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Robert J. Barth
and
Christopher R. Brigham

Introduction “Does head trauma cause a pre-existing benign meningioma to become malignant ” Meningiomas are “slow-growing neoplasms that most likely derive from the meningothelial cells of the arachnoid layer.” 1 This question provides an excellent foundation for exploring the process of causation analysis. The baseless nature of claims of trauma causing cancer had long been highlighted in publications documenting United States (US) Supreme Court rulings from the 1990s regarding expert witness work. A prominent and quotable example is the work of Peter

in AMA Guides® Newsletter
Joel Weddington
,
Charles N. Brooks
,
Mark Melhorn
, and
Christopher R. Brigham

A worker who claims to have shoulder pain from years of pulling on grapevines or sorting laundry on hangers may have an occupational disease. On the other hand, if the job is limited to teaching or computer keyboarding, shoulder pain is unlikely to be work related. However, most cases are not so clear-cut and require detailed, thoughtful, and time-consuming causation analysis. Traditionally physicians have approached this in a cursory manner, eg, reporting, “In my opinion, the work activities caused (or did not cause) the patient's shoulder pain.” However

in AMA Guides® Newsletter
J. Mark Melhorn
,
Christopher R. Brigham
, and
James B. Talmage

extension osteotomy, arthroscopic partial trapeziectomy, implant arthroplasty, and trapeziectomy with or without ligament reconstruction and tendon interposition and occasionally fusion. Causation Analysis The AMA text Guides to the Evaluation of Disease and Injury Causation 4 provides a protocol for assessing causation, which was reviewed in the May – June 2012 issue of the Guides Newsletter . 5 Causation analysis should be conducted in an independent context, based on fact rather than opinions. The protocol includes: Definitively establishing a diagnosis

in AMA Guides® Newsletter
Kathryn Mueller
and
Charles N Brooks

Given their education and training, treating physicians often address causality only from the standpoint of differential diagnosis (i.e., what is causing the individual's symptoms and signs). Etiology may be further considered from a prophylactic or therapeutic standpoint (i.e., how to prevent recurrent injury or eliminate the cause of the illness). In workers’ compensation, however, causation analysis must extend beyond diagnosis, prophylaxis, and treatment. Physicians must consider whether the condition is attributable to the workplace, their opinion on

in AMA Guides® Newsletter
Christopher R. Brigham
,
Charles N. Brooks
, and
James B. Talmage

Causation analysis should always be based on current scientific evidence and the facts of a specific case. However, certain beliefs have evolved that lack scientific basis. One unsupportable myth is that “favoring” one lower extremity will often result in injury or illness of the opposite lower limb. This is exemplified by the case of a 40-year-old male long-shoreman who reportedly sustained an injury to left knee at work on September 1, 2009. His past history is remarkable for prior knee problems bilaterally, including high school football injuries that

in AMA Guides® Newsletter
Stephen L. Demeter
,
Charles N. Brooks
, and
J. Mark Melhorn

increasing prevalence of RCTs with aging in asymptomatic persons complicates causation analysis. When evaluating an individual who has shoulder pain following an injury or activity and a magnetic resonance imaging (MRI) scan that shows an RCT, it can be difficult to determine if the discomfort is due to the tear, a ligamentous or capsular sprain, a muscular strain, a labral tear, inflammation (arthritis, bursitis, or tendonitis), or other cause. The RCT may simply be a pre-existing asymptomatic abnormality found incidentally on the imaging study, especially in middle

in AMA Guides® Newsletter
Christopher R. Brigham
,
James B. Talmage
,
Charles Brooks
,
Gunnar Andersson
, and
Craig Uejo

disease is still more commonly used. Regardless, research in the last 10 years has dramatically altered our understanding of the etiology of DDD. Before exploring these issues, it is useful to review causation analysis and the process of determining whether a condition is work-related. The AMA Guides, Sixth Edition, Section 2.5b, Causality, Exacerbation, and Aggravation (6th ed, 25) explains: Causality requires determination that each of the following has occurred to a reasonable degree of medical certainty: A causal event took place. The patient

in AMA Guides® Newsletter
Rawson L. Wood
,
Mathew J. Greenston
,
Charles E. Bain
, and
Charles N. Brooks

MVC caused the IDD. Hence, the question arises, is there is a causal relationship between a common occurrence and an inevitable condition or are the 2 coincidental? Causation analysis must be based on the facts and science, not merely a temporal relationship and/or opinion. 1 To determine causality, the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides ® ) , Sixth Edition, Section 2.5b, Causality, Exacerbation, and Aggravation, states, “Causality requires determination that each of the following has occurred to a reasonable degree of medical

in AMA Guides® Newsletter
Stephen L. Demeter
and
E. Randolph Soo Hoo

responsible for an effect (injury, disease, impairment, etc.). Only probable causes (at least more probable than not) are included. Hence, the first step in apportionment is scientifically based causation analysis. Second, one must allocate responsibility among the probable causes and select apportionment percentages consistent with the medical literature and facts of the case in question. Arbitrary, merely opinion based unscientific apportionment estimates which are nothing more than speculations must be avoided. When appropriate current impairment can also be apportioned

in AMA Guides® Newsletter
Charles N. Brooks
and
James B. Talmage

modification, each defensible, but resulting in slightly different ratings. DEFINITIONS Apportionment The AMA Guides defines apportionment as, “The extent to which each of 2 or more probable causes are found responsible for an effect (injury, disease, impairment, etc)” (6th ed, 609). Possible causes are excluded. Therefore, the first step in apportionment is causation analysis. Causality The AMA Guides states a cause is, “In general anything that produces an effect. In medicine, cause refers to an identifiable factor (e.g., genetic abnormality, toxic

in AMA Guides® Newsletter