The sixth edition of the WHO manual on semen examination: ensuring quality and standardization in basic examination of human ejaculates

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.

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A Historical Review of Complex Regional Pain Syndrome in the “Guides Library”

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.novdec01 ◽

2009 ◽

Vol 14 (6) ◽

pp. 1-9

Author(s):

Robert J. Barth

Keyword(s):

Differential Diagnosis ◽

Complex Regional Pain Syndrome ◽

Reflex Sympathetic Dystrophy ◽

International Association ◽

Historical Review ◽

Pain Syndrome ◽

Sixth Edition

Abstract Complex regional pain syndrome (CRPS) is a controversial, ambiguous, unreliable, and unvalidated concept that, for these very reasons, has been justifiably ignored in the “AMA Guides Library” that includes the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides), the AMA Guides Newsletter, and other publications in this suite. But because of the surge of CRPS-related medicolegal claims and the mission of the AMA Guides to assist those who adjudicate such claims, a discussion of CRPS is warranted, especially because of what some believe to be confusing recommendations regarding causation. In 1994, the International Association for the Study of Pain (IASP) introduced a newly invented concept, CRPS, to replace the concepts of reflex sympathetic dystrophy (replaced by CRPS I) and causalgia (replaced by CRPS II). An article in the November/December 1997 issue of The Guides Newsletter introduced CRPS and presciently recommended that evaluators avoid the IASP protocol in favor of extensive differential diagnosis based on objective findings. A series of articles in The Guides Newsletter in 2006 extensively discussed the shortcomings of CRPS. The AMA Guides, Sixth Edition, notes that the inherent lack of injury-relatedness for the nonvalidated concept of CRPS creates a dilemma for impairment evaluators. Focusing on impairment evaluation and not on injury-relatedness would greatly simplify use of the AMA Guides.

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Sleep Impairment

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.mayjun04 ◽

2009 ◽

Vol 14 (3) ◽

pp. 7-10

Author(s):

Craig Uejo ◽

Stephen Demeter

Keyword(s):

Rotator Cuff ◽

Distal Clavicle ◽

Rotator Cuff Disease ◽

Degenerative Arthritis ◽

Sixth Edition ◽

Cuff Tear ◽

Shoulder Region ◽

Illness Causation ◽

Traumatic Rotator Cuff Tear ◽

Distal Clavicle Resection

Abstract In the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, distal clavicle resection (resection arthroplasty of the acromioclavicular joint [ACJ]) results in ratable impairment, but only a single diagnosis within a region may be rated. Therefore, if another impairing condition is present in the shoulder region (eg, impingement syndrome or rotator cuff disease) only that resulting in the greatest causally related impairment is rated. In the setting of an occupational or other compensable injury or illness, causation of the impairment often is a key issue because, typically, only impairment that is causally related to the injury can be rated. For example, assume that a lifting injury at work caused a tear in a rotator cuff tendon that was already attenuated by repetitive impingement on inferiorly projecting spurs from longstanding degenerative arthritis of the ACJ. If surgery was performed for a traumatic rotator cuff tear and the distal clavicle also was resected due to preexisting ACJ arthritis, the latter surgery is not considered to be related to the injury. In other words, because the ACJ arthritis was neither caused nor worsened by the injury, this condition is not rated. The distal clavicular resection may have been warranted to diminish pain due to ACJ arthritis and/or eliminate the distal clavicle as a source of impingement.

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Obstacles to Claiming Permanence and Injury-Relatedness for “Posttraumatic” Headache

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.mayjun02 ◽

2009 ◽

Vol 14 (3) ◽

pp. 3-6

Author(s):

Robert J. Barth

Keyword(s):

Complete Recovery ◽

World Health ◽

Related Factors ◽

Posttraumatic Headache ◽

Sixth Edition ◽

Causative Relationship ◽

Short Period ◽

The One ◽

Health Organization ◽

Subjective Reports

Abstract “Posttraumatic” headaches claims are controversial because they are subjective reports often provided in the complex of litigation, and the underlying pathogenesis is not defined. This article reviews principles and scientific considerations in the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides) that should be noted by evaluators who examine such cases. Some examples in the AMA Guides, Sixth Edition, may seem to imply that mild head trauma can cause permanent impairment due to headache. The author examines scientific findings that present obstacles to claiming that concussion or mild traumatic brain injury is a cause of permanent headache. The World Health Organization, for example, found a favorable prognosis for posttraumatic headache, and complete recovery over a short period of time was the norm. Other studies have highlighted the lack of a dose-response correlation between trauma and prolonged headache complaints, both in terms of the frequency and the severity of trauma. On the one hand, scientific studies have failed to support the hypothesis of a causative relationship between trauma and permanent or prolonged headaches; on the other hand, non–trauma-related factors are strongly associated with complaints of prolonged headache.

