AMA Guides® Newsletter - Issue Archive

Articles

1. Carpal Tunnel Syndrome: Impairment Rating by the AMA Guides, Fifth Edition

   James B. Talmage, Christopher R. Brigham, Charles N. Brooks

   Pages 1–3, 9-10

   DOI: 10.1001/amaguidesnewsletters.2006.JanFeb01

   Abstract

   The pain, numbness, and paresthesias of carpal tunnel syndrome generally are intermittent and are felt in the wrist, hand, thumb, and fingers, often in a distribution approximating that of the median nerve. No specific physical examination exists for carpal tunnel syndrome, and, in the impairment rating assessment, the physical examination focuses on detecting signs of permanent nerve damage (decreased sensation and thenar weakness on opposition). According to the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), provocative tests have no role in impairment rating. The AMA Guides, Fifth Edition, requires nerve conduction testing (NCT), even in “believable” instances, but no uniform definition of an abnormal NCT exists and examiners should realize the uses and limits of NCT. For example, if the NCT is normal, the symptoms, even if believable, do not rise to the level of an impairment. Impairment assessment must take place when the patient is at maximum medical improvement. If the NCT is grossly abnormal (axon loss) and/or degenerative changes are present on needle electromyography, and if physical exam shows sensory and/or thenar weakness, the examiner can use tables in the AMA Guides to rate the disability, combining sensory and motor impairments as appropriate. A one-page sidebar in this issue of The Guides Newsletter addresses the causes of carpal tunnel syndrome.
   Show more

2. Diagnostic Conceptualization for CRPS-1: Challenges in the IASP's Diagnostic Conceptualization for CRPS-1 (Formerly Conceptualized as RSD)

   Robert J. Barth, Tom W. Bohr

   Pages 4–8, 12

   DOI: 10.1001/amaguidesnewsletters.2006.JanFeb02

   Abstract

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

3. Causes of Carpal Tunnel Syndrome

   Pages 11–11

   DOI: 10.1001/amaguidesnewsletters.2006.JanFeb03