bluuebunny/crossref_metadata_2025_split huggingface dataset:
Literature Review
Authors: Talmage James B. 
Published: December 2020

Abstract
Evaluating physicians should understand how their impairment evaluations are used, and to these ends Section 1.5 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, discusses impairment and workers’ compensation. Permanent disability rewards may be paid according to a schedule that associates impairments of certain body parts, functions, or systems (eg, amputation or loss of sight or hearing) with specific awards. Typically, a schedule in the workers’ compensation law equates disability and a maximum number of weeks of benefits, but what occurs when an injured worker has both scheduled and unscheduled injuries? Under Colorado statute, scheduled injuries involve those to the neck, head, torso, and any injury not specifically enumerated in the statutory schedule. Because schedules usually do not cover all conditions following injuries, nonscheduled awards are available and are based on the extent of impairment, the nature of the injury, and the employee's occupation, experience, training, and age. The Colorado Supreme Court ruled that when a work-related injury results in both a scheduled and a nonscheduled injury, the scheduled injury must be converted to a whole person impairment rating and combined with the nonscheduled injury's whole person impairment when calculating permanent disability benefits. In its decision, the court relied heavily on and cited provisions in the AMA Guides.
Impairment Tutorial: Rating Pain After a Musculoskeletal Injury
Authors: Talmage James B. , Brigham Christopher R. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, notes that pain is a subjective perception, and usually no exact relationships exist among the degree of pain, extent of pathologic change, and extent of impairment. Chapters 3, 14, and 15 regarding the musculoskeletal system, mental and behavioral disorders, and pain, respectively, may be relevant in evaluating an individual's pain following musculoskeletal injury. The eight diagnostic characteristics of chronic pain are duration, dramatization, diagnostic dilemma, drugs, dependence, depression, disuse, and dysfunction; if four of the eight are present, a presumptive diagnosis is established. The fourth edition of AMA Guides distinguishes chronic pain syndrome and psychogenic pain (the former is not considered a mental disorder), but diagnosis of pain should consider psychological factors that are judged to play a significant role in the onset, severity, exacerbation, or maintenance of the pain. Thus, two individuals may have identical musculoskeletal histories, physical exams, and pain out of proportion to their injuries, but when one of the patients has psychological factors that are known and understood, the evaluating physician may diagnose a pain disorder associated with psychological factors. Because formally associating psychological factors and diagnosis usually requires legal discovery, physicians may keep the psychological factors confidential, diagnose chronic pain syndrome, and evaluate using Chapter 15 of the fourth edition of the AMA Guides.
Legal Update: Nevada Requires Impairment Evaluation Certificate
Authors: Brigham Christopher R. , Mangraviti James J. 
Published: December 2020

Abstract
How should an individual with pain arising from muscle be rated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides)? Syndromes of muscle pain include simple muscle strains and two controversial conditions, myofascial pain and fibromyalgia. Tables in the AMA Guides can be used for rating forearm injuries that affect grip or pinch strength; a separate set of tables can be used to rate the injury in a lower extremity. Injuries to some muscles (deltoid, biceps, and triceps) are not described in these sections but almost always test as grade 4. Major injury to muscle is well understood and noncontroversial, but terms such as myofascial pain syndrome and fibromyalgia describe controversial muscle pains. Some physicians attempt to differentiate myofascial pain and fibromyalgia on the basis of taut bands in myofascial pain and tender points in fibromyalgia, but the interrater reliability of these findings is low and the consensus view suggests that the cause of these two conditions is unknown. Muscle pain, like muscle contraction headache, irritable bowel syndrome, and dysmenorrhea, are real symptoms for which no impairment rating is provided. Our understanding of these conditions should improve with future research, enabling us to define criteria for evaluating impairment.
Impairment Tutorial: Impairment From Coronary Artery Disease
Authors: Talmage James B. 
Published: December 2020

