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The Fourth Edition of the Guides to the Evaluation of Permanent Impairment (Guides) continues an activity begun by the American Medical Association (AMA) almost four decades ago, the purpose of which was to bring greater objectivity to estimating the degree of long-standing or “permanent” impairments. The rationale for this new edition is that the pace of progress and advance in medicine continues to be rapid, and that a new look at the impairment criteria for all organ systems is advisable. This edition has been prepared under the auspices of the AMA's Council on Scientific Affairs.

In preparing the Fourth Edition, the Guides’ editors, AMA staff members, and the Council's liaison members first selected well-qualified individuals who, as chairs, would be responsible for preparing the chapters on organ system impairments and other subjects. Then the AMA staff requested nominations of knowledgeable, interested physicians from all the state medical societies and the medical specialty societies that make up the AMA federation. Thereafter, the chairs and committee members selected by them and the AMA staff prepared the text.

All of the chapters of this edition have undergone peer review, either by the committees who prepared them or by other knowledgeable persons. In March 1992, representatives of 11 medical specialty societies, the Social Security Administration, the US Department of Veterans Affairs, the American Bar Association, and the Oklahoma State Workers’ Compensation Agency, a representative agency that mandates the Guides’ use, met to consider a draft of the Fourth Edition and provide further peer review. After this meeting, the chairs made appropriate changes. A multidisciplinary ad hoc committee provided special assistance with the musculoskeletal system.

The Fourth Edition has some new features. Case reports or examples are included in most of the parts dealing with the different organ systems. A chapter on pain is included. Organ transplantation and the adverse effects of pharmaceuticals are considered. The Glossary contains informative material on the Americans with Disability Act (ADA) of 1992. New data are cited in Chapter 1 on the widespread use of the Guides by state workers’ compensation agencies.

The Fourth Edition continues to convey several basic principles. A key tenet is that the book applies only to permanent impairments, which are defined as adverse conditions that are stable and unlikely to change. Evaluating the magnitude of these impairments is in the purview of the physician, while determining disability is usually not the physician's responsibility. This edition emphasizes that impairment percentages derived by using Guides criteria represent estimates rather than precise determinations. Permanent impairments are evaluated in terms of p. vhow they affect the patient's daily activities, and this edition recognizes that one's occupation constitutes part of his or her daily activities.

Many persons helped with the Fourth Edition. The authors of and the contributors to the Guides, reviewers, and responsible AMA staff members are listed after the Foreword. The editors acknowledge especially the research and assistance of Alfred B. Swanson, MD, and Genevieve de Groot Swanson, MD, whose work was essential in preparing the hand and upper extremity section in the chapter on the musculoskeletal system.

The editors also wish to acknowledge the hundreds of Guides users who have written the AMA in past years and offered their suggestions. While the editors’ goal has been to prepare the best Guides yet, we realize there still is room for improvement. The Guides readers and users can contribute to this process. Therefore, we invite all to continue offering their comments and advice.

Theodore C. Doege, MD, MS, Editor

Thomas P. Houston, MD, Associate Editor

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    Jr Luck JV, DW. Florence A brief history and comparative analysis of disability systems and impairment rating guides. Orthoped Clin North Am. 1988;19:839-844.

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