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- Author or Editor: Stephen L. Demeter x
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Abstract
The fourth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) devoted only a single page to the rating of thrombotic and hemorrhagic disorders, based primarily on analogous impairments from other organ systems and impairments in the activities of daily living (ADLs). The AMA Guides, Fifth Edition, rated thrombotic disorders by the effects on the organ system; criteria for rating hemorrhagic and platelet disorders were based on the treatment required and interferences in ADLs. The sixth edition introduced significant changes, among which are the following: The ratings for hematological disorders were deliberately reduced, especially the highest ratings, because of the inevitable involvement of other organ systems. The goal is for evaluators to rate each organ system based on its defined criteria rather than combining multiple organ system difficulties into a single organ system rating. Also in the AMA Guides, Sixth Edition, separate tables are used to rate hemorrhagic conditions caused by platelet disorders, hemophilia, and clotting disorders. Further, major changes were required because of global methodological changes in this edition, including a significant expansion of the methodology used in rating clotting defects. Finally, the rating for the use of warfarin was altered, and thrombotic disorders are rated using the specific coagulation defect.
Abstract
In 1956, the Board of Trustees of the American Medical Association convened an ad hoc Committee on Medical Rating of Physical Impairment that published thirteen articles in JAMA between 1958 and 1970, including one on pulmonary impairment rating on November 22, 1965. That article rated pulmonary impairment by radiographic abnormalities, the historical description of the degree of shortness of breath, the results of at least two of three spirometric tests (forced vital capacity, forced expiratory flow in one second, and the maximal ventilatory volume), the maximal ventilatory volume, and oxygen saturation (if performed). Use of the examinee's history has come full circle from being part of the impairment rating process to being excluded to being reintroduced in the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition. The concept that asthma is not easily rated using methods applicable to other pulmonary diseases was introduced in the fifth edition and was modified for use in the sixth edition. Since the publication of the fifth edition, several medications have been approved for treatment of asthma. Future editions likely will refine the medication usage table to reflect medications in clinical use at the time and, one hopes, also will eliminate the clumsy reference to “beclomethasone equivalents” and are likely instead to reference low, medium, and high doses of the inhaled corticosteroids.
Abstract
The goal of impairment assessment is to accurately estimate the loss of structure and/or function due to an injury or illness. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) sometimes provides two or more methods for rating a given condition, or, in the case of two or more impairing conditions, it may be inappropriate to rate less significant conditions if the rating for the primary impairment already takes into account the deficit(s). Either scenario offers opportunities for “double-dipping” or rating the same impairment more than once. Duplicative ratings commonly occur when two or more impairing conditions are present in a single organ system and even more often if multiple organ systems are involved. Because of methodological changes, ratings using the AMA Guides, Sixth Edition, are less susceptible to double-dipping than those from earlier editions, especially musculoskeletal ratings. To avoid duplication, the rater must look closely at all elements included in the impairment classes and determine if any similarity exists in the other organ systems or conditions rated (eg, is the patient's coronary artery disease responsible for the diminished exercise capacity, or is it the cardiomyopathy, or is it chronic obstructive pulmonary disease). When two or more conditions are present, evaluators should rate the higher or highest impairment and then eliminate, as much as possible, the influence of similar symptoms, signs, or diagnostic test abnormalities when rating the lower impairments.
Abstract
Aneurysms may result in ratable permanent impairment, and this article provides a basic understanding of aneurysms and how to rate them using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. An aneurysm is a bulge in a blood vessel, commonly in the arterial circulation and in the cerebral and renal vasculature or in the aorta. Because ruptured aneurysms frequently are lethal, generally they are treated prophylactically once they have reached a certain size. Endovascular repair is associated with an increased risk of all-cause mortality and abdominal aortic aneurysm mortality. The AMA Guides, Fifth Edition, rated aneurysms solely on the risk of rupture (ie, a future impairment, one of the few exceptions to their general proscription in the AMA Guides), and the impairment percentages can be quite large. These impairments are rated using the rating systems for the affected organ system when the individual is at maximum medical improvement (MMI). In addition, the risk of future impairment should be assessed when the individual is at MMI, and that rating should be combined with the rating for organ system vascular compromise. The justification for rating the risk of future events should be clarified in the report, which should cite the method reported in the present article because the AMA Guides, Sixth Edition, does not provide a methodology for rating this disease process.
