Apportionment of Musculoskeletal Injuries

2015 ◽  
Vol 20 (5) ◽  
pp. 3-11
Author(s):  
Stephen L. Demeter ◽  
Christopher Brigham ◽  
James B. Talmage ◽  
J. Mark Melhorn ◽  
Steven D. Feinberg
Keyword(s):  
Musculoskeletal Injuries ◽  
Sixth Edition ◽  
Body Regions ◽  
Recent Edition ◽  
The Individual ◽  
Causation Analysis ◽  
Injury Causation

Abstract When they apportion impairment in musculoskeletal cases, evaluators encounter a variety of unique issues and problems. The first step in apportionment is scientifically based causation analysis. Arbitrary or opinion-based unscientific apportionment estimates that amount to little more than speculation should be avoided. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth and Fifth Editions, are similar in their assessment of orthopedic impairment, but significant differences exist between these and the Sixth Edition. Individuals may experience impairments on several occasions. For example, if the first injury was rated using an earlier edition of the AMA Guides and a second injury occurs and is rated using a more current edition, then the most recent edition in the current jurisdiction is used to recalculate the rating for the first injury. Regarding which edition of the AMA Guides to use, evaluators should be aware of the jurisdictional requirements and also the timing to ensure that the individual is at maximum medical improvement. If the issue to be determined is apportioning the cause of the injury and not the impairment rating, then different criteria are used and the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, is an invaluable resource. Extensive sidebars discuss qualitative vs qualitative apportionment and steps that evaluators can take to ensure that body regions and conditions are not confused (ie, that an apples-to-apples comparison is taking place).

Shoulder Pain at Work: Causation Analysis

2017 ◽  
Vol 22 (1) ◽  
pp. 11-16
Author(s):  
Joel Weddington ◽  
Charles N. Brooks ◽  
Mark Melhorn ◽  
Christopher R. Brigham
Keyword(s):  
Epidemiological Data ◽  
Case Law ◽  
Individual Case ◽  
Shoulder Injury ◽  
Work Related ◽  
Clear Cut ◽  
The Individual ◽  
Causation Analysis ◽  
Injury Causation ◽  
Relevant Factors

Abstract In most cases of shoulder injury at work, causation analysis is not clear-cut and requires detailed, thoughtful, and time-consuming causation analysis; traditionally, physicians have approached this in a cursory manner, often presenting their findings as an opinion. An established method of causation analysis using six steps is outlined in the American College of Occupational and Environmental Medicine Guidelines and in the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, as follows: 1) collect evidence of disease; 2) collect epidemiological data; 3) collect evidence of exposure; 4) collect other relevant factors; 5) evaluate the validity of the evidence; and 6) write a report with evaluation and conclusions. Evaluators also should recognize that thresholds for causation vary by state and are based on specific statutes or case law. Three cases illustrate evidence-based causation analysis using the six steps and illustrate how examiners can form well-founded opinions about whether a given condition is work related, nonoccupational, or some combination of these. An evaluator's causal conclusions should be rational, should be consistent with the facts of the individual case and medical literature, and should cite pertinent references. The opinion should be stated “to a reasonable degree of medical probability,” on a “more-probable-than-not” basis, or using a suitable phrase that meets the legal threshold in the applicable jurisdiction.

The AMA Guides in Pennsylvania “Post-Protz”: Act 111 and Case Law Update

2020 ◽  
Vol 25 (3) ◽  
pp. 12-19
Author(s):  
Justin D. Beck ◽  
Judge David B. Torrey
Keyword(s):  
Case Law ◽  
General Assembly ◽  
Disability Benefits ◽  
Permanent Disability ◽  
Sixth Edition ◽  
Legal Questions ◽  
The Supreme Court ◽  
Recent Edition ◽  
Impairment Ratings

Abstract Medical evaluators must understand the context for the impairment assessments they perform. This article exemplifies issues that arise based on the role of impairment ratings and what edition of the AMA Guides to the Impairment of Permanent Impairment (AMA Guides) is used. This discussion also raises interesting legal questions related to retroactivity, applicability of prior precedent, and delegation. On June 20, 2017, the Supreme Court of Pennsylvania handed down its decision, Protz v. WCAB (Derry Area Sch. Dist.), which disallows use of the “most recent edition” of the AMA Guides when determining partial disability entitlement under the Pennsylvania Workers’ Compensation Act. An attempted solution was passed by the Pennsylvania General Assembly and was signed into law Act 111 on October 24, 2018. Although it affirms that the AMA Guides, Sixth Edition, must be used for impairment ratings, the law reduces the threshold for total disability benefits from 50% to 35% impairment. This legislative adjustment benefited injured workers but sparked additional litigation about whether, when, and how the adjustment should be applied (excerpts from the laws and decisions discussed by the authors are included at the end of the article). In using impairment as a threshold for permanent disability benefits, evaluators must distinguish between impairment and disability and determine an appropriate threshold; they also must be aware of the compensation and adjudication process and of the jurisdictions in which they practice.

