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- Author or Editor: Mohammed Ranavaya x
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Abstract
Impairment and disability resulting from claims of multiple chemical sensitivity (MCS) challenge independent medical examiners because of polemics associated with the syndrome, and the mainstream medical community has questioned its very existence as a medical disease entity. Since the syndrome was described in 1952, MCS has had many names, including universal allergy, total allergy syndrome, ecologic illness, 20th century disease, and chemical AIDS. Epidemiologic data show that a higher proportion of females (up to 88%) suffer from MCS, and the percentage of unemployment among MCS sufferers may be as high as 85%. The best explanation to date for MCS is that it is an illness belief system manifested by culturally shaped illness behavior. Several distinguished scientific organizations, including the AMA, conclude that there is no scientific evidence to support the MCS concept of a physiologic exposure–disease relationship; the proposed diagnostic tests and treatments have not been shown to have value; and MCS should not be a recognized clinical syndrome. Impairment evaluations should follow the guidelines in Chapters 1 and 2 of the AMA Guides to the Evaluation of Permanent Impairment. Evaluators must recognize that MCS claimants often present with comorbid psychiatric conditions, and iatrogenic disability also is a concern among MCS patients.
Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, changes the definition of “normal” (ie, the process of differentiating between an individual whose lung function is “normal” as opposed to an individual with Class 2 respiratory impairment) because the definition has changed over time. For example, the AMA Guides, First Edition (1971), used from the VA-Army 1961 Cooperative Study to construct tables of “normal” or “predicted” values during spirometry. Regression equations were used to calculate the predicted forced vital capacity, forced expiratory volume in the first second, and mandatory minute ventilation for men and women, by age and height. The Second Edition (1984) used data from a pulmonary function study in 251 healthy white individuals who lived 1400 meters above sea level (Utah), more than 90% of whom were members of the Mormon church (a very narrow segment of the American population). The AMA Guides, Third and Fourth Editions, continued to rely on the study just cited and made a distinction between “normal” and “mildly impaired.” The AMA Guides, Fifth Edition, uses the four classes of respiratory impairment and the same whole person impairment ratings for each class, unchanged from the Fourth Edition. The Fifth Edition has reverted to using the 95% confidence interval to determine “normal,” so that the same individual who, under the Fourth Edition guidelines was up to 25% impaired, would become normal under the pulmonary impairment guides of the Fifth Edition.
Abstract
The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, uses approaches to respiratory system impairment rating that are similar to those of previous editions, with two significant changes: First, criteria for asthma impairment were updated to incorporate guidelines recently published by the American Thoracic Society (ATS), and, second, respiratory impairment criteria now incorporate the lower limit of normal for forced vital capacity, forced expiratory volume in the first second (FEV1), and diffusing capacity for carbon monoxide. In 1993, the ATS published Guidelines for the Evaluation of Impairment/Disability in Patients with Asthma that recommended evaluating three parameters: degree of airflow limitation (postbronchodilator FEV1); the degree of reversibility of the airflow limitation; and the minimum amount of medication needed to maintain maximal medical improvement (MMI). The ATS Guidelines contained a scoring system that was used to place the individual into one of six impairment classes. The Fifth Edition uses the same method of scoring the three clinical parameters and using the point score to determine which of the four impairment classes best describes the impairment. The Fifth Edition discussion of occupational asthma indicates the importance of removing the individual from further exposure to the sensitizing agent; MMI usually occurs within 2 years after removal from exposure.
Abstract
The diagnostic criteria for asthma usually are straightforward and generally follow the Guidelines of the American Thoracic Society (ATS). The assessment of impairment and disability from asthma is complex because of the variable nature of the disease, and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) gives physicians discretion to adjust the class of impairment based on the frequency of asthma attacks and the physician's judgment. A physician with expertise in lung disease may use the ATS Guidelines for impairment along with the AMA Guides to determine respiratory and whole person impairment, and a table compares the AMA Guides and the ATS Guidelines in support of assessing whole person impairment. An evaluation protocol addresses the steps in the process (all should be well documented): confirm the presence of asthma; determine its severity; estimate the permanent whole person impairment (a table lists classes of whole person impairment based on the AMA Guides and the ATS Guidelines); and assess work-related asthma. In some cases, an individual with airway hyperresponsiveness may not have an impairment but may have disability for specific jobs. The protocol and suggestions offered here may be practical in most circumstances for evaluating asthma impairment and disability.
Abstract
Physicians must account for the effects of multiple impairments using a summary value. Sometimes, when dealing with multiple impairments in a single case, the evaluating physician may be confused about whether specific impairments are added or combined, particularly during the assessment of hand or limb injuries. Combining is accomplished by using the Combined Values Chart presented in the Appendix of each edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). With a few exceptions, the general rule is that all impairments should be combined. The combining must occur at the same hierarchal level (eg, upper extremity impairment can be combined only with another upper extremity impairment from the same limb), and whole person impairment (WPI) can be combined only with another WPI impairment. In case of impairments from a different limb (either from both upper or lower limbs) even though they may be expressed at the same hierarchal limb (eg, upper extremity or lower extremity), they should be combined at the WPI level only after the individual limb is fully rated and the final impairment for that limb is expressed at the WPI level. Evaluators should remember that impairing factors (sensory, motor, vascular, and so on) are combined at the smallest common unit (ie, digit < hand < upper extremity < whole person).
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.
