AMA Guides® Newsletter - Issue Archive

Articles

1. Rating Peripheral Neuropathy

   Christopher R. Brigham

   Pages 1–10

   DOI: 10.1001/amaguidesnewsletters.2003.JanFeb01

   Abstract

   This article discusses the evaluation of peripheral nerve impairment and focuses on assessing peripheral polyneuropathies. Although peripheral neuropathy is a common neurological disorder, no uniform criteria exist for either evaluation or diagnosis, and 30% of cases remain idiopathic. The patient must be at maximum medical improvement (MMI) before permanent impairment is rated, but determining MMI is challenging, particularly if neuropathy is secondary to an underlying medical condition such as hypothyroid or diabetic neuropathy or toxic exposure. A table in this article directs readers to specific tables from the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) for determining maximum motor and sensory loss. Sensory dysfunction is evaluated by whether it interferes with performance of daily functions, and another table compares sensory gradings according to the AMA Guides, Fifth Edition (Tables 16-10 and 13-23) and the Fourth Edition (Table 11). When using these tables, evaluators should be aware of differences in terminology: sensation is the acceptance and activation of impulses in the afferent nerve fibers of the nervous system, and sensibility is the conscious appreciation and interpretation of the stimulus. In addition, a box discusses two-point discrimination testing and steps the examiner can take to minimize the variability of this procedure. Grading a sensory deficit requires considerable judgment and interpretation, which makes the findings less objective than findings that are independently verifiable.
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2. Clinical Update: Pain and Suffering

   Sheila Wendler

   Pages 5–5

   DOI: 10.1001/amaguidesnewsletters.2003.JanFeb02

   Abstract

   Attorneys use the term pain and suffering to indicate the subjective, intangible effects of an individual's injury, and plaintiffs may seek compensation for “pain and suffering” as part of a personal injury case although it is not usually an element of a workers’ compensation case. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, provides guidance for rating pain qualitatively or quantitatively in certain cases, but, because of the subjectivity and privateness of the patient's experience, the AMA Guides offers no quantitative approach to assessing “pain and suffering.” The AMA Guides also cautions that confounders of pain behaviors and perception of pain include beliefs, expectations, rewards, attention, and training. “Pain and suffering” is challenging for all parties to value, particularly in terms of financial damages, and using an individual's medical expenses as an indicator of “pain and suffering” simply encourages excessive diagnostic and treatment interventions. The affective component, ie, the uniqueness of this subjective experience, makes it difficult for others, including evaluators, to grasp its meaning. Experienced evaluators recognize that a myriad of factors play a role in the experience of suffering associated with pain, including its intensity and location, the individual's ability to conceptualize pain, the meaning ascribed to pain, the accompanying injury or illness, and the social understanding of suffering.
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3. Impairment Tutorial: Permanent Impairment Evaluation of the Temporomandibular Joint

   Chris Brown

   Pages 6–11

   DOI: 10.1001/amaguidesnewsletters.2003.JanFeb03

   Abstract

   Temporomandibular joint dysfunction (TJD) is a term applied to a group of problems that affect the muscles of mastication, the temporomandibular joint, and their supporting structures. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, deals only briefly with TMD in Section 11.4b, noting that this dysfunction may impede mastication, affect speech, cause lower facial deformity, and produce pain. Objective criteria (disk displacement and radiographic evidence of joint degeneration, range of motion [ROM], and surgical intervention) have been used to diagnose TMD, but the AMA Guides, Fifth Edition, usually bases the diagnosis on dietary restrictions or problems with speech. A table in the article provides a description of disk displacement and joint degeneration; based on symptoms, clinical findings, and imaging results, examiners can place the patient in one of five stages. Evaluators should use generally accepted ROM measurement principles, and the reproducibility of active ROM is an important indicator of measurement accuracy. Surgical correction includes arthroscopy or arthroplasty. Challenges in developing a process for rating TMD impairment include what factors relate to impairment, what should be the range of impairment, and who should perform the rating. At present, the AMA Guides states that “permanent impairment requires a medical assessment performed by the physician.”
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4. Questions and Answers

   Pages 8–10

   DOI: 10.1001/amaguidesnewsletters.2003.JanFeb04