bluuebunny/crossref_metadata_2025_split huggingface dataset:
Impairment Tutorial: Permanent Impairment Evaluation of the Temporomandibular Joint
Authors: Brown Chris 
Published: December 2020

Abstract
Temporomandibular joint dysfunction (TJD) is a term applied to a group of problems that affect the muscles of mastication, the temporomandibular joint, and their supporting structures. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, deals only briefly with TMD in Section 11.4b, noting that this dysfunction may impede mastication, affect speech, cause lower facial deformity, and produce pain. Objective criteria (disk displacement and radiographic evidence of joint degeneration, range of motion [ROM], and surgical intervention) have been used to diagnose TMD, but the AMA Guides, Fifth Edition, usually bases the diagnosis on dietary restrictions or problems with speech. A table in the article provides a description of disk displacement and joint degeneration; based on symptoms, clinical findings, and imaging results, examiners can place the patient in one of five stages. Evaluators should use generally accepted ROM measurement principles, and the reproducibility of active ROM is an important indicator of measurement accuracy. Surgical correction includes arthroscopy or arthroplasty. Challenges in developing a process for rating TMD impairment include what factors relate to impairment, what should be the range of impairment, and who should perform the rating. At present, the AMA Guides states that “permanent impairment requires a medical assessment performed by the physician.”
Longshore and Harbor Workers' Compensation Act: Use of AMA Guides
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
The US Congress passed the Longshore and Harbor Workers’ Compensation Act (LHWCA) in 1927 to provide coverage to longshore laborers working on navigable waters of the United States when no state workers’ compensation law applied. After amendments that extended and standardized the Act, the Longshore Compensation Act provides more than $670 million in monetary, medical, and vocational rehabilitation benefits to more than 72,000 individuals annually. Under the LHWCA, ratings are performed for “scheduled injuries” (ie, a scheduled member of the body), including upper extremity injuries (excluding the shoulder), lower extremity injuries, and hearing loss. Impairment ratings typically are expressed in terms of whole person permanent impairment, but under the LHWCA impairment is expressed in the smallest applicable body part (eg, an injury of two digits is expressed as a hand rating). Definitions of terms such as injury, disability, and impairment are similar in the LHWCA and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Claims examiners are advised to require any physician selected to evaluate permanent medical impairment to use the AMA Guides, where applicable, to be detailed in their assessment report, and to rate and report permanent impairment according to the AMA Guides. Boxes in the article present portions of the LHWCA that address compensation for disability and the basic elements required to evaluate anatomical impairment.
Impairment Tutorial: Hearing Impairment
Authors: Mueller Kathryn , Brigham Christopher R. 
Published: December 2020

Abstract
A 1999 study of adults showed hearing loss was the fifth most common disability in the US population, and almost 50% of workers in carpentry, plumbing, and mining had hearing impairment. Determining hearing impairment according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 11.2a, Criteria for Rating Impairment Due to Hearing Loss, is straightforward, if limited. Examiners should be aware that hearing can be temporarily impaired by recent exposure to loud noise and should test only after an extended period without such exposure. Audiometers should be properly calibrated, and technicians must be appropriately trained to obtain accurate measurements. The evaluator should separately test both of the individual's ears at 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz (the representative or test frequencies) and then identify the total worst ear decibel level using the AMA Guides Table 11-1 or 11-2. The evaluator can use Tale 11-3 to convert hearing impairment to whole person loss. Tinnitus also can be rated if a hearing loss in that ear affects speech discrimination; in such instances, the tinnitus rating is limited to a 5% loss. The article includes a Hearing Impairment Rating Sheet that can be used to record data from the hearing impairment evaluation.
The Independent Medical Evaluation Relationship
Authors: Richman Jack 
Published: December 2020

Abstract
According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, an independent medical evaluation (IME) is “an evaluation performed by an independent medical examiner, who evaluates—but does not provide care for—the individual.” In April 2002, the Work Fitness and Disability Evaluation Section of the American College of Occupational and Environmental Medicine (ACOEM) prepared a motion defining the rationale why there is no a priori establishment of a patient–physician relationship during an IME. A figure in the article includes the text of the resolution, which was proposed and debated at the House of Delegates but has not yet been adopted by ACOEM. A table prepared by the College of Physicians and Surgeons of Ontario (CPSO) enumerates differences between the usual doctor–patient relationship and IMEs in terms of duty to provide care, maintaining records, access to records, and fees. CPSO also clarifies that physicians who agree to conduct third-party examinations of individuals whom they are not currently treating have been hired by a third party to perform a particular task, typically to provide an opinion or answer specific questions about the individual. Clear and effective communication with the individual are particularly important because the individual's livelihood or compensation for injury, as well as the person's continuing health, are at stake.
Comparative Analysis of Third Edition, Revised; Fourth; and Fifth Edition Ratings: The State of Colorado Study
Authors: Brigham Christopher R. , Mueller Kathryn , Van Zet Douglas , Northrup Debra J. , Whitney Edward B. , McReynolds Martha M. 
Published: December 2020

