bluuebunny/crossref_metadata_2025_split huggingface dataset:
Clinical Update: Measuring Shoulder Joint Motion
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
Accurate measurement of shoulder motion is critical in assessing impairment following shoulder disorders. To this end, measuring and recording joint motion are important steps in diagnosing, determining the severity and progression of a disorder, assessing the results of treatment, and evaluating impairment. Shoulder movement usually is composite rather than in a single plane, so isolating single movements is challenging. Universal goniometers with long arms are used to measure shoulder motion, and testing must be performed and recorded consistently. Passive motion may be carried out cautiously by the examiner; two measurements of the same patient by the same examiner should lie within 10° of each other. Shoulder extension and flexion are illustrated. Maximal flexion of the shoulder also includes slight external rotation and abduction, and controlling or eliminating these components during evaluation is challenging. Abduction and adduction are illustrated. Deficits in external rotation may occur in patients who have undergone reconstructive procedures with an anterior approach; deficits in internal rotation may result from issues with shoulder instability. The authors recommend recording the shoulder's range of motion measurements according to the Upper Extremity Impairment Evaluation Record in the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition.
Letter to the Editor: The Continuing Challenge of Evaluating RSD Impairment and Disability
Authors: Knobler Robert L. , Brooks Charles N. , Ensalada Leon H. , Talmage James B. , Brigham Christopher R. 
Published: December 2020

Abstract
The author of the two-part article about evaluating reflex sympathetic dystrophy (RSD) responds to criticisms that a percentage impairment score may not adequately reflect the disability of an individual with RSD. The author highlights the importance of recognizing the difference between impairment and disability in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): impairment is the loss, loss of use, or derangement of any body part, system, or function; disability is a decrease in or the loss or absence of the capacity to meet personal, social, or occupational demands or to meet statutory or regulatory requirements because of an impairment. The disparity between impairment and disability can be encountered in diverse clinical scenarios. For example, a person's ability to resume occupational activities following a major cardiac event depends on medical, social, and psychological factors, but nonmedical factors appear to present the greatest impediment and many persons do not resume work despite significant improvements in functional capacity. A key requirement according to the AMA Guides is objective documentation, and the author agrees that when physicians consider the disability evaluation of people, more issues than those relating to the percentage loss of function should be considered. More study of the relationships among impairment, disability, and quality of life in patients with RSD are required.
Letter to the Editor: Assessing Mild Traumatic Brain Injury
Authors: Mandel Steven , Maitz Edward A. , Gordon John E. , Massari David , Esposito Joely , Mandel Heidi 
Published: December 2020

Abstract
The authors respond to an article, Assessing Mild Traumatic Brain Injury, that appeared in the November/December 1998 issue of the Guides Newsletter. The authors of the article referred to several shortcomings of neuropsychological assessment; specifically, they questioned the ecological (real-world) validity of such testing for less severely impaired individuals. The authors of the letter agree that neuropsychological testing may underestimate problems with attention, concentration, and memory that patients experience in real-world settings. The letter writers identify research that indicates a correlation between neuropsychological test findings and an individual's ability to perform in a work environment, and they emphasize the need to consider the individual's environment before determining the degree of functional impairment based on neuropsychological test findings. The letter writers also suggest that evaluators use recently developed measures of malingering in test batteries, and they dispute the existence of an “overreliance on technicians for test administration.” The authors of the original article respond that questions of ecological validity are less relevant when neuropsychologists do not generalize from test scores to real-world performance. The authors of the article mention their work in detecting malingering and report only preliminary and variable success. Finally, the authors of the original article note that limited space precluded discussion of all the issues raised by the letter's authors.
Challenge of Evaluating Multiple Chemical Sensitivity
Authors: Ranavaya Mohammed I. 
Published: December 2020

Abstract
Impairment and disability resulting from claims of multiple chemical sensitivity (MCS) challenge independent medical examiners because of polemics associated with the syndrome, and the mainstream medical community has questioned its very existence as a medical disease entity. Since the syndrome was described in 1952, MCS has had many names, including universal allergy, total allergy syndrome, ecologic illness, 20th century disease, and chemical AIDS. Epidemiologic data show that a higher proportion of females (up to 88%) suffer from MCS, and the percentage of unemployment among MCS sufferers may be as high as 85%. The best explanation to date for MCS is that it is an illness belief system manifested by culturally shaped illness behavior. Several distinguished scientific organizations, including the AMA, conclude that there is no scientific evidence to support the MCS concept of a physiologic exposure–disease relationship; the proposed diagnostic tests and treatments have not been shown to have value; and MCS should not be a recognized clinical syndrome. Impairment evaluations should follow the guidelines in Chapters 1 and 2 of the AMA Guides to the Evaluation of Permanent Impairment. Evaluators must recognize that MCS claimants often present with comorbid psychiatric conditions, and iatrogenic disability also is a concern among MCS patients.
Upper Extremity Impairment Evaluation: Fifth Edition Revisions
Authors: Brigham Christopher R. , Brooks Charles N. 
Published: December 2020

