bluuebunny/crossref_metadata_2025_split huggingface dataset:
Clinical Update: Overview of Work-Capacity Restrictions
Authors: Bleecker Margit L. 
Published: December 2020

Abstract
Early return to work is fundamental in the treatment of occupational injuries, but the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) may require temporary or permanent work restrictions. The US Department of Labor Physical Demand Characteristics of work classifies jobs by exertional level (sedentary, light, medium, heavy, and very heavy). The Workplace Functional Ability Guidelines (WFAGs) consist of 21 categories of health impairment and emphasize what the worker can do, ie, the “functional ability.” Musculoskeletal symptoms and signs such as strength, range of motion, or radiographic findings are not good predictors of functional abilities, nor does standardizing the method for work-capacity determination. Measures of physical work performance, even when conducted by highly trained individuals, have low interrater reliability when used for complex tasks. Any discrepancy in expectations between the physician and worker about capabilities and anticipated progress should be resolved. This may be best done if the physician is familiar with the requirements of the job and can offer suggestions about, for example, reducing the stress on an injured body part by using a different model of a tool. Individual differences in motivation, pain tolerance, conditioning, and so on make it difficult to determine work restrictions, but physicians should attempt to return the worker to gainful employment as early as possible.
Somatization
Authors: Ensalada Leon H , Brigham Christopher R. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fourth Edition, notes that individuals may consciously exaggerate the symptoms of a disorder in the clinical or impairment evaluation setting, an activity that is associated with the process of somatization. This article reviews the phenomena of somatization, its magnitude, factors that contribute, and somatizing disorders themselves. Somatization is characterized by the propensity to experience and report somatic symptoms that have no pathophysiologic explanation, to misattribute them to disease, and to seek medical attention for them. Reported symptoms could result from organic disease—which is precisely the point because somatizing patients choose symptoms, consciously or not, that will be taken as evidence of real, physical disease. The prevalence of somatization reportedly ranges from 5% to 60% and varies with the medical specialty and the clinical setting. Studies have reported that in 25% to 50% of all primary care encounters, physicians found no significant objective cause to explain the presenting symptoms. The somatization process contributes to somatoform disorders, which are mental disorders and are not intentionally produced or feigned. A table compares three types of somatizing disorders: somatoform disorders, factitious disorders, and malingering. The presence of somatization distorts symptom presentation and can confound assessment methodologies, but the AMA Guides instructs that impairment is rated on the basis of objective findings, not solely on subjective complaints.
Tools and Resources: Nonorganic Findings
Authors: Brigham Christopher R. , Ensalada Leon H. 
Published: December 2020

Abstract
Experienced medical examiners perform detailed physical examinations that document negative, positive, and nonorganic findings. The latter are observations or subjective reports that cannot be readily explained on an anatomical basis. Nonorganic findings have been described since the early part of the 20th century, and nonorganic physical signs in low back pain were defined in 1979. Cervical nonorganic signs also have been developed, standardized, and proven reliable. Nonorganic symptoms and signs may indicate symptom magnification behavior or malingering, particularly if multiple findings are noted and are closely correlated with psychological distress and abnormal illness behavior. The presence of these findings does not necessarily preclude organic pathology. Table 1 extensively lists some of the tests commonly used by independent medical examiners to determine whether findings are nonorganic. Columns in the table list the area for which the test is used (eg, back pain, muscle spasm, or muscle weakness), the name of the test or maneuver (eg, log rolling, pinch test, or others), and a description with notes and recommendations.
Impairment Tutorial: Rating Sensory and Motor Deficits of the Upper Extremity
Authors: Brooks Charles N. 
Published: December 2020

Abstract
The three components of electrodiagnosis useful in evaluation of the peripheral nervous system and spinal cord include electromyography (EMG), electroneurography (nerve conduction studies), and somatosensory evoked potentials. EMG examination involves introduction of a special recording needle into a muscle belly. Electrical potentials located within a few millimeters of the needle are picked up by an electrode and are transmitted from the muscle to amplifiers that filter and display results visually for the electromyographer. Three types of spontaneous activity in electrical potentials are of the greatest relevance: positive sharp waves, fibrillation potentials, and fasciculations (fasciculation potentials on the EMG result from irregular firing of motor units). Electromyography can help assess the status of nerve fibers indirectly, but the integrity of large myelinated sensory and motor neurons can be evaluated directly by nerve conduction studies (NCS), also known as electroneurography. NCS can assess motor neurons, sensory neurons, or mixed nerve trunks. Sensory nerve conduction velocity can be studied in a manner analogous to motor conduction velocity: sensory fibers can be directly stimulated, and the evoked response can be measured at the wrist and elbow. Somatosensory evoked potentials occasionally are useful as an adjunct to EMG and NCS in the diagnosis of peripheral nervous system pathology. These tests also are useful when it is unclear whether an individual has a true radiculopathy.
Impairment Tutorial: Rating Sensory and Motor Deficits of the Lower Extremities
Authors: Brooks Charles N. 
Published: December 2020

