the Evaluation of Permanent Impairment does not define MMI but does state 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. Certain principles are common to definitions of MMI and its synonyms. A generic definition could be: “Maximum medical improvement is when further treatment will probably not result in significant, sustained improvement in the symptoms or signs of an injury or illness, or an individual's physical or mental capacities.” The signs may be physical, radiographic, laboratory, electrodiagnostic, or other findings, and the definition implies that the condition is medically stable in the sense that further treatment probably will not result in appreciable, prolonged improvement.
Impairment Tutorial: Spinal Cord Stimulation and Intraspinal Opioids:Impairment Rating Issues
Authors: Talmage James B. , Ensalada Leon H.
Published: December 2020

Evaluators must understand the complex overall process that makes up an independent medical evaluation (IME), whether the purpose of the evaluation is to assess impairment or other care issues. Part 1 of this article provides an overview of the process, and Part 2 [in this issue] reviews the pre-evaluation process in detail. The IME process comprises three phases: pre-evaluation, evaluation, and postevaluation. Pre-evaluation begins when a client requests an IME and provides the physician with medical records and other information. The following steps occur at the time of an evaluation: 1) patient is greeted; arrival time is noted; 2) identity of the examinee is verified; 3) the evaluation process is explained and written informed consent is obtained; 4) questions or inventories are completed; 5) physician reviews radiographs or diagnostic studies; 6) physician records start time and interviews examinee; 7) physician may dictate the history in the presence of the examinee; 8) physician examines examinee with staff member in attendance, documenting negative, physical, and nonphysiologic findings; 9) physician concludes evaluation, records end time, and provides a satisfaction survey to examinee; 10) examinee returns satisfaction survey before departure. Postevaluation work includes preparing the IME report, which is best done immediately after the evaluation. To perfect the IME process, examiners can assess their current approach to IMEs, identify strengths and weaknesses, and consider what can be done to improve efficiency and quality.
Common Tips for IMEs (Part 1): Perfecting the IME Process
Authors: Brigham Christopher R.
Published: December 2020

The pre-evaluation phase of an independent medical evaluation (IME) consists of several steps that lead to the evaluation itself. A table lists typical issues and tasks facing independent medical evaluators. The evaluation begins when the client requests an IME, and the scope of issues depends on the case's specifics and setting. The evaluating physician must understand the client's expectations and the nature of the evaluation, and specialists in the same field as the treating physician often perform the evaluation. Clients usually are responsible for obtaining medical records and other documentation. At the time of referral, the client is given the date and the time of the evaluation. Analysis of medical records is essential. Often, records provided by a client are disorganized or incomplete, and staff members can develop lists of records provided, identify missing items, and contact the client to obtain them. Staff also should notify the physician before particularly complex evaluations so the physician can allocate adequate time for a detailed review. Issues and deficiencies typically encountered in IMEs include the following: inadequate objective foundations for diagnoses and conclusions, undocumented findings, use of tests that lack validity and reliability, presence or absence of nonphysiologic and behavioral findings, and unsupported conclusions.
Spinal Impairment Evaluation: Fifth Edition Changes
Authors: Haralson Robert H.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, was published in November 2000 and contains major changes from its predecessor. In the Fourth Edition, all musculoskeletal evaluation and rating was described in a single chapter. In the Fifth Edition, this information has been divided into three separate chapters: Upper Extremity (13), Lower Extremity (14), and Spine (15). This article discusses changes in the spine chapter. The Models for rating spinal impairment now are called Methods. The AMA Guides, Fifth Edition, has reverted to standard terminology for spinal regions in the Diagnosis-related estimates (DRE) Method, and both it and the Range of Motion (ROM) Method now reference cervical, thoracic, and lumbar. Also, the language requiring the use of the DRE, rather than the ROM Method has been strengthened. The biggest change in the DRE Method is that evaluation should include the treatment results. Unfortunately, the Fourth Edition's philosophy regarding when and how to rate impairment using the DRE Model led to a number of problems, including the same rating of all patients with radiculopathy despite some true differences in outcomes. The term differentiator was abandoned and replaced with clinical findings. Significant changes were made in evaluation of patients with spinal cord injuries, and evaluators should become familiar with these and other changes in the Fifth Edition.
Feature II: Lower Extremity Impairment Evaluation: Fifth Edition Revisions
Authors: Brigham Christopher R.
Published: December 2020

Chapter 17, The Lower Extremities, in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, continues to provide three means of assessing impairment: anatomic, diagnostic, and functional. Changes from the AMA Guides, Fourth Edition, include the following: The principles of assessment have been expanded to clarify when the different evaluation methods should be used (eg, less specific functional methods typically should not form the basis for a rating if more specific anatomic or diagnostic methods are available). A new cross-usage chart, Guide to the Appropriate Combination of Evaluation Methods (Table 17-2), indicates which methods can and cannot be appropriately used in combination. The evaluation of causalgia and complex regional pain syndrome now follows the same principles used to evaluate central nervous system lesions, and additional case examples are provided. Corresponding tables from the AMA Guides, Fourth and Fifth Editions, are compared. Guidance is provided about how to approach range-of-motion deficits in multiple directions in the same joint, and additional tests are discussed. Finally, the chapter provides Figure 17-10, Lower Extremity Impairment Evaluation Record and Worksheet, a useful template to simplify making the assessment and recording the evaluation, along with six case examples.
Tools and Resources: Web Sites of Interest
Authors: Brigham Christopher R.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, explains that independent medical evaluations (IMEs) are not the same as impairment evaluations, and the evaluation must be designed to provide the data to answer the questions asked by the requesting client. This article continues discussions from the September/October issue of The Guides Newsletter and examines what occurs after the examinee arrives in the physician's office. First are orientation and obtaining informed consent, and the examinee must understand that there is no patient–physician relationship and the physician will not provide treatment bur rather will send a report to the client who requested the IME. Many physicians ask the examinee to complete a questionnaire and a series of pain inventories before the interview. Typical elements of a complete history are shown in a table. An equally detailed physical examination follows a meticulous history, and standardized forms for reporting these findings are useful. Pain and functional status inventories may supplement the evaluation, and the examining physician examines radiographic and diagnostic studies. The physician informs the interviewee when the evaluation is complete and, without discussing the findings, asks the examinee to complete a satisfaction survey and reviews the latter to identify and rectify any issues before the examinee leaves. A future article will discuss high-quality IME reports.
Vision Impairment Rating and the Fifth Edition: A New Approach Based on Activities of Daily Living
Authors: Blais Bernard R.
Published: December 2020

