Showing papers in "AMA guides newsletter in 2022"

Long COVID-19 Neurological and Psychological Claims: Assessment Guidelines

Abstract: Post–severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) conditions are referred to by a wide range of names, including long COVID, post-acute COVID-19, long-term effects of COVID, post-acute COVID syndrome, chronic COVID, long-haul COVID, late sequelae, and others, as well as the research term, post-acute sequelae of SARS-CoV-2 infection (PASC). Symptoms may include difficulty thinking or concentrating, fatigue, depression, anxiety, and other complaints. The results of studies are clouded by self-reports, lack of objective cognitive data, misattribution, and ill-defined psychological issues. Prospective cohort studies with objective assessment are needed to clarify the impact of COVID-19. While we do not dismiss the presence of long COVID or chronic COVID-19 symptoms lasting beyond a typically expected viral respiratory-transmitted syndrome, neither do we uncritically accept such a syndrome in all those who were diagnosed as having COVID-19, especially in those whose initial presentation was asymptomatic or mild. Evaluators must be astute and perform unbiased, thorough assessments and focus on objective findings while carefully assessing the potential for confounding or alternate conditions.

Cardiac Manifestations of “Long COVID” (Post–COVID-19 Conditions)

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.

Common Errors in Spinal Impairment Rating: AMA Guides, Sixth Edition, Definitions of Radiculopathy vs Nonverifiable Radicular Complaints

Abstract: In assessing spinal impairment, it is imperative to distinguish between limb pain or numbness that might be radicular, but with no objective verification, from symptoms that represent, in fact, true radiculopathy, ie, pain, numbness, or weakness that was related to objective radiculopathy. In the sixth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), this distinction determines what row in the spine tables is used to rate impairment. Failure to discern between nonverifiable radicular complaints and true radiculopathy is a source of frequent errors in spinal impairment rating. True radiculopathy is pain, numbness, and/or weakness from nerve root damage, most commonly from a disc herniation. This article will review how the AMA Guides has dealt with the concept of radiculopathy through the years.

Observed Errors in Lower Extremity Impairment Rating: Recognition and Prevention

Abstract: Impairment evaluations not performed following processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) usually result in erroneous ratings. Common lower extremity impairment rating (IR) errors include using the diagnosis-based approach for more than one diagnosis within a region, and incorrectly assessing gait abnormalities, motion loss, nerve injuries, and complex regional pain syndrome. Rigorous adherence to the AMA Guides methodology and recognition of common IR errors can prevent the promulgation of erroneous impairment ratings.

Pulmonary Manifestations of “Long COVID” (Post–COVID-19)

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.

Q&A: Rating Partial Vs Total Knee Replacement

Abstract: QUESTION: In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, is there a difference in rating a partial vs total knee replacement? Table 16-3, Knee Regional Grid—Lower Extremity Impairments, only lists “total knee replacement.”ANSWER: The original (2008) printing of the AMA Guides, Sixth Edition, only listed total knee replacement (TKR) in Table 16-3 (6th ed, 511), which made it unclear how unicompartmental knee replacements, whether unicondylar or patellofemoral, should be rated.However, in the 2014 printing of the sixth edition, and in the digital edition of the AMA Guides Sixth Edition 2022, partial knee replacement is in the same row as TKR in Table 16-3.

Best Practices for the Independent Medical Examination of Mental and Behavioral Disorders

Abstract: Independent medical examinations (IMEs) are elective evaluations of clinical conditions and differ from a clinical consultation in several important ways. They are conducted in many medicolegal contexts and are performed by a regulated health professional who is not the treating health care provider. An IME seeks objective information about the examinee's diagnoses, functional abilities and impairments, and other features relevant to addressing medicolegal-related cases by relying on multiple data sources. Best practice guidelines have been established for the completion of physical IMEs. However, similar mental and behavioral disorder (M&BD) standards are less common, and M&BD IMEs often do not follow a consistent process. This article offers guidance on applying and adapting existing standards to M&BD IMEs. We outlined the appropriate use of psychiatric nomenclature and how to apply recent changes to Chapter 14 of the AMA Guides to the Evaluation of Permanent Impairment. The article further offers a mechanism for introducing greater objectivity into an otherwise subjective process by employing relevant psychological validity testing and conducting a coherence analysis in formulating an opinion. In summary, we provide a synopsis of current best practices and offer the examiner a method for aligning M&BD IMEs with equally high standards of excellence.