Abstract
Previous issues of The Guides Newsletter have presented overviews of electrodiagnostic evaluation, including electromyography, nerve conduction studies, and somatosensory-evoked responses. This article contains suggestions for nonelectromyographers who read reports and identify questionable uses of electrodiagnosis, specifically for the evaluation of radiculopathy and focal neuropathy (eg, nerve entrapments), the two most common presentations. Some subtle abnormalities (eg, changes in motor unit recruitment pattern, changes in firing rate, or reduction in motor units recruited) often are overinterpreted by poorly trained or inexperienced electromyographers. Nerve conduction studies often are overused and may accompany the electromyogram without apparent indication, but they are nearly useless in diagnosing radiculopathy and should be included only for nerve entrapment or differential diagnosis of plexus injury. Nerve conduction studies often are accompanied by F waves and H reflexes. The F wave helps assess proximal portions of nerves and is used primarily in the diagnosis of Landry-Guillain-Barré syndrome but has poor sensitivity and specificity in evaluation of radiculopathy or entrapment neuropathy. The H reflex is used primarily in S1 radiculopathy evaluation. The article includes six questions a clinician should bear in mind while interpreting the electrodiagnostic report. Improperly trained physicians may report false positive or negative results, so examiners should be aware of the qualifications of physicians to whom they refer their patients.
Fifth Edition: the New Standard
Authors: Brigham Christopher R. , Talmage James B. , Ensalada Leon H. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, is available and includes numerous changes that will affect both evaluators who and systems that use the AMA Guides. The Fifth Edition is nearly twice the size of its predecessor (613 pages vs 339 pages) and contains three additional chapters (the musculoskeletal system now is split into three chapters and the cardiovascular system into two). Table 1 shows how chapters in the Fifth Edition were reorganized from the Fourth Edition. In addition, each of the chapters is presented in a consistent format, as shown in Table 2. This article and subsequent issues of The Guides Newsletter will examine these changes, and the present discussion focuses on major revisions, particularly those in the first two chapters. (See Table 3 for a summary of the revisions to the musculoskeletal and pain chapters.) Chapter 1, Philosophy, Purpose, and Appropriate Use of the AMA Guides, emphasizes objective assessment necessitating a medical evaluation. Most impairment percentages in the Fifth Edition are unchanged from the Fourth because the majority of ratings currently are accepted, there is limited scientific data to support changes, and ratings should not be changed arbitrarily. Chapter 2, Practical Application of the AMA Guides, describes how to use the AMA Guides for consistent and reliable acquisition, analysis, communication, and utilization of medical information through a single set of standards.
Case Studies: Spinal Impairment Evaluation: Comparison of the Third Edition Revised, Fourth, and Fifth Editions
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
Significant differences exist regarding spinal impairment rating among the Third Edition Revised, and the Fourth and Fifth Editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Table 1 summarizes the rating criteria used in these three editions. The AMA Guides, Third Edition Revised used only the method that was subsequently labeled the Range of Motion (ROM) Model or Method to assess impairment. The AMA Guides, Fourth Edition, introduced the Injury or Diagnosis-related estimates (DRE) Method, but it had a limited role, primarily as a differentiator, when a patient's final category of disability was in doubt. The AMA Guides, Fifth Edition retains both ROM and DRE, but they are termed methods rather than models. The DRE Method remains the principal means to evaluate an individual who has an injury, but changes were made regarding when and how it is used. In specified cases, the ROM Method is used to assess impairment not caused by an injury (eg, multilevel involvement, recurrent radiculopathy, or multiple pathologic episodes that produce alteration of motion segment integrity or radiculopathy). Table 2 presents seven exemplar cases that demonstrate the differences in impairment ratings among the three editions, and the text discusses the ratings and differences among the outcomes according to edition used.
Fifth Edition: Causalgia, RSD, CRPS Impairment Evalaution
Authors: Ensalada Leon H. 
Published: December 2020