Abstract
Chapter 16, The Upper Extremities, in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, presents several changes from the Fourth Edition. The changes are minor compared to those in Chapter 15, The Spine, but are more significant than those in Chapter 17, The Lower Extremities. This article examines some of the most important revisions, notably the more rigorous standards for upper extremity evaluation, the requirement to compare motion findings to those of the contralateral extremity, entrapment neuropathies evaluation, and strength assessment. The principles of assessment are essentially unchanged in the AMA Guides, Fifth Edition, and Section 16.1c now clarifies the process of combining assessments. The Fifth Edition provides more direction about how to measure motion, but the values for motion deficits remain the same as in the Fourth Edition. Among important changes in the Fifth Edition regarding rating peripheral nerve impairment are: grading sensory deficits, rating entrapment neuropathies, and evaluating complex regional pain syndrome. The most noteworthy changes in assessing impairment due to other disorders are the following: explicit directions about how to rate these other disorders; elimination of rating for joint crepitation; inclusion of new radiographic criteria for rating carpal instability, and introduction of a new process for rating shoulder instability. The discussion of strength is expanded in the Fifth Edition of the AMA Guides.
Sexual Dysfunction Impairment
Authors: Hirsch Irvin H. , Mandel Steven , Brigham Christopher R. 
Published: December 2020

Abstract
Male sexual dysfunction (MSD) and female sexual dysfunction (FSD) may be of multifactorial etiology; rating these disorders heretofore has been based on subjective, patient-reported criteria. This article discusses the process of determining sexual disability by incorporating objective, laboratory-based data in order to render more reliable and valid determinations, including whether the patient has received appropriate treatment and is at maximum medical improvement. MSD is of organic, psychogenic, mixed, or indeterminate cause, and identification of specific MSD etiology can be made via a thorough sexual and medical history, physical examination, and tailored laboratory testing. Routine laboratory studies should include complete blood count, serum chemistry, lipid profile, and serum free/total testosterone and prolactin levels. Using the history and physical examination and laboratory studies, evaluators can differentially diagnose more than 80% of patients as having either organic or psychogenic MSD. Objective laboratory studies for MSD include nocturnal penile tumescence, duplex Doppler ultrasound, and neurosensory testing. FSD is a prevalent, age-related women's health issue that reportedly affects up to half of women older than 50. FSD evaluation requires a comprehensive sexual and medical history as well as physical examination, pelvic examination, hormonal profile, and an evaluation by a sex therapist. Laboratory testing is not yet fully defined but may include measurements of genital blood flow, vaginal pH and compliance, and genital vibratory sensory threshold determination.
Combining Values
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
To account for the effects of multiple impairments, evaluating physicians must provide a summary value that combines multiple impairments so the whole person impairment is equal to or less than the sum of all the individual impairment values. A common error is to add values that should be combined and typically results in an inflated rating. The Combined Values Chart in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, includes instructions that guide physicians about combining impairment ratings. For example, impairment values within a region generally are combined and converted to a whole person permanent impairment before combination with the results from other regions (exceptions include certain impairments of the spine and extremities). When they combine three or more values, physicians should select and combine the two lowest values; this value is combined with the third value to yield the total value. Upper extremity impairment ratings are combined based on the principle that a second and each succeeding impairment applies not to the whole unit (eg, whole finger) but only to the part that remains (eg, proximal phalanx). Physicians who combine lower extremity impairments usually use only one evaluation method, but, if more than one method is used, the physician should use the Combined Values Chart.
Legal Update: Rating Pain: Rating Pain: Chapter 18 and Workers’ Compensation
Authors: Mueller Kathryn 
Published: December 2020

