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James B. Talmage

Abstract

The primary methods of evaluating impairment in the upper extremity are range of motion testing and neurological examination. For certain conditions that do not cause motion or neurological deficits yet leave the extremity significantly impaired, the editors of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, provided Section 3.1m, Impairment Due to Other Disorders of the Upper Extremity. The AMA Guides emphasizes that the criteria described in these “other disorders” should be applied only when the other criteria have not adequately encompassed the extent of the impairments. The evaluator must carefully read the criteria for rating each derangement to ensure the rating is correct and not duplicative. Table 26, Upper Extremity Impairment Due to Carpal Instability Patterns, includes values based on radiographic findings, and Table 27, Impairment of the Upper Extremity after Arthroplasty of Specific Bones or Joints, features ratings for resection arthroplasty and implant arthroplasty. Tables 28, 29, and 30 for musculotendinous impairments require that the percent of digit impairment be multiplied by the relative value of the digit according to Table 18. The AMA Guides does not assign a large role to functional measurements such as pinch and grip strength tests because they are influenced by subjective factors that are difficult to control.

in AMA Guides® Newsletter
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James B. Talmage
in AMA Guides® Newsletter
James B. Talmage

Abstract

Upper extremity entrapment neuropathies are chronic injuries to peripheral nerves, presumably from sustained pressure on the nerve in question. These conditions are controversial, and physicians disagree, unfortunately too often, about whether a neuropathy is present, what caused the neuropathy, and what the proper impairment rating should be. Carpal tunnel syndrome is the most common entrapment or “pressure neuropathy” and must be differentiated from other causes of nerve dysfunction such as viral illness, toxins (eg, heavy metals), and systemic diseases such as diabetes or vasculitis. Each of the upper extremity nerves has many potential sites of entrapment, which most frequently occurs secondary to a congenital anomaly such as anomalous fibrous band, muscle bellies, or arteries. Ganglion cysts, lipomas, tumors, and fracture callus or nonunion also have been reported as a cause of these rare neuropathies. Diagnosis of entrapment is challenging because entrapments are uncommon to rare, but arm pain is common in individuals who move their arms repetitively at work, avocation, or sport, and establishing causation also is controversial. Severe entrapment essentially is total destruction of the nerve involved, but, in a lifetime of practice, most physicians will not see a nerve entrapment that progresses to complete loss of all motor and sensory function.

in AMA Guides® Newsletter
James B. Talmage

Abstract

The duration of opioid therapy after surgery is the strongest known predictor of ultimate misuse, and researchers have reported that the number of days for which medication was prescribed and the total number of postoperative prescriptions each predicts long-term use. This article addresses the question of rating the impairment for an individual with no history of substance use disorder before a work injury, who is prescribed opioids for this injury, and who subsequently develops opioid use disorder (OUD). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, should be used in conjunction with the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Sixth Edition. A person who is prescribed opioids is not yet at maximum medical improvement (MMI) and cannot be rated. Referral for substantiation of the diagnosis and for initiation of treatment are necessary before OUD is confirmed and the patient is at MMI. The AMA Guides is based on impairments of activities of daily living (ADL), so a patient's MMI should result in a happy outcome and no impairment, although the burden of treatment compliance may be a relevant consideration. The article concludes with an extensive literature review, including abstracts of published articles regarding OUD in various settings.

in AMA Guides® Newsletter
James B. Talmage

Abstract

In 2011, the American Medical Association published the AMA Guides to the Evaluation of Work Ability and Return to Work (AMA's Return to Work), Second Edition, which began with a review of consensus statements attesting that, in general, work is good for a person's health and well-being. Since publication of AMA's Return to Work, the Australian Royal College of Physicians has issued a consensus statement about the negative health consequences of becoming unemployed and the health benefits of returning to work. Key points include: for most individuals, working improves general health and well-being and reduces psychological distress; even musculoskeletal and mental health conditions attributed to work can benefit from activity-based rehabilitation and an early return to suitable work; long-term work absence is harmful to physical and mental health and well-being; the negative effects of remaining away from work include stress on the worker's families, including children. Of the potential consequences of unemployment in mid-adult life, the worst is premature death. In causation research, unlike medical treatment studies, individuals cannot be randomly assigned to a group that is forced to remain at work and a group that is forced to be unemployed. Even so, causation research has found strong evidence for a protective effect of employment on depression and general mental health. In performing evaluations, physicians must accurately assess work ability and recognize the healthy benefits of work.

in AMA Guides® Newsletter
James B. Talmage
in AMA Guides® Newsletter