bluuebunny/crossref_metadata_2025_split huggingface dataset:
Impairment Ratings: Observations Based on Review of More Than 6,000 Cases
Authors: Brigham Christopher R. , Uejo Craig , Dilbeck Leslie , Uehlein W. Frederick 
Published: December 2020

Abstract
The goal of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is “to provide a standardized, objective approach to evaluating medical impairment,” resulting in reliable, reproducible impairment ratings with high levels of interrater consistency. The authors reviewed 6233 impairment ratings that took place between July 2006 and January 2010 that reflected 11991 ratable diagnoses and found poor interrater reliability (78% disagreement rate). A previous study conducted in 2005 was published in The Guides Newsletter (May/June and July/August 2006 issues) and evaluated 2100 cases for impairment rating review and found that 80% of ratings resulted in different outcomes when reviewed by an expert reviewer. The current study found an average difference of 10.0% whole person permanent impairment (WPI) between the original WPI ratings calculated with the fifth edition and the revised ratings after expert review; the 2005 study found a similar difference, 9.9% WPI. The reasons for poor interrater reliability with fifth edition ratings are many and include inaccurate clinical and causation analysis, failure to use the AMA Guides appropriately, and bias. The error rate in this study was lowest for patients in Hawaii, where the AMA Guides, Fifth Edition, has been used since 2001, only a relatively small number of authors who have been trained in the use of the AMA Guides perform the evaluations, there is no systematic coaching by attorneys about how to use the AMA Guides, and impairment ratings are routinely reviewed to determine their accuracy.
Causes of Erroneous Fifth Edition Ratings
Authors: Brigham Christopher R. , Auerbach Marjorie Eskay , Talmage James B. , Barth Robert , Uejo Craig , Melhorn Mark , Dilbeck Leslie 
Published: December 2020

Abstract
The application of the processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) should result in reliable impairment ratings, ie, reproducible impairment ratings when the AMA Guides is applied appropriately. This article reviews some of the causes of erroneous impairment ratings based on misapplication of the fifth edition. The first two chapters of the AMA Guides provide the principles of assessing impairment, a key of which is that physicians must be independent and unbiased. Treating physicians cannot be unbiased because they inherently have a patient advocacy role, and they may use approaches that will increase the patient's impairment rating. Clinical and causation errors are common in evaluations; the greatest source of error is examiner inexperience. Evaluations should take place only when the patient is at maximum medical improvement, and evaluators must distinguish between impairment related to the alleged injury and that due to other injury, degenerative disease, or illness, not self-reports. A box shows common causes of erroneous impairment ratings based on the fifth edition. Both the rating physician and the party requesting the rating should recognize the high likelihood of error and should become knowledgeable about the AMA Guides, and the evaluating physician should have had formal training regarding use of the AMA Guides and should possess demonstrated competency in assessing impairment.
Case Example: Spinal Impairment: California Case
Authors: Brigham Christopher R. , Talmage James , Eskay-Auerbach Marjorie , Stevens Patty 
Published: December 2020

Abstract
Accurate, unbiased impairment ratings must follow the procedures and processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This Case Example from California in 2010 illustrates some problems that result from rating a lumbar injury as if it were an inguinal hernia. At critical issue in this case is whether sufficient clinical findings were available to support a rating for lumbar radiculopathy; the evaluating (and also, treating) physician gave the patient the benefit of doubt with a rating of “nonverifiable radicular (nerve root) pain” but did not address the patient's ability to perform activities of daily living (ADLs). The State of California Workers’ Compensation Appeals Board (WCAB) affirmed on August 20, 2010, that the State relies on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, to determine impairment. WCAB noted that “medical opinion that departs unreasonably from a strict application of the [AMA] Guides can be challenged, and it would not be acceptable as substantial evidence.” In the present case, the rating provided by the evaluating physician was based on an obviously inapplicable section of the AMA Guides and is not appropriate. Evaluators must use the procedures defined in the AMA Guides, perform evaluations according to the standards in the AMA Guides, and do so without bias.
Prescription Narcotics: An Obstacle to Maximum Medical Improvement
Authors: Barth Robert J. 
Published: December 2020