Q&A: Rating Brachial Plexus Injury

Abstract: QUESTION: How do I assess impairment for a patient with a brachial plexus injury involving the middle and lower trunks but not the upper trunk?ANSWER: Rating impairment for a brachial plexus injury using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, is straightforward. Table 15-20, Brachial Plexus Impairment: Upper Extremity Impairments (6th ed, 434-435), lists impairments for the entire brachial plexus, as well as upper, middle, and lower trunks individually, each in different rows. If both middle and lower trunks were injured, each would be rated, and the upper limb impairments combined per instructions number 8 and 13 on page 481.The classic anatomic description of the brachial plexus describes the C5 through T1 nerve roots as contributing to the plexus, with the middle trunk composed of just the C7 nerve root, while the lower trunk is formed by the fusion of the C8 and T1 nerve roots. However, this “classic plexus” is found in only 37% to 77% of cadaver dissections.1 The two most common anatomic anomalies are “prefixed” and “postfixed” plexi. In a prefixed plexus, the C4 nerve root has a substantial contribution, while the T1 nerve root has minimal or no contribution to the plexus. In a postfixed plexus, there is minimal or no C5 contribution to the plexus and a substantial T2 nerve root contribution. Thus, standard charts of the nerve root contributing to individual peripheral nerves or trunks of the plexus may not correspond to an individual patient's anatomy.Assuming C7 supplies sensation to the middle finger and C8 and T1 to the little finger and ulnar forearm, rating sensory deficit without obvious duplication is more straightforward.Rating the motor deficit is more complex. No nerve to a single muscle leaves either the middle or lower trunk of the classic plexus. Hence, one cannot determine whether the injury does or does not involve the trunk by involvement or sparing that nerve, respectively. Normal paraspinal muscles on needle electromyography (EMG) with clear denervation in limb muscles helps localize the lesion as distal to the nerve root division into anterior and posterior primary rami. Stimulating proximal to the plexus at the level of individual nerve root during nerve conduction testing is challenging and rarely done. Magnetic resonance imaging (MRI) may not clarify the level of injury. However, in cases of open trauma with immediate surgery to repair vascular damage, the operative report may accurately describe the extent of any concomitant brachial plexus injury.Because most muscles are innervated by more than one nerve root—a fail-safe redundancy in the case of injury—residual weakness in any one muscle may be from injury to the lower trunk, middle trunk, or both. Hence, it is wise to rate the severity of the motor loss on physical examination by assuming any one muscle is innervated by nerves derived from only one trunk.For example, the triceps is classically described as innervated by the C7, C8, and partially by the T1 nerve roots. If the triceps has grade 3/5 weakness on examination, and if that is considered middle trunk weakness when rating the middle trunk, and lower trunk weakness when rating the lower trunk, the motor deficit rating will be duplicative (rating the same weakness twice).Similarly, classic innervation charts show C7 and C8 contributing to the flexor carpi ulnaris, flexor digitorum profundus, abductor digiti minimi, first dorsal interosseous, extensor digitorum communis, and extensor carpi ulnaris. Logically weakness in these muscles should be attributed to and rated as either middle or lower trunk motor deficits, but not both.Brachial plexus injuries are uncommon, and it takes considerable time and thought to thoroughly examine and correctly rate the residuals.

Q&A: Use of Hip Motions When Rating Total Hip Replacement

Abstract: QUESTION: When rating impairment after total hip replacement using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, I know that if using range of motion (ROM) as a stand-alone method, one would add the percentage lower extremity impairments (LEIs) for each of the six hip motions, and the total is the impairment rating. When using the diagnosis-based impairment method, I have always assumed that if all motion impairments are mild, that is a good result, and I have selected class 2 in Table 16-4, Hip Regional Grid (6th ed, 515). However, I read the report of another physician who, using the same diagnosis-based method, noted mild deficits in all six hip motions, added the percentage impairments for each, and selected class 3, a fair result with a higher rating. Whose logic is correct?ANSWER: Instructions at the top of the right column of the AMA Guides, Sixth Edition, page 543, state the following:Because total hip replacement is listed in Table 16-4, Hip Regional Grid (6th ed, 515), ROM would only rarely, if ever, be used as the rating method following this surgery.Instead, ROM is often used as one factor in physical examination adjustment for grade selection. Although not explicitly stated in the AMA Guides, less commonly, it may be one factor in class selection, eg, when the class criteria for a diagnosis or surgical procedure (such a total hip replacement) reference a good, fair, or poor result.Instructions for how to use ROM to select a class appear in the sixth edition on page 548 in step 4. After determining the total impairment of a joint due to motion loss(es), go to Table 16-25, (6th ed, 550)” … to classify the severity of the lower extremity motion measurements in the ICF [International Classification of Functioning, Disability, and Health] format.” For example, 20% LEI due to motion loss(es) of a joint is classified as moderate severity and class 2, whereas 30% LEI would be classified as severe and class 3. The classification from Table 16-25, combined with other outcome data from a total hip replacement, would be used to determine whether there was a good, fair, or poor result, corresponding to class 2, 3, and 4, respectively. Grade modification would be done following class selection. Table 16-25 shows how one determines whether joint motion loss is mild, moderate, severe, or very severe in Table 16-7, Physical Examination Adjustment (6th ed, page 517). However, to avoid “double-dipping” data, if ROM was used to select the class, it would not be used again in physical examination adjustment.Returning to the question posed, if there were mild impairment for each of the six hip motions per Table 16-24, the total would be 5% × 6 = 30% LEI. Per Table 16-25, this is severe (class 3) impairment. However, ROM is only one factor in determining the outcome of a total hip replacement, and the final class could be 2, 3, or 4, depending on whether there was a good, fair, or poor result, respectively.

