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Charles N. Books
,
James B. Talmage
, and
J. Mark Melhorn

Abstract

Indications for excision of the distal clavicle include symptomatic degenerative arthritis of the acromioclavicular joint, impingement syndrome, and osteolysis of the distal clavicle if nonoperative treatment has failed. Distal clavicular resection (DCR), one could argue, is by definition an impairment because of the loss of a portion of a body part, the clavicle. Yet a competently performed and uncomplicated DCR generally results in improved function, not loss of use. DCR was first mentioned in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, which stated that a resection arthroplasty of the acromioclavicular joint warrants 10% upper extremity impairment (UEI). Rating DCR using the AMA Guides, Fifth Edition, is almost the same as using the fourth edition, but evaluators can use one of two approaches: The rating physician can select a 3% rating for DCR using the fifth edition and claim to be literally following the instructions and providing a sensible rating in view of the generally good results reported in the orthopedic literature following a DCR. Alternatively, a rating physician who is aware of the historical precedent underlying the 10% UEI in Table 16-27 could cite this and the absence of an instruction in the Arthroplasty section to justify a 10% impairment rating. In the sixth edition, DCR is a key factor in classifying an acromioclavicular joint injury or disease but is disregarded in the rating of rotator cuff or glenohumeral pathology.

in AMA Guides® Newsletter
Charles N. Brooks
,
James B. Talmage
, and
Kathryn Mueller

Abstract

The terms subjective and objective often appear in health care records, and one commonly hears about “subjective symptoms” and “objective complaints”—yet the former is redundant and the latter an oxymoron. Objectively verifiable pathology may explain a patient's symptoms, but complaints themselves are never objective but rather, by definition, subjective. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, defines the terminology: Subjective information is more open to interpretation, but objective data are factual, reproducible, and often measurable or quantifiable. Objective findings generally have much higher inter-examiner reliability than subjective findings. Symptoms and most findings on physical (particularly neuromusculoskeletal) examination are subjective. Diagnostic study results and a minority of physical findings are objective. Some physical findings, such as strength and range of motion measurements, are both subjective and objective. Repeat testing, assessment of plausibility, and use of confirmatory physical findings can be used to validate or “objectify” subjective findings (eg, by determining if a weakness is corroborated by other neurologic or physical findings, imaging study results, and/or electrodiagnostic testing). The use of objective, or at least less subjective, findings in impairment rating should improve interrater reliability. Thus, evaluating physicians should not regard subjective complaints and findings, and they should lend greater weight to objective findings.

in AMA Guides® Newsletter
Restricted access
James B. Talmage
,
Christopher R. Brigham
, and
Marjorie Eskay-Auerbach
in AMA Guides® Newsletter
Christopher R. Brigham
,
Charles N. Brooks
, and
James B. Talmage

Abstract

Causation analysis always should be based on current scientific evidence and the facts of a specific case rather than common opinions or beliefs, eg, the myth that “favoring” one lower extremity often results in injury or illness of the opposite lower limb. Temporal sequence does not prove causation, and in causation analysis one also must consider temporal disparity: Was an injury or exposure likely to cause the condition in question, or is there another, more probable, cause? To conclude that a given cause and effect are etiologically associated with a reasonable degree of medical probability or certainty (ie, more than 50% probability), all three of the following criteria must be met: the cause is medically probably; the effect is medially probably; and the cause and effect probably are etiologically related. That is, causation analysis must be based on an analytical approach and not patient history alone. The medical literature reveals no generally accepted studies that support a causal relationship based on an individual's “favoring” one extremity. Rather, evaluators must base conclusions on scientific evidence and facts of the case at hand rather than relying solely on patient history or false logic such as the post hoc propter hoc fallacy.

in AMA Guides® Newsletter
J. Mark Melhorn
,
Christopher R. Brigham
, and
James B. Talmage

Abstract

Carpometacarpal (CMC) joint subluxation refers to the changes that occur in the CMC joint as seen on x-rays and observed during physical examination. The CMC joint is the most commonly involved arthritic joint in the hand, and arthritis may appear in localized or systemic forms. A diagnosis of thumb-CMC arthritis is based on symptoms of localized pain, tenderness, and instability on physical examination and radiographic evaluation. The AMA Guides to the Evaluation of Disease and Injury Causation provides a protocol for assessing causation and requires that all three of the following criteria must be met: 1) the patient has an illness compatible with a disease-producing agent or an injury; 2) the worker's exposure in the occupational environment potentially caused the disease or is a plausible mechanism of injury of sufficient magnitude to cause the condition; and 3) the preponderance of evidence supports the disease or injury as occupational in origin. If any one of the three is possible but not probable, causation has not been established. The authors review several published articles and conclude that, based on the clinical facts and current science, CMC joint subluxation is unrelated to work and instead is reflective of aging. The article concludes with a comparison of impairment ratings of CMC-related disability using the fifth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment, both of which lead to identical impairment ratings but by different means.

in AMA Guides® Newsletter
Restricted access
Christopher R. Brigham
,
Lee Ensalada
, and
James B. Talmage
in AMA Guides® Newsletter
Restricted access
Christopher R. Brigham
,
J. Mark Melhorn
, and
James B. Talmage

Abstract

Following successful surgical treatment of an inguinal hernia (ie, preparing the defect), there should be no ratable impairment unless there is clearly recognized nerve injury or a complication such as infection. The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth and Sixth Editions, provide guides to the rating of permanent impairment for hernias. Both stress that impairment evaluation is predicated on the existence of a causal relationship between the individual's condition and an event or exposure. If a patient has an appropriate repair, then the defect should be resolved; that is, there should be no physical examination findings of a palpable deficit nor of a protrusion. If a palpable defect is present and the hernia is causally related to an injury, then the hernia is ratable. As with all ratings, the underlying basis must be reliable; that is, the history, including reported activities of daily living (ADL), must be supportable. In the AMA Guides, Fifth Edition, three examples show ratings, all of which depend on objective findings of palpable defects (protrusions). The sixth edition outlines the assignment of one of four classes of findings and interferences with ADLs. Impairment is based on objective findings when the individual is at maximum medical improvement.

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

Abstract

More than 20 million Americans have osteoarthritis (OA), which affects the knee more often than any other joint and is the most common cause of long-term disability in persons older than 65 years. Knee OA is common, particularly in older patients and especially the obese. Knee injury, depending on the severity and type, can increase the risk of developing and the rate of progression of OA. In assessing impairment for knee OA, the evaluator must obtain a thorough history and physical examination and identify all potential risk factors. To opine that an injury caused OA, the evaluator should demonstrate that the traumatized knee shows significant arthritis but that the contralateral uninjured knee is radiographically normal; for an evaluator to suggest that pre-existing arthritis was aggravated, the involved knee should show significantly more advanced OA than the contralateral joint. Joint space widths (cartilage intervals) of both knees must be measured carefully on anteroposterior films obtained standing with a film-to-camera distance of 90 cm (36 in) and the beam at the level of and parallel to the joint surface. Taking into account all of the data (history, physical findings, and radiographic measurements from both the involved and contralateral joint), the rating physician can assess causation, estimate impairment, and apportion the latter to one or more etiologies.

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