Nonspecific Chronic Back Pain: Sixth Edition Approaches

2019 ◽  
Vol 24 (5) ◽  
pp. 14-15
Author(s):  
Jay Blaisdell ◽  
James B. Talmage
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Intervertebral Disk ◽  
Key Factors ◽  
Sixth Edition ◽  
Whole Person ◽  
Class 1 ◽  
A Cell ◽  
Intervertebral Disk Herniation ◽  
The Individual

Abstract Ratings for “non-specific chronic, or chronic reoccurring, back pain” are based on the diagnosis-based impairment method whereby an impairment class, usually representing a range of impairment values within a cell of a grid, is selected by diagnosis and “specific criteria” (key factors). Within the impairment class, the default impairment value then can be modified using non-key factors or “grade modifiers” such as functional history, physical examination, and clinical studies using the net adjustment formula. The diagnosis of “nonspecific chronic, or chronic reoccurring, back pain” can be rated in class 0 and 1; the former has a default value of 0%, and the latter has a default value of 2% before any modifications. The key concept here is that the physician believes that the patient is experiencing pain, yet there are no related objective findings, most notably radiculopathy as distinguished from “nonverifiable radicular complaints.” If the individual is found not to have radiculopathy and the medical record shows that the patient has never had clinically verifiable radiculopathy, then the diagnosis of “intervertebral disk herniation and/or AOMSI [alteration of motion segment integrity] cannot be used.” If the patient is asymptomatic at maximum medical improvement, then impairment Class 0 should be chosen, not Class 1; a final whole person impairment rating of 1% indicates incorrect use of the methodology.

Medical and Legal Issues Raised by the Protz Decision Issued by the Pennsylvania Supreme Court

2017 ◽  
Vol 22 (4) ◽  
pp. 12-13
Author(s):  
LuAnn Haley ◽  
Marjorie Eskay-Auerbach
Keyword(s):  
Supreme Court ◽  
Scientific Evidence ◽  
Workers Compensation ◽  
Sixth Edition ◽  
Complex Concept ◽  
The Supreme Court ◽  
Compensation Claims ◽  
Recent Edition ◽  
Impairment Ratings ◽  
Definition Of

Abstract Pennsylvania adopted the impairment rating provisions described in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in 1996 as an exposure cap for employers seeking predictability and cost control in workers’ compensation claims. In 2017, the Supreme Court of Pennsylvania handed down the Protz decision, which held that requiring physicians to apply the methodology set forth in the most recent edition of the AMA Guides reflected an unconstitutional delegation of legislative power to the American Medical Association. The decision eliminates the impairment-rating evaluation (IRE) mechanism under which claimants were assigned an impairment rating under the most recent edition of the AMA Guides. The AMA Guides periodically are revised to include the most recent scientific evidence regarding impairment ratings, and the AMA Guides, Sixth Edition, acknowledges that impairment is a complex concept that is not yet defined in a way that readily permits an evidence-based definition of assessment. The AMA Guides should not be considered standards frozen in time simply to withstand future scrutiny by the courts; instead, workers’ compensation acts could state that when a new edition of the AMA Guides is published, the legislature shall review and consider adopting the new edition. It appears unlikely that the Protz decision will be followed in other jurisdictions: Challenges to using the AMA Guides in assessing workers’ compensation claims have been attempted in three states, and all attempts failed.

scholarly journals Medicolegal Causation Investigation of Bacterial Endocarditis Associated with an Oral Surgery Practice Using the INFERENCE Approach

2021 ◽  
Vol 18 (14) ◽  
pp. 7530
Author(s):  
Putri Dianita Ika Meilia ◽  
Maurice P. Zeegers ◽  
Herkutanto ◽  
Michael D. Freeman
Keyword(s):  
Oral Surgery ◽  
Invasive Procedure ◽  
Bacterial Endocarditis ◽  
Infection Prevention And Control ◽  
Healthcare Associated Infection ◽  
Department Of Health ◽  
The Individual ◽  
Healthcare Associated ◽  
And Control ◽  
Causation Analysis

