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Steven Mandel
and
Christopher R. Brigham
in AMA Guides® Newsletter
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Robert Thayer Sataloff
,
Joseph Sataloff
, and
Steven Mandel

Abstract

Momentary or intermittent tinnitus—perceived sounds that originate within a person's head rather than in the outside world—is common; continuous tinnitus is abnormal but not unusual. According to the National Center for Health Statistics, 32% of US adults acknowledge having experienced tinnitus at some time; 6.4% characterize the condition as debilitating or severe; and prevalence increases with age to approximately 70 years and declines thereafter. A patient with tinnitus is assessed initially using a comprehensive otologic and neurotologic history, a physical examination, and selected tests of otologic function. Current tests can evaluate hearing and balance, but no good, comprehensive, objective methods exist to determine the presence of tinnitus, quantify the symptoms, or assess its severity. For these reasons, there are no scientific data on which to base a judgment regarding impairment or disability, and tinnitus alone generally is not considered compensable. The AMA Guides to the Evaluation of Permanent Impairment allows some adjustment for unilateral, but not bilateral, tinnitus that may impair speech discrimination. No scientific justification supports this policy, and there is no defensible basis for this disparity. Thus, additional research is necessary before this subjective symptom can be used reliably in impairment and disability determinations.

in AMA Guides® Newsletter
Irvin H. Hirsch
,
Steven Mandel
, and
Christopher R. Brigham

Abstract

Male sexual dysfunction (MSD) and female sexual dysfunction (FSD) may be of multifactorial etiology; rating these disorders heretofore has been based on subjective, patient-reported criteria. This article discusses the process of determining sexual disability by incorporating objective, laboratory-based data in order to render more reliable and valid determinations, including whether the patient has received appropriate treatment and is at maximum medical improvement. MSD is of organic, psychogenic, mixed, or indeterminate cause, and identification of specific MSD etiology can be made via a thorough sexual and medical history, physical examination, and tailored laboratory testing. Routine laboratory studies should include complete blood count, serum chemistry, lipid profile, and serum free/total testosterone and prolactin levels. Using the history and physical examination and laboratory studies, evaluators can differentially diagnose more than 80% of patients as having either organic or psychogenic MSD. Objective laboratory studies for MSD include nocturnal penile tumescence, duplex Doppler ultrasound, and neurosensory testing. FSD is a prevalent, age-related women's health issue that reportedly affects up to half of women older than 50. FSD evaluation requires a comprehensive sexual and medical history as well as physical examination, pelvic examination, hormonal profile, and an evaluation by a sex therapist. Laboratory testing is not yet fully defined but may include measurements of genital blood flow, vaginal pH and compliance, and genital vibratory sensory threshold determination.

in AMA Guides® Newsletter
Seth D. Cohen
,
Steven Mandel
, and
David B. Samadi

Abstract

To properly assess men and women with sexual dysfunction, evaluators should take a biopsychosocial approach that may require consultation with multiple health care professionals from various fields in order to get to the root of the sexual dysfunction; this multidisciplinary methodology offers the best chance of successful treatment. For males, this article focuses on erectile dysfunction (ED) and hypogonadism. The initial evaluation of ED involves a thorough case history, preferably taken from the patient and partner, physical examination, and proper laboratory and diagnostic tests, including an acknowledgment of the subjective complaint. The diagnosis is established on the basis of an individual's report of the consistent inability to attain and maintain an erection sufficient to permit satisfactory sexual intercourse. Initial workups for ED should entail a detailed history that can be obtained from a validated questionnaire such as the International Index of Erectile Function and the Sexual Health Inventory for Men. Hypogonadism is evaluated using the validated Androgen Deficiency in the Aging Male questionnaire and laboratory testing for testosterone deficiency. Treatments logically can begin with the least invasive and then progress to more invasive strategies after appropriate counseling. The last and most important treatment component when caring for men with sexual dysfunction—and, arguably, the least practiced—is close follow-up.