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Use of the AMA Guides in State Workers' Compensation Systems: 2009 Update

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.marapr02 ◽

2009 ◽

Vol 14 (2) ◽

pp. 13-16

Author(s):

Christopher R. Brigham ◽

Jenny Walker

Keyword(s):

New York ◽

North Carolina ◽

South Carolina ◽

South Dakota ◽

Rhode Island ◽

Workers Compensation ◽

Fourth Edition ◽

Sixth Edition ◽

Specific Guideline ◽

Compensation Systems

Abstract The AMAGuides to the Evaluation of Permanent Impairment (AMA Guides) is the most widely used basis for determining impairment and is used in state workers’ compensation systems, federal systems, automobile casualty, and personal injury, as well as by the majority of state workers’ compensation jurisdictions. Two tables summarize the edition of the AMA Guides used and provide information by state. The fifth edition (2000) is the most commonly used edition: California, Delaware, Georgia, Hawaii, Kentucky, New Hampshire, Idaho, Indiana, Iowa, Kentucky, Massachusetts, Nevada, North Dakota, Ohio, Vermont, and Washington. Eleven states use the sixth edition (2007): Alaska, Arizona, Louisiana, Mississippi, Montana, New Mexico, Oklahoma, Pennsylvania, Rhode Island, Tennessee, and Wyoming. Eight states still commonly make use of the fourth edition (1993): Alabama, Arkansas, Kansas, Maine, Maryland, South Dakota, Texas, and West Virginia. Two states use the Third Edition, Revised (1990): Colorado and Oregon. Connecticut does not stipulate which edition of the AMA Guides to use. Six states use their own state specific guidelines (Florida, Illinois, Minnesota, New York, North Carolina, and Wisconsin), and six states do not specify a specific guideline (Michigan, Missouri, Nebraska, New Jersey, South Carolina, and Virginia). Statutes may or may not specify which edition of the AMA Guides to use. Some states use their own guidelines for specific problems and use the Guides for other issues.

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Nonspecific Chronic Back Pain: Sixth Edition Approaches

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2019.sepoct03 ◽

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.

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State-by-State Use of AMA Guides

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2019.sepoct01 ◽

2019 ◽

Vol 24 (5) ◽

pp. 3-7, 16

Keyword(s):

Expert Testimony ◽

Narrow Range ◽

The United States ◽

Workers Compensation ◽

Federal Employees ◽

Permanent Disability ◽

Sixth Edition ◽

History Of ◽

Canadian Provinces

Abstract This article presents a history of the origins and development of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), from the publication of an article titled “A Guide to the Evaluation of Permanent Impairment of the Extremities and Back” (1958) until a compendium of thirteen guides was published in book form in 1971. The most recent, sixth edition, appeared in 2008. Over time, the AMA Guides has been widely used by US states for workers’ compensation and also by the Federal Employees Compensation Act, the Longshore and Harbor Workers’ Compensation Act, as well as by Canadian provinces and other jurisdictions around the world. In the United States, almost twenty states have developed some form of their own impairment rating system, but some have a narrow range and scope and advise evaluators to consult the AMA Guides for a final determination of permanent disability. An evaluator's impairment evaluation report should clearly document the rater's review of prior medical and treatment records, clinical evaluation, analysis of the findings, and a discussion of how the final impairment rating was calculated. The resulting report is the rating physician's expert testimony to help adjudicate the claim. A table shows the edition of the AMA Guides used in each state and the enabling statute/code, with comments.