Investigating causation is a primary goal in forensic/legal medicine, aiming to establish the connection between an unlawful/negligent act and an adverse outcome. In malpractice litigation involving a healthcare-associated infection due to a failure of infection prevention and control practices, the medicolegal causal analysis needs to quantify the individual causal probabilities to meet the evidentiary requirements of the court. In this paper, we present the investigation of the most probable cause of bacterial endocarditis in a patient who underwent an invasive procedure at a dental/oral surgical practice where an outbreak of bacterial endocarditis had already been identified by the state Department of Health. We assessed the probability that the patient’s endocarditis was part of the outbreak versus that it was an unrelated sporadic infection using the INFERENCE (Integration of Forensic Epidemiology and the Rigorous Evaluation of Causation Elements) approach to medicolegal causation analysis. This paper describes the step-by-step application of the INFERENCE approach to demonstrate its utility in quantifying the probability of causation. The use of INFERENCE provides the court with an evidence-based, transparent, and reliable guide to determine liability, causation, and damages.

Parallaxes and the significance of their errors

1978 ◽  
Vol 48 ◽  
pp. 69-73
Author(s):  
A. R. Upgren
Keyword(s):  
Gaussian Distribution ◽  
Nonlinear Least Squares ◽  
Trigonometric Parallaxes ◽  
Recent Edition ◽  
The Mean ◽  
The Individual ◽  
Van Vleck ◽  
The Right ◽  
Machine Readable ◽  
Machine Readable Form

This is a brief report whose principal purpose is to summarize the present status of trigonometric parallaxes and to present the results of a new analysis of their errors. The review articles by Gliese, Strand, Upgren and Vasilevskis fully describe the methods used by investigators of parallax errors and their results; here we shall update the tabulation of the parallaxes and describe some recent results and conclusions. Although the pages on the left side of the most recent edition of the Yale Parallax Catalogue and its Supplement have been available in machine-readable form for years, the pages on the right side listing the individual parallax determinations by each observatory became similarly available only last year at the Van Vleck Observatory. Thus it has now become a simple matter to tabulate and analyze the parallaxes of each observatory separately without lengthy tabulation procedures being made by hand. One study has already been made from these data in which the frequency distribution of all trigonometric parallaxes in the Yale Catalogue was fit to a Gaussian distribution using a nonlinear least—squares procedure. This distribution is shown in Figure 1. The major conclusion was that the best estimate of the mean error of all of the parallaxes is about +0.”016, in agreement with a much simpler approach made by Hertzsprung. The large parallaxes did not affect the ability of the program to fit a Gaussian distribution to the smaller parallaxes.

Effects of Aging on Impairment Ratings: Part 4: Musculoskeletal Issues

2019 ◽  
Vol 24 (6) ◽  
pp. 3-11
Author(s):  
Stephen L. Demeter ◽  
Charles N. Brooks ◽  
J. Mark Melhorn
Keyword(s):  
Medical Literature ◽  
Diffuse Idiopathic Skeletal Hyperostosis ◽  
Older Individuals ◽  
Repetitive Motion ◽  
Age Related ◽  
Spinal Ligaments ◽  
Impairment Ratings ◽  
Effects Of Aging ◽  
Causation Analysis ◽  
Injury Causation

Abstract This article is the fourth of five in a series on the effects of age-related changes in impairment evaluations as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. The present article addresses the musculoskeletal system and differs from the first three articles, which focused on apportionment of an impairment rating between aging and other causes. The medical literature supports the notion that age-related osteoarthritis (OA) changes in the hand and digits frequently are associated with injury and/or repetitive motion. Thus, apportionment is indicated, but deciding which came first, the imaging abnormality or the injury, requires consummate skill on behalf of the rating physician. OA also occurs in the knees and hips of older individuals. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory disorder characterized by calcification and ossification of spinal ligaments and entheses and is unique, in the authors’ opinion, because of a positive correlation between aging and back pain caused by this condition. The article also addresses the association—or the lack thereof—between pathology and aging, as well as degenerative changes and symptoms, to facilitate causation analysis. For a fuller discussion of causation analysis for the spine, readers can consult the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition.