Abstract
Coronary artery disease is quite common, and physicians often are asked about the work capacity of patients with coronary disease; less commonly are physicians asked to rate the patient's permanent impairment. In such cases, Chapter 6, Cardiovascular System, of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is used to rate impairment. The AMA Guides directs the physician who is rating impairment to place the individual in one of four classes of impairment. Class 1 impairment is rarely used because patients often have neither significant lesions nor a history of angina. The likelihood of disease progression may qualify these individuals as impaired even in the absence of symptoms. Patients with Class 2 impairment have no symptoms even with moderately heavy activity, and moderate dietary adjustment or medication is required to prevent symptoms. Class 3 impairment describes individuals who have symptoms of congestive heart failure or angina with moderately heavy activity. According to the AMA Guides criteria, patients in Class 3 would qualify for US Social Security benefits. Class 4 impairment describes individuals who have symptoms during ordinary activity and should have signs or laboratory evidence of cardiac enlargement and abnormal ventricular function. For each class, the AMA Guides describes a range of impairment ratings and provides examples.
Performing Quality Impairment Evaluations
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
An impairment evaluation aims to produce a report that is clear and consistent with the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, which outlines the three-step process of medical evaluation, analysis of the findings, and comparison of the results with the impairment criteria. This article reviews common errors that can occur in each of these steps. Medical evaluation is the basis for the evaluation of impairment and relies on the patient's medical history; the latter must include adequate background information, specify data sources, document pre-existing status and specifics of the injury, and document history from onset to current status. The medical evaluation should support a report that explains the effects of the medical condition on life activities; whether the medical condition is stable; whether the individual is likely to suffer incapacitation, injury, harm, or further impairment; and whether restrictions or accommodations are warranted. Common errors in this step include determinations of permanency and stability, and raters should be aware that the AMA Guides is used to assess impairment, not disability. Forms from the AMA Guides are appropriate and help mitigate errors. An audit form is included and can help physicians produce consistent, efficient reports.
Clinical Update: Dysphagia
Authors: Spiegel Joseph R. , Mandel Steven , Sataloff Robert T. , Creed Judith 
Published: December 2020

Abstract
Physicians are infrequently asked to evaluate an individual with facial disfigurement following an injury because, when the face is injured, typically it heals without any ratable impairment. When a permanent facial disfigurement must be rated, physicians can use Section 9.2 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Chapter 9 of the AMA Guides is unique because it deals only with permanent impairment related to the face's structural integrity, which may be only one aspect of a patient's condition that requires an impairment rating. Facial disfigurement may be the result of a complicated process, for example, a burn that involves multiple organ systems, each with a loss of function that requires an impairment rating. These ratings fall into one of four classes: Class 1 is used when the disorder is limited to the cutaneous structures and may involve a scar or abnormal pigmentation in the cutaneous structures of the face. Class 2 involves loss of some significant underlying supporting structure of the face without significant functional loss or major disfigurement such as a depressed orbital rim, frontal bone, or nasal bone. Class 3 indicates loss of a normal anatomic part or area of the face, eg, an eye. A facial disfigurement so severe that it precludes social acceptance is a Class 4 impairment.
Impairment Tutorial: Rating Facial Disfigurement After an Injury
Authors: Taylor Marc T. 
Published: December 2020

Abstract
This article discusses two important cases that involve the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). First, in Vargas v Industrial Com’n of Arizona, a claimant had a pre-existing non–work-related injury to his right knee as well as a work-related injury, and the issue was apportionment of the pre-existing injury. The court held that, under Arizona's statute, the impairment from the pre-existing injury should be subtracted from the current work-related impairment. In the second case, Colorado courts addressed the issue of apportionment in a workers’ compensation claim in which the pre-existing injury was asymptomatic at the time of the work-related injury (Askey v Industrial Claim Appeals Office). In this case, the court held that the worker's benefits should not be reduced to account for an asymptomatic pre-existing condition that could not be rated accurately using the AMA Guides. The AMA Guides bases impairment ratings on anatomic or physiologic loss of function, and if an examinee presents with two or more sequential injuries and calculable impairments, the AMA Guides can be used to apportion between pre-existing and subsequent impairments. Courts often use the AMA Guides to decide statutorily determined benefits and are subject to interpretation by courts and administrative bodies whose interpretations may vary from state to state.
Clinical Update: Functional Capacity Evaluations and Disability
Authors: Pransky Glenn 
Published: December 2020

Abstract
According to the AMA Guides to the Evaluation of Permanent Impairment, a functional capacity evaluation (FCE) measures an individual's physical abilities via a set of activities in a structured setting and provides objective data about the relationship between an impairment and maximal ability to perform work activities. A key distinction between FCEs and self-reported activities of daily living is that the former involve direct observation by professional evaluators. Numerous devices can quantify the physical function of a specific part of the musculoskeletal system but do not address the performance of whole body tasks in the workplace, and these devices have not been shown to predict accurately the ability to perform all but the simplest job tasks. Information about reliability has been proposed as a way to identify magnification and malingering, but variability due to pain and poor comprehension of instructions may cause variations in assessments. Structured work capacity evaluations involve a set of activities but likely underestimate the individual's ability to do jobs that involve complex or varying activities. Job simulations involve direct observation of an individual performing actual job tasks, require a skilled and experienced evaluator, and raise questions about expense, time, objectivity and validity of results, and interpretation of results in terms of the ability to perform specific jobs. To understand the barriers to return to work, examiners must supplement FCEs with information regarding workplace environment, accommodations, and demotivators.
Psychiatric Assessment in Injury and Disability
Authors: Scott Marcia 
Published: December 2020