Abstract
In 2002, the Department of Labor and Employment, the State of Colorado, performed a study to identify changes among the Third Edition, Revised (December 1990); the Fourth Edition (June 1993); and the Fifth Edition (November 2000) of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This three-part article summarizes the differences found. The study was based on a random sample of 250 cases identified by the Division of Workers’ Compensation of the State of Colorado and stratified into three broad categories: 40 upper extremity cases, 60 lower extremity cases, and 150 whole person cases. Only case records with adequate documented evidence to enable rating among all three editions of the AMA Guides were included. The average age of the examinee was 42.9 years (SD, 11.1 years, range, 18 to 71 years, 171 [68%] male); equal percentages of men and women were present in the upper extremity impairment ratings (20 men, 20 women), but lower extremity and whole person impairments occurred primarily among males (73% and 71% men, respectively). Interrater reliability was obtained from an independent expert medical review of 20% of the cases. Three figures show percentages of upper extremity, lower extremity, and whole person impairment according to the edition used; ratings generally are lower with more recent editions.
Clinical Update: Thoracic Outlet Syndrome
Authors: Brigham Christopher R. , Brooks Charles N. , Talmage James B. 
Published: December 2020

Abstract
The diagnosis, cause, and treatment of thoracic outlet syndrome (TOS) are challenging, and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) gives no specific instructions about rating impairments associated with this disorder. TOS is a group of symptoms and signs, including pain, weakness, paresthesias, numbness, swelling, and/or coldness arising at the base of the neck or superior chest but involving the upper limbs. Causes include compression of the brachial plexus (neurogenic TOS) or, less frequently, subclavian vein and/or artery (vascular TOS). Provocative tests for TOS attempt to induce symptoms and/or signs by compressing the subclavian artery or vein or brachial plexus, but palpitation of the radial pulse in various extremity positions is of limited diagnostic value. Diagnostic studies may include radiographs of the cervical spine, upper chest, and/or shoulder; MRI scans of the thoracic outlet; arteriography or venography, and electrodiagnostic testing. The differential diagnosis for TOS is broad and includes cervical radiculopathy, superior sulcus tumor, other peripheral nerve entrapment syndromes, complex regional pain syndrome, and psychiatric disease. The evaluator must determine if the symptoms, physical findings, and diagnostic study results support the diagnosis; the report should list the rating options considered, discuss the rationale for selecting the method(s) used, and explain how the percentage was calculated.
Impairment Tutorial: Cervical Fusions: A Paradox in the Fifth Edition
Authors: Haralson Robert H. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, presents an impairment paradox: Single-level fusions rating using the Diagnosis-related estimates (DRE) method often result in higher impairment values than do multilevel cervical spine fusions. In the AMA Guides, Chapter 15, The Spine, the definition of Cervical Category IV (alteration of motion segment integrity or bilateral or multilevel radiculopathy) changed from the definition in the fourth edition for Cervicothoracic Category IV (loss of motion segment integrity or multilevel neurological compromise) because of changes in the definition of “alteration of motion segment integrity,” which now also includes surgical arthrodesis. This applies only for single-level fusions because the AMA Guides, states the range-of-motion (ROM) method is used in situations when “there is alteration of motion segment integrity (eg, fusions).” The AMA Guides, Fourth Edition, rated impairment on the basis of the injury, not the surgical procedure, and the maximum whole person permanent impairment for a patient with a single-level, single-sided cervical radiculopathy who had a discectomy and fusion would be 15%, but the minimum award for a similar patient rated using the DRE method is 25%. The author reports that, for the reasons outlined, evaluators should rate all cervical fusions, including single-level fusions, using the ROM method.
Comparative Analysis: The State of Colorado Study, Part III
Authors: Brigham Christopher R. , Mueller Kathryn , Van Zet Douglas , Northrup Debra J. , Whitney Edward B. , McReynolds Martha M. 
Published: December 2020