Spinal Alteration of Motion Segment Integrity Using the Sixth Edition

2019 ◽  
Vol 24 (3) ◽  
pp. 10-13
Author(s):  
Patrick R. Luers
Keyword(s):  
Angular Motion ◽  
Resonance Imaging ◽  
Key Factors ◽  
Sixth Edition ◽  
Motion Segment ◽  
Flexion Extension ◽  
Technical Factors ◽  
Impairment Ratings ◽  
The Individual

Abstract Spinal impairment evaluation includes determination of the presence or absence of alteration of motion segment integrity (AOMSI). The diagnosis-related estimate (DRE) method is the principal methodology used to evaluate spinal AOMSI impairment in the fourth and fifth editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In the AMA Guides, Sixth Edition, impairment ratings are calculated using the diagnosis-based impairment (DBI) method that uses five impairment classes determined by diagnoses and specific criteria, adjusted by consideration of non-key factors and grade modifiers. This article includes a correction of numbers in the AMA Guides, Sixth Edition, Figure 17-6. The following factors must be considered to determine if AOMSI is present: 1) flexion/extension radiographs are performed when the individual is at maximum medical improvement and are technically adequate; 2) the proper methodology is used in obtaining measurements of translation and angular motion; 3) normal translation and angular-motion thresholds consistent with the literature are used in determining AOMSI. Imaging modalities such as videofluoroscopy, digital fluoroscopy, and upright/motion magnetic resonance imaging cannot be used to establish an AOMSI permanent impairment using the AMA Guides. A number of technical factors can affect the image quality associated with measurements of AOMSI, including film centering, artifacts, poor edge resolution, endplate normal variations and spurring, and use of analog rather than digital radiography.

Reliability of Cervical Spine Palpation

2018 ◽  
Vol 23 (3) ◽  
pp. 5-6
Author(s):  
Edward I. Dagher
Keyword(s):  
Cervical Spine ◽  
Physical Examination ◽  
Methodological Approach ◽  
Muscle Spasm ◽  
Sixth Edition ◽  
Zygapophyseal Joints ◽  
Spinous Processes ◽  
Interexaminer Reliability ◽  
Posterior Neck ◽  
The Individual

Abstract Palpitation is an important component of a comprehensive musculoskeletal and neurologic examination of the cervical spine in individuals with neck pain, but examiners should not base diagnostic conclusions (eg, facetogenic pain) and interventional procedures on palpatory findings alone. A methodological approach to palpation of the posterior neck includes evaluation of the paraspinal musculature, the tissues that overlie the facet (zygapophyseal) joints, and the midline spinous processes. Although studies have shown low interexaminer reliability, palpation is an important component of the physical examination for determining general anatomic regions of symptoms and in establishing rapport with the examinee. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the diagnosis-related estimate (DRE) or injury method lists both muscle spasm and muscle guarding as potential physical exam findings by palpation. In this edition, the range-of-motion method for rating spinal impairment states that an examiner cannot find muscle spasm on exam and rate the individual's impairment on the same day because, by definition, the individual is not at maximum medial improvement. Despite acceptance by the AMA Guides, Fifth Edition, neither spasm nor guarding appears to be a reliable finding on palpation. The AMA Guides, Sixth Edition, provides a different method for determining spinal impairment, and the authors recommend limiting physical examination findings used in impairment rating to those with acceptable interrater reliability.

Carpometacarpal (CMC) Joint Subluxation: Causation Analysis and Impairment Evaluation

2012 ◽  
Vol 17 (5) ◽  
pp. 1-7
Author(s):  
J. Mark Melhorn ◽  
Christopher R. Brigham ◽  
James B. Talmage
Keyword(s):  
Physical Examination ◽  
Radiographic Evaluation ◽  
X Rays ◽  
Plausible Mechanism ◽  
Impairment Ratings ◽  
Sufficient Magnitude ◽  
Causation Analysis ◽  
Injury Causation ◽  
Current Science ◽  
Cmc Joint

Abstract Carpometacarpal (CMC) joint subluxation refers to the changes that occur in the CMC joint as seen on x-rays and observed during physical examination. The CMC joint is the most commonly involved arthritic joint in the hand, and arthritis may appear in localized or systemic forms. A diagnosis of thumb-CMC arthritis is based on symptoms of localized pain, tenderness, and instability on physical examination and radiographic evaluation. The AMA Guides to the Evaluation of Disease and Injury Causation provides a protocol for assessing causation and requires that all three of the following criteria must be met: 1) the patient has an illness compatible with a disease-producing agent or an injury; 2) the worker's exposure in the occupational environment potentially caused the disease or is a plausible mechanism of injury of sufficient magnitude to cause the condition; and 3) the preponderance of evidence supports the disease or injury as occupational in origin. If any one of the three is possible but not probable, causation has not been established. The authors review several published articles and conclude that, based on the clinical facts and current science, CMC joint subluxation is unrelated to work and instead is reflective of aging. The article concludes with a comparison of impairment ratings of CMC-related disability using the fifth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment, both of which lead to identical impairment ratings but by different means.

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