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Lorne Direnfeld
in AMA Guides® Newsletter
Lorne Direnfeld
in AMA Guides® Newsletter
Lorne Direnfeld
in AMA Guides® Newsletter
Lorne Direnfeld
in AMA Guides® Newsletter
Lorne Direnfeld

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, discusses rating cranial nerve and spinal cord impairments. Evaluation of impairment of the cranial nerves is based on clinical neurological assessment, and many cranial nerves also are addressed in other chapters of the AMA Guides (eg, the visual system or the ear, nose, and throat). With respect to cranial nerve I, an impairment estimate associated with anosmia or parosmia should be given only if this significantly interferes with daily activities. For cranial nerve II, the AMA Guides recommends ophthalmologic testing of visual fields and best correction. For cranial nerves III, IV, and VI, the reader is referred to section 8.3, and, for cranial nerve V, the AMA Guides provides a method of determining impairment associated with trigeminal neuralgia. A table provides data regarding impairment for conditions that affect the seventh cranial (facial) nerve; sensory loss related to the facial nerve does not interfere with activities of daily living. Auditory impairment (cranial nerve VIII) is rated according to criteria in the ear, nose, throat, and related structures chapter, including tinnitus. Cranial nerves IX, X, XI, and XII are involved in breathing, swallowing, speaking, and some visceral functions, and ratings criteria are presented. In terms of spinal cord impairments, the AMA Guides divides pathology into six categories: station and gait; use of the upper extremities; respiration; urinary bladder function; anorectal function; and sexual function.

in AMA Guides® Newsletter
William Shaw
and
Lorne Direnfeld

Abstract

The term nonverifiable radicular complaints is an oxymoron because if the complaint is radicular one should know the cause, but the word nonverifiable contradicts such knowledge. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) explains that nonverifiable radicular complaints “follow anatomic pathways but cannot be verified by neurologic findings.” A frequent error in impairment rating is to assign patients to Category II based on incorrect use of nonverifiable radicular complaints when Category I or 0% impairment is the correct rating. Some physicians inappropriately use the Range of Motion model and cite tables from the third edition. Other physicians may place a patient in Category II using the Injury Model without a specific basis in the AMA Guides, but the key point is that a diagnosis of nonverifiable radicular complaints indicates that the physician can identify the nerve root involved. Absent the latter, the patient does not have nonverifiable radicular complaints. The Injury Model is the preferred method in rating spinal injury in the AMA Guides, Fourth Edition, and this model clearly intends to place patients with some back pain, some leg pain, and some leg numbness—but not a true radicular pattern—in Category I.

in AMA Guides® Newsletter
Lorne K. Direnfeld

Abstract

Lower urinary tract dysfunction may result from a variety of neurologic disorders, including traumatic spinal cord injury, head injury, a cauda equina syndrome, or trauma to the peripheral lumbosacral nerves. Urinary incontinence can be divided into five categories: stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, and total incontinence. A table lists each type, provides a description, and gives both common and neurological examples. Evaluation of voiding dysfunction should not be based on symptoms alone, and urodynamic evaluation is required also. Indeed, urodynamic evaluation is the only means to establish a functional interrelationship of the components of the lower urinary tract. Most ratings of neurogenic bladder dysfunction are performed using Section 4.3d, Urinary Bladder Dysfunction, and Table 17, Criteria for Neurologic Impairment of the Bladder in the AMA Guides to the Evaluation of Permanent Impairment. Ratings for whole-person permanent impairment depend on symptomatology (ie, urgency, dribbling, or incontinence), voluntary control, and bladder reflex activity. If problems with urinary system dysfunction are related to a combination of neurologic and urologic pathology, including pathology in the upper urinary tract, ratings from both sections can be combined using the Combined Values Chart.

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
Chet Nierenberg
,
Christopher Brigham
,
Lorne K. Direnfeld
, and
Clarissa Burket

Abstract

An independent medical evaluation (IME) may be more comprehensive and may contain more elements than an impairment evaluation, but to date no standards have defined a high-quality IME. The authors, a group of experienced IME physicians, note the variability of requirements in individual IME cases, but they have identified standards that generally apply to IME reports and include the following: definition of IME and key concepts; examiner qualifications; methodology and procedures; the physical examination; suggested generalized report format; and quality assurance. An IMR is a specialized examination and report, ideally performed by a medical physician with special training and experience in IMEs; an IME is not a medical consultation and report but rather an opportunity to determine diagnosis and document the clinical course over time. Examiners should be qualified by experience and qualifications and ideally should have a special credential from an independent medical examiners association and must be knowledgeable about IME report writing. A section of the article describes the structure of the IME report, which may vary from examiner to examiner but should include careful attention to descriptive data, history, record review, oral history, physical examination, records of other objective data, and an opinion section (with diagnoses, discussion, past medical treatment, maximum medical improvement, future medical treatment, causation and apportionment, disability/functional status, prognosis, answers to specific questions, and references.

in AMA Guides® Newsletter
Lorne Direnfeld
,
Christopher R. Brigham
, and
Elizabeth Genovese

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), does not provide a Diagnosis-based estimate of impairment due to syringomyelia, a disorder in which a cyst (syrinx), develops within the central spinal cord and destroys neural tissue as it expands. The AMA Guides, however, does provide an approach to rating a syringomyelia based on objective findings of neurological deficits identified during a neurological examination and demonstrated by standard diagnostic techniques. Syringomelia may occur after spinal cord trauma, including a contusion of the cord. A case study illustrates the rating process: The case patient is a 46-year-old male who fell backwards, landing on his upper back and head; over a five-year period he received a T5-6 laminectomy and later partial corpectomies of C5, C6, and C7, cervical discectomy C5-6 and C6-7; iliac crest strut graft fusion of C5-6 and C6-7; and anterior cervical plating of C5 to C7 for treatment of myelopathy; postoperatively, the patient developed dysphagia. The evaluating physician should determine which conditions are ratable, rate each of these components, and combine the resulting whole person impairments without omission or duplication of a ratable impairment. The article includes a pain disability questionnaire that can be used in conjunction with evaluations conducted according to Chapter 3, Pain, and Chapter 17, The Spine.

in AMA Guides® Newsletter