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Christopher R. Brigham
and
James B. Talmage

Abstract

Permanent impairment cannot be assessed until the patient is at maximum medical improvement (MMI), but the proper time to test following carpal tunnel release often is not clear. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) states: “Factors affecting nerve recovery in compression lesions include nerve fiber pathology, level of injury, duration of injury, and status of end organs,” but age is not prognostic. The AMA Guides clarifies: “High axonotmesis lesions may take 1 to 2 years for maximum recovery, whereas even lesions at the wrist may take 6 to 9 months for maximal recovery of nerve function.” The authors review 3 studies that followed patients’ long-term recovery of hand function after open carpal tunnel release surgery and found that estimates of MMI ranged from 25 weeks to 24 months (for “significant improvement”) to 18 to 24 months. The authors suggest that if the early results of surgery suggest a patient's improvement in the activities of daily living (ADL) and an examination shows few or no symptoms, the result can be assessed early. If major symptoms and ADL problems persist, the examiner should wait at least 6 to 12 months, until symptoms appear to stop improving. A patient with carpal tunnel syndrome who declines a release can be rated for impairment, and, as appropriate, the physician may wish to make a written note of this in the medical evaluation report.

in AMA Guides® Newsletter
Lorne Direnfeld
,
James Talmage
, and
Christopher Brigham

Abstract

This article was prompted by the submission of two challenging cases that exemplify the decision processes involved in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In both cases, the physical examinations were normal with no evidence of illness behavior, but, based on their histories and clinical presentations, the patients reported credible symptoms attributable to specific significant injuries. The dilemma for evaluators was whether to adhere to the AMA Guides, as written, or to attempt to rate impairment in these rare cases. In the first case, the evaluating neurologist used alternative approaches to define impairment based on the presence of thoracic outlet syndrome and upper extremity pain, as if there were a nerve injury. An orthopedic surgeon who evaluated the case did not base impairment on pain and used the upper extremity chapters in the AMA Guides. The impairment ratings determined using either the nervous system or upper extremity chapters of the AMA Guides resulted in almost the same rating (9% vs 8% upper extremity impairment), and either value converted to 5% whole person permanent impairment. In the second case, the neurologist evaluated the individual for neuropathic pain (9% WPI), and the orthopedic surgeon rated the patient as Diagnosis-related estimates Cervical Category II for nonverifiable radicular pain (5% to 8% WPI).

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

Abstract

The sacroiliac joint (SIJ) is an accepted source of pain in patients with ankylosing spondylitis and other spondyloarthropathies, osteoarthritis, infections, and tumors, but the occurrence of isolated SIJ pain in the absence of such diseases is controversial. The term, sacroiliac joint dysfunction, which is used widely, describes pain from an SIJ that has no identifiable lesion but is presumed to have some mechanical etiology. Practitioners currently have no universally accepted gold standard for identifying a disc, facet joint, of SIJ as the pain generator. Treatment options for SIJ pain include medications, physical therapy, bracing, manual therapy, injections, radiofrequency neurotomy, and arthrodesis. Optimal management of patients with SIJ pain remains controversial. In the AMA Guides, Sixth Edition, a clinically established and causally related diagnosis of SIJ dysfunction is rated using the first row in Table 17-4. Surgery does not change the diagnosis or rating: The SIJ is not a motion segment of the lumbar spine, and SIJ fusion is not an alteration of motion segment integrity. Clinically, pain presumed to be from SIJ dysfunction is low back pain, so if this is the clinical diagnosis, the spine chapter in the AMA Guides, Fifth Edition, should be used. In such cases, the first step is to determine whether to use the diagnosis-related estimate or the range-of-motion method, and the article provides guidance about situations in which the use of each is appropriate.

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

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, notes that pain is a subjective perception, and usually no exact relationships exist among the degree of pain, extent of pathologic change, and extent of impairment. Chapters 3, 14, and 15 regarding the musculoskeletal system, mental and behavioral disorders, and pain, respectively, may be relevant in evaluating an individual's pain following musculoskeletal injury. The eight diagnostic characteristics of chronic pain are duration, dramatization, diagnostic dilemma, drugs, dependence, depression, disuse, and dysfunction; if four of the eight are present, a presumptive diagnosis is established. The fourth edition of AMA Guides distinguishes chronic pain syndrome and psychogenic pain (the former is not considered a mental disorder), but diagnosis of pain should consider psychological factors that are judged to play a significant role in the onset, severity, exacerbation, or maintenance of the pain. Thus, two individuals may have identical musculoskeletal histories, physical exams, and pain out of proportion to their injuries, but when one of the patients has psychological factors that are known and understood, the evaluating physician may diagnose a pain disorder associated with psychological factors. Because formally associating psychological factors and diagnosis usually requires legal discovery, physicians may keep the psychological factors confidential, diagnose chronic pain syndrome, and evaluate using Chapter 15 of the fourth edition of the AMA Guides.

in AMA Guides® Newsletter
Robert B. Snyder
and
James B. Talmage

Abstract

The decision about whether a case of documented COVID-19 illness is accepted as occupationally acquired and thus work compensable is made by insurers, or if contested, by judges or administrative bureaus. Causation for COVID-19 may be difficult to show because of the lack of accurate information and difficulty in meeting some of the criteria established by Bradford Hill. Nevertheless, physicians will be asked for medical records and documentation of illness. This article provides preliminary guidance to assist physicians in responding to insurers or workers compensation agencies' requests for information on the medial aspects of COVID-19.

in AMA Guides® Newsletter
Mohammed I. Ranavaya
and
James B. Talmage

Abstract

Although several states use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) when they evaluate individuals with impairments and disabilities, various disability systems exist in the United States. Disability and compensation systems have arisen to ensure that disadvantaged members of society with a medically determinable impairment, which may lead to a disability, have recourse to compensation from various sources, including state and federal workers’ compensation laws, veterans’ benefits, social welfare programs, and legal avenues. Each of these has differing definitions of disability, entitlement, benefits, procedures of claims application, adjudication, and the roles and relative weights assigned to medical vs administrative deliberations. Workers’ compensation statutes were enacted because of inadequacies of recovery from claims for injured workers under common law. Workers’ compensation is a no-fault system adopted to resolve the dilemmas of tort claims by providing automatic coverage to employees injured during the course of employment; in exchange for coverage, employees forego the right to sue the employer except for wanton neglect. Other workers’ compensation programs in the United States include the Federal Employees Compensation Act; the Federal Employers Liability Act (railroads); the Jones Act (Merchant Marine Act); the Longshore and Harbor Workers’ Compensation Act; the Department of Veterans Affairs; Social Security; and private, long-term disability insurance.

in AMA Guides® Newsletter