bluuebunny/crossref_metadata_2025_split huggingface dataset:
Diagnostic Conceptualization for CRPS-1: Challenges in the IASP's Diagnostic Conceptualization for CRPS-1 (Formerly Conceptualized as RSD)
Authors: Barth Robert J. , Bohr Tom W. 
Published: December 2020

Abstract
Complex regional pain syndrome-type 1 (CRPS-1) is a problematic diagnosis of a characteristic burning pain that is present without stimulation or movement, occurs beyond the territory of a single peripheral nerve, and is disproportionate to the inciting event. This article highlights some challenging aspects of the diagnostic formulation for CRPS-1 by the International Association for the Study of Pain (IASP) and provides recommendations to address the issues. First, the terminology, CRPS-1, was created specifically to replace the previous term, “reflex sympathetic dystrophy.” Unfortunately, no gold standard diagnostic tests exist for CRPS-1, and the concept itself has a long and continuing history of controversy, not the least factor of which is the lack of reliable diagnostic schemes. Next, IASP's criteria for CRPS-1 do not standardize the diagnostic process and depart from epidemiologic guidelines, particularly regarding continuing pain, allodynia, or hyperalgesia disproportionate to any inciting event. Further, the IASP protocol overlaps diagnostic criteria for somatoform disorders, eg, those in the American Psychiatric Association's diagnostic manual, DSM-IV-TR. Finally, according to the IASP protocol, the majority of CRPS-1 patients present with symptoms that are indistinguishable from those in the DSM-IV-TR guidelines, and the majority of CRPS-1 cases are indistinguishable from the formal definition of malingering.
Erroneous Impairment Ratings
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
This article continues a discussion of the results of a nationwide study that reviewed 2100 impairment ratings and found a large number of errors (see the May/June issue of The Guides Newsletter). Spinal impairment ratings, for example, often are erroneous. Although the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) clearly specifies use of the Diagnosis related estimates (DRE) method, evaluators sometimes incorrectly use the range-of-motion (ROM) method, which is fraught with potential error and typically results in higher impairment ratings. The most common problem associated with rating the lower extremities is combining multiple duplicative impairments. Multiple impairments typically are combined rather than added because the latter usually results in overrating impairments. A sidebar highlights red flags to erroneous AMA Guides ratings, and evaluators can take a number of steps to ensure accurate ratings. The first of these is to ensure an unbiased rating, preferably by a board-certified physician who, ideally, also has certification in the performance of independent medical and impairment examinations. The client requesting the evaluation should provide a cover letter describing the specifics of the evaluation, and the evaluator's report should comply with standards defined in the AMA Guides. All submitted reports should be reviewed by a physician experienced in the use of the AMA Guides; this cannot be accomplished by a nonphysician reviewer.
Erroneous Impairment Ratings
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
A nationwide study in 2005 of 2100 cases referred for impairment rating review found 80% to be erroneous, and 89% of these erroneous ratings were higher than appropriate. Among whole person erroneous ratings (839 of 1037 cases critiqued), the original physician's rating averaged 15.5% whole person permanent impairment, but following rerating by physician experts, the corrected rating averaged 5.6%; only 7% of the cases were underrated. All ratings were based on the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition. Tables and figures show error rates according to portion of the body affected, expert vs original rating, and other explanatory variables. Two physicians who use the AMA Guides should arrive at similar conclusions about impairment ratings, but most physicians have not received instruction about assessing impairment, disability, or causation and lack an adequate ability to assess these issues. Causation requires a given cause and a given effect that are associated with a reasonable degree of medical probability and also requires documentation with appropriate scientific evidence (not self-reports or historical time frames). Those who prepare and review assessments of impairment should ensure that clinical causation assessments were accurate, that the rating was performed at maximal medical improvement, that examination findings were consistent, and that the individual's normal state was determined.
Impairment Tutorial: Rating Permanent Impairment for Artificial Disc Replacements
Authors: Talmage James B. , Brooks Charles N. , Brigham Christopher R. 
Published: December 2020

