bluuebunny/crossref_metadata_2025_split huggingface dataset:
Determining Impairment and Disability for Mental and Behavioral Disorders
Authors: Leclair Norma J. , Leclair Steven W. , Brigham Christopher R. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 14, Mental and Behavioral Disorders, focuses on the particularly challenging process of evaluating a person with a mental or behavioral disorder. This chapter is unique: It does not include numeric impairment ratings because no precise methods exist for assessing impairment in mental disorders. This article focuses on the process of gathering qualitative data and relevant information to substantiate the behavioral impairment assessment, for which the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition–Text Revised (DSM-IV-TR) is used. Impairment ratings in the AMA Guides reflect “consensus-derived estimates that reflect the severity of the impairment and the degree to which the impairment decreases an individual's ability to perform common activities of daily living [ADL]” and designates four relevant areas to consider: ADL; social functioning; concentration, persistence, and pacing; and deterioration or decompensation in complex or work-like settings. The validity of an impairment classification depends on the process used to collect and analyze the data, including clinical treatment records, hospital discharge summaries, community mental health program activity reports, patient and family interviews, reports from work evaluation or rehabilitation centers, supported employment records, and workplace evaluations. Defining maximum medical improvement in patients with mental and behavioral disorders is difficult and, in some instances, may be impossible.
Impairment Tutorial: Rating Spondylolisthesis
Authors: Brigham Christopher R. , Haralson Robert H. 
Published: December 2020

Abstract
Spondylolisthesis generally is defined as an anterior or posterior slipping or displacement of one vertebra on another. A unilateral or bilateral defect of the pars interarticularis without displacement of the vertebra is known as spondylolysis or, less frequently, spondyloschisis. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes that the two common types of spondylolisthesis are isthmic (related to the presence of spondylolysis and occurring in the immature spine) and degenerative spondylolisthesis (usually found in older individuals with degenerative changes, usually at the fourth or fifth lumbar vertebra). The AMA Guides classifies spondylolisthesis based on the etiology of the slip: congenital, isthmic, degenerative, traumatic, pathologic, and iatrogenic/postsurgical. In addition, grades ranging from I to V are assessed based on the severity of the displacement of the vertebra above on the vertebra below. Some of the confusion concerning terminology used in the AMA Guides regarding alteration of motion segment integrity arises because multiple different but similar terms exist, eg, those from the American Academy of Orthopaedic Surgeons vs the AMA Guides. The AMA Guides specifies that an x-ray finding of spondylolisthesis alone does not equal alteration of motion segment integrity, and a Diagnosis-related estimate (DRE) is the appropriate method for assessing spondylolisthesis (except in rare occurrences of multilevel spinal involvement, when the range-of-motion method is recommended).
Legal Update: Use of the AMA Guides: 2003 Update
Authors: Brigham Cathy V. , Brigham Christopher R. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is widely used in federal workers’ compensation, Longshore and Harbor Workers’ Act, and automobile casualty (personal injury) cases. The AMA Guides, Fifth Edition, is widely used, but not all state workers’ compensation systems make use of the current edition; in fact, relevant state statutes may or may not specify which edition of the AMA Guides to use and how to do so. Thirty-six states make use of the AMA Guides within their workers’ compensation systems, and 23 states use the Fifth Edition. Eleven states use the AMA Guides, Fourth Edition: Alabama, Arkansas, Connecticut, Delaware, Indiana (both Fourth and Fifth Editions), Kansas, Maine, Maryland, South Dakota, Texas, and West Virginia. Two states use the Third Edition, Revised: Colorado and Oregon. Some states do not use the AMA Guides and instead rely on state specific guidelines, and these include California, Florida, Illinois, Minnesota, New York, North Carolina, Utah, and Wisconsin. Other states may use their own guidelines for specific issues and use the AMA Guides for other issues (eg, state of Washington). Some states do not specify the use of any specific guidelines, including Michigan, Mississippi, Missouri, Nebraska, New Jersey, South Carolina, and Virginia. A table summarizes state statutes dealing with rating impairment in workers’ compensation cases, including AMA Guides edition most used, statute/code, comments, and relevant websites.
Clinical Update: Grip Strength: An Uncommon Impairment
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
Upper extremity impairment rarely is assessed using grip strength, according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), because results can be influenced by subjective factors that are difficult to control, including sex, age, comorbidities, fatigue, handedness, time of day, pain, and the individual's cooperation. The AMA Guides, Section 16.5b, Impairment Evaluation Methods, discusses the approach used for rating peripheral nerve injuries, but this section applies only to specific nerve lesions with resulting weakness of the muscles supplied or sensory changes. Strength correlates only poorly with performance of the activities of daily living, and grip strength testing using a dynamometer or other types of isometric strength testing has not been shown to reliably discriminate between submaximal and maximal efforts. Grip strength usually is not used in the presence of decreased motion, painful conditions, deformities, or absence of body parts (eg, missing digit), nor is it used to rate weakness from a peripheral nerve lesion. In rare cases, the AMA Guides allows the use of loss of strength (eg, due to a severe muscle tear that healed leaving a palpable muscle defect). Impairment ratings based on objective anatomic findings take precedence, and loss of strength is rarely combined and only if based on unrelated etiologic or pathomechanical causes.
Impairment Tutorial: Convert, Add, or Combine?
Authors: Fries Ian Blair , Brooks Charles N. 
Published: December 2020

