bluuebunny/crossref_metadata_2025_split huggingface dataset:
Employability
Authors: Engelberg Alan 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, provides useful definitions of employability, employability determination, and medical determinations related to employability. As the AMA Guides notes, and the term medical determination related to employability has supplanted the use of employability. Clearly, factors unrelated to health status affect both employability and its determination, but the physician's role is limited to providing useful medical information, culminating in a statement of risk to the employer. The physician's purview never includes a determination of employability, nor does it justify an opinion that an individual is or is not employable. Managers in human resources departments can clarify the basic principles of equal employment opportunity and thereby minimize the risk of intentional or inadvertent discriminatory actions. Disability evaluation covers the interplay of the injured employee, the human resources function, and the health care providers. When a worker's health status is a factor, the physician's assistance in helping an employer determine employability is crucial, but physicians must never voluntarily state that a person is or is not employable. Physicians can assist an employer in determining if a medical condition precludes travel to work, being at work for a specified time, and assignment of appropriate tasks with or without reasonable accommodation.
Impairment Tutorial: The Challenge of Evaluating RSD Impairment and Disability (Part I)
Authors: Ensalada Leon H. 
Published: December 2020

Abstract
Reflex sympathetic dystrophy (RSD) refers to subjective complaints of pain associated with soft-tissue changes that may not be caused by sympathetic nervous system dysfunction and for which no reflex has been demonstrated. One definition indicates that RSD, like causalgia, is manifested by pain, allodynia, hyperalgesia, and hyperesthesia and, frequently, by vasomotor and sudomotor disturbances and skeletal muscle hypotonia. The diagnosis of RSD depends on the patient's response to regional sympathetic blockade but does not take into account the questionable validity of the sympathetic mediation hypothesis, the placebo effect, or inadequately performed regional sympathetic blockade. These confounders have contributed to the misdiagnosis and overdiagnosis of RSD and causalgia. Since the publication of the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition, the International Association for the Study of Pain has proposed a new term, complex regional pain syndrome (CRPS) that replaces RDS and causalgia. Dissenting views suggest that the criteria for RDS are vague or that patients with RSD are not a homogeneous population. Evaluators should eliminate alternative diagnoses and then base a finding of RSD, causalgia, or CRPS on a preponderance of clinical evidence. [Part 2 of this article in the next issue of The Guides Newsletter will address impairment due to RSD/causalgia/CRPS.]
Evaluating Impairment from Allergic Disorders
Authors: Welch Laura 
Published: December 2020

Abstract
More than 15 million Americans have allergic rhinitis alone, and approximately 12 million have other allergic manifestations such as urticaria, angioedema, eczema, or sensitivity to food, drugs, or insect bites. Almost 10% of patients who seek care at a physician's office do so for one of the common allergic diseases, but rating impairment for allergic disorders is uncommon because typically they do not produce “permanent” impairment and are not work- or liability-related. Section 9.3a, Respiration in Chapter 9, Ear, Nose, Throat, and Related Structures, of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) addresses the process of assessing impairment due to allergic rhinitis, the first type of allergy. Because allergic rhinitis is seasonal, the examiner must determine if permanent impairment is present and if the patient is at maximum medical improvement. The second major manifestation of allergy is allergic skin disease, including urticaria-angioedema and is discussed in Chapter 13, The Skin, where a table classifies skin disorder impairments. The third primary manifestation of allergic disease is eczema, also called atopic dermatitis, which also is discussed in Chapter 13. Allergic diseases are common but generally are quite treatable. Evaluators should ensure that the patient has had an appropriate trial of therapeutic agents before assigning a permanent partial impairment; because of treatment options, the latter should be rare.
Letter to the Editor
Authors: Mueller Kathryn 
Published: December 2020

Abstract
This letter responds to “Evaluating impairment from allergic disorders” in the March/April 1999 issue of The Guides Newsletter. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not provide clear direction about whether allergies themselves constitute impairment. Consider a worker whose symptoms of asthma subsequent to workplace exposure to toluene diioscyanate resolve when he or she is removed from the job and is no longer exposed to the chemical. Because everyday exposure to diisocyanates is not common and the patient no longer requires medication, one could conclude the patient has no impairment. In contrast, consider a patient who has developed latex allergies as a result of being a health care worker and has experienced two anaphylactic reactions at work after entering rooms where powdered latex gloves had been used and must travel with an epinephrine pen. This person would have a minimum of a Class I impairment because of the few limitations of this person's activities of daily living (ADLs) and the condition requires no or intermittent treatment. Both patients might feel they had permanent changes in their body functions that required permanent changes in their ADLs. Clinicians who make evaluations should be aware of patients’ need for medications or monitoring, the severity of the patient's reactions, and limitations on social activities (eg, need for medications and need to avoid seasonal pollens).
Impairment and Disability Compensation Systems in the United States
Authors: Ranavaya Mohammed I. , Talmage James B. 
Published: December 2020

