bluuebunny/crossref_metadata_2025_split huggingface dataset:
Questions and Answers
Authors: Brigham Christopher R. , Talmage James B. 
Published: December 2020

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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

Abstract
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.
Letter to the Editor
Authors: Bohr Tom 
Published: December 2020

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

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

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