Abstract
The first four editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) used the range of motion (ROM) method and derived impairment percentages. This method is reliable and works well to rate finger joint injuries such as fractures or sprains that cause reduced finger joint ROM, but it frequently underestimates the functional difficulty (impairment) caused by tendon injuries that restrict the excursion of tendons. For this reason, the AMA Guides, Fifth Edition, introduced a second method to rate ROM in fingers, the total active motion (TAM) method. When an evaluator calculates the patient's impairment using the traditional method from the first four editions of the AMA Guides, the impairment percentage is likely to underestimate the patient's “real world” difficulty or function; the TAM method measures flexion when the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints are in full simultaneous flexion, and it measures extension when all three joints are in full simultaneous extension. Based on an example and using the Combined Values Chart in the Fifth Edition and the traditional method (the only method allowed in the first four editions), one would assess a 16% impairment of the digit; using the TAM method now available in the Fifth Edition, the impairment is more appropriately estimated at 61%.
Natural Rubber Latex Allergy
Authors: Musmand Jon , Brigham Christopher R. 
Published: December 2020

Abstract
Natural rubber latex (NRL) allergy is discussed in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, in Section 8.5, Natural Rubber Latex Allergy, and refers to an IgE-mediated immediate hypersensitivity reaction to one or more protein allergens in latex devices, especially gloves. Among health care workers, NRL allergy is the most common cause of occupationally induced rhinoconjunctivitis and asthma, and clinical manifestations range from dermatitis and contact urticaria, allergic rhinoconjunctivitis, and asthma, to anaphylaxis. Evaluating physicians must be cognizant that a suggestive clinical history is necessary but not sufficient to diagnose NRL allergy, and FDA-approved NRL-specific IgE serum tests may have sensitivity as low as 75% and up to 27% false-positive results. No FDA-approved skin test reagent is available for testing. In evaluating impairment due to NRL allergy, evaluators should determine if the individual's problem can be resolved by avoidance of wearing latex gloves. Most patients who have asthma or air passage disruption impairment due to NRL have problems with bronchospasm only when they are exposed, and these patients may not necessarily have any ratable impairment due to NRL (but individuals who have atopic dermatitis may have ongoing symptoms due to pre-existing allergic rhinitis). Efforts to decrease the incidence of NRL allergy have been encouraging, and some patients diagnosed with NRL allergy may return to work in a latex-safe environment.
Lumbosacral Corticospinal and Cauda Equina Injuries
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
Spinal cord injuries can affect many functions, interfere with the activities of daily living, and result in significant impairment. This article reviews cauda equina and conus medullaris syndromes, examines the process of rating corticospinal tract damage, and provides a case example. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), cauda equina syndrome refers to the polyradicular symptomatology resulting from single- or double-level compression of the lumbosacral nerve roots in the dural sac and may include low-back pain, saddle anesthesia, sciatica, motor weakness of the lower extremities, chronic paraplegia, and bladder, bowel, or sexual dysfunction. Conus medullaris syndrome is caused by a compression injury at T12 or L1, and flaccid paralysis of the legs and anal sphincter with variable sensory deficits may be present. The AMA Guides, Fifth Edition, includes Table 15-6, Rating Corticospinal Tract Impairment, which presents criteria for rating the neurological impairment. The physician must determine which systems are impaired, then which categories are appropriate and what value within a range should be selected. This requires the use of judgment because large ranges are provided. Spinal injuries that involve corticospinal tract damage are assessed using the Diagnosis-related estimate (DRE) method, but the range-of-motion method can be used in specified situations. A case example demonstrates how to assess neurological impairment.
Impairment Rating in Traumatic Brain Injury
Authors: Zasler Nathan D. , Martelli Michael F. , Bender Mark C. 
Published: December 2020

Abstract
Traumatic brain injury (TBI) usually is described in terms of the severity of the initial neurologic insult and is defined by the Glasgow Coma Scale (GCS) score; the presence and duration of amnesia (retrograde and anterograde); and the presence and duration of alteration in or loss of consciousness. According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), the evaluating physician should consider the following: narrative history; most recent clinical evaluation; assessment of current clinical status; plans for future treatment; diagnosis and clinical impressions; and estimated time for full or partial recovery. Individuals who present with brain disease or damage also may experience impairments in several parts of the body or nervous system. Physicians who evaluate TBI must be familiar with numerous relevant sections in Chapter 13, The Central and Peripheral Nervous System, as shown in a table in the article. Individual impairments can be combined using the Combined Values Chart in the AMA Guides. Also, the AMA Guides requires the examiner to grade mental status impairment based on the individual's ability to perform activities of daily living and may require neuropsychological testing. The evaluation of TBI impairment and disability is by no means a simple undertaking for any clinician, and evaluators must familiarize themselves with disability and impairment evaluation protocols and their limitations.
Apportionment Analysis
Authors: Brigham Christopher R. , Roth Henry J. 
Published: December 2020