in AMA Guides® Newsletter
Seth D. Cohen
,
Steven Mandel
, and
David B. Samadi

Abstract

Sexual dysfunction is more common in women (43%) than men (31%), and the evaluating physician must consider the individual's chronological and physiologic age, personal and interpersonal sexual experiences, life events, and relationship issues that may have an effect on female sexual health. The medical history should include focused questions about medical and/or surgical illnesses, use of medications, and urogynecological history. Validated, reliable, standardized questionnaires are useful to identify the presence or absence of various domains of female sexuality such as sexual desire, sexual arousal, orgasm, and/or sexual pain (eg, the Female Sexual Function Index). Serum hormone testing should be dictated by clinical suspicion, and the physician also may assess multiple androgen and estrogen values, as well as pituitary function and levels of thyroid stimulating hormone. Systemic androgens (eg, systemic dehydroepiandrosterone and/or systemic testosterone) may improve mood, energy, stimulation, sensation, arousal, and orgasm in women with sexual health concerns. Combining a biomedical and psychosocial approach to any kind of sexual dysfunction helps to optimize patient outcomes. In the case of hypoactive sexual desire disorder (HSDD), individual or couples-based therapy with a sexual health therapist should be part of the consultation. If the biologic basis of the sexual health concern can be diagnosed by history, physical examination, laboratory testing, and directed imaging studies, then management can be directed to evidence-based management strategies.

in AMA Guides® Newsletter
Justin J. Arnett
,
Steven Mandel
,
Steve M. Aydin
, and
Christopher R. Brigham

Abstract

Lateral epicondylitis, often called “tennis elbow,” is a musculoskeletal condition characterized by pain around the lateral elbow and adjacent forearm with resisted wrist extension or passive terminal wrist flexion with the elbow in full extension, plus tenderness over and/or just distal to the lateral epicondyle. The name is a misnomer because the pathology is neither inflammatory nor located in the lateral epicondyle but rather represents a chronic tendinosis with disorganized tissue and neovessels of the tendon originating from the extensor carpi radialis brevis muscle and less commonly the extensor digitorum communis muscle, which originate on the lateral epicondyle. Clinical assessment involves understanding the chronology, precipitating activities, current symptoms, and interference with activities of daily living. Physical examination is performed bilaterally and includes palpitation provocative testing, measuring elbow and wrist motions, and neurological evaluation. Many treatments have been proposed, but little quality evidence supports any specific approach; more than 90% of cases are managed nonoperatively. Severe cases that have failed at least months of nonoperative management may warrant surgical assessment, but studies of surgical results for treatment of lateral epicondylitis are limited. Impairment rating may be necessary in a minority of cases and involves using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, based on diagnosis-based impairment and using Table 15-4, Elbow Regional Grid: Upper Extremity Impairments.

in AMA Guides® Newsletter
Sarah H. Gulick
,
Steven Mandel
,
Edward A. Maitz
, and
Christopher R. Brigham

Abstract

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus affects the mental health of many. Isolation, fear of infection, and social distancing may affect psychological functioning. Research continues to evolve and reveal the psychological symptoms reported by coronavirus disease 2019 (COVID-19) patients. Depression, anxiety, posttraumatic stress disorder (PTSD), and psychosis have been reported in the literature for COVID-19 patients. Potential preliminary treatment recommendations include various forms of psychotherapy, such as dialectical behavioral therapy, mindfulness-based cognitive therapy, and cognitive behavioral therapy. More research should be done regarding other additional treatment recommendations that may facilitate psychological healing in COVID-19 patients.

in AMA Guides® Newsletter
Joseph R. Spiegel
,
Steven Mandel
,
Robert T. Sataloff
, and
Judith Creed

Abstract

Physicians are infrequently asked to evaluate an individual with facial disfigurement following an injury because, when the face is injured, typically it heals without any ratable impairment. When a permanent facial disfigurement must be rated, physicians can use Section 9.2 of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Chapter 9 of the AMA Guides is unique because it deals only with permanent impairment related to the face's structural integrity, which may be only one aspect of a patient's condition that requires an impairment rating. Facial disfigurement may be the result of a complicated process, for example, a burn that involves multiple organ systems, each with a loss of function that requires an impairment rating. These ratings fall into one of four classes: Class 1 is used when the disorder is limited to the cutaneous structures and may involve a scar or abnormal pigmentation in the cutaneous structures of the face. Class 2 involves loss of some significant underlying supporting structure of the face without significant functional loss or major disfigurement such as a depressed orbital rim, frontal bone, or nasal bone. Class 3 indicates loss of a normal anatomic part or area of the face, eg, an eye. A facial disfigurement so severe that it precludes social acceptance is a Class 4 impairment.

in AMA Guides® Newsletter