AMA Guides® Newsletter - Issue Archive

Articles

1. Rating Post-Operative Backs (Part I)

   James B. Talmage

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.1997.JulAug01

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition, uses the Injury Model to rate impairment in people who have experienced back injuries. Injured individuals who have not required surgery can be rated using differentiators. Challenges arise when assessing patients whose injuries have been treated surgically before the patient is rated for impairment. This article discusses five of the most common situations: 1) What is the impairment rating for an individual who has had an injury resulting in sciatica and who has been treated surgically, either with chemonucleolysis or with discectomy? 2) What is the impairment rating for an individual who has a back strain and is operated on without reasonable indications? 3) What is the impairment rating of an individual with sciatica and a foot drop (major anterior tibialis weakness) from L5 root damage? 4) What is the rating for an individual who is injured, has true radiculopathy, undergoes a discectomy, and is rated as Category III but later has another injury and, ultimately, a second disc operation? 5) What is the impairment rating for an older individual who was asymptomatic until a minor strain-type injury but subsequently has neurogenic claudication with severe surgical spinal stenosis on MRI/myelography? [Continued in the September/October 1997 The Guides Newsletter]
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2. Impairment Tutorial: Rating Pain After a Musculoskeletal Injury

   James B. Talmage, Christopher R. Brigham

   Pages 4–5

   DOI: 10.1001/amaguidesnewsletters.1997.JulAug02

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, notes that pain is a subjective perception, and usually no exact relationships exist among the degree of pain, extent of pathologic change, and extent of impairment. Chapters 3, 14, and 15 regarding the musculoskeletal system, mental and behavioral disorders, and pain, respectively, may be relevant in evaluating an individual's pain following musculoskeletal injury. The eight diagnostic characteristics of chronic pain are duration, dramatization, diagnostic dilemma, drugs, dependence, depression, disuse, and dysfunction; if four of the eight are present, a presumptive diagnosis is established. The fourth edition of AMA Guides distinguishes chronic pain syndrome and psychogenic pain (the former is not considered a mental disorder), but diagnosis of pain should consider psychological factors that are judged to play a significant role in the onset, severity, exacerbation, or maintenance of the pain. Thus, two individuals may have identical musculoskeletal histories, physical exams, and pain out of proportion to their injuries, but when one of the patients has psychological factors that are known and understood, the evaluating physician may diagnose a pain disorder associated with psychological factors. Because formally associating psychological factors and diagnosis usually requires legal discovery, physicians may keep the psychological factors confidential, diagnose chronic pain syndrome, and evaluate using Chapter 15 of the fourth edition of the AMA Guides.
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3. Impairment Questions and Answers

   Pages 5–5

   DOI: 10.1001/amaguidesnewsletters.1997.JulAug03

   Abstract

   Effective May 1, 1997, all physicians and chiropractors who rate workers’ compensation permanent partial disabilities (PPD) are required to become members of the Nevada Division of Industrial Relations panel of rating physicians and chiropractors. The State of Nevada previously used the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Second Edition, but now uses the Fourth Edition to rate PPD. To become panel members, Nevada physicians must complete a State-approved training course and a written examination. On March 17, 1997, Nevada conducted its first mandated written examination, for which the questions were supplied by the American Board of Independent Medical Examiners (ABIME). The ABIME exam covers the knowledge, skills, and abilities necessary to perform independent medical exams, and ABIME has conducted physician testing in Canada, the United States, Australia, and Hong Kong. The trend toward written credential tests for evaluating physicians is likely to expand because of the shortage of highly qualified examiners. The AMA Guides is the most widely used standard not only for rating permanent impairment but also as an index to PPD, and other jurisdictions are likely to follow the example of Nebraska and to require physicians to obtain training and demonstrate competency in impairment rating.
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4. Legal Update: Nevada Requires Impairment Evaluation Certificate

   Christopher R. Brigham, James J. Mangraviti

   Pages 6–6

   DOI: 10.1001/amaguidesnewsletters.1997.JulAug04

   Abstract

   How should an individual with pain arising from muscle be rated using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides)? Syndromes of muscle pain include simple muscle strains and two controversial conditions, myofascial pain and fibromyalgia. Tables in the AMA Guides can be used for rating forearm injuries that affect grip or pinch strength; a separate set of tables can be used to rate the injury in a lower extremity. Injuries to some muscles (deltoid, biceps, and triceps) are not described in these sections but almost always test as grade 4. Major injury to muscle is well understood and noncontroversial, but terms such as myofascial pain syndrome and fibromyalgia describe controversial muscle pains. Some physicians attempt to differentiate myofascial pain and fibromyalgia on the basis of taut bands in myofascial pain and tender points in fibromyalgia, but the interrater reliability of these findings is low and the consensus view suggests that the cause of these two conditions is unknown. Muscle pain, like muscle contraction headache, irritable bowel syndrome, and dysmenorrhea, are real symptoms for which no impairment rating is provided. Our understanding of these conditions should improve with future research, enabling us to define criteria for evaluating impairment.
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5. Clinical Update: Rating Muscle Pains

   James B. Talmage

   Pages 7–7

   DOI: 10.1001/amaguidesnewsletters.1997.JulAug05