Abstract
This article concludes the three-part discussion of differences among the editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): Third Edition Revised, Fourth, and Fifth Editions. The discussion begins with a comparison of different editions of the AMA Guides for evaluating lower extremity impairment and spinal impairment. The AMA Guides, Fourth Edition, introduced the Diagnosis related estimates (DRE) model, and in this edition the range-of-motion (ROM) model has only a limited role (ie, primarily as a differentiator). A table summarizes the criteria of spinal impairment criteria by edition of the AMA Guides. The authors summarize differences in the impairment ratings of various body systems based on the use of different editions of the AMA Guides, including differences in ratings of the cardiovascular, pulmonary, digestive, and other systems. Critiquing the AMA Guides, the authors call for improvements, including the following: add a system to rate permanent impairments, including functional limitations; base impairment ratings on scientific evidence and a valid whole person impairment scale; make the AMA Guides reliable, comprehensive, internally consistent, comprehensible, accessible (ie, the AMA Guides are complex and difficult to use, and not all physicians are capable of rating impairment), and acceptable. Despite the shortcomings, no other widely accepted basis to assess impairment is available, and future editions of the AMA Guides will improve the process of providing fair assessments of functional loss.
Chapter 14 or 18 for Pain Complaints? Avoiding the Common but Mistaken Dichotomy of Psychological vs Organic
Authors: Barth Robert J. , Brigham Christopher R. 
Published: December 2020

Abstract
In accordance with the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 18, Pain, pain that is attributable to mental illness does not also qualify for an additional pain-related evaluation. Evaluators must discriminate between presentations of pain that represent mental illness vs those that do not and must decide whether to rate using Chapter 18 or 14. Dichotomous thinking often opposes the notion of psychological vs physiological-organic presentations, but all presentations of pain include psychological aspects, and all mental illnesses include physiological aspects. One type of illustrative mental illness involves conditions that are overtly mental but have been found via extensive scientific study to have a physiological basis (eg, schizophrenia and Alzheimer's disease). Another presentation that is claimed to be of a medical nature actually overlaps with psychological issues (eg, complex regional pain syndrome, type 1 [CRPS-1] and fibromyalgia). Further, the AMA Guides summarizes the lack of a strong correlation between tissue damage or physiology and pain: Pain can exist without tissue damage, and tissue damage can exist without pain. Pain, chronic pain, and impairment from pain are largely, even primarily, psychological phenomena. Accordingly, the determination whether to rely on the pain chapter or the mental/behavioral chapter in the evaluation of a pain presentation cannot be reduced to a misleading dichotomy of psychological vs organic pain.
Special Feature: Referral Letter for the Performance of an Independent Medical Evaluation
Authors: Brigham Christopher R. , Walker Phil 
Published: December 2020

Abstract
Clients who request an independent medical or impairment evaluation are more likely to obtain a quality report from an evaluating provider if they request the appropriate evaluator, provide needed information, and clarify the specifics of their referral. The referral should identify the information needed for the assessment, define the standards for the evaluation, and provide detailed questions to be answered. Failure to provide this information often will result in a poor outcome. The article includes a sample generic referral letter to an impairment evaluator; this example letter can be modified based on the specifics of a case. For example, a workers’ compensation case in California could include the question, What is the overall percentage of permanent disability caused by the industrial injury, and what is the percentage of permanent disability due to all other factors, including prior injuries? The generic referral letter instructs the evaluator to use the standards in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition and refers the evaluator to Chapter 2, Philosophy, Purpose, and Appropriate Use of the AMA Guides. The article includes a sample paragraph that could be included in the generic referral letter and includes specific questions that address statutory requirements under California law, along with instructions about apportionment decisions and documentation.
Impairment Tutorial: Billing for Impairment Ratings
Authors: Colledge Allan , Krohm Greg 
Published: December 2020

Abstract
The AMA Current Procedural Terminology (CPT) codebook lists specific codes that can be used for impairment ratings, and in some industrial cases insurance carriers require an impairment rating determination at medical stability for which a CPT code is needed. For billing purposes, an impairment rating performed by the treating physician usually is considered an extension of the treatment process (office visit, medical records review, diagnostic studies, current physical findings, and a written report). A table in this issue of The Guides Newsletter shows current nonspecific CPT procedure codes; if the report does not conform to the established criteria as outlined in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), the evaluating physician may not be entitled to reimbursement. A work-related or medical disability examination involves taking a medical history commensurate with the patient's condition, examination, diagnosis, assessment of capabilities and stability, calculation of impairment, development of a treatment plan, and completion of documentation or certificates and report. Treating physicians who perform the examination can bill this work using CPT code 9455; CPT code 99456 applies if a nontreating physician performed the work (the code is used for each 30-minute increment). AMA recommends tht payment for these codes be dependent on the complexity of the case, the time required in the evaluation and report writing, and the value of the examiner's time.
Special Features: Workers' Compensation Benefits
Authors: Colledge Alan , Krohm Greg 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) specifies that impairment evaluation may be conducted by a treating or nontreating physician. A treating physician who is knowledgeable about the use of the AMA Guides may be the appropriate professional to evaluate impairment, but in cases that involve pain, disability, and medicolegal (forensic) issues, a truly independent medical examiner typically is most appropriate. All specialties share the same elevated risk of iatrogenesis when treating and evaluating/forensic roles are mixed because mixing compromises the quality of care and threatens the viability of the therapeutic relationship. Further, all treating specialties share the same bias toward offering treatment for most complaints—rather than engaging in the type of cautious skepticism that is required for competent impairment evaluation and other forensic duties. Finally, no treating clinician, regardless of specialty, can offer allegiance to judicial and administrative decision-makers. Treating clinicians often find themselves in a position in which they would be cutting off a source of their own income if they were to offer opinions that the clinical presentation is not valid, work related, or injury related, nor is the patient in need of further treatment. Such a financial conflict of interest can be eliminated only by referral to independent examiners and restricting treating clinicians from becoming involved in such decisions.
Carpal Tunnel Syndrome: Impairment Rating by the AMA Guides, Fifth Edition
Authors: Talmage James B. , Brigham Christopher R. , Brooks Charles N. 
Published: December 2020

