bluuebunny/crossref_metadata_2025_split huggingface dataset:
Spinal Impairment Evaluation: Process Improvement
Authors: Brigham Christopher R. , Talmage James B. , Eskay-Auerbach Marjorie 
Published: December 2020

Abstract
Impairment evaluation of the spine has evolved notably since the 1958 publication by the American Medical Association of an article titled A Guide to the Evaluation of Permanent Impairment of the Extremities and Back. Significant differences exist among the editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) currently in use, including the third edition, revised (1988), fourth (1993), fifth (2000), and sixth (2008) editions. This article reviews exemplary cases according to the instructions and methods of each edition, beginning with a table that summarizes spinal impairment criteria by edition of the AMA Guides. Another extensive table presents seven exemplar cases that demonstrate the differences in impairment ratings between the fourth, fifth, and sixth editions; each example is discussed in terms of different approaches taken in each of these editions. In the AMA Guides, Sixth Edition, the process of rating impairment was simplified by the elimination of the range of motion method. In the examples presented, the impairment values calculated using the sixth edition fall between those obtained using the fourth and fifth editions. Evaluating physicians must know the appropriate edition of the AMA Guides to use in each case and must understand the differences between them, particularly the changes included in the sixth edition.
Impairment Rating for Non-Specific Back Pain Under the AMA Guides, Sixth Edition: The Legal Perspective
Authors: Haley Luann 
Published: December 2020

Abstract
The method for rating impairments for lumbar spine injuries has evolved over time and has changed with each edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The AMA Guides, Sixth Edition, uses a diagnosis-based impairment rating system as the template for evaluating impairment ratings for spinal conditions. A majority of US states use the AMA Guides to determine an impairment rating for injured workers and use this impairment rating to determine financial compensation, but no state system is the same as another's, and each state has a unique statutory scheme. Some cases warrant the finding of a permanent impairment when the injured worker has significant residual pain complaints and limitations that have been verified by the evaluator as being consistently present from the injury date. The AMA Guides, Sixth Edition, allows an assignment of permanent impairment, at the discretion of the evaluator, in cases of chronic lumbar sprains/strains. Evaluators should carefully consider whether it is appropriate to assign an award of permanent impairment for spinal conditions without verifiable objective findings. An evaluator's decision of no impairment vs class 1 impairment is a significant determination in compensation claims and will continue to include subjective factors until advances in medical science permit a more accurate assessment of complaints of non-specific back pain.
Carpal Instability
Authors: Cohen Mark S. 
Published: December 2020

Abstract
The wrist is the articulation between the distal forearm bones (radius and ulna) and eight carpal bones. The most common carpal instability is between the scaphoid and lunate, termed scapholunate instability. Complete scapholunate dissociation results in a gap between the scaphoid and lunate on posterior–anterior (PA) radiographic projections (scapholunate gap). On lateral radiographs, the scaphoid assumes a flexed posture and the lunate extends, resulting in increased scapholunate and radiolunate angles. The second most common carpal instability patters is between the triquetrum and lunate, termed lunotriquetral instability. Ulnar translocation of the carpus, also known as carpal translation, refers to medial displacement of the entire carpus on the forearm (radius and ulna) and is the most common radiocarpal instability. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, carpal instabilities are rated using Table 15-3, Wrist Regional Grid; the impairment class is determined using Table 15-9, Clinical Studies Adjustment: Upper Extremities. Measurements from plain radiographs are used in Table 15-9 to characterize the instability as mild, moderate, or severe; these characterizations, in turn, determine the class. The assessment of carpal instability using radiographic measurements has limitations, particularly that the radiographic parameters used to grade impairment are imprecise; angular measurements between individual bones are particularly variable, and carpal bone axes can be difficult to determine due to bony overlap on plain radiographs.
Left Ventricular Hypertrophy
Authors: Demeter Steven L. 
Published: December 2020

Abstract
The fourth, fifth, and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) use left ventricular hypertrophy (LVH) as a variable to determine impairment caused by hypertensive disease. The issue of LVH, as assessed echocardiographically, is a prime example of medical science being at odds with legal jurisprudence. Some legislatures have allowed any cause of LVH in a hypertensive individual to be an allowed manifestation of hypertensive changes. This situation has arisen because a physician can never say that no component of LVH was not caused by the hypertension, even in an individual with a cardiomyopathy or valvular disorder. This article recommends that evaluators consider three points: if the cause of the LVH is hypertension, is the examinee at maximum medical improvement; is the LVH caused by hypertension or another factor; and, if apportionment is allowed, then a careful analysis of the risk factors for other disorders associated with LVH is necessary. The left ventricular mass index should be present in the echocardiogram report and can guide the interpretation of the alleged LVH; if not present, it should be requested because it facilitates a more accurate analysis. Further, if the cause of the LVH is more likely independent of the hypertension, then careful reasoning and an explanation should be included in the impairment report. If hypertension is only a partial cause, a reasoned analysis and clear explanation of the apportionment are required.
Evaluating Lumbar Radiculopathy
Authors: Talmage James B. , Eskay-Auerbach Marjorie , Blaisdell J. Edward 
Published: December 2020

