bluuebunny/crossref_metadata_2025_split huggingface dataset:
Legal Update: Use of Impairment as a Threshold Determinate for Disability
Authors: Brigham Christopher R. 
Published: December 2020

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

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

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

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

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

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

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

Abstract
Physicians may need to defend their impairment evaluation opinions during cross-examination, and, in contrast to direct examination during which leading questions cannot be asked, during cross-examination the laws of evidence allow the questioning attorney to pose leading questions that are designed to elicit more information than a “yes” or “no” answer. A witness being cross-examined with leading questions typically may respond “yes,” “no,” or “I don't know,” but physicians should not volunteer information during examination because this may disclose inappropriate information. Similarly, physicians should avoid vague terms such as “I guess,” “I believe,” or “It's possible.” If the witness does not know the answer, the proper response is “I don't know,” or “I don't remember.” The expert's professional qualifications, expert opinion, and reasoning in forming that opinion are all subject to challenge, and the expert must be qualified to perform permanent impairment evaluations and prepare a report with supportable conclusions. The article includes examples of cross-examinations based on principles from the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapters 1 and 2. For example, evaluators may be criticized for erroneously using the terms guidelines instead of guides and disability instead of impairment; physicians who use impairment and disability interchangeably should expect close cross-examination. Evaluating physicians also may be challenged regarding their status as “independent and unbiased” examiners based on having seen the patient only once or, as a treating physician, on numerous occasions.
Impairment Tutorial: Impairment Classes and Ranges
Authors: Brigham Christopher R. , Mueller Kathryn 
Published: December 2020

Abstract
Many chapters in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) provide a range of numbers within four or five impairment classes, and evaluating physicians are required to justify the choice of a class and the impairment rating within the range specified for that class. The process of assigning a class is accomplished by an assessment of the patient's disease process, objective findings, activities of daily living (ADLs), and required continuing medical treatment. A table in the article provides hyperlinks to different scales for measurement of instrumental activities of daily living and ADL; use of these standardized instruments increases the reliability of assessing the impact on ADLs. After describing the patient's ability to perform ADLs, the evaluating physician should ensure that the physical examination and laboratory findings lead to the final diagnosis used for rating. To provide an impairment rating, the evaluator must identify and confirm a physiologic abnormality via physical examination or laboratory or x-ray findings consistent with the diagnosis. Impairment rating must be based on a clearly established diagnosis, not solely on subjective complaints from the patient. As with all impairment evaluations, the rating should be based on a thoughtful evaluation and obtaining the data needed to apply the criteria specified in the AMA Guides.
Impairment Tutorial: Impairment from Coronary Artery Disease: Fifth Edition Approach
Authors: Talmage James B. , Brigham Christopher R. 
Published: December 2020

Abstract
Before the publication of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, each chapter focused on a single organ system and provided a description of the diagnostic and evaluative methods for assessing impairment at the organ system level and functional impairment of the whole person. Beginning with the Fourth and continuing into the Fifth Edition, a new chapter focused not on a single organ system but rather on pain. The author of this article takes issue with others who propose that pain should not only be conceptualized as a disabling factor but also as an impairment. Some have argued that, “[d]espite its stated intent, the [AMA] Guides does not maintain a clear focus on functional impairment … it blurs the line between impairment and disability. The [AMA] Guides defines impairment so broadly as to include disability, effectively confusing the 2 concepts.” For these very reasons, argues the author of this article, pain should not be conceptualized as an impairment, and rating schemes should not promote or reinforce inappropriate behavior, for example, by providing a reward for reporting more pain. The latter will lead to more diagnostic testing, more treatment, and more physician-prescribed work absence, culminating in the reinforcement of perceived illness and incapacity.
Impairment Tutorial: Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating
Authors: Direnfeld Lorne , Talmage James , Brigham Christopher 
Published: December 2020