The assessment of visual impairment has been significantly revised from the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition. The Fifth Edition, Chapter 12, The Visual System, bases ratings on an estimate of the severity of the effects of certain types of visual loss on the ability to perform activities of daily living (ADLs). Permanent visual impairment is defined as a permanent loss of vision that remains after a patient reaches maximal medical improvement in the underlying medical condition. To assess vision loss, physicians must conduct a visual assessment, including the cause, severity, and prognosis of the underlying disorder and the expected or documented effects of the vision loss on the patient's ability to perform ADLs. Tables in Chapter 12 guide the assessment of visual impairment and consider the results of visual acuity testing, acuity-related impairment rating, and associated classifications. Table 12-10, Classification of Impairment of the Visual System and of the Whole Person, uses clinical data to classify the individual in one of six classes associated with a range of whole person impairment. According to the Fifth Edition of the AMA Guides, examining ophthalmologists or optometrists are required to have new visual acuity charts, appropriate visual field testing equipment, and other equipment for testing contrast sensitivity and glare tests as needed.
Impairment Tutorial: Recurrent Radioculpathy: Recurrent Radioculpathy and Apportionment
Authors: Brigham Christopher R. , Ensalada Leon H.
Published: December 2020

Recurrent radiculopathy is evaluated by a different approach in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, compared to that in the Fourth Edition. The AMA Guides, Fifth Edition, specifies several occasions on which the range-of-motion (ROM), not the Diagnosis-related estimates (DRE) method, is used to rate spinal impairments. For example, the AMA Guides, Fifth Edition, clarifies that ROM is used only for radiculopathy caused by a recurrent injury, including when there is new (recurrent) disk herniation or a recurrent injury in the same spinal region. In the AMA Guides, Fourth Edition, radiculopathy was rated using the Injury Model, which is termed the DRE method in the Fifth Edition. Also, in the Fourth Edition, for the lumbar spine all radiculopathies resulted in the same impairment (10% whole person permanent impairment), based on that edition's philosophy that radiculopathy is not quantifiable and, once present, is permanent. A rating of recurrent radiculopathy suggests the presence of a previous impairment rating and may require apportionment, which is the process of allocating causation among two or more factors that caused or significantly contributed to an injury and resulting impairment. A case example shows the divergent results following evaluation using the Injury Model (Fourth Edition) and the ROM Method (Fifth Edition) and concludes that revisions to the latter for rating permanent impairments of the spine often will lead to different results compared to using the Fourth Edition.
Impairment Tutorial: Impairment Evaluation of Ear, Nose, Throat, and Related Structures: Fifth Edition Revisions
Authors: Mueller Kathryn , Brigham Christopher R.
Published: December 2020

Chapter 11, Ear, Nose, Throat, and Related Structures of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, includes a new section on voice impairment, a new table on vestibular disorders, and information regarding combined facial disorders and disfigurements. Impairments are based on anatomic, physiological, and functional approaches and involve the assessment of subjective information (eg, statements provided by the patient) and objective factors determined by clinical examination or functional tests. The rating of hearing loss is unchanged from the Fourth Edition in the AMA Guides, Fifth Edition, and tables guide the conversion of monoauricular and binaural hearing impairments into whole person impairments. A tinnitus rating can be combined with the binaural hearing impairment loss before conversion to a whole person permanent impairment. Total disfigurement of the face can be graded between 16% and 50%; a table guides evaluators in rating facial disorders or disfigurement. Impairments of the nose, throat, and related structures include respiration, mastication, deglutition, olfaction and taste, speech, and voice. Although hearing loss is measured using anatomic, physiological, and functional approaches, many other assessments in Chapter 11 are based on interference in the activities of daily living, and the examiner must perform a careful assessment and apply the criteria in the AMA Guides.
Acromioplasty: Is It An Impairment?
Authors: Brooks Charles N.
Published: December 2020

Acromioplasty can be performed open or arthroscopically and removes the spurred, curved, or hooked portion of the acromion. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) has not addressed whether acromioplasty itself constitutes an impairment. On the one hand, if impairment is defined as “a loss, loss of use, or derangement of any body part, organ system, or organ function,” then acromioplasty is an impairment because of the loss of a small portion of the scapula. On the other hand, acromioplasty generally results in improved function (ie, no or negative impairment) and may increase rather than decrease an individual's ability to perform the activities of daily living. This does not indicate that patients who undergo acromioplasty have no impairment whatsoever, and remaining motion deficits should be rated according to existing criteria in the AMA Guides. For example, failure to properly reattach the deltoid muscle or excessive acromial resection may result in deltoid weakness or strength. Often during acromioplasty, the removal of the clavicular spur is accomplished via excision of distal clavicle (resection arthroplasty), which is a permanent impairment. Acromionectomy, which is functionally similar to distal clavicular resection, and transposing the 10% upper extremity impairment rating for distal clavicular resection to a total acromionectomy appears to be justified.