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GunnarB.J.Andersson,MD,PhD,SeniorMedicalEditor

Chairs,Contributors,and Reviewers

ChapterChairs

MargitBleecker,MD,PhD

CenterforOccupationalandEnvironmentalNeurology

Baltimore,Maryland

TheCentralandPeripheralNervousSystem

FrancisI.Catlin,MD,ScD

BaylorCollegeofMedicine

Houston,Texas

Ear,Nose,Throat,andRelatedStructures

LindaCocchiarella,MD,MSc

AmericanMedicalAssociation

Chicago,Illinois

ImpairmentEvaluationand RecordsandReports

AugustColenbrander,MD

CaliforniaPacificMedicalCenterandSmith-KettlewellEyeResearch Institute

SanFrancisco,California

TheVisualSystem

EdwardCovington,MD

ClevelandClinic

Cleveland,Ohio

Pain

PaulE.Epstein,MD

UniversityofPennsylvania

Philadelphia,Pennsylvania

TheRespiratorySystem

EugeneFrenkel,MD

UniversityofTexasSouthwesternMedicalCenter

Dallas,Texas

TheHematopoieticSystem

RobertH.HaralsonIII,MD

Maryville,Tennessee

TheSpine

FrankE.Jones,MD

Nashville,TN

TheUpperExtremities

PhilippM.Lippe,MD

StanfordUniversity

SanJose,California

Pain

JamesV.Luck,Jr,MD

OrthopaedicHospital

LosAngeles,California

TheLowerExtremities

JamesR.McPherson,MD

MayoClinic

Rochester,Minnesota

TheDigestiveSystem

ArthurT.Meyerson,MD

NewYorkUniversitySchoolofMedicine

NewYork,NewYork

MentalandBehavioralDisorders

InderPerkash,MD

StanfordUniversity

PaloAlto,California

TheUrinaryandReproductiveSystems

NelsonG.Richards,MD

Richmond,Virginia

TheCentralandPeripheralNervousSystem

HarveyA.Rubenstein,MD,FACP,FACE

GeorgetownUniversitySchoolofMedicine

McLean,Virginia

TheEndocrineSystem

JosephSataloff,MD,MSc,DSc

ThomasJeffersonUniversity Philadelphia,Pennsylvania

ImpairmentEvaluationandRecordsandReports

GenevievedeGrootSwanson,MD, MichiganStateUniversity

GrandRapids,Michigan

TheUpperExtremities

JamesS.Taylor,MD

ClevelandClinic

Cleveland,Ohio

TheSkin

DennisC.Turk,PhD

UniversityofWashington

Seattle,Washington

Pain

NancyWebb,MD

Kelsey-SeyboldClinic

Houston,Texas

TheVisualSystem

ScottWright,MD

MayoClinic

Rochester,Minnesota

TheCardiovascularSystem:HeartandAorta

TheCardiovascularSystem:SystemicandPulmonaryArteries

Contributors

GunnarB.J.Andersson,MD,PhD

Rush-Presbyterian-StLuke’sMedicalCenter Chicago,Illinois

WilliamS.Beckett,MD

UniversityofRochesterSchoolofMedicineandDentistry Rochester,NewYork

ScottBrown,MD

PhysicalMedicineandRehabilitation

SinaiRehabilitationCenter Baltimore,Maryland

NeilBusis,MD

PittsburghNeurologicalGroup Pittsburgh,Pennsylvania

SeineChiang,MD

UniversityofAlabama Birmingham,Alabama

LindaCocchiarella,MD,MSc

AmericanMedicalAssociation Chicago,Illinois

RobertCofield,MD

MayoClinic

Rochester,Minnesota

PhillipCoogan,MD

Nashville,Tennessee

G.TheodoreDavis,MD Albuquerque,NewMexico

RobertDobie,MD

NationalInstituteonDeafnessandCommunicativeDisorders Bethesda,Maryland

AnthonyDorto,MD,DC Hollywood,Florida

KennethW.Eckmann,MD TheNeurologyCenter Wheaton,Maryland

PatriciaG.Engasser,MD StanfordUniversity UniversityofCalifornia,SanFrancisco Atherton,California

LorenH.Engrav,MD

UniversityofWashingtonSchoolofMedicine Seattle,Washington

BlairC.Filler,MD

OrthopaedicHospital LosAngeles,California

JohnJ.Gerhardt,MD Portland,Oregon

DarleneG.Kelley,MD,PhD MayoClinic Rochester,Minnesota

RandallD.Lea,MD

CenterofOrthopaedicCare&EvaluationMedicine BatonRouge,Louisiana

BarryS.Levinson,MD

UniversityofTexasSouthwesternMedicalCenterandDallasVeterans AdministrationMedicalCenter Dallas,Texas