Abstract
For workers’ compensation, most requests for a permanent impairment rating of low back injuries involve the diagnostic labels of nonspecific chronic low back pain or intervertebral disk herniation. Use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, to choose the right diagnosis and class for these injuries is the first step and involves correctly choosing between “nonverifiable radicular complaints” and “residual radiculopathy.” Evaluators must be able to distinguish persisting radiculopathy, as defined in the sixth edition, from resolved radiculopathy and from nonverifiable radicular complaints and to support findings with objective clinical evidence. Clinical evidence of chronic radiculopathy might include motor weakness, muscle atrophy, impaired sharp–dull discrimination, and/or abnormal electrodiagnostic tests, provided the findings are persistent and there are reflex abnormalities. When considering radiculopathy in the appropriate spine grid of the AMA Guides, Sixth Edition, the evaluator must distinguish radicular (limb) symptoms that are continuous, intermittent, or completely resolved. Positive electromyography (EMG) studies for acute radiculopathy are a sufficient objective finding to state the person has radiculopathy on the date of the test; individuals with positive needle EMG do have persisting radiculopathy at maximum medical improvement, but this does not mean that radiculopathy must persist despite time and treatment.
Pulmonary Impairment Rating
Authors: Blaisdell Jay , Talmage James B. , Demeter Stephen 
Published: December 2020

Abstract
Nonspecific spinal pain and intervertebral disc herniations are common, and in evaluating spinal impairment physicians should carefully assess the significance of imaging findings, physical examination findings, and reports of limb pain. A case example illustrates key principles in assessing cervical pain in an individual with questionable arm complaints. A 62-year-old man had a slip and fall injury. Imaging studies revealed degenerative disc disease with disc bulges and without specific disc herniations according to the radiologists, but his physician reviewed magnetic resonance imaging (MRI) films and reported multiple disc herniations. The case example illustrates the significance of the finding of degenerative disc disease, determining whether to rate for “soft tissue and nonspecific conditions” or “motion segment lesions,” and assessing “nonverifiable radicular complaints.” The authors note that cervical degenerative disc “disease” is more aptly a radiologic diagnosis reflecting aging rather than a clinical syndrome and does not necessarily imply that the degenerative disc disease is the cause of the pain. To distinguish between nonverifiable radicular complaints without objective evidence of radiculopathy and unreliable vague complaints involving the extremity, evaluators should determine that the complaints are consistently and repetitively recognized in medical records and that they lie in the distribution of a single nerve root that the examiner can name. The diagnosis of “intervertebral disc herniation” cannot be made, and instead the “nonspecific chronic pain” diagnosis can be used. Nor can the diagnosis of alteration of motion segment integrity be used because the case lacks radiographically documented instability.
Carpal Tunnel Syndrome and Trigger Fingers in a Patient with Rheumatoid Arthritis and Systemic Lupus Erythematosus: Case Example
Authors: Brigham Christopher R. , Melhorn J. Mark , Brooks Charles N. , Feinberg Steven D. , Talmage James B. 
Published: December 2020

Abstract
Causation analysis involves determining what conditions are related to a compensable injury or illness; apportionment is the allocation of responsibility among two or more probable causes; and assessing impairment is based on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). These three are separate activities, but sometimes all three must be addressed in a single evaluation and may be required for a specified jurisdiction (eg, California). Evaluators thus must ask if jurisdictional issues dictate or influence the approach to causation and apportionment; which edition of the AMA Guides to use; and how to approach causation and apportionment in the present case example: A 63-year-old woman with rheumatoid arthritis and systemic lupus erythematosus is assessed by an orthopedic surgeon who is the agreed medical evaluator (AME). In addition to her pre-existing rheumatoid arthritis and lupus, the individual also had Sjogren's syndrome, osteoarthritis, degenerative disc disease, left carpal tunnel syndrome, osteopenia, and obesity. She has undergone multiple surgical procedures, and treatment for her collagen vascular disease includes leflunomide (immunosuppressant), hydroxychloroquine, and prednisone. In this case, impairments were not the result of “cumulative trauma” but rather were secondary to underlying chronic inflammatory disease, and her occupational permanent impairment rating accordingly would be zero.
Communicating with Patients, Employers, and Insurers
Authors: Kertay Les 
Published: December 2020