Abstract
Although several states use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) when they evaluate individuals with impairments and disabilities, various disability systems exist in the United States. Disability and compensation systems have arisen to ensure that disadvantaged members of society with a medically determinable impairment, which may lead to a disability, have recourse to compensation from various sources, including state and federal workers’ compensation laws, veterans’ benefits, social welfare programs, and legal avenues. Each of these has differing definitions of disability, entitlement, benefits, procedures of claims application, adjudication, and the roles and relative weights assigned to medical vs administrative deliberations. Workers’ compensation statutes were enacted because of inadequacies of recovery from claims for injured workers under common law. Workers’ compensation is a no-fault system adopted to resolve the dilemmas of tort claims by providing automatic coverage to employees injured during the course of employment; in exchange for coverage, employees forego the right to sue the employer except for wanton neglect. Other workers’ compensation programs in the United States include the Federal Employees Compensation Act; the Federal Employers Liability Act (railroads); the Jones Act (Merchant Marine Act); the Longshore and Harbor Workers’ Compensation Act; the Department of Veterans Affairs; Social Security; and private, long-term disability insurance.
Literature Review
Authors: Mueller Kathryn 
Published: December 2020

Abstract
Before the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, spine impairment was based on range of motion (ROM) testing combined with ratings for specific spine disorders and neurologic impairment. The AMA Guides, Fourth Edition, uses the Injury or Diagnosis-related Estimates (DRE) Model to rate spinal impairment. This model is based on history, physical examination (but not ROM unless ROM is used as a differentiator), and other test data. Table 71, DRE Impairment Category Differentiators, lists DRE impairment category differentiators and discusses the differences between ratings, choosing between differentiators, and their reliability and validity. Guarding is “a spasm of muscles to minimize motion or agitation of sites affected by injury or disease,” and spasm often is overreported by physicians who are unaware of its definition. Loss of reflexes, presenting as diminished or absent deep tendon reflexes, remains the hallmark of objective physical evidence. Decreased circumference is associated with atrophy. Loss of motion segment integrity is measured on lateral flexion and extension x-rays. Loss of bowel or bladder control suggests significant spinal cord injury. The final differentiator is bladder studies, measured using a cystometrogram and showing unequivocal neurologic compromise of the bladder with resulting incontinence.
Clinical Update: Spinal Cord Impairments
Authors: Direnfeld Lorne K. 
Published: December 2020

Abstract
Lower urinary tract dysfunction may result from a variety of neurologic disorders, including traumatic spinal cord injury, head injury, a cauda equina syndrome, or trauma to the peripheral lumbosacral nerves. Urinary incontinence can be divided into five categories: stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, and total incontinence. A table lists each type, provides a description, and gives both common and neurological examples. Evaluation of voiding dysfunction should not be based on symptoms alone, and urodynamic evaluation is required also. Indeed, urodynamic evaluation is the only means to establish a functional interrelationship of the components of the lower urinary tract. Most ratings of neurogenic bladder dysfunction are performed using Section 4.3d, Urinary Bladder Dysfunction, and Table 17, Criteria for Neurologic Impairment of the Bladder in the AMA Guides to the Evaluation of Permanent Impairment. Ratings for whole-person permanent impairment depend on symptomatology (ie, urgency, dribbling, or incontinence), voluntary control, and bladder reflex activity. If problems with urinary system dysfunction are related to a combination of neurologic and urologic pathology, including pathology in the upper urinary tract, ratings from both sections can be combined using the Combined Values Chart.
Questions and Answers
Authors: Brigham Christopher R. , Talmage James B. 
Published: December 2020

Abstract
Workers’ compensation in Canada is a legislated system of social insurance that is funded by assessments levied on employers. Thirteen established Workers’ Compensation Board (WCB) systems have regional jurisdiction and responsibility for administering and adjudicating compensation for the injured worker. Disability awards for certain injuries are determined by statute; others are determined using an acceptable reference or impairment schedule such as the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). On August 22, 1960, Dr D. E. Bell presented to the Association of Workers’ Compensation Boards of Canada an impairment rating schedule to represent the loss of earning capacity and fulfill the spirit of workers’ compensation. Dr Bell's schedule has served as the basis for many Canadian WCB Primary Rating Schedules. Most jurisdictions refer to the AMA Guides in instances when the primary schedule is inadequate. A table in this article lists the current primary and secondary schedules for assessment of impairment in Canada; another table shows the differences in the ratings between Dr Bell's schedule and the AMA Guides. The AMA Guides is used principally only in Yukon and Prince Edward Island and is used for impairment estimations of more complicated injuries in all regions but Quebec.
Editorial Comment: The Dangers of Diagnosis
Authors: Brigham Christopher R. , Talmage James B. , Ensalada Leon 
Published: December 2020