Abstract
The increasingly severe epidemic of overuse, abuse, and death involving prescription narcotics is of specific relevance to workers’ compensation, which is the primary venue for use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Because of the scientific knowledge base regarding prescription narcotics for chronic benign pain, evaluators may question how any patient could credibly be considered to have reached maximum medical improvement (MMI) if that patient has a prescription for a narcotic. Hyperalgesia associated with narcotics does not appear to be permanent, but evidence indicates that prescription narcotics cause significant problems in addition to worsening pain: endocrine disruption, sleep abnormalities, immune system compromise, cognitive impairment, substance abuse, and generalized ill health and disability, among others. Evaluators may worry that refusing to evaluate a person who is not at MMI because they are receiving a prescription narcotic may unintentionally delay resolution of the person's claim. In a more efficient approach, an evaluator could undertake the complete evaluation process, including creating an impairment rating, and document in the evaluation report that the rating is being provided despite reasons to be concerned that the impairment is artificially inflated in a nonpermanent way by the unjustifiable narcotic prescription. Evaluators should not state that the impairment from side effects of the opioids is permanent.
Case Example: Rating Lower Extremity Injuries Involving Multiple Diagnoses in One Region Using the AMA Guides, Sixth Edition
Authors: Uejo Craig , Brooks Charles N. 
Published: December 2020

Abstract
Injuries to a specific region can result in more than one diagnosis. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, states that, in most cases, only one diagnosis in a region (eg, hip, knee, or foot/ankle) is appropriate. If a patient has two significant diagnoses (eg, ankle instability and posterior tibial tendonitis), the examiner should use the diagnosis with the highest impairment rating in that region that is causally related. The rationale for this principle is that the rating for the diagnosis with the highest impairment also encompasses the functional loss of diagnoses with lesser impairment; it also attempts to prevent the use of multiple diagnoses to inflate the impairment rating. In the Case Example, a 62-year-old female teacher was tripped and fell on her left knee at work; the diagnoses were osteoarthritis and medial collateral ligament sprain. Despite activity modification and extensive treatment, she reported only moderate improvement; an orthopedic surgeon was consulted and recommended total knee replacement (TKR), but the patient declined and decided to retire with the option to consider TKR later, if necessary. Causation is an issue because tricompartmental arthritis clearly was not caused by the fall, but one wonders about the role of the individual's arthritis is unclear. Evaluators should be aware that such apportionment varies by jurisdiction.
Rating the Impact of Visual Impairment
Authors: Colenbrander August 
Published: December 2020

Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) used the Snell Visual Efficiency Scale (1925). Following scientific progress, the Vision chapter in the fifth and sixth editions of the AMA Guides began using the Functional Vision Score (FVS) that is endorsed by the International Council of Ophthalmology and the International Society for Low Vision Research and Rehabilitation. Use of the FVS provided an opportunity to correct many inconsistencies in the VES system and also is better integrated with modern measurement methods and the ratings used for other organ systems. The FVS score is obtained by combining the Functional Acuity Score and the Functional Field Score; if any adjustments are introduced in this combination, they must be completely justified and cannot be based on subjective arguments. The disability is rated on the basis of functional considerations and is not influenced by nonfunctional factors. Combining visual acuity loss and visual field loss into a single number is attractive for administrative and legal purposes, but this step is meaningless in the context of rehabilitation because rehabilitation for visual acuity loss is entirely different from rehabilitation for visual field loss. The FVS system provides internationally endorsed statistical estimates of the effects of visual impairment on the ability to perform activities of daily living.
Subjective, Objective, or Both?
Authors: Brooks Charles N. , Talmage James B. , Mueller Kathryn 
Published: December 2020

Abstract
The terms subjective and objective often appear in health care records, and one commonly hears about “subjective symptoms” and “objective complaints”—yet the former is redundant and the latter an oxymoron. Objectively verifiable pathology may explain a patient's symptoms, but complaints themselves are never objective but rather, by definition, subjective. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, defines the terminology: Subjective information is more open to interpretation, but objective data are factual, reproducible, and often measurable or quantifiable. Objective findings generally have much higher inter-examiner reliability than subjective findings. Symptoms and most findings on physical (particularly neuromusculoskeletal) examination are subjective. Diagnostic study results and a minority of physical findings are objective. Some physical findings, such as strength and range of motion measurements, are both subjective and objective. Repeat testing, assessment of plausibility, and use of confirmatory physical findings can be used to validate or “objectify” subjective findings (eg, by determining if a weakness is corroborated by other neurologic or physical findings, imaging study results, and/or electrodiagnostic testing). The use of objective, or at least less subjective, findings in impairment rating should improve interrater reliability. Thus, evaluating physicians should not regard subjective complaints and findings, and they should lend greater weight to objective findings.
Chronic Pain: Fundamental Scientific Considerations, Specifically for Legal Claims
Authors: Barth Robert J. 
Published: December 2020