Abstract
In 2005, the Food and Drug Administration (FDA) approved an artificial disc replacement (ADR), and physicians likely will be called on to evaluate permanent impairment in some patients who have been treated using an ADR. The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition, was published in 2000, before the approval of ADRs, and thus is silent about evaluating ADR-associated impairment. FDA based its approval on the results of a study in which the indications were tightly limited and for which the list of relative contraindications was quite long. One review of 100 consecutive lumbar spine surgery patients found that 95% had at least 1 contraindication to ADR. The AMA Guides recommends using the Diagnosis-related estimates (DRE) method, but some situations (eg, multilevel involvement in the same spinal region) warrant use of the range-of-motion (ROM) method. Assuming a single injury and one level of loss of the activities of daily living, the DRE is the correct method to rate the permanent impairment, and the authors recommend that ADR be accepted as the equivalent to loss of motion segment integrity, warranting a rating from CRE Category IV. ADR is in its infancy, and until the AMA Guides, Sixth Edition, is available, evaluators can rate one level ADR from DRE Category IV.
Ulnar Neuropathy at the Elbow Due to Repetition: Myth or Reality?
Authors: Katz Richard T. 
Published: December 2020

Abstract
Repetitive strain injury (RSI), also known as cumulative trauma disorder, implies that an injury exists and was caused by repetitive strain, but both implications are debatable. Ulnar neuropathy at the elbow (UNE), also known as cubital tunnel syndrome, is the second most common upper extremity compression neuropathy (after carpal tunnel syndrome). This article examines one particular aspect of the RSI debate: Is there scientific evidence to support a causal relationship between UNE and repetitive elbow flexion and extension in the workplace? The authors extensively searched published articles, books, and federal task force publications to look for evidence supporting a causal relationship between UNE and RSI. This included a literature review followed by a study of pertinent review articles, bibliographies, national task force reports related to musculoskeletal problems in the workplace, and relevant case reports. In brief, after extensive searches the authors found no credible medical literature to support a causal relationship between RSI and UNE. Case reports and cadaver studies provide tenuous support for causation of UNE by high-force activities such as pitching in baseball. The only prospective study that systematically assessed any causal relationship between RSI and UNE showed there is none. This article includes a three-page Feature Companion, “Rating Guidance: Ulnar Neuropathy,” that identifies common errors and provides an example rating report.
The Challenge of Hand Arm Vibration Syndrome (HAVS)
Authors: Katz Richard T. 
Published: December 2020

Abstract
Hand arm vibration syndrome (HAVS) has been defined as a constellation of vascular, neurological, and musculoskeletal signs and symptoms in workers who use hand-held vibrating tools (eg, drills, grinders, saws, or jackhammers); pathological features affect primarily vascular, neurological, and muscle tissues. Researchers have hypothesized changes in central nervous system processing, but no significant somatotopic cortical changes have been found using functional magnetic resonance imaging. Differential diagnosis of HAVS includes a variety of anatomical, circulatory, and vasospastic disorders and was standardized in the Stockholm Workshop classification scale (1987). Available laboratory tests generally are incapable of grading the severity of individual cases, and no protocol reliably distinguishes between psychogenic and organic abnormalities. Some proposed tests are impractical, and multimodality testing is confounded by statistical fallacies. Vascular tests, including the cold provocation tests, correlate poorly with disease staging according to the Stockholm Scale, and plethysmography before and after cold provocation, were found to be unsatisfactory. Job tasks that involve vibrating machines are associated with musculoskeletal symptoms but sorting out the roles and latency periods of vibration, repetitive movements, grip and push factors, and worker postures is imprecise. The AMA Guides to the Evaluation of Permanent Impairment, does not provide directions about rating impairment associated with HAVS, but evaluators can use Chapter 16 The Upper Extremities, basing the rating on motion, neurological, and/or vascular deficits.
Observation Compromises the Credibility of an Evaluation
Authors: Barth Robert J 
Published: December 2020

Abstract
Impairment evaluations often occur within an adversarial context that involves a claimant or plaintiff vs a defense or benefits system; this adversarial context may precipitate proposals for observations of a clinical evaluation (eg, by an attorney or attorneys for one or both parties, a court reporter, a clinical expert, other consultant; audio or video also may be recorded). Evaluators, judges, and state workers’ compensation systems sometimes allow such observation, but a century of scientific research has reliably demonstrated that any observation changes an examinee's presentation in ways that are not themselves predictable. Such contamination leaves the evaluation results without a scientifically credible analysis, rendering observed evaluations futile exercises at best and sources of misinformation at worst. This article reviews the research in social psychology regarding “social facilitation and inhibition,” which has identified an extensive list of factors that are affected by observation (eg, complexity or novelty of the issue being evaluated, perceptions of the observer as an evaluator, stranger, or ally, number of observers, and other factors). No mechanism allows an evaluator to systematically account for the effects of all such variables for any given evaluation. When observation is mandatory, the evaluator should clearly document and communicate that a credible direct evaluation was rendered impossible, to the detriment of the referring party and the system as a whole.
Resources: Internet Resources for the Independent Medical Evaluator – 2007
Authors: Brigham Christopher R. , Walker Jenny 
Published: December 2020