Abstract
In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, apportionment refers to the “distribution or allocation of causation among multiple factors that caused or significantly contributed to the injury or disease and existing impairment,” and causation is the process of determining “an identifiable factor (eg, accident or exposure to hazards) that results in a medically identifiable condition.” Causality assessment requires a clear understanding and discussion of causal relationships; apportionment analysis refers to the extent to which factors may have contributed to a particular effect or impairment. A causal relationship requires three elements—a cause, an effect, and a specific relationship between them—the absence of any one of which disqualifies causality. Apportionment is an estimate of the degree to which each of various medically probable occupational or nonoccupational factors contributed to a particular impairment. The unique legal standards of compensability and apportionment vary by locality, and the apportionment of disability involves assessing the functional effects of different injuries over time. Evaluators should consider the effect of using the Combined Values Chart on the final assessment and must carefully distinguish factors that are combined vs those that are added or subtracted. A sidebar discusses important changes to the State of California's Workers’ Compensation.
Permanent Impairment—Disability Rating Study: Impact of the AMA Guides on Permanent Disability Ratings in the State of California
Authors: Brigham Christopher R , Bellusci Dave , Beuret Terry 
Published: December 2020

Abstract
Following passage of California Senate Bill No. 899 (SB 899) in 2005, disability in California is rated using the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition. The authors compare the disability ratings under the new law to those under the pre-2005 California Permanent Disability Rating Schedule. The authors reviewed 267 cases, of which 250 were ratable, and the ratings of expert reviewers who used the AMA Guides were compared with the ratings of the pre-2005 evaluations (the reviewers who used the AMA Guides to examine the earlier evaluations were blinded to the results of the earlier evaluations). The average permanent disability ratings were 22% under the old schedule and 6.4% under the new schedule, possibly because the current AMA Guides bases impairment primarily on objective data, not subjective complaints and opinions regarding work restrictions. The AMA Guides also has changed certain tests and minimized others (eg, range of motion and grip, respectively). Study limitations include sample selection and differences between pre-2005 evaluators and the highly proficient experts who used the AMA Guides for the present study. The authors conclude that this study shows ratings that are lower than those typically given by treating physicians and other examiners, and they note potential causes of the discrepancies, including evaluation by physicians who are not yet expert and experienced in using the AMA Guides.
Questions and Answers
Authors: Talmage James B. , Melhorn J. Mark , Brigham Christopher 
Published: December 2020

Abstract
This Case Exercise presents and critiques the case of a 52-year-old right hand dominant male who received a Qualified Medical Evaluation regarding his right wrist injury; the examination report includes several erroneous conclusions that are discussed following the case presentation: The examinee is a retail clerk at a liquor store who complained of progressive right hand pain and numbness in 2004; the examination took place in 2006, and the examiner reports an extensive list of relevant reports reviewed. Because the patient declines a carpal tunnel release procedure, the physician declares the patient to be at maximum medical improvement and uses tables in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, to rate 19% whole person impairment and to apportion 90% to work activities. Readers can pause at this point to evaluate the case and then compare their results with the analysis. The author notes that the report does not discuss activities of daily living and does not report in detail the results of physical testing. Nor does the written report correctly explain how the rating was performed, with a detailed discussion of the rating process with reference to specific criteria and to specific tables, figures, and page numbers. As written, the report provides inadequate information to grade sensory or motor deficits and suggests the use of subjective reports, not objective findings.
Impairment Tutorial: Neurological Impairment Evaluation: Overview of Sixth Edition Approaches
Authors: Direnfeld Lorne , Brigham Christopher R. , Genovese Elizabeth 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), does not provide a Diagnosis-based estimate of impairment due to syringomyelia, a disorder in which a cyst (syrinx), develops within the central spinal cord and destroys neural tissue as it expands. The AMA Guides, however, does provide an approach to rating a syringomyelia based on objective findings of neurological deficits identified during a neurological examination and demonstrated by standard diagnostic techniques. Syringomelia may occur after spinal cord trauma, including a contusion of the cord. A case study illustrates the rating process: The case patient is a 46-year-old male who fell backwards, landing on his upper back and head; over a five-year period he received a T5-6 laminectomy and later partial corpectomies of C5, C6, and C7, cervical discectomy C5-6 and C6-7; iliac crest strut graft fusion of C5-6 and C6-7; and anterior cervical plating of C5 to C7 for treatment of myelopathy; postoperatively, the patient developed dysphagia. The evaluating physician should determine which conditions are ratable, rate each of these components, and combine the resulting whole person impairments without omission or duplication of a ratable impairment. The article includes a pain disability questionnaire that can be used in conjunction with evaluations conducted according to Chapter 3, Pain, and Chapter 17, The Spine.