Abstract
The presence of multiple ratable entities, including symptoms, physical findings, test results, diagnoses, and/or procedures, complicates impairment evaluation; further, patients may have several findings in the same anatomic area and/or findings unrelated to the condition being rated. In complex cases involving a final extremity or whole person impairment (WPI), the examining physician must consider all possible ratable impairments, discarding duplicative or mutually exclusive ratings and converting, adding, or combining to obtain the final rating. Failure to follow the instructions detailed in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is a common source of error in impairment rating. The AMA Guides provides multipliers and, for the upper extremity, tables to convert a body part impairment to an extremity and then to a whole person rating. Jurisdictional requirements vary, but rating physicians commonly are asked to provide a single impairment percentage for the limb or whole person; when two or more impairments are involved, the rater must add or combine the percentages, carefully following the specific instructions in the AMA Guides. Adding two ratings is no different than deriving any other arithmetic sum, but impairment percentages much more commonly are combined than added to ensure that, no matter how many impairments are present, the total is never greater than 100% loss of an extremity or 100% WPI.
Motion Analysis of the Cervical Spine
Authors: Luers Patrick R. 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, defines a motion segment as “two adjacent vertebrae, the intervertebral disk, the apophyseal or facet joints, and ligamentous structures between the vertebrae.” The range of motion from segment to segment varies, and loss of motion segment integrity is defined as “an anteroposterior motion of one vertebra over another that is greater than 3.5 mm in the cervical spine, greater than 2.5 mm in the thoracic spine, and greater than 4.5 mm in the lumbar spine.” Multiple etiologies are associated with increased motion in the cervical spine; some are physiologic or compensatory and others are pathologic. The standard radiographic evaluation of instability and ligamentous injury in the cervical spine consists of lateral flexion and extension x-ray views, but no single pattern of injury is identified in whiplash injuries. Fluoroscopy or cineradiographic techniques may be more sensitive than other methods for evaluating subtle abnormal motion in the cervical spine. The increased motion thus detected then must be evaluated to determine whether it represents normal physiologic motion, normal compensatory motion, motion related to underlying degenerative disk and/or facet disease, or increased motion related to ligamentous injury. Imaging studies should be performed and interpreted as instructed in the AMA Guides.
Clinical Update: Assessing Common Issues in Electrophysiologic Studies
Authors: Ross Mitchell K. 
Published: December 2020

Abstract
Electrodiagnosis is a quantitative electrophysiologic test that may identify and localize the site of neurologic dysfunction and detect subclinical changes and compensatory processes. Electrodiagnostic (EDX) studies useful in evaluating the peripheral nervous system and spinal cord include electromyography (EMG), nerve conduction studies, and somatosensory evoked potentials. The primary uses of these tests are to evaluate radiculopathy, entrapment neuropathy, or other peripheral nerve study, and results must be presented completely, concisely, and in a standardized format understandable to nonelectromyographers (who may include adjusters, attorneys, hearing officers, and judges with varying degrees of knowledge about clinical neurology). Needle EMG remains the most sensitive electrophysiologic test for determining radiculopathy. Any EDX report should contain the fundamental test results and a summary of the findings and should make clear when facts other than neurophysiological data are included. Reports must be internally consistent to avoid compromising the report's integrity. Errors of fact and technique, incomplete or irrelevant data, and over-, mis-, and underinterpretation of data are too frequent in EMG reports. EDX studies objectively define peripheral nerve injuries, entrapment neuropathies, and radiculopathies; the findings must be clearly presented with supportable conclusions. Carpal tunnel syndrome practice parameters from the American Academy of Neurology and the American Academy of Physical Medicine and Rehabilitation are provided.
Legal Update: Apportionment and California Workers’ Compensation Reform
Authors: Walker Phil 
Published: December 2020