Abstract
Rating patients with head trauma and multiple neurological injuries can be challenging. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 13.2, Criteria for Rating Impairment Due to Central Nervous System Disorders, outlines the process to rate impairment due to head trauma. This article summarizes the case of a 57-year-old male security guard who presents with headache, decreased sensation on the left cheek, loss of sense of smell, and problems with memory, among other symptoms. One year ago the patient was assaulted while on the job: his Glasgow Coma Score was 14; he had left periorbital ecchymosis and a 2.5 cm laceration over the left eyelid; a small right temporoparietal acute subdural hematoma; left inferior and medial orbital wall fractures; and, four hours after admission to the hospital, he experienced a generalized tonic-clonic seizure. This patient's impairment must include the following components: single seizure, orbital fracture, infraorbital neuropathy, anosmia, headache, and memory complaints. The article shows how the ratable impairments are combined using the Combining Impairment Ratings section. Because this patient has not experienced any seizures since the first occurrence, according to the AMA Guides he is not experiencing the “episodic neurological impairments” required for disability. Complex cases such as the one presented here highlight the need to use the criteria and estimates that are located in several sections of the AMA Guides.
Spinal Alteration of Motion Segment Integrity
Authors: Luers Patrick 
Published: December 2020

Abstract
The Diagnosis-related estimate (DRE) method is the principal methodology to evaluate spinal impairment, and alteration of motion segment integrity results at least in a DRE Category IV rating, based on a single-level fusion. Multilevel fusions are rated using the range-of-motion (ROM) method. Detailed examination of the medical literature identifies definitions of loss of motion segment integrity that differ from those in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fourth and Fifth Editions. Evaluators should note that the descriptions of certain figures were revised in the Errata to the Fifth Edition of the AMA Guides. Evaluators should note three key points from the AMA Guides: permanent impairment is based on findings at maximal medical improvement (MMI); motion in the spite must be abnormal to qualify for permanent impairment; and imaging results, by themselves, cannot be used to establish a DRE impairment rating. Overall, evaluators should consider flexion/extension radiographs that are technically adequate and taken at MMI; read and understand the Errata for Figures 15-3a, 15-3b, and 15-3c; and apply only normal translation and angular motion thresholds that are consistent with the scientific literature.
Cervical Whiplash: Assessment, Treatment, and Impairment Rating
Authors: Colledge Alan L. , Pack Roger , Brigham Christopher R. , Brooks Charles N. 
Published: December 2020

Abstract
Whiplash-associated disorder (WAD) refers to complaints attributed to a shear-hyperextension then hyperflexion cervical injury, typically following a rear-end motor vehicle collision. Research suggests that chronic whiplash symptoms should be the exception rather than the rule, and the surge of chronic whiplash symptoms probably reflects the focus on biological treatment of WAD, ignoring the cultural, psychological, and sociological influences. The physician evaluating and/or treating a whiplash patient needs to have a solid understanding of the complexities and controversies associated with this disorder. Evaluation should be prompt and thorough, but, unless indicated, evaluators should avoid sophisticated diagnostic studies (eg, magnetic resonance imaging studies correlate poorly with whiplash symptoms). Treatment generally should be simple and consists primarily of reassurance and home exercise. Disability, both occupational and avocational, should be avoided or minimized. As with other impairment evaluations, the clinical assessment (history, physical examination, and review of diagnostic studies) must be thorough. If there are ratable findings, examiners must determine their reliability and whether the examinee has achieved maximal medical improvement. Most cases of WAD do not result in permanent impairment, but when there is ratable impairment it usually falls in DRE Cervical Category II, with a rating of 5% to 8% whole person permanent impairment. Managing patients’ beliefs and expectations following motor vehicle injury can help guide them to continue or promptly return to normal activities. {223}
Clinical Update: Understanding Causation: An Example Using Carpal Tunnel Syndrome
Authors: Melhorn J. Mark 
Published: December 2020