Abstract
Scientific findings have indicated that psychological and social factors are the driving forces behind most chronic benign pain presentations, especially in a claim context, and are relevant to at least three of the AMA Guides publications: AMA Guides to Evaluation of Disease and Injury Causation, AMA Guides to Work Ability and Return to Work, and AMA Guides to the Evaluation of Permanent Impairment. The author reviews and summarizes studies that have identified the dominant role of financial, psychological, and other non–general medicine factors in patients who report low back pain. For example, one meta-analysis found that compensation results in an increase in pain perception and a reduction in the ability to benefit from medical and psychological treatment. Other studies have found a correlation between the level of compensation and health outcomes (greater compensation is associated with worse outcomes), and legal systems that discourage compensation for pain produce better health outcomes. One study found that, among persons with carpal tunnel syndrome, claimants had worse outcomes than nonclaimants despite receiving more treatment; another examined the problematic relationship between complex regional pain syndrome (CRPS) and compensation and found that cases of CRPS are dominated by legal claims, a disparity that highlights the dominant role of compensation. Workers’ compensation claimants are almost never evaluated for personality disorders or mental illness. The article concludes with recommendations that evaluators can consider in individual cases.
To Spinal Image or Not To Spinal Image, That is the Question
Authors: Auerbach Marjorie Eskay 
Published: December 2020

Abstract
Although back pain is the most common and expensive cause of work disability in the United States, our understanding of low back pain (LBP) is limited despite the advantages of advanced imaging technologies. Diagnostic studies often are requested for fear of missing serious or occult pathology or to reassure patients but have a low likelihood of identifying a specific cause for the reported symptoms in patients who present with nonspecific LBP. From a clinical perspective, the information provided in lumbar imaging, whether plain X rays or magnetic resonance imaging (MRI), has not been found either to influence treatment recommendations or improve outcomes. Further, routine advanced imaging is not associated with improved outcomes and identifies many radiographic findings that correlate poorly with symptoms; imaging is recommended when severe or progressive neurologic deficit is present or if serious underlying disease is suspected. Surgery rates are highest where imaging rates are highest, and a significant proportion of the variation in rates of spine surgery can be explained by differences in the rates of advanced spinal imaging. Because imaging has no role in the impairment rating of nonspecific LBP, an individual's having a work injury that requires an impairment rating is not a reason to order spinal imaging. To answer the question in this article's title, the answer usually is not to order a spinal image.
Maximum Medical Improvement
Authors: Brooks Charles N. , Brigham Christopher R. 
Published: December 2020

Abstract
Most acute injuries and illnesses resolve, ie, reach maximum medical improvement (MMI), within days or weeks and without permanent impairment. Fractures, more severe soft tissue injuries and illness, and conditions that require surgery take longer to reach MMI, often about a year, with a range of six months to two years. Serious head, spinal cord, and other catastrophic injuries commonly take two or more years to reach MMI. These more severe injuries and illnesses understandably are more likely to result in permanent impairment. However, various parties to the claim process may request impairment rating prematurely: The claimant or plaintiff whose injury or illness has resulted in loss of income and financial hardship may push for an early impairment award or settlement. The surgeon who has operated and is done with postoperative follow-up may want to be rid of claim forms and move on to other patients. The overburdened adjuster may want to get the claim closed, thereby diminishing their workload. But rating impairment prior to MMI, ie, before it is permanent, often results in erroneously inflated ratings. In general, functional status, physical findings, and/or clinical study results improve over time, sometimes with and sometimes without treatment. This usually results in a concurrent decrease in, and sometimes even resolution of, impairment. With knowledge of the appropriate terminology and definitions, the evaluating physician should be able to render an opinion regarding MMI that is both understandable and legally sustainable in the applicable jurisdiction.
AMA Guides, Sixth Edition: Spinal Impairment Case Examples
Authors: Hazlewood Jeffrey , Talmage James B. , Eskay-Auerbach Marjorie 
Published: December 2020

Abstract
Chapter 17, The Spine and Pelvis, of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, is used frequently when determining an individual's permanent impairment rating at maximum medical improvement (MMI). Frequently, ratings for diagnoses of “nonverifiable back pain,” herniated discs, nonverifiable radicular pain, and radiculopathy are requested. Definitions of terminology used in the AMA Guides may differ from those used by some physicians when they see patients, and evaluators should use terminology that is consistent with that of the AMA Guides. For example, for the purposes of the AMA Guides, radiculopathy is defined as “significant alteration in the function of a single or multiple nerve roots and is usually caused by mechanical or chemical irritation of one or several nerves.” This article presents fifteen cases, the whole person impairment associated with each case, and a discussion of the process whereby the rating was obtained. Accurate and fair ratings of common cases of injury-related back and leg pain require a thorough knowledge of the definitions outlined in the AMA Guides, Sixth Edition, as well as thorough knowledge of the peripheral nervous system. Also, an accurate and detailed subjective history of pain reports (including true “radicular” referral patterns) and objective physical examination, as well as a review of the medical records and previous documentations, are essential.
The Historical Development of Burden of Treatment Compliance
Authors: Demeter Stephen L. 
Published: December 2020

