AMA Guides® Newsletter

Articles

Evaluating Impairment from Allergic Disorders

Laura Welch

Pages 1–3

DOI: 10.1001/amaguidesnewsletters.1999.MarApr01

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.
Clinical Update: Evaluating the Allergic Patient: Practical Techniques

Rebecca Bascom, Timothy J. Craig, Diane Schuler

Pages 3–4

DOI: 10.1001/amaguidesnewsletters.1999.MarApr02

Abstract
Despite rapid advances in understanding of the biology of allergic disorders, practical techniques for evaluating the allergic patient remain fairly constant. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) requires appropriate assessment before an examiner diagnoses the disorder, determines causation, evaluates whether the patient has reached maximal medical improvement, and rates permanent impairment, if any. A careful history includes both occupational and environmental assessment. Patients with allergic occupational asthma typically must be removed from exposure to the allergen. The environmental assessment should determine the nature of the patient's dwelling, its construction material, heating and ventilation, and the presence or absence of a damp basement, pets, rodents or cockroaches, or hobbies performed in the home. A physical examination should focus on the eyes, nose, lungs, and skin and should exclude obstructive sleep apnea. A thorough medical evaluation always is required, and assessment of immunologic sensitization involves diagnostic allergy skin testing or laboratory assessment. Although the allergens used in such tests are purified and the tests themselves increasingly are standardized, concerns remain regarding nonstandardized laboratories and remote testing. Spirometry is an essential element in objectively defining the nature and severity of respiratory complaints; rhinolaryngoscopy helps differentiate asthma from laryngeal dysfunction and can evaluate sinus disease; and limited cut CT of the sinuses is more cost effective than plain sinus films.
Tools and Resources: Cautions in Using the Guides

Christopher R. Brigham

Pages 4–7

DOI: 10.1001/amaguidesnewsletters.1999.MarApr03

Abstract
The approach to evaluation of lower extremity impairments in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) differs from that given in previous editions. This article uses case studies to illustrate practical applications of current approaches to ankle impairment and to foot and toe impairment. Anatomic methods for rating ankle impairments include evaluations of muscle atrophy and limb length discrepancy. The Diagnosis-related estimates section provides ratings for ligamentous laxity and displaced fractures of the ankle. The arthritis section contains ratings for radiographically determined and graded diagnosis. Methods for rating ankle impairments include assessing gait derangement, range of motion, joint ankylosis, and manual muscle testing. The methods used for rating lower extremity impairments also are applicable for the foot and toes, and examiners may deploy less commonly used rating techniques such as those employed for amputations, skin loss, causalgia and reflex sympathetic dystrophy, and vascular disorders. The examiner must understand the applicable rating methods used, estimate percentages via each, and decide which methods best describe the impairment(s) without overlooking or duplicating ratings. The examiner also should report the rating options considered, the reasons for selecting the method(s) used, the method by which the percentage was calculated, and the rationale for any variance from the AMA Guides. [A companion Quick Reference, Measuring Impairments of the Hand and Digits, appears on pp 5-6 of this issue of The Guides Newsletter.]
Quick Reference: Measuring Impairments of the Hand and Digits

Pages 5–6

DOI: 10.1001/amaguidesnewsletters.1999.MarApr04

Abstract
Many states require the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in their workers’ compensation systems. In 20 states (see Table), this requirement is specified by statute (a law that is enacted and passed by a state's legislature). The state statutes that deal with the AMA Guides may or may not specify which edition to use and how to use it. In any case, ultimately it is the responsibility of the courts to interpret these statutes, which may be ague, to determine which edition of the AMA Guides should be used and to establish how that edition should be used. Evaluators should use the edition of the AMA Guides that is required by the local regulatory authority because of an incorrect version of the AMA Guides could result in judicial invalidation of an impairment rating (see, eg, McCabe v North Dakota Workers’ Compensation Bureau). A table that identifies the edition used and authorizing statute number for the 20 states is included.
Impairment Questions and Answers

Pages 7–7

DOI: 10.1001/amaguidesnewsletters.1999.MarApr05
Impairment Tutorial: Lower Extremity Impairments of the Ankle and Foot

William S. Shaw, Charles N. Brooks

Pages 8–9

DOI: 10.1001/amaguidesnewsletters.1999.MarApr06
Legal Update: State-Specific Use of the Guides to the Evaluation of Permanent Impairment

James J. Mangraviti

Pages 10–10

DOI: 10.1001/amaguidesnewsletters.1999.MarApr07
Literature Review

James B. Talmage

Pages 11–11

DOI: 10.1001/amaguidesnewsletters.1999.MarApr08