Abstract
Medical evidence is drawn from observation, is multifactorial, and relies on the laws of probability rather than a single cause, but, in law, finding causation between a wrongful act and harm is essential to the attribution of legal responsibility. These different perspectives often result in dissatisfaction for litigants, uncertainty for judges, and friction between health care and legal professionals. Carpal tunnel syndrome (CTS) provides an example: Popular notions suggest that CTS results from occupational arm or hand use, but medical factors range from congenital or acquired anatomic structure, age, sex, and body mass index, and perhaps also involving hormonal disorders, diabetes, pregnancy, and others. The law separately considers two separate components of causation: cause in fact (a cause-and-effect relationship exists) and proximate or legal cause (two events are so closely related that liability can be attached to the first event). Workers’ compensation systems are a genuine, no-fault form of insurance, and evaluators should be aware of the relevant thresholds and legal definitions for the jurisdiction in which they provide an opinion. The AMA Guides to the Evaluation of Permanent Impairment contains a large number of specific references and outlines the methodology to evaluate CTS, including both occupational and nonoccupational risk factors and assigning one of four levels of evidence that supports the conclusion.
Differential Diagnosis for Complex Regional Pain Syndrome
Authors: Barth Robert J. , Haralson Robert 
Published: December 2020

Abstract
Complex regional pain syndrome (CRPS) is a controversial, ambiguous, and often unreliable concept that presents significant clinical and rating challenges, to the extent that, for any individual case, many of the differential diagnostic issues provide a far more probable explanation of symptoms than does CRPS. The International Association for the Study of Pain (IASP) introduced CRPS in 1994 specifically to replace “reflex sympathetic dystrophy” [RSD] and “causalgia.” The IASP diagnostic protocol for assessing CRPS has led to overdiagnosis, as well as questions regarding the protocol's reliability, validity, and high error rate during field trials. Using the IASP protocol and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the authors discuss the mental health and general medical evaluations that are part of the differential diagnosis of CRPS, which involves both psychological and general medical components. Finally, examiners should be aware that the probability rates for a diagnosis of CRPS following a thorough and extensive differential diagnosis is very small and is further limited by the general lack of scientific credibility for the concept of CRPS. A diagnosis of CRPS in the absence of ruling out all potential differentials is not credible. A sidebar discusses several chapters that are relevant to rating impairment due to causalgia, RSD, and CRPS.
Impairment Rating Insights
Authors: Brigham Christopher R. , Uehlein W. Frederick , Uejo Craig , Dilbeck Leslie 
Published: December 2020

Abstract
This article addresses a number of issues regarding impairment evaluation and the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). First, impairment is not synonymous with disability, and, as noted in the sixth and previous editions of the AMA Guides, no direct correlation exists between impairment and work restrictions or loss of earning capacity. An impairment rating does not directly equate to a permanent disability rating and does not solely determine compensation. The AMA Guides creates the opportunity for consistency of impairment ratings among physicians, but impairment ratings must be performed according to standards defined in the AMA Guides. Impairment rating values and methods in the AMA Guides can change between editions based on medical reasons. It is too early to determine the effects of changes in the sixth edition of the AMA Guides pending the accumulation of adequate experience using this edition, until impairment ratings associated with specific diagnoses can be compared, and until an adequate sample of cases can be evaluated and compared using the fifth and sixth editions. Use of the sixth edition may result in some lower impairment ratings, but this edition also expands the number of ratable conditions compared to previous versions. Finally, impairment determination is a medical issue, and more reasonable approaches should be developed to translate impairment into financial rewards.
Pain Disorders, Part II: Evaluating the Difficult Pain Patient
Authors: Katz Richard T. , Smith Stacey Lee 
Published: December 2020

Abstract
In the conclusion of this two-part article, the authors present the notion of psychiatric confounders to assist non–psychiatric physicians in assessing the “difficult pain patient.” Non–psychiatric physicians need not have a detailed understanding of all psychiatric diagnoses, but an understanding of certain diagnoses will assist in evaluating patients with enduring pain complaints. Psychosocial factors have important effects on the relationship between pain and disability. In one study, job satisfaction was a predictor of future disability in low back pain patients; in another study, psychiatric morbidity in a pain-free population predicted the development of back pain over a defined period. In many patients with persistent somatic and/or pain complaints, unrecognized psychiatric diagnoses drive or complicate symptoms and may precede the onset of low back pain. Mood, anxiety, and substance abuse disorders are common and can be associated with physical and pain complaints. Somatic symptoms often are the core feature of the depressed patient who presents to a primary care physician. Somatoform disorders are a spectrum of psychiatric disorders in which physical complaints are driven or aggravated by psychological factors; somatizing patients have chronic problems, many of which are pain-related and involve recurrent physical symptoms, often in different bodily systems, that wax and wane over time. Physicians who evaluate patients with pain complaints must understand the complexity of the challenge, including the probability that pain complaints indicate underlying psychopathology.