Abstract
Disability is a prototypically biopsychosocial phenomenon, and the majority of workplace absences resolve easily and with an expedited return to work. In a minority of worker absences, recovery is delayed less by clinical factors and more by psychosocial variables that can take up an inordinate amount of time from the health care provider (HCP) and also may drive up total costs. Multiple stakeholders participate in this process—the HCP, the patient, the employer, and the insurer—each of whom has overlapping but distinct perspectives and agendas. Often HCPs find themselves in the middle of a complex set of interactions in which competing agendas may be played out. By engaging in effective communications with key stakeholders, the HCP can play a key role in ensuring that the most appropriate clinical outcomes occur. Despite the complexity of the underlying variables, the principles of effective communication are relatively straightforward: Apply a biopsychosocial model rather than a purely biomedical one; bear in mind that key psychosocial variables involved in delayed recovery include variables on the part of the individual, the employer, and the HCP; recognize that psychosocial factors that contribute to delayed return to work are not impairments that require medial or psychological treatment; listen; reach out to employers; and develop nonadversarial relationships with claims adjusters whenever possible.
Rating Cognitive Impairment, Part I: Case Example Illustrates Need for Adherence to AMA Guides, Sixth Edition Methodology
Authors: Barth Robert J. 
Published: December 2020

Abstract
The assessment of impairment due to alteration in mental status, cognition, and highest integrative function may be challenging. A review of impairment assessments performed by others can provide valuable insights, including an appreciation of how evaluators may misapply the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. As a teaching example, this article presents an erroneous rating for a claim of cognitive impairment. The authors point out that most of the misdirection in the case example could be identified with reference to the AMA Guides, Sixth Edition, which reveals discrepancies between the rating processes in this case and actual sixth edition methodology. Nevertheless, the case example involved certain components that were so unconventional that it would have been impossible for the sixth edition contributors to anticipate the need to write a text that would have prevented these errors. The process of sorting out this misdirected rating revealed a previously unanticipated need to clarify sixth edition methodology, and the present article provides such clarification. The concluding section of this article provides a step-by-step protocol for the AMA Guides, Sixth Edition, methodology that involves rating cognitive impairment using Section 13.3d, Mental Status, Cognition, and Highest Integrative Function. The fourteen steps outline a meticulous process based on appropriate clinical assessment, application of evidence-based medicine, and the process outlined in the AMA Guides, Sixth Edition.
Shoulder Pain at Work: Causation Analysis
Authors: Weddington Joel , Brooks Charles N. , Melhorn Mark , Brigham Christopher R. 
Published: December 2020

Abstract
In most cases of shoulder injury at work, causation analysis is not clear-cut and requires detailed, thoughtful, and time-consuming causation analysis; traditionally, physicians have approached this in a cursory manner, often presenting their findings as an opinion. An established method of causation analysis using six steps is outlined in the American College of Occupational and Environmental Medicine Guidelines and in the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, as follows: 1) collect evidence of disease; 2) collect epidemiological data; 3) collect evidence of exposure; 4) collect other relevant factors; 5) evaluate the validity of the evidence; and 6) write a report with evaluation and conclusions. Evaluators also should recognize that thresholds for causation vary by state and are based on specific statutes or case law. Three cases illustrate evidence-based causation analysis using the six steps and illustrate how examiners can form well-founded opinions about whether a given condition is work related, nonoccupational, or some combination of these. An evaluator's causal conclusions should be rational, should be consistent with the facts of the individual case and medical literature, and should cite pertinent references. The opinion should be stated “to a reasonable degree of medical probability,” on a “more-probable-than-not” basis, or using a suitable phrase that meets the legal threshold in the applicable jurisdiction.
Is a Condition a Ratable Impairment? Nuances in Assessing Preexisting Conditions
Authors: Brigham Christopher R. , Brooks Charles N. , Demeter Stephen , Direnfeld Lorne , Hoo Randy Soo 
Published: December 2020

