AMA Guides® Newsletter - Issue Archive

Articles

1. Challenge of Evaluating Multiple Chemical Sensitivity

   Mohammed I. Ranavaya

   Pages 1–3

   DOI: 10.1001/amaguidesnewsletters.2000.MayJun01

   Abstract

   Impairment and disability resulting from claims of multiple chemical sensitivity (MCS) challenge independent medical examiners because of polemics associated with the syndrome, and the mainstream medical community has questioned its very existence as a medical disease entity. Since the syndrome was described in 1952, MCS has had many names, including universal allergy, total allergy syndrome, ecologic illness, 20th century disease, and chemical AIDS. Epidemiologic data show that a higher proportion of females (up to 88%) suffer from MCS, and the percentage of unemployment among MCS sufferers may be as high as 85%. The best explanation to date for MCS is that it is an illness belief system manifested by culturally shaped illness behavior. Several distinguished scientific organizations, including the AMA, conclude that there is no scientific evidence to support the MCS concept of a physiologic exposure–disease relationship; the proposed diagnostic tests and treatments have not been shown to have value; and MCS should not be a recognized clinical syndrome. Impairment evaluations should follow the guidelines in Chapters 1 and 2 of the AMA Guides to the Evaluation of Permanent Impairment. Evaluators must recognize that MCS claimants often present with comorbid psychiatric conditions, and iatrogenic disability also is a concern among MCS patients.
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2. Editorial Comment: The Dangers of Diagnosis

   Christopher R. Brigham, James B. Talmage, Leon Ensalada

   Pages 3–3, 6

   DOI: 10.1001/amaguidesnewsletters.2000.MayJun02

   Abstract

   Physicians are rewarded during their medical training for making diagnoses, particularly if the diagnosis is of a rare disorder. Unfortunately, the diagnosis—specifically, the disease label—may have undesirable consequences: the disease label categorizes a person as a patient, reducing their autonomy; the label legitimizes medical intervention that may or may not be beneficial; the disease label sanctions the “sick role,” with concomitant relief from social obligations, which may become an established behavior pattern; and “having a disease” classifies an individual as abnormal and may entail diminished employability or even deprivation of liberty by institutionalization. Multiple chemical sensitivity (MCS), an illness belief system manifested by culturally shaped illness behavior, raises questions regarding how symptoms become diseases of fashion, and the process seems to involve two phases: A genuine organic disease whose cause is challenging to detect and substantiate is appropriated as a template, and the template is broadcast to others who may have quite different symptoms but embrace the template as the explanation for their problems. Sympathetic physicians, patient support groups, and the media facilitate this broadcasting. Physicians who want to be patient advocates should encourage function, not impairment, and ability, not disability. The authors suggest that MCS is a form of illness behavior magnified by the medical model for care, not a consequence of underlying organ system dysfunction.
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3. Quick Reference: Chapter 3: The Musculoskeletal System and Chapter 4: The Nervous System

   Pages 4–4

   DOI: 10.1001/amaguidesnewsletters.2000.MayJun03

   Abstract

   Lesions of the peripheral nervous system (PNS), whether due to injury or illness, commonly result in residual symptoms and signs and, hence, permanent impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, divides PNS deficits into sensory and motor and includes pain in the former. This article, which regards rating sensory and motor deficits of the lower extremities, is continued from the March/April 2000 issue of The Guides Newsletter. Procedures for rating extremity neural deficits are described in Chapter 3, The Musculoskeletal System, section 3.1k for the upper extremity and sections 3.2k and 3.2l for the lower limb. Sensory deficits and dysesthesia are both disorders of sensation, but the former can be interpreted to mean diminished or absent sensation (hypesthesia or anesthesia) Dysesthesia implies abnormal sensation in the absence of a stimulus or unpleasant sensation elicited by normal touch. Sections 3.2k and 3.2d indicate that almost all partial motor loss in the lower extremity can be rated using Table 39. In addition, Section 4.4b and Table 21 indicate the multistep method used for spinal and some additional nerves and be used alternatively to rate lower extremity weakness in general. Partial motor loss in the lower extremity is rated by manual muscle testing, which is described in the AMA Guides in Section 3.2d.
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4. Impairment Tutorial: Rating Sensory and Motor Deficits of the Lower Extremities

   Charles N. Brooks

   Pages 5–6

   DOI: 10.1001/amaguidesnewsletters.2000.MayJun04

   Abstract

   Previous issues of The Guides Newsletter have presented overviews of electrodiagnostic evaluation, including electromyography, nerve conduction studies, and somatosensory-evoked responses. This article contains suggestions for nonelectromyographers who read reports and identify questionable uses of electrodiagnosis, specifically for the evaluation of radiculopathy and focal neuropathy (eg, nerve entrapments), the two most common presentations. Some subtle abnormalities (eg, changes in motor unit recruitment pattern, changes in firing rate, or reduction in motor units recruited) often are overinterpreted by poorly trained or inexperienced electromyographers. Nerve conduction studies often are overused and may accompany the electromyogram without apparent indication, but they are nearly useless in diagnosing radiculopathy and should be included only for nerve entrapment or differential diagnosis of plexus injury. Nerve conduction studies often are accompanied by F waves and H reflexes. The F wave helps assess proximal portions of nerves and is used primarily in the diagnosis of Landry-Guillain-Barré syndrome but has poor sensitivity and specificity in evaluation of radiculopathy or entrapment neuropathy. The H reflex is used primarily in S1 radiculopathy evaluation. The article includes six questions a clinician should bear in mind while interpreting the electrodiagnostic report. Improperly trained physicians may report false positive or negative results, so examiners should be aware of the qualifications of physicians to whom they refer their patients.
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5. Tools and Resources: Recommended Reading List for Impairment Evaluation

   Christopher R. Brigham

   Pages 7–8

   DOI: 10.1001/amaguidesnewsletters.2000.MayJun05

6. Literature Review

   Pages 7–7, 10

   DOI: 10.1001/amaguidesnewsletters.2000.MayJun06

7. Clinical Update: Use and Abuse of Electrophysiologic Studies

   Richard T. Katz

   Pages 9–10

   DOI: 10.1001/amaguidesnewsletters.2000.MayJun07