bluuebunny/crossref_metadata_2025_split huggingface dataset:
Legal Update: Use of the Guides Down Under
Authors: Ranavaya Mohammed I. , Dowda Dwight K. 
Published: December 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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