Abstract
In April 2004, California implemented workers’ compensation reforms to reduce workers’ compensation premiums for California employers while speeding medical treatment for injured workers. The new law requires the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, particularly regarding apportionment analysis for impairment; the AMA Guides does not directly evaluate disability. Under the new California law, the following are clear: apportionment of permanent disability is based on a) causation and requires both the overall percentage of permanent disability caused by the industrial injury, and b) the percentage of permanent disability due to all other factors, including previous injuries. Less clear about the new law are the following: does apportionment to “causation” mean the physician should apportion out preexisting “pathology” even if it was not disabling prior to aggravation; what happens if a worker fails to disclose a prior injury; and are the standards of the AMA Guides on apportionment similar to those in California's new Labor Code? In the AMA Guides, the discussion of causation, apportionment analysis, and aggravation is different from the legal precedent for disability in California. New in the law is the explicit statement that the employer shall be liable only for the percentage of permanent disability directly caused by the industrial injury. Legal decisions are expected to clarify the interpretation of apportionment.
Clinical Update: The Impairment Impact Inventory: Comparison of Responses by Treatment-seekers and Claimants Undergoing Independent Medical Examinations
Authors: Turk Dennis C. , Robinson James P. , Aulet Mary 
Published: December 2020

Abstract
In the adversarial setting of an independent medical evaluation (IME), claimants may be incentivized to exaggerate the severity of their problems. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) describes a protocol for assessing impairment associated with chronic pain, including the Impairment Impact Inventory (I3) that consists of 26 items that assess the burden of illness in three domains: pain intensity, interference with activities of daily living, and emotional distress. A study was performed to establish preliminary norms for the I3 and to compare responses of claimants undergoing IMEs with those of treatment-seeking chronic pain patients: 183 patients completed the I3, including fibromyalgia syndrome patients (FMS group), 35 multidisciplinary pain center patients (PC group), and 72 claimants undergoing IMEs. Patients in the latter two groups had a variety of chronic pain problems (and hypothetically may be more likely to exaggerate their problems). The three groups had similar mean scores on the total I3 and for each of the FMS, PC, and IME groups. Results support the hypothesis that participants, in aggregate, do not exaggerate their pain when they undergo IMEs, although some quite possibly do. These results are a step toward establishing a scientific basis for the impairment rating system described in the AMA Guides from consensus-based rules to an evidence-based system for making decisions about impairment.
Impairment Tutorial: Chapter 14 or 18 for Pain Complaints? Guidance From Chapter 14 and Other Mental Health Resources
Authors: Barth Robert J. 
Published: December 2020

Abstract
This is the second in a series of articles that address pain complaints and mental illness. The AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, should not be used if the pain presentation is attributable to mental illness, and the evaluator must distinguish between presentations that should be evaluated using Chapter 18, Pain, and those that should be evaluated using Chapter 14, Mental and Behavioral Disorders. Chapter 14 is unique in its avoidance of numerical impairment ratings but has been praised for its internal consistency and emphasis on following the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The only section of Chapter 14 that discusses pain complaints is somatoform pain disorders, which presents several problems, including nomenclature (the phrase somatoform pain disorder is antiquated and disappeared from DSM in 1994, and other forms of mental illness are not somatoform disorders). The DSM is the foundation of the evaluation process, and its discussion of any given mental illness is the gold standard definition of that illness; therefore, any attempt to evaluate pain complaints as a possible manifestation of mental illness must use DSM protocols. The article concludes with a discussion of the components of the evaluation process: awareness of the most prominent diagnostic possibilities; presenting complaints; health history; social history; review of records; family history; collateral interviews; and psychological testing.
Chapter 14 or 18 for Pain Complaints? Guidance From Chapter 18 and Other Pain Resources
Authors: Barth Robert J. 
Published: December 2020

Abstract
This article is part three of a four-part series that examines the rating of pain complaints and mental illness using the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides). Chapter 18 provides physicians with a method for evaluating impairment associated with “chronic pain states” for which there may be “no demonstrable active disease or unhealed injury,” and Chapter 14 should be considered when symptoms are out of proportion to physical findings. This article focuses on the directions from Chapter 18 and other pain resources. The authors note that Chapter 18 specifically addresses the issue of distinguishing between uses of Chapters 18 and 14, but the directions are contradictory with respect to the key question, Do “psychological factors” play a “major role” in the presentation of pain? Resources such as Bonica's Management of Pain point out that “[t]issue damage and nociception are neither necessary nor sufficient for pain,” suggesting that psychological factors are nearly always present and obviating the use of Chapter 18. A potential solution would be to ask, “Is the presentation of pain consistent with any mental illness as defined in the American Psychiatric Association's Diagnostic and Statistical Manual?” The decision rule then would be if the presentation of pain is consistent with any mental illness, then the mental and behavior chapter should be used.
Left Page: Rating Total Ankle Replacement
Authors: Brooks Charles N. 
Published: December 2020

