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on scientific evidence. Musculoskeletal impairments, the types of impairments most commonly encountered, are not based on scientific evidence but rather consensus of a selected group of “experts.” Impairment ratings should be based on a valid whole person impairment (WPI) scale that accurately reflects functional loss. There are significant variances throughout the Guides in terms of relative functional loss. For example, a patient with severe low back pain with an ongoing single-level radiculopathy after surgery will be limited to 10% whole person permanent
function (Cartesian dualism), and that symptoms, signs, and illness primarily arise from an identifiable underlying disease abnormality (scientific reductionism). 9 In addition, there are at least six domains of potential influence on eventual worker disability, including medical, personal, psychological, sociocultural, systemic (including compensation and insurance), and workplace elements. 10 , 11 ❏ The conventional biomedical paradigm does not address behavioral health (BH) concerns, such as psychological factors; medically unexplained physical symptoms (MUPS
. Once it has been established that both (A) and (B) are probable, there also must be a probable relationship established between the two before a final positive causality conclusion can be promulgated. A conclusion that a cause did contribute to an effect or impairment must rely on the documentation of circumstances that were present and verification that the type and magnitude of the factors were sufficient and bore the necessary temporal relationship to the condition. Many ratings of impairment lack this critical analysis. Causation must be based on scientific
. Conceptual and Practical Shifts There are at least six major conceptual and practical changes that need to be accomplished: Eliminate the dualistic separation of mind and body and the scientific reductionism that follows from it. We cannot continue to consider the mind and body as separate entities, or work-related illness or injury as separate from the individual characteristics of the worker, especially in potential DFRUD. 1 , 2 This requires taking a more holistic view of the worker and including psychosocial considerations much earlier in the course of claims
Abstract
A method for determining the severity of a presentation of cognitive impairment has been developed and scientifically validated specifically for use with cases in which the causative diagnosis is traumatic brain injury. The method determines if the impairment, as demonstrated on neuropsychology testing, is consistent with the severity of the claimed cause. Such scientific linkage of an objective measurement of impairment severity and the severity of the cause is quite rare. The research related to this method did not consider methodology for impairment rating presented in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), so this article compares the new method to the impairment rating methodology from the AMA Guides, Sixth Edition, Section 13.3d, Mental Status, Cognition, and Highest Integrative Function. This article offers an example of how neuropsychology test results for an individual case can be applied to the classes of impairment that are included in Table 13-8, Criteria for Rating Neurologic Impairment Due to Alteration in Mental Status, Cognition, and Highest Integrative Function. This method has the advantages of standardization, objectivity, and being based on scientific findings that make the unique contribution of actually linking severity of impairment to severity of the causative factors. The authors caution that the method is only a subset of the methodology from Section 13.3d and does not justify abandonment of the remainder of this section of the AMA Guides.
Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) used the Snell Visual Efficiency Scale (1925). Following scientific progress, the Vision chapter in the fifth and sixth editions of the AMA Guides began using the Functional Vision Score (FVS) that is endorsed by the International Council of Ophthalmology and the International Society for Low Vision Research and Rehabilitation. Use of the FVS provided an opportunity to correct many inconsistencies in the VES system and also is better integrated with modern measurement methods and the ratings used for other organ systems. The FVS score is obtained by combining the Functional Acuity Score and the Functional Field Score; if any adjustments are introduced in this combination, they must be completely justified and cannot be based on subjective arguments. The disability is rated on the basis of functional considerations and is not influenced by nonfunctional factors. Combining visual acuity loss and visual field loss into a single number is attractive for administrative and legal purposes, but this step is meaningless in the context of rehabilitation because rehabilitation for visual acuity loss is entirely different from rehabilitation for visual field loss. The FVS system provides internationally endorsed statistical estimates of the effects of visual impairment on the ability to perform activities of daily living.
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.
A method for determining whether the severity of a presentation of cognitive impairment (as demonstrated on neuropsychology testing) is consistent with the severity of the claimed causative diagnosis has been developed and scientifically validated, specifically for cases in which the causative diagnosis is traumatic brain injury. 1 Such scientific linkage of an objective measurement of impairment severity to severity of the causative diagnosis is exceedingly rare for any type of impairment, not just cognitive impairment, and is consequently highly
classification of CRPS as a mythical concept, because it lacks scientific validation. 3 As such, the American Medical Association could have justifiably ignored the concept of CRPS and avoided mentioning it in the various publications which have made up the “ Guides Library,” including the AMA Guides to the Evaluation of Permanent Impairment, the Guides Casebook, the Guides Newsletter, the Guides to the Evaluation of Disease and Injury Causation , and other Guides publications core to case assessment. However, ignoring this concept could have caused the Guides
. American Academy of Clinical Neuropsychology, Oxford University Press, 2008). The editors of the Guides concurred that a small clinical rating can be offered for pain problems such as post-traumatic headaches without objective criteria. While everyone wishes to practice evidence based medicine, the lack of scientific evidence in a certain area does not dictate that we ignore daily realities of medical practice.
