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James B. Talmage
and
Robert B. Snyder

Abstract

Evidence shows that chronic opioid therapy is usually not beneficial; weaning patients off opioids many times results in less pain and better function, and opioid-induced hyperalgesia is real and frequent. Further evidence suggests that surgical outcomes are better if patients are weaned off opioids before surgery, and that the chronic use of opioids may adversely alter the assessment of maximum medical improvement (MMI).

in AMA Guides® Newsletter
Marjorie Eskay-Auerbach
and
James B. Talmage

Abstract

Physicians frequently are asked to assess work ability in individuals with low back pain (LBP) who also require an impairment rating. Physicians may be tempted to base their decisions about the individual's work ability on spinal anatomy/diagnosis as established by imaging, because that may seem objective. However, a review of the current medical literature consistently demonstrates that anatomical abnormalities identified on imaging do not predict functional ability. Rather, recent studies have demonstrated a strong association between the number of symptoms and functional status, on the one hand, and the lack of correlation between findings on imaging and symptoms, on the other hand. For example, a systematic review by Mayo Clinic physicians of 33 published studies in which 3110 asymptomatic adults were imaged using magnetic resonance imaging (MRI) showed that, in middle age when most problematic back pain problems present, roughly half of asymptomatic adults had disc bulges, roughly one-third had disc protrusions, and roughly one-quarter had annular fissures. The authors of the present study also review related studies regarding low back pain and conclude that current scientific knowledge suggests that imaging alone is not useful in predicting function or in assessing future risk. Degenerative changes on imaging are not a sound basis for work restrictions because they do not correlate with risk or capacity.

in AMA Guides® Newsletter
James B. Talmage
,
Christopher R. Brigham
, and
Charles N. Brooks

Abstract

The pain, numbness, and paresthesias of carpal tunnel syndrome generally are intermittent and are felt in the wrist, hand, thumb, and fingers, often in a distribution approximating that of the median nerve. No specific physical examination exists for carpal tunnel syndrome, and, in the impairment rating assessment, the physical examination focuses on detecting signs of permanent nerve damage (decreased sensation and thenar weakness on opposition). According to the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), provocative tests have no role in impairment rating. The AMA Guides, Fifth Edition, requires nerve conduction testing (NCT), even in “believable” instances, but no uniform definition of an abnormal NCT exists and examiners should realize the uses and limits of NCT. For example, if the NCT is normal, the symptoms, even if believable, do not rise to the level of an impairment. Impairment assessment must take place when the patient is at maximum medical improvement. If the NCT is grossly abnormal (axon loss) and/or degenerative changes are present on needle electromyography, and if physical exam shows sensory and/or thenar weakness, the examiner can use tables in the AMA Guides to rate the disability, combining sensory and motor impairments as appropriate. A one-page sidebar in this issue of The Guides Newsletter addresses the causes of carpal tunnel syndrome.

in AMA Guides® Newsletter
Charles N. Brooks
,
Richard E. Strain Jr.
, and
James B. Talmage

Abstract

The primary function of the acetabular labrum, like that of the glenoid, is to deepen the socket and improve joint stability. Tears of the acetabular labrum are common in older adults but occur in all age groups and with equal frequency in males and females. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, is silent about rating tears, partial or complete excision, or repair of the acetabular labrum. Provocative tests to detect acetabular labrum tears involve hip flexion and rotation; all rely on production of pain in the groin (typically), clicking, and/or locking with passive or active hip motions. Diagnostic tests or procedures rely on x-rays, conventional arthrography, computerized tomography, magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and hip arthroscopy. Hip arthroscopy is the gold standard for diagnosis but is the most invasive and most likely to result in complications, and MRA is about three times more sensitive and accurate in detecting acetabular labral tears than MRI alone. Surgical treatment for acetabular labrum tears usually consists of arthroscopic debridement; results tend to be better in younger patients. In general, an acetabular labral tear, partial labrectomy, or labral repair warrants a rating of 2% lower extremity impairment. Evaluators should avoid double dipping (eg, using both a Diagnosis-related estimates and limited range-of-motion tests).

in AMA Guides® Newsletter
Christopher R. Brigham
,
James B. Talmage
, and
Marjorie Eskay-Auerbach

Abstract

Impairment evaluation of the spine has evolved notably since the 1958 publication by the American Medical Association of an article titled A Guide to the Evaluation of Permanent Impairment of the Extremities and Back. Significant differences exist among the editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) currently in use, including the third edition, revised (1988), fourth (1993), fifth (2000), and sixth (2008) editions. This article reviews exemplary cases according to the instructions and methods of each edition, beginning with a table that summarizes spinal impairment criteria by edition of the AMA Guides. Another extensive table presents seven exemplar cases that demonstrate the differences in impairment ratings between the fourth, fifth, and sixth editions; each example is discussed in terms of different approaches taken in each of these editions. In the AMA Guides, Sixth Edition, the process of rating impairment was simplified by the elimination of the range of motion method. In the examples presented, the impairment values calculated using the sixth edition fall between those obtained using the fourth and fifth editions. Evaluating physicians must know the appropriate edition of the AMA Guides to use in each case and must understand the differences between them, particularly the changes included in the sixth edition.

in AMA Guides® Newsletter
Restricted access
Christopher R. Brigham
,
James B. Talmage
, and
Craig Uejo
in AMA Guides® Newsletter
James Talmage
,
J. Mark Melhorn
, and
Mark H. Hyman
in AMA Guides® Newsletter