Abstract
In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the methods for rating impairment to causalgia, reflex sympathetic dystrophy (RSD), and complex regional pain syndromes (CRPS) differ from the approaches found in previous editions. Methods for evaluating impairment due to causalgia, RSD, and CRPS can be described as having anatomic or functional bases. The physical evaluation determines the anatomic impairment and is based on history and a detailed examination; the functional evaluation measures the individual's performance of the activities of daily living (ADL). Chapter 13 of the AMA Guides, Fifth Edition, considers causalgia and RSD in Section 13.8, Criteria for Rating Impairments Related to Chronic Pain, and defines chronic pain as the diagnoses of causalgia, posttraumatic neuralgia, and reflex sympathetic dystrophy. In contradistinction to Chapters 16 and 17 and the Glossary, the new term CRPS is not used here. Chapter 16 considers CRPS, RSD (now CRPS I), and causalgia (now CRPS II) and notes that, “contrary to previous suggestions, regional sympathetic blockade has no role in the diagnosis of CRPS.” Chapter 17 uses a functional approach for assessing impairment due to causalgia, RSD, and CRPS. Pending further guidance, evaluators should ensure that their methods for rating lower extremity impairments due to causalgia, RSE, and CRPS are internally consistent.
Clinical Update: Fibromyalgia Syndrome: Impairment and Disability Issues
Authors: Brigham Christopher R. , Leclair Norma J. 
Published: December 2020

Abstract
Fibromyalgia is a perplexing, controversial syndrome with many unanswered questions regarding both etiology and manifestations and impairment and disability issues. This article reviews controversies attending this diagnosis, examines the debates concern etiology, explains why this diagnosis is unratable by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, and explore issues of disability. Health care professionals debate whether the diagnostic criteria actually define a distinct clinical disorder, but the American College of Rheumatology published, for research purposes, classification criteria for Fibromyalgia Syndrome (FMS) that since have been widely used: FMS has been defined as a complex, chronic condition characterized by widespread noninflammatory musculoskeletal pain, severe fatigue, and sleep disturbances. Many health care professionals maintain that FMS is best understood from a biopyschosocial perspective because of the absence of visible clinical signs and inability to confirm the condition by laboratory tests. FMS may affect between 3 and 6 million people in the United States, with a 10:1 predominance in women, most between 35 and 60 years of age. Section 18.3b, When This Chapter Should Not Be Used to Rate Pain-Related Impairment, advises that “the pain of individuals with ambiguous or controversial pain syndromes is considered unratable” and provides three discriminatory questions.
Impairment Tutorial: Respiratory System: Fifth Edition Redefines Normal
Authors: Talmage James B. , Ranavaya Mohammed 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, changes the definition of “normal” (ie, the process of differentiating between an individual whose lung function is “normal” as opposed to an individual with Class 2 respiratory impairment) because the definition has changed over time. For example, the AMA Guides, First Edition (1971), used from the VA-Army 1961 Cooperative Study to construct tables of “normal” or “predicted” values during spirometry. Regression equations were used to calculate the predicted forced vital capacity, forced expiratory volume in the first second, and mandatory minute ventilation for men and women, by age and height. The Second Edition (1984) used data from a pulmonary function study in 251 healthy white individuals who lived 1400 meters above sea level (Utah), more than 90% of whom were members of the Mormon church (a very narrow segment of the American population). The AMA Guides, Third and Fourth Editions, continued to rely on the study just cited and made a distinction between “normal” and “mildly impaired.” The AMA Guides, Fifth Edition, uses the four classes of respiratory impairment and the same whole person impairment ratings for each class, unchanged from the Fourth Edition. The Fifth Edition has reverted to using the 95% confidence interval to determine “normal,” so that the same individual who, under the Fourth Edition guidelines was up to 25% impaired, would become normal under the pulmonary impairment guides of the Fifth Edition.
Objectifying the Spinal Impairment Examination: Fifth Edition Approaches
Authors: Haralson Robert H. , Brigham Christopher R. 
Published: December 2020