Abstract
In order to answer questions posed by their clients, evaluating physicians must understand the context of a case or jurisdiction, in part because medical and legal perspectives may differ when an evaluator assesses issues such as causation and apportionment. A condition is not necessarily a ratable impairment, nor do symptomatic conditions necessarily prevent an individual from working. Attorneys may pose very specific apportionment questions based on laws unique to a given jurisdiction; for example, a patient may have an occupational injury or illness that results in impairment, but causation of the impairment may be multifactorial and may involve, for example, age-related degeneration, a pre-existing injury or illness, an occupational injury or illness, and/or subsequent trauma or disease. In some states, the presence of a pre-existing condition when an employee is injured may involve Second Injury Funds that were created to relieve a portion of the employer's/insurer's claim costs when the employer hired or retained an employee with a pre-existing medical condition who then suffered a “second” injury. The latter situation requires more extensive treatment and/or a greater disability due to the combined effects of both conditions. Apportionment of causation and impairment may be complex, requiring evaluation of nonoccupational and occupational risk factors and the natural history of the underlying condition.
Independent Medical Evaluation Best Practices
Authors: Brigham Christopher , Direnfeld Lorne K. , Feinberg Steven , Kertay Les , Talmage James B. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, states that an independent medical evaluation (IME) usually is a “one-time evaluation performed by an independent medical examiner who is not treating the patient or claimant, to answer questions posed by the party requesting the IME.” Evaluators must adhere to best practice standards and must know that these standards may change over time and must meet the needs of the relevant jurisdiction. IMEs take place in several arenas, including automobile casualty, workers’ compensation, personal injury, medical malpractice, and long-term disability and differ from traditional clinical evaluations. The evaluating physician must be independent and has no (or only a limited) physician–patient relationship. The qualifications required of an IME examiner vary by arena, jurisdiction, and issues. Medical evaluators should be board certified and can obtain a special credential from, eg, the American Board of Independent Medical Examiners or the International Association of Independent Medical Evaluators. In addition, evaluators should have demonstrated abilities in report writing and court testimony, and a section of this article provides a general outline of the topics that should be covered in a thorough report. Quality IME reports are the result of thoughtful, thorough evaluations performed by physicians who have knowledge, skills, and experience in both clinical medicine and the assessment of medicolegal issues.
Precision Matters in Behavioral Health, Too
Authors: Kertay Les 
Published: December 2020

Abstract
Behavioral health terminology is an area beset by imprecision that results from confusing claim determinations, unnecessary evaluations, and poor outcomes that result from inappropriate treatment. In medical evaluation reports, one notes references to depression, anxiety, and stress, which are not diagnoses but often are treated as such. Behavioral factors can affect claims in four ways: the presence of a formal clinical diagnosis that meets specific criteria, psychological symptoms, difficult life circumstances, and behavioral overlays. Only the first of these can be attributed to a workplace injury or illness, and determining a causal relationship requires, at minimum, a precise diagnosis. For example, by depression does the health provider mean major depressive disorder with specifiers, persistent depressive/dysthymic disorder, adjustment disorder with depressed mood, or some other specific condition? The behavioral layers can affect the outcome of the claims process and may or may not be appropriate targets of an evidence-informed intervention aimed at returning an injured or ill worker to a higher level of function. The point is not to argue whether or not behavioral interventions are appropriate in workers’ compensation, personal injury, and other claims; the point, rather, is that precise language is the first, necessary step in sorting out the myriad ways in which behavior affects claim incidence, duration, and cost.
Spinal Alteration of Motion Segment Integrity Using the Sixth Edition
Authors: Luers Patrick R. 
Published: December 2020

Abstract
Spinal impairment evaluation includes determination of the presence or absence of alteration of motion segment integrity (AOMSI). The diagnosis-related estimate (DRE) method is the principal methodology used to evaluate spinal AOMSI impairment in the fourth and fifth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In the AMA Guides, Sixth Edition, impairment ratings are calculated using the diagnosis-based impairment (DBI) method that uses five impairment classes determined by diagnoses and specific criteria, adjusted by consideration of non-key factors and grade modifiers. This article includes a correction of numbers in the AMA Guides, Sixth Edition, Figure 17-6. The following factors must be considered to determine if AOMSI is present: 1) flexion/extension radiographs are performed when the individual is at maximum medical improvement and are technically adequate; 2) the proper methodology is used in obtaining measurements of translation and angular motion; 3) normal translation and angular-motion thresholds consistent with the literature are used in determining AOMSI. Imaging modalities such as videofluoroscopy, digital fluoroscopy, and upright/motion magnetic resonance imaging cannot be used to establish an AOMSI permanent impairment using the AMA Guides. A number of technical factors can affect the image quality associated with measurements of AOMSI, including film centering, artifacts, poor edge resolution, endplate normal variations and spurring, and use of analog rather than digital radiography.