Abstract
This article is the third in a series of four that explore the effects of age-related changes in impairments as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. Specifically, this article focuses on evaluation of disturbances of the nervous system, divided for discussion here into four parts—the central nervous system (CNS), the peripheral nervous system, vision, and hearing—and offers guidance in using the AMA Guides, Fifth and Sixth Editions, in a variety of specific disorders within each group. For example, the CNS discussions address disorders of consciousness and awareness; sleep and arousal disorders; alterations in metal status, cognition, and highest integrative function; aphasia or dysphagia; emotional or behavioral disorders resulting from CNS causation (fifth edition only); chronic pain; and others. One of the most challenging issues in evaluating peripheral neuropathy regards carpal tunnel syndrome, and rating physicians should provide references in their reports to justify their position. Rating visual problems usually requires attention to the medical records to document preinjury visual status. The AMA Guides, Fifth and Sixth Editions, do not use age-adjusted corrections in assessing age-related diminished hearing, but local jurisdictions and circumstances may apply apportionment. In apportioning impairment due to aging, the examiner must understand both the science and the specific legal processes involved.
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) infections began in late 2019/early 2020 and quickly achieved pandemic proportions. Of significance is that, while most individuals recover, some do not. Those who have persistent symptoms are diagnosed with long COVID, or post-COVID syndrome. Individuals with long COVID develop symptoms related to multiple organ systems. One of the more frequent systems affected is the pulmonary system. Individuals develop shortness of breath and/or fatigue. These are sometimes unrelated to any abnormalities on physiological or radiographic testing. More frequently, however, there are abnormalities found radiographically (especially on computed tomography) and on physiological testing (generally, abnormalities in the diffusion capacity for carbon monoxide or in a 6-minute walk test with the oxygen saturation being measured during the test). This article reviews many published articles and is organized by the duration of signs, symptoms, and/or testing abnormalities after the initial diagnosis of COVID-19. The date of maximum medical improvement is suggested to be 12 months, although currently this cannot be definitively supported. More time will need to pass so that appropriate data can be collected.
Abstract
The Centers for Disease Control has defined long COVID—or post–COVID-19 conditions—as a clinical syndrome reflecting a wide range of new, persistent, or recurring health problems experienced by individuals infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]). What is known is that symptoms in these individuals diminish with time. It is unclear how long it takes to achieve maximum medical improvement. This article addresses the cardiac manifestations (including the pulmonary vascular and peripheral vascular manifestations) of long COVID. Emphasis is placed on recent articles (published in the last year) and issues relating to impairment evaluations.
Abstract
There is an association between obesity and restriction on pulmonary function testing when relying on the forced vital capacity (FVC) as the defining parameter for restriction. Body mass index (BMI) may not be the best measure of obesity, but it is the most commonly used. Multiple examples of regression formulae have been developed to explain the relationship between obesity and restriction, but these may be too complicated for general use. This article reviews the medical literature concerning this association.
Abstract
A long-standing criticism of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) has been the inequity between the internal medicine ratings and the orthopedic ratings; in the comparison, internal medicine ratings appear inflated. A specific goal of the AMA Guides, Sixth Edition, was to diminish, where possible, those disparities. This led to the use of the International Classification of Functioning, Disability, and Health from the World Health Organization in the AMA Guides, Sixth Edition, including the addition of the burden of treatment compliance (BOTC). The BOTC originally was intended to allow rating internal medicine conditions using the types and numbers of medications as a surrogate measure of the severity of a condition when other, more traditional methods, did not exist or were insufficient. Internal medicine relies on step-wise escalation of treatment, and BOTC usefully provides an estimate of impairment based on the need to be compliant with treatment. Simplistically, the need to take more medications may indicate a greater impairment burden. BOTC is introduced in the first chapter of the AMA Guides, Sixth Edition, which clarifies that “BOTC refers to the impairment that results from adhering to a complex regimen of medications, testing, and/or procedures to achieve an objective, measurable, clinical improvement that would not occur, or potentially could be reversed, in the absence of compliance.