Abstract
This article was prompted by the submission of two challenging cases that exemplify the decision processes involved in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In both cases, the physical examinations were normal with no evidence of illness behavior, but, based on their histories and clinical presentations, the patients reported credible symptoms attributable to specific significant injuries. The dilemma for evaluators was whether to adhere to the AMA Guides, as written, or to attempt to rate impairment in these rare cases. In the first case, the evaluating neurologist used alternative approaches to define impairment based on the presence of thoracic outlet syndrome and upper extremity pain, as if there were a nerve injury. An orthopedic surgeon who evaluated the case did not base impairment on pain and used the upper extremity chapters in the AMA Guides. The impairment ratings determined using either the nervous system or upper extremity chapters of the AMA Guides resulted in almost the same rating (9% vs 8% upper extremity impairment), and either value converted to 5% whole person permanent impairment. In the second case, the neurologist evaluated the individual for neuropathic pain (9% WPI), and the orthopedic surgeon rated the patient as Diagnosis-related estimates Cervical Category II for nonverifiable radicular pain (5% to 8% WPI).
Impairment Tutorial: Consistency in Measurement
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
The International Association of Industrial Accident Boards and Commissions (IAIABC) is an organization of medical directors, administrators, and administrative law judges for workers’ compensation systems. It was founded in 1914, and current membership represents 41 US states, the District of Columbia, Puerto Rico, 9 Canadian provinces, and 3 other governments in a forum for education and discussion regarding the various medical, legal, and administrative issues in workers’ compensation systems. In 2001, the IAIABC formed an Occupational Impairment Rating Guide Committee to study the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) and to suggest revisions specific to workers’ compensation. The committee's goal is to create a supplement to the AMA Guides for jurisdictions to consider for adoption to clarify and/or to replace methodology in the AMA Guides to make impairment rating more uniform and consistent. The IAIABC Guides has been developed to address impairment of the musculoskeletal system and impairment due to chronic pain with the goal of minimizing or eliminating the need for multiple independent medical evaluations and “dueling doctor depositions.” There are no plans to write supplemental guides for impairment of other body systems, and AMA and IAIABC are engaged in active dialog during the development of the AMA Guides, Sixth Edition.
Comparative Analysis: The State of Colorado Study, Part II
Authors: Brigham Christopher R. , Mueller Kathryn , Van Zet Douglas , Northrup Debra J. , Whitney Edward B. , McReynolds Martha M. 
Published: December 2020

Abstract
[Continued from the January/February 2004 issue of The Guides Newsletter.] To understand discrepancies in reviewers’ ratings of impairments based on different editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), users can usefully study the history of the revisions as successive editions attempted to provide a comprehensive, valid, reliable, unbiased, and evidence-based system. Some shortcomings of earlier editions have been addressed in the AMA Guides, Fifth Edition, but problems remain with each edition, largely because of the limited scientific evidence available. In the context of the history of the different editions of the AMA Guides and their development, the authors discuss and contextualize a number of key terms and principles including the following: definitions of impairment and normal; activities of daily living; maximum medical improvement; impairment percentages; conversion of regional impairments; combining impairments; pain and other subjective complaints; physician judgment; and causation analysis; finally, the authors note that impairment is not synonymous with disability or work interference. The AMA Guides, Fifth Edition, contrasts impairment evaluations and independent medical evaluations (this was not done in previous editions) and discusses impairment evaluations, rules for evaluations, and report standards. Upper extremity and lower extremity impairment evaluations are discussed in terms of clinical assessments and rating processes, analyzing important changes between editions and problematic areas (eg, complex regional pain syndrome).
Pain, Impairment, and Disability in the AMA Guides
Authors: Robinson James P. , Turk Dennis C. , Loeser John D. 
Published: December 2020

Abstract
This article clarifies important conceptual issues associated with the assessment of pain and considers reasons why pain should be considered in impairment and disability ratings. The authors address conceptual issues rather than specific pain assessment methods and limit the discussion to the musculoskeletal and neurologic injuries seen most frequently during impairment disability evaluations. Several groups of experts worked on the AMA Guides, and little is known about which elements of the AMA system are well substantiated and which need revision. In addition, the AMA Guides, as actually used, often differ from the guides as written. Self-reports that disability applicants provide about their experiences provide a first-person perspective that, in principle, may be important to assessors. Pain and “unbearable” sensations cannot be incorporated into impairment evaluations in the AMA Guides because pain is inherently subjective and because pain and its effects must be analyzed at the level of the whole person. In summary, although the AMA Guides, Fifth Edition, seems to support including pain in impairment ratings, this support is vitiated by inconsistencies in the conceptualization of impairment, contradictory information about how examiners should interpret pain, and inadequate guidance about how examiners should combine subjective and objective data.
Impairment Tutorial: Chapter 14 or 18 for Pain Complaints? Summation, Case Example, and Broader Implications
Authors: Barth Robert J. 
Published: December 2020

Abstract
In the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition, two chapters claim relevance for pain complaints that lack an objectively demonstrable general medical basis: Chapter 14, Mental and Behavioral Disorders, and Chapter 18, Pain. Parts 1 and 2 of this four-part series examined forms of mental illness that commonly invoke complaints of pain; Part 2 also evaluations using the mental/behavioral chapter vs the pain chapter, and Part 3 noted the self-negating nature of the pain chapter's rationale (ie, the pain chapter presents a rationale that, taken literally, indicates it should not be used). A detailed case example illustrates how the decision about using the mental/behavioral chapter or the pain chapter often can be clarified by simply performing a thorough clinical evaluation (see Part 2 of this series). Examiners should be aware of the role of thoughts, behavior, and environmental contingencies on presentations of chronic pain even when no scientifically credible and objective general medical findings explain the pain. For example, the AMA Guides points out that in as much as 85% of low back pain cases, no explanatory physical pathology can be identified; therefore, readers are encouraged to be mindful of the professional literature. The authors of this series deny any attempt to move all instances of chronic pain into the category of mental illness but report little reason not to do so.