AMA Guides® Newsletter - Issue Archive

Articles

1. Minimizing Impairment Evaluation Difficulties and Risks

   Christopher R. Brigham

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.1999.SepOct01

   Abstract

   Significant professional and legal difficulties and risks may be associated with the performance of impairment evaluations, particularly in the context of an independent medical evaluation (IME). Many IMEs occur in legal arenas and may involve individuals with challenging personalities, and the circumstances of performing an IME are unique because there exists no physician-patient relationship. The best defense against professional or legal difficulties is prevention, including establishing a well-thought-out process for performing these evaluations, being consistent with directives provided in the AMA Guides to the Evaluation of Permanent Impairment, and, if a problem arises, dealing with it directly and documenting the circumstances. If an examinee is uncooperative, the examining physician may need to explain his or her role, and, if the examinee remains uncooperative or is disruptive, the examiner may stop the examination, notify the client, contact the police as appropriate, and document what occurred. Injury claims against an examiner may be forestalled by preventive strategies such as obtaining written informed consent from the patient to perform the evaluation, having a member of the examiner's staff present during the evaluation, and, after the examination, using a patient satisfaction survey to document “no difficulties with the evaluation.” IMEs require examiners to be familiar with legal aspects of confidentiality, libel and slander, negligence, and other issues. Examiners should ensure their medical malpractice insurance is suitable for this work.
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2. Clinical Update: Functional Capacity Evaluations—An Update

   Laura Welch

   Pages 4–7

   DOI: 10.1001/amaguidesnewsletters.1999.SepOct02

   Abstract

   Functional capacity evaluations (FCEs) have become an important component of disability evaluation during the past 10 years to assess an individual's ability to perform the essential or specific functions of a job, both preplacement and during rehabilitation. Evaluating both job performance and physical ability is a complex assessment, and some practitioners are not yet certain that an FCE can achieve these goals. An FCE is useful only if it predicts job performance, and factors that should be assessed include overall performance; consistency of performance across similar areas of the FCE; consistency between observed behaviors during the FCE and limitations or abilities reported by the worker; objective changes (eg, blood pressure and pulse) that are appropriate relative to performance; external factors (illness, lack of sleep, or medication); and a coefficient of variation that can be measured and assessed. FCEs can identify specific movement patterns or weaknesses; measure improvement during rehabilitation; identify a specific limitation that is amenable to accommodation; and identify a worker who appears to be providing a submaximal effort. FCEs are less reliable at predicting injury risk; they cannot tell us much about endurance over a time period longer than the time required for the FCE; and the FCE may measure simple muscular functions when the job requires more complex ones.
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3. Quick Reference: Chapter 3: The Peripheral Nervous System

   Pages 5–6

   DOI: 10.1001/amaguidesnewsletters.1999.SepOct03

   Abstract

   Most impairment ratings for conditions affecting the cervical spine are relatively straightforward and can be addressed using the first three categories of the Injury Model in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This real-life case study illustrates how higher impairment categories are applied, including combining categories; the importance of rating the patient's condition based on the injury (as opposed to treatment outcome); and how apportionment is handled in different jurisdictions. Mr Smith, a 64-year-old high school principal, presented with numbness and burning pain from the chest to the feet, unsteadiness of gait, and difficulty maintaining an erection. Symptoms reportedly began two years earlier when he tripped and fell down a flight of stairs at work, striking his face. An MRI scan revealed marked spinal stenosis and cervical cord compression at C3 due to a combination of posterior C3-4 disc protrusion and osteophyte formation. Via an anterior approach, the orthopedic surgeon performed a C4 corpectomy, C3-4 and C4-5 discectomies, and then inserted a tricortical iliac bone graft between C3 and C5. Mr Smith improved postoperatively but still complained of numbness from upper chest to feet, mild unsteadiness of gait, and difficulty maintaining an erection. Evaluators can use the Injury Model, recalling that surgery to treat an impairment does not modify the original impairment, and in the jurisdiction in which Mr Smith was rated, if a claimant was asymptomatic before a work injury, the entire impairment is attributed thereto.
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4. Literature Review

   Kathryn Mueller

   Pages 7–7

   DOI: 10.1001/amaguidesnewsletters.1999.SepOct04

   Abstract

   Before the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, spine impairment was based on range of motion (ROM) testing combined with ratings for specific spine disorders and neurologic impairment. The AMA Guides, Fourth Edition, uses the Injury or Diagnosis-related Estimates (DRE) Model to rate spinal impairment. This model is based on history, physical examination (but not ROM unless ROM is used as a differentiator), and other test data. Table 71, DRE Impairment Category Differentiators, lists DRE impairment category differentiators and discusses the differences between ratings, choosing between differentiators, and their reliability and validity. Guarding is “a spasm of muscles to minimize motion or agitation of sites affected by injury or disease,” and spasm often is overreported by physicians who are unaware of its definition. Loss of reflexes, presenting as diminished or absent deep tendon reflexes, remains the hallmark of objective physical evidence. Decreased circumference is associated with atrophy. Loss of motion segment integrity is measured on lateral flexion and extension x-rays. Loss of bowel or bladder control suggests significant spinal cord injury. The final differentiator is bladder studies, measured using a cystometrogram and showing unequivocal neurologic compromise of the bladder with resulting incontinence.
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5. Case Study: Cervical Spine Injury Case Study

   Lorne Direnfeld

   Pages 8–9

   DOI: 10.1001/amaguidesnewsletters.1999.SepOct05

6. Impairment Tutorial: Rating Cervical Pain

   Richard T. Katz

   Pages 9–11

   DOI: 10.1001/amaguidesnewsletters.1999.SepOct06