Abstract
Physicians are rewarded during their medical training for making diagnoses, particularly if the diagnosis is of a rare disorder. Unfortunately, the diagnosis—specifically, the disease label—may have undesirable consequences: the disease label categorizes a person as a patient, reducing their autonomy; the label legitimizes medical intervention that may or may not be beneficial; the disease label sanctions the “sick role,” with concomitant relief from social obligations, which may become an established behavior pattern; and “having a disease” classifies an individual as abnormal and may entail diminished employability or even deprivation of liberty by institutionalization. Multiple chemical sensitivity (MCS), an illness belief system manifested by culturally shaped illness behavior, raises questions regarding how symptoms become diseases of fashion, and the process seems to involve two phases: A genuine organic disease whose cause is challenging to detect and substantiate is appropriated as a template, and the template is broadcast to others who may have quite different symptoms but embrace the template as the explanation for their problems. Sympathetic physicians, patient support groups, and the media facilitate this broadcasting. Physicians who want to be patient advocates should encourage function, not impairment, and ability, not disability. The authors suggest that MCS is a form of illness behavior magnified by the medical model for care, not a consequence of underlying organ system dysfunction.
Letter to the Editor: The Continuing Challenge of Evaluating Carpal Tunnel Syndrome Impairment
Authors: Martin J. True 
Published: December 2020

Abstract
The author responds to The Continuing Challenge of Evaluating Carpal Tunnel Syndrome Impairment in the March/April 2000 issue of The Guides Newsletter. Carpal Tunnel Syndrome (CTS) is a clinical diagnosis based on the patient's history and objective findings on examination. Patients present with dull, aching discomfort of the hand, forearm, or upper arm; paresthesias and tingling of the hand; subjective weakness or numbness; and, occasionally, autonomic changes. Nerve conduction velocity studies are highly accurate in documenting median nerve entrapment at the level of the wrists, but this is an anatomic finding and does not mean that the entrapment produces any symptoms. An electrophysiologic study does not predict if or when the median nerve entrapment will become symptomatic, which is based on the patient's history. Electromyography (EMG) and nerve conduction velocity (NCV) studies do not help distinguish among the many etiologies of CTS. EMG/NCV testing can provide significant, highly accurate information regarding the physiologic function of the median nerve at the level of the wrist, but physicians must know how to interpret this information in the clinical setting. [The Editor responds: Several traditional findings of CTS have little or no diagnostic value, and electrodiagnosis is the diagnostic test of choice, although reported sensitivities range from 49% to 84% with specificities of 95% to 97%.]
Clinical Update: Evaluation of Low Back Pain
Authors: Martin True , Brigham Christopher R. , Brooks Charles N. 
Published: December 2020

Abstract
This article provides an overview of the neurological examination and diagnostic studies commonly used in the evaluation of low back pain, information that is essential for both clinical assessment and impairment rating in the AMA Guides to the Evaluation of Permanent Impairment. Clinical evaluation begins with a careful review of medical records. After taking a thorough history, the physician performs the physical examination, including neurological testing, on the patient. The clinical evaluation also determines data needed for impairment evaluation. Neurological examination helps distinguish among the various types of pathology suggested by the history, but to some extent the neurological examination lacks sensitivity and specificity and only about two-thirds (69%) of patients with documented L4-L5 or L5-S1 disc herniations demonstrated weakness or deep tendon reflex changes. To maximize information from the evaluation, physicians routinely test for nonorganic physical signs. Isolated positive signs have no clinical or predictive value, and only a score of three or more positive signs is considered clinically significant. Further, these tests were not designed to detect malingering. Used in isolation, the history, neurological examination, and various diagnostic studies do not have the necessary sensitivity and specificity to diagnose and identify the structural pathology responsible for lumbar radiculopathy. Integrating these components into a logical, unbiased evaluation, physicians usually can perform an accurate assessment.
Fifth Edition: Asthma Impairment Evaluation
Authors: Talmage James B. , Ranavaya Mohammed 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, uses approaches to respiratory system impairment rating that are similar to those of previous editions, with two significant changes: First, criteria for asthma impairment were updated to incorporate guidelines recently published by the American Thoracic Society (ATS), and, second, respiratory impairment criteria now incorporate the lower limit of normal for forced vital capacity, forced expiratory volume in the first second (FEV1), and diffusing capacity for carbon monoxide. In 1993, the ATS published Guidelines for the Evaluation of Impairment/Disability in Patients with Asthma that recommended evaluating three parameters: degree of airflow limitation (postbronchodilator FEV1); the degree of reversibility of the airflow limitation; and the minimum amount of medication needed to maintain maximal medical improvement (MMI). The ATS Guidelines contained a scoring system that was used to place the individual into one of six impairment classes. The Fifth Edition uses the same method of scoring the three clinical parameters and using the point score to determine which of the four impairment classes best describes the impairment. The Fifth Edition discussion of occupational asthma indicates the importance of removing the individual from further exposure to the sensitizing agent; MMI usually occurs within 2 years after removal from exposure.
Independent Medical Evaluations: The Client Perspective
Authors: Christian Jennifer , Siktberg David , Brigham Christopher R. , Brooks Charles N. 
Published: December 2020