Q&A: Rating Horner Syndrome

Abstract: QUESTION: How is Horner syndrome rated?ANSWER: Horner syndrome is a relatively rare, usually unilateral disorder characterized by a constricted pupil (miosis), drooping of the upper eyelid (ptosis), and absence of facial sweating (anhidrosis). It results from disruption of the sympathetic nerve supply to the face, including the eye. The neural disruption can be caused by many different diseases and injuries, both congenital and acquired, and some cases are idiopathic.The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not specifically address Horner syndrome. However, in the sixth edition, ptosis can be rated using Table 11-5, Criteria for Rating Impairment due to Facial Disorders and/or Disfigurement (6th ed, 262), as explained in Section 11.3a, Criteria for Rating Impairment due to Facial Disorders and/or Disfigurement (6th ed, 261-265). Usually, Horner syndrome does not result in significant visual impairment. However, Chapter 12, The Visual System, Section 12.4b, Individual Adjustments (6th ed, 305-306), explains considerations for other functions. In the unlikely event the ptosis is of sufficient severity to restrict the visual field, that impairment can be rated. Because miosis often helps correct visual acuity deficit from astigmatism, there is usually no visual acuity loss from Horner syndrome.

Observed Errors in Upper Extremity Impairment Rating: Recognition and Prevention

Abstract: Impairment evaluations not performed following processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) will result in erroneous ratings. Common errors in impairment rating (IR) for upper extremity are frequently seen in physician IR reports and independent medical examination reports. Recognizing these errors can result in the prevention and management of these ratings. Common errors include rating impairment using the diagnosis-based approach for more than one diagnosis within a region and making incorrect assessments of motion loss, nerve injuries, entrapment disorders, and complex regional pain syndrome.

Addressing Mental and Social Health in Workers' Compensation

Abstract: Humans interpret and react to symptoms. We only seek care for a symptom when it becomes a concern.1 Variation in symptom intensity and magnitude of capability relates more to unhelpful thoughts, feelings of worry and despair regarding symptoms, and feelings of insecurity around role and livelihood (mental and social health opportunities) than pathophysiology.2 Work claims are meant to address pathology that results from injury. Injuries have predictable recovery trajectories. When the recovery trajectory seems off track, consider pre-existing non-trauma pathology and mental and social health opportunities. Appropriate management of new pathology under the work claim and pre-existing pathology and mental and social health opportunities outside the work claim, along with a supportive environment that anticipates these aspects of normal human illness behavior, can help people get and stay healthy in the context of workers' compensation.

The Lost Art of Spinal Physical Examination

Abstract: Spinal examination findings of “spasm” and “facet pain” are unreliable. A thorough neurological examination can help differentiate true symptomatic radiculopathy from nonverifiable radicular complaints. Manual muscle testing may miss subtle findings. The correct diagnosis for most low-back injuries in the worker's compensation setting is “nonspecific spinal pain.”

Obesity As A Cause of Restrictive Ventilatory Defect

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.

Credibility of Expert Witnesses

Abstract: Credibility of expert witnesses is essential. It is important that medical experts do not incorrectly assume that administrative law judges are their audience. Instead, it should be noted that most disputes will be resolved between the parties and their representatives. When providing opinions, experts are well-served by understanding the audience as much as practical. The best advice for experts rendering opinions is to remain true to the questions posed and follow the scientific method.

Avoiding Psychiatric Disability Overdiagnosis, Part 3: Iatrogenesis in Diagnosing Mental Health Work Disability—The Need for Implementing a Comprehensive Psychiatric Work Disability Assessment

Abstract: Claims of occupational psychiatric disability have significantly increased over the past 20 years. This article is the third in a series on avoiding psychiatric disability overdiagnosis. The first article focused on general disability issues and their effects and defined basic terms and models. The second article focused on improving the diagnosis and assessment of mental health disorders and psychiatric work disability. In this final article, we focus on iatrogenesis in diagnosing mental health work disability and argue for implementing a comprehensive disability assessment approach.