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Entrapment Neuropathies: Electrodiagnostic Criteria

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2019.novdec02 ◽

2019 ◽

Vol 24 (6) ◽

pp. 12-15

Author(s):

Jay Blaisdell ◽

James B. Talmage

Keyword(s):

Nerve Conduction ◽

Task Force ◽

Conduction Block ◽

Cubital Tunnel Syndrome ◽

Conduction Delay ◽

Test Results ◽

Sixth Edition ◽

Entrapment Neuropathies ◽

Axon Loss ◽

Tunnel Syndrome

Abstract Like the diagnosis-based impairment (DBI) method and the range-of-motion (ROM) method for rating permanent impairment, the approach for rating compression or entrapment neuropathy in the upper extremity (eg, carpal tunnel syndrome [CTS]) is a separate and distinct methodology in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Rating entrapment neuropathies is similar to the DBI method because the evaluator uses three grade modifiers (ie, test findings, functional history, and physical evaluation findings), but the way these modifiers are applied is different from that in the DBI method. Notably, the evaluator must have valid nerve conduction test results and cannot diagnose or rate nerve entrapment or compression without them; postoperative nerve conduction studies are not necessary for impairment rating purposes. The AMA Guides, Sixth Edition, uses criteria that match those established by the Normative Data Task Force and endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM); evaluators should be aware of updated definitions of normal from AANEM. It is possible that some patients may be diagnosed with carpal or cubital tunnel syndrome for treatment but will not qualify for that diagnosis for impairment rating; evaluating physicians must be familiar with electrodiagnostic test results to interpret them and determine if they confirm to the criteria for conduction delay, conduction block, or axon loss; if this is not the case, the evaluator may use the DBI method with the diagnosis of nonspecific pain.

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Rating Spinal Nerve Extremity Impairment Using the Sixth Edition

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.julaug01 ◽

2009 ◽

Vol 14 (4) ◽

pp. 1-6

Author(s):

Christopher R. Brigham

Keyword(s):

Nerve Root ◽

Spinal Nerve ◽

Upper Extremities ◽

Motor Deficits ◽

Nerve Injuries ◽

Sixth Edition ◽

Federal Employee ◽

Nerve Root Injury ◽

Root Injury ◽

Rating Process

Abstract The AMAGuides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, does not provide a separate mechanism for rating spinal nerve injuries as extremity impairment; radiculopathy was reflected in the spinal rating process in Chapter 17, The Spine and Pelvis. Certain jurisdictions, such as the Federal Employee Compensation Act (FECA), rate nerve root injury as impairment involving the extremities rather than as part of the spine. This article presents an approach to rate spinal nerve impairments consistent with the AMA Guides, Sixth Edition, methodology. This approach should be used only when a jurisdiction requires ratings for extremities and precludes rating for the spine. A table in this article compares sensory and motor deficits according to the AMA Guides, Sixth and Fifth Editions; evaluators should be aware of changes between editions in methodology used to assign the final impairment. The authors present two tables regarding spinal nerve impairment: one for the upper extremities and one for the lower extremities. Both tables were developed using the methodology defined in the sixth edition. Using these tables and the process defined in the AMA Guides, Sixth Edition, evaluators can rate spinal nerve impairments for jurisdictions that do not permit rating for the spine and require rating for radiculopathy as an extremity impairment.

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Spine Impairment Evaluation: Sixth Edition Approaches

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.janfeb01 ◽

2009 ◽

Vol 14 (1) ◽

pp. 1-5

Author(s):

Craig Uejo ◽

Marjorie Eskay-Auerbach ◽

Christopher R. Brigham

Keyword(s):

Functional Status ◽

Spinal Injury ◽

Current Medical ◽

Clinical Testing ◽

Medical Evidence ◽

Sixth Edition ◽

Whole Person ◽

Rating Process ◽

Impairment Ratings ◽

Class Assignment

Abstract Evaluators who use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, should understand the significant changes that have occurred (as well as the Clarifications and Corrections) in impairment ratings for disorders of the cervical spine, thoracic spine, lumbar spine, and pelvis. The new methodology is an expansion of the Diagnosis-related estimates (DRE) method used in the fifth edition, but the criteria for defining impairment are revised, and the impairment value within a class is refined by information related to functional status, physical examination findings, and the results of clinical testing. Because current medical evidence does not support range-of-motion (ROM) measurements of the spine as a reliable indicator of specific pathology or permanent functional status, ROM is no longer used as a basis for defining impairment. The DRE method should standardize and simplify the rating process, improve validity, and provide a more uniform methodology. Table 1 shows examples of spinal injury impairment rating (according to region of the spine and category, with comments about the diagnosis and the resulting class assignment); Table 2 shows examples of spine impairment by region of the spine, class, diagnosis, and associated whole person impairment ratings form the sixth and fifth editions of the AMA Guides.

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