Abstract
A careful and thorough physical examination is a critical component of the spinal impairment evaluation. Two methods have been used for this evaluation, the Diagnosis-related estimates (DRE) method and the Range of Motion (ROM) method, but the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, states that “the DRE method is the principal methodology used to evaluate an individual who has had a distinct injury.” The DRE rating is based on objective findings at the time of evaluation and includes the following clinical findings: muscle spasm; muscle guarding; asymmetric spinal motion (previously called dysmetria); nonverifiable radicular pain; reflexes, neurological changes such as weakness or loss of sensation, atrophy, radiculopathy, and electrodiagnostic changes; alteration of motion segment integrity; cauda equina–like syndrome; and urodynamic tests. This article examines the definitions of the findings and discusses their use in the DRE method. For example, the AMA Guides, Fifth Edition, defines muscle spasm as a sudden, involuntary contraction of a muscle or group of muscles, and muscle spasm must be present at the time of a DRE-based evaluation; in the Fourth Edition, examiners used only a history of spasm. The AMA Guides, Fifth Edition also has different parameters, compared with the Fourth Edition, for determining atrophy.
Legal Update: State-Specific Use of the AMA Guides
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
Many states require use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in their workers’ compensation systems; state statutes may or may not specify which edition of the AMA Guides to use and how to use them. Thirty-five states make use of the AMA Guides, and 60% (21) of them use the Fifth Edition. Eleven states use the Fourth Edition (Alabama, Arkansas, Delaware, Kansas, Maine, Maryland, Nevada, Ohio, South Dakota, Texas, and West Virginia). One state uses the Third Edition–Revised (Colorado), and one state uses the Second Edition (Louisiana). Some states use their own guidelines for specific issues and use the AMA Guides for other issues (eg, Washington State rates spinal impairment using the state's own guidelines but rates extremity disorders using the AMA Guides). Many states use a statutory schedule to assess amputations, hearing loss, visual loss, hernias, and disfigurement; some states may use a statutory schedule and use the AMA Guides for nonscheduled injuries. Physicians who practice in a state that does not make use of the AMA Guides in state workers’ compensation cases may need to assess impairment using the “latest edition” of the AMA Guides. The article includes a tabular summary of state statutes that deal with rating impairment in workers’ compensation cases.
Pain Evaluation: Fifth Edition Approaches
Authors: Robinson James , Turk Dennis C. , Loeser John D. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, stresses that impairment assessment should be based on objective evidence of organ dysfunction. Using this model, pain-related impairment (PRI) such as migraine headache not associated with definable organ dysfunction is difficult to reconcile with patients’ reports of limitations in their activities of daily living (ADL). Chapter 18 of the AMA Guides, Fifth Edition, systematically addresses PRI and differs from previous editions by allowing examiners to award both quantitative and qualitative impairments. PRI is challenging to integrate with other chapters of the AMA Guides, which provide conventional impairment ratings (CIR) based on objectively measurable organ dysfunction. Examining physicians should consider PRI when performing an impairment evaluation on an individual who has a condition associated with pain, including almost any orthopedic condition and most neurological conditions. The examiner must determine if an individual's PRI should be considered as incorporated in the CIR or if the PRI increases the burden of illness above that acknowledged in the CIR—and only in the latter case should the physician use Chapter 18. This chapter distinguishes ratable vs unratable PRI, but better terminology may be uncontroversial and controversial PRI, respectively. Ten steps are involved in a PRI assessment and require the examining physician to use a multiaxial approach, synthesize information from multiple sources, and carefully assess the individual's credibility and pain behavior.
Clinical Update: Chronic Fatigue Syndrome
Authors: Ensalada Leon H. , Brigham Christopher R. 
Published: December 2020

Abstract
Chronic fatigue syndrome (CFS) is a term applied to individuals who report severe chronic fatigue out of proportion to their efforts, but the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth and Fifth Editions, are clear that no ratable impairment is linked to CFS. Chronic fatigue is not synonymous with CFS; only a small fraction of persons who present with chronic fatigue symptoms meet the criteria for CFS; and CFS, like fibromyalgia and multiple chemical sensitivity, is poorly understood. CFS may be associated with disability but primarily is based on psychological rather than physical symptoms. No tests confirm the diagnosis of CFS, and routine laboratory testing is reserved for excluding other medical conditions. CFS is an illness without a disease and often is characterized by illness behavior expressed as somatization. To date, no convincing evidence supports the notion that CFS is an infectious, neuroendocrine, or immunologic disorder. Thus, sophisticated behavioral assessment is critical and may include a fatigue rating scale, a depression scale, and psychological and personality inventories. No specific treatment has been recommended for CFS treatment, but cognitive and behavioral interventions may be useful to address psychological symptoms; medication is reserved for specific symptoms indicative of depression or anxiety.
Impairment Tutorial: Rating After IDET Procedures: Rating Permanent Impairment in Patients Who Have Already Had Intra-discal Electrothermal Annuloplasty (IDET) Procedures
Authors: Talmage James B. , Haralson Robert H. 
Published: December 2020

Abstract
Intra-discal electrothermal annuloplasty (IDET) is a relatively recently described surgical procedure for chronic low back pain that is caused by degenerative discs is unresponsive to nonoperative treatment. IDET involves percutaneously inserting a catheter into a disc(s) and then heating the catheter to 90 °C for 17 minutes. Randomized controlled trials are in progress but not yet reported, so the proper role of IDET in the care of chronic back pain is not yet known. Neither the Fourth nor the Fifth Edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) specifically addresses IDET. Evaluators who use the AMA Guides, Fifth Edition, apply the Diagnosis-related estimates (DRE) method to assess impairment when the patient is at maximum medical improvement (MMI). Because the long-term effects of IDET are not known and the patient's disc probably has been permanently changed by the procedure, evaluators should consult the AMA Guides, Fifth Edition, regarding categorization. This is because the injury and surgery have not resulted in a normal disc but rather one that may be prone to future problem episodes. If the evaluator chooses to use the range-of-motion method from the AMA Guides, Fourth Edition, in some scenarios the authors recommend considering IDET as if it were “surgical treatment” of the disc.