Abstract
A long-standing criticism of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) has been the inequity between the internal medicine ratings and the orthopedic ratings; in the comparison, internal medicine ratings appear inflated. A specific goal of the AMA Guides, Sixth Edition, was to diminish, where possible, those disparities. This led to the use of the International Classification of Functioning, Disability, and Health from the World Health Organization in the AMA Guides, Sixth Edition, including the addition of the burden of treatment compliance (BOTC). The BOTC originally was intended to allow rating internal medicine conditions using the types and numbers of medications as a surrogate measure of the severity of a condition when other, more traditional methods, did not exist or were insufficient. Internal medicine relies on step-wise escalation of treatment, and BOTC usefully provides an estimate of impairment based on the need to be compliant with treatment. Simplistically, the need to take more medications may indicate a greater impairment burden. BOTC is introduced in the first chapter of the AMA Guides, Sixth Edition, which clarifies that “BOTC refers to the impairment that results from adhering to a complex regimen of medications, testing, and/or procedures to achieve an objective, measurable, clinical improvement that would not occur, or potentially could be reversed, in the absence of compliance.
Commentary on Two-Point Discrimination in the Use of Upper Extremity Nerve Function in the AMA Guides
Authors: Talmage James B. , Melhorn J. Mark 
Published: December 2020

Abstract
This article responds to the previous article in this issue of The Guides Newsletter (Two-point Discrimination in the Use of Upper Extremity Nerve Function in the AMA Guides) and discusses why the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, has chosen to retain the use of static two-point discrimination for both acute single incident digital nerve injury and for upper extremity focal entrapment neuropathy. The authors clarify that the AMA Guides, Sixth Edition does not use two-point discrimination as a diagnostic criterion for entrapment neuropathy such as carpal tunnel syndrome. Instead, it uses two-point discrimination as a criterion to judge severity, specifically to help select the proper integer for the rating to be assigned for the diagnosis determined by other criteria. Two-point testing is not sensitive but is specific to significant nerve impairment (ie, severity, not diagnosis), and the authors note its advantages of being familiar to most impairment examiners, having a basis in published literature, having variations of the testing protocol that help “objectify” the apparent sensory deficit, and correlating with severity. Thus, if a rating is to be done “according to the AMA Guides,” two-point discrimination remains a required and important part of assessment of the upper extremity neurologic impairment of the hand.
Q&A: Rating Multiple Pelvic Fractures
Authors: Talmage James B. 
Published: December 2020

Abstract
Part 1 of this series examined many of the rules in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, regarding rating nerve entrapment or focal neuropathies; the current article, part 2, examines how to read and match the findings in an electrodiagnostic report to the criteria in Appendix 15-B, Electrodiagnostic Evaluation of Entrapment, as explained in Section 15.4f, and determine the severity of the test findings as listed in Table 15-23. Physicians who perform nerve conduction studies often use their own definitions of mild, moderate, and severe; these definitions are not standardized and frequently differ from the electrophysiologic definitions used in the AMA Guides, Sixth Edition. When examiners rate focal entrapment neuropathy, they must match data from the electrodiagnostic report to the criteria in Appendix 15-B, and a figure shows a hypothetical motor nerve conduction report for a case that shows both mild neuropathy (conduction delay) of the median nerve at the wrist (carpal tunnel syndrome) and severe neuropathy (axon loss) of the ulnar nerve at the elbow (cubital tunnel syndrome). If both fibrillations and positive waves are seen in the same muscle, the reviewer can be more confident that other electromyographic potentials were not misinterpreted as fibrillations. Prepared with the results of electrodiagnostic studies, the evaluator can work through the steps of history, physical findings, and functional scale to determine the final upper limb impairment according to the AMA Guides.
GUEST EDITORIAL: In the Line of Fire: IME Burnout
Authors: Pinsky Tim 
Published: December 2020

Abstract
Physicians suffer more burnout than many other American workers and rank near the top of all professions in burnout. Physicians who perform independent medical evaluations (IME) face the usual challenges (too many bureaucratic tasks, too many hours of work, insufficient income, and loss of status) that contribute to burnout among all physicians. Both “innate personality traits” and external factors (circumstances, examinees, time, performance, and risk) contribute to burnout among physicians who perform IME. Stressed because of multilayered litigation, insurance, and bureaucratic processes, IME physicians face a high concentration of difficult patients who are disgruntled with their jobs and, often, their lives. Examinees’ negative attitudes and outlooks contribute to pessimism and depression that can be contagious to the examiner, and because IMEs are one-time evaluations with no longitudinal care, the opportunity to establish rapport is limited. Physicians who are coping with the pressures of the IME milieu may need to realize that they have a greater sphere of positive influence than they realize: By conducting oneself in a professional and ethical fashion, writing fair reports, relying on evidence-based medicine, and applying the AMA Guides to the Evaluation of Permanent Impairment in a proficient manner, physicians who conduct IMEs can recognize and, one hopes, avoid IME burnout.