Abstract
The pain, numbness, and paresthesias of carpal tunnel syndrome generally are intermittent and are felt in the wrist, hand, thumb, and fingers, often in a distribution approximating that of the median nerve. No specific physical examination exists for carpal tunnel syndrome, and, in the impairment rating assessment, the physical examination focuses on detecting signs of permanent nerve damage (decreased sensation and thenar weakness on opposition). According to the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), provocative tests have no role in impairment rating. The AMA Guides, Fifth Edition, requires nerve conduction testing (NCT), even in “believable” instances, but no uniform definition of an abnormal NCT exists and examiners should realize the uses and limits of NCT. For example, if the NCT is normal, the symptoms, even if believable, do not rise to the level of an impairment. Impairment assessment must take place when the patient is at maximum medical improvement. If the NCT is grossly abnormal (axon loss) and/or degenerative changes are present on needle electromyography, and if physical exam shows sensory and/or thenar weakness, the examiner can use tables in the AMA Guides to rate the disability, combining sensory and motor impairments as appropriate. A one-page sidebar in this issue of The Guides Newsletter addresses the causes of carpal tunnel syndrome.
Erroneous Impairment Ratings Companion: Impairment Rating Critique and the Longshore and Harbor Workers’ Compensation Act
Authors: Uejo Craig , Walker Phil 
Published: December 2020

Abstract
A 2005 Benefits Review Board decision by the US Department of Labor, Peter J. Desjardins vs Bath Iron Works Corporation affirmed a decision and order (2004-LHC-1364) regarding the utility of impairment rating critique. The administrative law judge credited the rating opinion of an expert physician reviewer (who had not seen the claimant) over that of the treating physician. The claimant's physician was awarded 20% upper extremity impairment, but, following the review and opinion of an expert reviewer, the award was reduced to 4%. The claimant appealed, largely on the argument that the expert reviewer had reviewed the report by the patient's physician, not the claimant himself and that the expert's opinion properly relied on the correct use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The appeals judges noted that the administrative judge properly noted that the AMA Guides was suitable for use (and was the basis of the treating physician's award). The administrative law judge found that the expert reviewer's opinion was based on the specifics of the present case and on his knowledge and application of the AMA Guides, which together warranted determinative weight, based on the expert reviewer's credentials, experience, and well-reasoned opinion. This decision confirms that expert reviewers can provide evidence for the fact finder to evaluate the treating physician's opinion to determine if it is well reasoned and documented.
Challenges in the Diagnostic Conceptualization of CRPS-1 (Formerly Conceptualized as RSD)
Authors: Barth Robert J. , Bohr Tom W. 
Published: December 2020

Abstract
From the previous issue, this article continues a discussion of the potentially confusing aspects of the diagnostic formulation for complex regional pain syndrome type 1 (CRPS-1) proposed by the International Association for the Study of Pain (IASP), the relevance of these issues for a proposed future protocol, and recommendations for clinical practice. IASP is working to resolve the contradictions in its approach to CRPS-1 diagnosis, but it continues to include the following criterion: “[c]ontinuing pain, which is disproportionate to any inciting event.” This language only perpetuates existing issues with current definitions, specifically the overlap between the IASP criteria for CRPS-1 and somatoform disorders, overlap with the guidelines for malingering, and self-contradiction with respect to the suggestion of injury-relatedness. The authors propose to overcome the last of these by revising the criterion: “[c]omplaints of pain in the absence of any identifiable injury that could credibly account for the complaints.” Similarly, the overlap with somatoform disorders could be reworded: “The possibility of a somatoform disorder has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a somatoform scenario.” The overlap with malingering could be addressed in this manner: “The possibility of malingering has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a malingering scenario.” The article concludes with six recommendations, and a sidebar discusses rating impairment for CRPS-1 (with explicit instructions not to use the pain chapter for this purpose).