Abstract
Independent medical evaluations (IMEs) are widely—and often, inappropriately—used in the claims management process. An IME includes a review of all pertinent medical records; an interview (history) and physical examination; a review of laboratory results and test results; and an edited and signed written report. The primary value of an IME is the report, because a credible medical opinion obtained at the right time can provide information necessary to initiate appropriate action in claims management, both for insurers, who will have a solid basis for acceptance or denial of a claim, and for claimant attorneys, who may use the evaluation to gain acceptance of a claim. A list of common problems in IMEs shows issues about which evaluators should be particularly careful, including questions of use, timing, choice of examiner, adequacy of questions asked and information received, expectations not defined, and framing the evaluation in a negative manner. From a client perspective, IMEs can be improved in several ways, and physicians should understand these opportunities for improving the quality, effectiveness, and value of evaluations. Because referral letters sometimes fail to ask detailed, focused, and probing questions, examiners who have any doubt about the conduct or objectives of the IME should contact the referral source. Detailed checklists and specifications can help ensure completeness and compliance. The article includes a box with definitions of frequently used IME terminology.
Legal Update: Catastrophic Impairment: Catastrophic Impairment: Use of the AMA Guides in Ontario
Authors: Klimek Edward 
Published: December 2020

Abstract
Chapter 18, Pain, is the first attempt in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, to define comprehensive pain evaluation and rating. Chapter 18 focuses on situations in which the pain itself is a major cause of suffering, dysfunction, or medical intervention even though an examining physician can find no demonstrable active disease or autonomic changes. These statements likely would be rejected by rating systems that require a physiologic basis for rating. Other chapters in the AMA Guides typically account for pain as part of specific impairment ratings; for example, a physician who rates cervical spine impairment must decide if a rating for pain beyond the original rating is appropriate. Many rating systems would reject such a rating for pain because of its subjective nature, but, despite these difficulties, even restrictive rating systems may require the use of Chapter 18 because, according to the AMA Guides, no other available method exists for considering impairment of certain conditions such as postherpetic neuralgias or migraines. As the AMA Guides acknowledges, Chapter 18 seems to allow impairment ratings caused by pain and suffering but at the same time to forestall actually assigning a number. One hopes for refinements in our understanding of chronic pain treatment and outcomes; in the interim, knowledgeable raters should guide nonmedical personnel toward a reasonable understanding of this chapter.
Clinical Update: IME Report Standards: Independent Medical Evaluation Report Standards
Authors: Brigham Christopher R. 
Published: December 2020

Abstract
Independent medical examinations (IMEs) are performed by a physician or another health care provider who is not involved in the examinee's care and for the purpose of clarifying medical and case issues. Poor quality evaluations and reports are unfair to both the client and the examinee, and this article presents standards of a quality IME report. Evaluators should know the purpose of the IME so the length and detail of the examination are sufficient to address the questions posed with supportable conclusions. One table lists common issues in IMEs, another explains them, and a third divides the preparation of reports into three steps: clinical evaluation, calculation of the impairment rating, and discussion of how the impairment rating was calculated. A fourth table includes an extensive checklist that lists the components of most quality IME reports. The use of templates assists in ensuring a best-practices approach to the evaluation. Most experienced examiners use questionnaires, pain drawings, and inventories as an adjunct to the interview, and the process must be planned carefully to ensure all relevant history and subjective information are obtained. All reports should be completed as soon as possible following the evaluation to ensure efficiency and to generate a report of the highest quality.