AMA Guides® Newsletter - Issue Archive

Articles

1. Quotables from the Guides on General Principles

   Kathryn Mueller

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.1999.JulAug01

   Abstract

   This article reviews portions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) that are useful to evaluators making individual case decisions in various legal systems. The first step is a determination of permanency, and evaluators should know that many state laws have unique definitions of “maximum medical improvement.” Next, the evaluator should establish a definitive diagnosis that identifies the existence of an abnormality and impairment of the activities of daily living. Based on his or her judgment and expertise, training, skill, and thoroughness, the evaluating physician must use clinical judgment regarding whether or not the results of tests or impairment measurements are reasonable for a particular patient and the impairment under evaluation. The AMA Guides notes that an evaluator may increase an impairment rating after determining that the estimate for the anatomic impairment does not sufficiently reflect the severity of the patient's condition. When findings between two physicians differ, then the stability of the medical issue may be in question, and the involved physicians should be in communication and should have access to all prior physician reports and test results. Evaluators may need to educate patients about the difference between impairment and disability. Clear report writing is the key to successful impairment evaluations.
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2. Impairment Questions and Answers

   Pages 4–4

   DOI: 10.1001/amaguidesnewsletters.1999.JulAug02

   Abstract

   Symptom validity testing, also known as forced-choice testing, is a way to assess the validity of sensory and memory deficits, including tactile anesthesias, paresthesias, blindness, color blindness, tunnel vision, blurry vision, and deafness—the common feature of which is a claimed inability to perceive or remember a sensory signal. Symptom validity testing comprises two elements: A specific ability is assessed by presenting a large number of items in a multiple-choice format, and then the examinee's performance is compared with the statistical likelihood of success based on chance alone. Scoring below a norm can be explained in many different ways (eg, fatigue, evaluation anxiety, limited intelligence, and so on), but scoring below the probabilities of chance alone most likely indicates deliberate deception. The positive predictive value of the symptom validity technique likely is quite high because there is no alternative explanation to deliberate distortion when performance is below the probability of chance. The sensitivity of this technique is not likely to be good because, as with a thermometer, positive findings indicate that a problem is present, but negative results do not rule out a problem. Although a compelling conclusion is that the examinee who scores below probabilities is deliberately motivated to perform poorly, malingering must be concluded from the total clinical context.
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3. Quick Reference: Rating Spine Impairment

   Pages 5–6

   DOI: 10.1001/amaguidesnewsletters.1999.JulAug03

   Abstract

   Spinal impairment evaluation includes determining the presence or absence of loss of motion segment (structural) integrity (LOMSI). The AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition, defines two ways of detecting LOMSI: anterior-posterior translation of one vertebra on another (more than 3.5 millimeters in the cervical spine or 5 millimeters in the thoracic or lumbar spine); or angular motion of one vertebra on another greater than 11 millimeters (15 millimeters at L5-S1). A finding of LOMSI results in at least a diagnosis-related estimate Category IV impairment rating in any of the three spinal regions. Measurements of vertebral translation and angular motion are made using standing lateral x-rays in maximal flexion and extension. The second method of detecting LOMSI is measurement of the angular motion between three adjacent vertebrae. Flexion and extension x-rays may not be necessary in every patient undergoing spinal impairment evaluation, particularly because patients rarely have LOMSI with normal supine spinal x-rays in the absence of translational or angular abnormality on routine films. Loss of structural integrity is rare in the workers’ compensation area and is seen most commonly in middle-aged women at L4-5 or following aggressive laminectomy. Attempted but unsuccessful fusion of a motion segment does not qualify as LOMSI.
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4. Literature Review

   Pages 7–11

   DOI: 10.1001/amaguidesnewsletters.1999.JulAug04

   Abstract

   Pain is the most common presenting complaint at an impairment evaluation. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), the term chronic pain is synonymous with chronic pain syndrome. The AMA Guides differentiates between pain of longstanding duration, termed persistent pain, and chronic pain syndrome, which is characterized as “the devastating and recalcitrant type [of pain] with major psychosocial consequences.” Persistent pain may exist in the absence of chronic pain syndrome, but chronic pain syndrome always presumes the presence of persistent pain, according to the AMA Guides. The assessment of chronic pain syndrome involves a multidimensional approach, and a physical examination alone may be misleading. Chronic pain syndrome is a biopsychosocial phenomenon of maladaptive behavior, and the AMA Guides describes diagnostic criteria for chronic pain syndrome. In addition, this article includes a checklist of characteristics shared by chronic pain patients, along with a list of essential questions that evaluators can ask in assessing pain and a list of pain, behavioral, and psychological inventories commonly used in independent medical evaluations. Physicians should choose a battery that is consistent with the needs of the assessment, and the final report should explain the findings and significance of the inventories used.
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5. Clinical Update: Symptom Validity Testing

   Leon H. Ensalada

   Pages 8–9

   DOI: 10.1001/amaguidesnewsletters.1999.JulAug05

6. Impairment Tutorial: Loss of Spinal Structural Integrity Is Not Instability

   Robert H. Haralson

   Pages 9–9

   DOI: 10.1001/amaguidesnewsletters.1999.JulAug06

7. Common Tips: Evaluating Pain

   Christopher R. Brigham, Leon H. Ensalada

   Pages 10–11

   DOI: 10.1001/amaguidesnewsletters.1999.JulAug07