Abstract
Total ankle replacement (TAR), also known as total ankle arthroplasty, has been used since the early 1970s, but, because of improvements in both techniques and materials, the procedure is used more frequently, and examiners are asked to rate permanent impairment resulting from TAR. The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) is silent about rating ankle impairment following arthroplasty but does provide a two-step method to rate the results of total hip and knee replacements. Using tables in the AMA Guides, examiners can rate disability associated with TAR. To provide a standard method for reporting the clinical status of the ankle and foot, the American Orthopaedic Foot and Ankle Society (AOFAS) published rating scales for four anatomic regions, one of which (the ankle-hindfoot scale), can be used to rate the clinical status of ankle, subtalar, talonavicular, and calcaneocuboid joints before and after treatment. The AOFAS scale includes neither patient satisfaction nor many other functional, physical, and radiographic findings, and the AOFAS ankle-hindfoot scale is not and never was intended to be comprehensive. Examiners can follow the same procedures for rating hip and knee replacements, substituting the AOFAS scale for rating clinical outcomes. [Two Quick References in this issue of The Guides Newsletter provide tables and figures relevant to rating upper extremity sensory and motor deficits and to measuring impairments of the hand and digits.]
Standards for Independent Medical Examinations
Authors: Nierenberg Chet , Brigham Christopher , Direnfeld Lorne K. , Burket Clarissa 
Published: December 2020

Abstract
An independent medical evaluation (IME) may be more comprehensive and may contain more elements than an impairment evaluation, but to date no standards have defined a high-quality IME. The authors, a group of experienced IME physicians, note the variability of requirements in individual IME cases, but they have identified standards that generally apply to IME reports and include the following: definition of IME and key concepts; examiner qualifications; methodology and procedures; the physical examination; suggested generalized report format; and quality assurance. An IMR is a specialized examination and report, ideally performed by a medical physician with special training and experience in IMEs; an IME is not a medical consultation and report but rather an opportunity to determine diagnosis and document the clinical course over time. Examiners should be qualified by experience and qualifications and ideally should have a special credential from an independent medical examiners association and must be knowledgeable about IME report writing. A section of the article describes the structure of the IME report, which may vary from examiner to examiner but should include careful attention to descriptive data, history, record review, oral history, physical examination, records of other objective data, and an opinion section (with diagnoses, discussion, past medical treatment, maximum medical improvement, future medical treatment, causation and apportionment, disability/functional status, prognosis, answers to specific questions, and references.
Questions and Answers: Pain-Related Impairment Questions
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
Physicians who perform impairment evaluations should base their ratings on the objective condition of the patient, along with credible subjective findings. In making interpretations and judgments, examiners have obligations that are distinct from the duty of care as a treating physician. An experienced attending clinician, for example, may be unfamiliar with the correct process of rating impairment or may not feel unbiased in performing the rating. If significant new diagnoses are discovered, the physician has a medical obligation to inform the requesting party and individual about the condition and to recommend or refer for further medical assessment. When the physician is uncertain about which method to use to calculate an impairment rating or if more than one method can accurately be used, the physician should calculate the impairment rating using different alternatives and choose the method or combination of methods that best represents the functional impairment of the individual. The attending physician often is the person most knowledgeable about the injured employee and is encouraged to render the final impairment rating, when possible. Depending on the jurisdiction, examiners may be required to comply with specific constraints and duties regarding the rating. Examiners should not question an individual's integrity but can appropriately comment on the person's credibility.
Special Features: Duties of the Examining Physician
Authors: Colledge Alan 
Published: December 2020

Abstract
Workers’ compensation systems provided $25.3 billion of compensation benefits in 1999, and nearly $19 billion of this was compensation for permanent injury. Under workers’ compensation, when injured worker have missed a predetermined amount of work time, they are eligible for wage indemnification (the amount is determined by the jurisdiction). Benefits continue until the disabling condition either permits a return to work or reaches a plateau at which healing ends and no significant improvement is likely (maximum medical improvement or a permanent and stationary condition). How the award is calculated differs from jurisdiction to jurisdiction: In some jurisdictions, permanent injury benefits are awarded only on the direct physical loss; other jurisdictions compensate to some degree for expected wage loss, loss of employment options, expenses for accommodating the disability, and, perhaps, an implicit award for psychological loss and pain. Some jurisdictions require all impairments to be combined as a single whole person impairment, but others use individual impairments expressed as a regional impairment. In some jurisdictions, the permanent benefit is statutory and has no medical or clinical basis (eg, some statutes limit or disallow awards for conditions such as tinnitus or certain psychological conditions). Evaluators must be aware of statutes, administrative rules, and case law that apply to the evaluation.