Abstract
Chapter 14 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) discusses diagnosis, mental impairment, impairment severity assessment, special impairment categories, report format, and psychiatric impairment evaluation. The chapter differs from others in the AMA Guides insofar as it does not provide percentages for estimates of mental impairment because such usage suggests a certainty that does not exist. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, is a widely accepted classification system for mental disorders, but it omits context. Few clinically standardized tests can identify functional or structural effects, and neuropsychological testing is not the standard for documenting subtle impairment. How individuals manage their illness and cope with life demands are better measures of impairment than diagnostic labels or numbers and kinds of symptoms. Further, assessment requires an evaluation of the context in which the illness unfolds, including premorbid function and previous response to treatment; details about the individual's life course; review of developmental and functional deficits; character style and comorbidities such as anxiety and substance abuse; severity of precipitants, current stage of the episode, and current effectiveness of treatment; and external supports that can moderate impairment. A table lists areas of functional impairment, symptoms to consider, and patient history relevant to symptoms.
Clinical Update: Subjective Illness and Disability
Authors: Scott Marcia 
Published: December 2020

Abstract
Symptoms are the body's major signaling device, but symptoms often are frustratingly vague, subjective, and ill reported. In addition, challenges attend making decisions about an individual's ability to function based solely on the medical diagnosis, particularly when impairment is subtle or subjective. Chronic fatigue syndrome (CFS) is a model for understanding the limits of the medical approach to determining impairment and disability. A protocol from the Center for Disease Control and Prevention (CDC) is used to define CFS. This protocol is not a list of diagnostic criteria, and some patients with chronic fatigue may not meet the CDC definition. The syndrome reflects dysfunction in the neuroendocrine system similar in some ways to that seen with depressive illness, and most patients seen for this condition fulfill the criteria for depression, which is another illness characterized by fatigue and somatic complaints. Physicians who evaluate and treat patients with subtle persistent illness know that employers and coworkers respond less positively to an employee's needs when illness is subtle than when impairment is obvious. Physicians must be clear about the family, job, and employment risks patients take when they stay out of work for medical reasons; they also must recognize the risk these patients take when they continue to work despite impaired performance.
Evaluating Shoulder Impairment
Authors: Katz Richard T. , Perraraju Sankar 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, offers several categories to describe impairment in the shoulder, including shoulder amputation, abnormal shoulder motion, peripheral nerve disorders, subluxation/dislocation, and joint arthroplasty. This article clarifies appropriate methods for rating shoulder impairment in a specific patient, particularly with reference to the AMA Guides, Section 3.1j, Shoulder, Section 3.1k, Impairment of the Upper Extremity Due to Peripheral Nerve Disorders, and Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. A table shows shoulder motions and associated degrees of motion and can be used in assessing abnormal range of motion. Assessments of shoulder impairment due to peripheral nerve lesion also requires assessment of sensory loss (or presence of nerve pain) or motor deficits, and these may be categorized to the level of the spinal nerves (C5 to T1). Table 23 is useful regarding impairment from persistent joint subluxation or dislocation, and Table 27 can be helpful in assessing impairment of the upper extremity after arthroplasty of specific bones of joints. Although inter-rater reliability has been reasonably good, the validity of the upper extremity impairment rating has been questioned, and further research in industrial medicine and physical disability is required.
Lower Extremity Impairments—Knee and Hip
Authors: Shaw William S. , Brooks Charles N. 
Published: December 2020

Abstract
The process of assessing lower extremity impairment described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, differs from that in previous editions. This article addresses common questions that arise in knee and hip impairment rating according to the new edition. Anatomic, diagnostic, or functional methods can be used to estimate lower extremity impairments. Functional methods include ratings based on diminished range of motion, weakness, or gait derangement. In general, only one method should be used to rate impairment associated with an injury or illness. Section 3.2i, Diagnosis-related Estimates, in the AMA Guides lists impairment ratings for many knee conditions and operative procedures. Decreased range of motion, ankylosis, diminished muscle function, and joint space narrowing are some rating methods for the knee. Similar anatomic, diagnostic, and functional methods may be used to rate impairment due to hip pathology, but most hip impairments are estimated by range-of-motion deficits. Assessing lower extremity impairments requires a thorough medical evaluation, careful analysis, experience, and clear judgment; evaluators must determine the applicable rating methods, use the methods to rate the impairment, and then decide which method or combination best describes the impairment, without overlooking or duplicating ratings. [A related Lower Extremity Impairment Checklist and Worksheet appears on page 4 of this issue of The Guides Newsletter. A related Quick Reference, Motion at the Wrist, Elbow, and Shoulder, appears on page 5.]
Legal Update: North Dakota Supreme Court: Third Edition of Guides is “Most Current”
Authors: Mangraviti James J. 
Published: December 2020

Abstract
The accurate measurement of hip motion is critical when one rates impairments of this joint, makes an initial diagnosis, assesses progression over time, and evaluates treatment outcome. The hip permits all motions typical of a ball-and-socket joint. The hip sacrifices some motion but gains stability and strength. Figures 52 to 54 in AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, illustrate techniques for measuring hip flexion, loss of extension, abduction, adduction, and external and internal rotation. Figure 53 in the AMA Guides, Fourth Edition, illustrates neutral, abducted, and adducted positions of the hip and proper alignment of the goniometer arms, and Figure 52 illustrates use of a goniometer to measure flexion of the right hip. In terms of impairment rating, hip extension (at least any beyond neutral) is irrelevant, and the AMA Guides contains no figures describing its measurement. Figure 54, Measuring Internal and External Hip Rotation, demonstrates proper positioning and measurement techniques for rotary movements of this joint. The difference between measured and actual hip rotation probably is minimal and is irrelevant for impairment rating. The normal internal rotation varies from 30° to 40°, and the external rotation ranges from 40° to 60°.
Clinical Update: Evaluating the Allergic Patient: Practical Techniques
Authors: Bascom Rebecca , Craig Timothy J. , Schuler Diane 
Published: December 2020

Abstract
Despite rapid advances in understanding of the biology of allergic disorders, practical techniques for evaluating the allergic patient remain fairly constant. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) requires appropriate assessment before an examiner diagnoses the disorder, determines causation, evaluates whether the patient has reached maximal medical improvement, and rates permanent impairment, if any. A careful history includes both occupational and environmental assessment. Patients with allergic occupational asthma typically must be removed from exposure to the allergen. The environmental assessment should determine the nature of the patient's dwelling, its construction material, heating and ventilation, and the presence or absence of a damp basement, pets, rodents or cockroaches, or hobbies performed in the home. A physical examination should focus on the eyes, nose, lungs, and skin and should exclude obstructive sleep apnea. A thorough medical evaluation always is required, and assessment of immunologic sensitization involves diagnostic allergy skin testing or laboratory assessment. Although the allergens used in such tests are purified and the tests themselves increasingly are standardized, concerns remain regarding nonstandardized laboratories and remote testing. Spirometry is an essential element in objectively defining the nature and severity of respiratory complaints; rhinolaryngoscopy helps differentiate asthma from laryngeal dysfunction and can evaluate sinus disease; and limited cut CT of the sinuses is more cost effective than plain sinus films.
Tools and Resources: Cautions in Using the Guides
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
The approach to evaluation of lower extremity impairments in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) differs from that given in previous editions. This article uses case studies to illustrate practical applications of current approaches to ankle impairment and to foot and toe impairment. Anatomic methods for rating ankle impairments include evaluations of muscle atrophy and limb length discrepancy. The Diagnosis-related estimates section provides ratings for ligamentous laxity and displaced fractures of the ankle. The arthritis section contains ratings for radiographically determined and graded diagnosis. Methods for rating ankle impairments include assessing gait derangement, range of motion, joint ankylosis, and manual muscle testing. The methods used for rating lower extremity impairments also are applicable for the foot and toes, and examiners may deploy less commonly used rating techniques such as those employed for amputations, skin loss, causalgia and reflex sympathetic dystrophy, and vascular disorders. The examiner must understand the applicable rating methods used, estimate percentages via each, and decide which methods best describe the impairment(s) without overlooking or duplicating ratings. The examiner also should report the rating options considered, the reasons for selecting the method(s) used, the method by which the percentage was calculated, and the rationale for any variance from the AMA Guides. [A companion Quick Reference, Measuring Impairments of the Hand and Digits, appears on pp 5-6 of this issue of The Guides Newsletter.]