JamesLockey,MD

UniversityofCincinnatiCollegeofMedicine Cincinnati,Ohio

JohnD.Loeser,MD

UniversityofWashington Seattle,Washington

DonlinLong,MD

JohnsHopkinsUniversityMedicalCenter Baltimore,Maryland

C.G.TobyMathias,MD

UniversityofCincinnati Cincinnati,Ohio

TomMayer,MD Dallas,Texas

MichaelMcGoon,MD MayoClinic Rochester,Minnesota

RickNishimura,MD MayoClinic Rochester,Minnesota

RajanPerkash,MD StanfordUniversity Sunnyvale,California

JohnPhair,MD

NorthwesternUniversity Chicago,Illinois

MohammedI.Ranavaya,MD

Chapmanville,

WestVirginia

DavidC.Randolph,MD,MPH Cincinnati,Ohio

EdwardA.Rankin Washington,DC

JamesP.Robinson,MD,PhD UniversityofWashington Seattle,Washington

JoelR.Saper,MD AnnArbor,Michigan

RobertThayerSataloff,MD,DMA

ThomasJeffersonUniversity GraduateHospital Philadelphia,Pennsylvania

GabrielSella,MD MartinsFerry,Ohio

WilliamS.Shaw,MD IntegratedHealthManagement Denver,Colorado

GeorgeM.Smith,MD

G.M.SmithAssociates,Inc AlisoViejo,California

MarkTaylor,MD SanAntonio,Texas

MarthaTerris,MD StanfordUniversity PaloAlto,California

MarkUtell,MD UniversityofRochester

Rochester,NewYork

JonathanVanGeest,PhD

AmericanMedicalAssociation Chicago,Illinois

Reviewers

PeterAmadio,MD Rochester,Minnesota

AriesArditi,PhD

NewYork,NewYork

IanBailey,OD

UniversityofCalifornia,Berkeley Berkeley,California

JohnR.Balmes,MD

UniversityofCalifornia,SanFrancisco SanFrancisco,California

PeterS.Barth,PhD

UniversityofConnecticut Storrs,Connecticut

WilliamBeckett,MD

UniversityofRochester Rochester,NewYork

JamesL.Becton,MD Augusta,Georgia

JanetteBertness,JD Providence,RhodeIsland

PeterV.Bieri,MD,FAADEP Lawrence,Kansas

StanBigos,MD UniversityofWashington Seattle,Washington

MartinBlack,MD Philadelphia,Pennsylvania

SidneyBlair,MD,FACS LoyolaUniversityMedicalCenter Maywood,Illinois

WilliamBlair,MD IowaCity,Iowa

ChristopherR.Brigham,MD Portland,Maine

CharlesBrooks,MD,PC Bellevue,Washington

RobertBuchanan,MD OklahomaCity,Oklahoma

WilliamB.Bunn,MD,JD,MPH NorthwesternUniversity Chicago,Illinois

JohnF.Burton,Jr,PhD,LLB

Rutgers:TheStateUniversityofNewJersey

NewBrunswick,NewJersey

ThomasN.Byrne,MD

NewHaven,Connecticut

DanielBarryCarr,MD Boston,Massachusetts

SusanO.Cassidy,MD,JD

Madison,Connecticut

RobertCohen,MD Chicago,Illinois

AlanL.Colledge,MD SaltLakeCity,Utah

AnneL.Corn,EdD VanderbiltUniversity Nashville,Tennessee

JamesCulver,MD Cleveland,Ohio

StevenDarnell,MBA Camas,Washington

StanleyDersinski,MD RedwoodCity,California

MaryDombovy,MD Rochester,NewYork

JosephDrozda,MD Chesterfield,Missouri

EleanorFaye,MD NewYork,NewYork

MichaelFeuerstein,PhD

UniformedServicesUniversity Bethesda,Maryland

DonaldFletcher,MD Birmingham,Alabama

LindaForst,MD,MPH UniversityofIllinois

Chicago,Illinois

RobertJ.Gatchel,PhD

UniversityofTexas Dallas,Texas

ElizabethGenovese-Stone,MD,MBA BalaCynwyd,Pennsylvania

PhilipHarber,MD UniversityofCalifornia,LosAngeles LosAngeles,California

HollyB.Hahn,MD IndianaUniversity Indianapolis,Indiana

ScottHalderman,MD SantaAna,California

StephenHanauer,MD UniversityofChicago Chicago,Illinois

RowlandHazard,MD UniversityofVermont Williston,Vermont

GeorgeE.Healy,Jr,MD Providence,RhodeIsland

LeaHyvärinen,MD Helsinki,Finland

MariellJessup,MD UniversityofPennsylvania Philadelphia,Pennsylvania

NormanJohanson-Phil,MD Philadelphia,Pennsylvania

AlanJohnston,PhD UniversityofMelbourne Melbourne,Australia

MortonKasden,MD Louisville,Kentucky

RichardKatz,MD StLouis,Missouri

GideonLetz,MD,MPH SanFrancisco,California

PhilipLevy,MD Phoenix,Arizona

StephenLord,JD Boise,Idaho

DeanS.Louis,MD AnnArbor,Michigan

BorisD.Lushniak,MD,MPH NIOSH Cincinnati,Ohio

PeterJ.Mandel,MD SanFrancisco,California

RobertMassof,PhD

JohnsHopkinsUniversity Baltimore,Maryland

MarkMelhorn,MD Wichita,Kansas

KathrynMueller,MD Littleton,Colorado

JohnNiparko,MD

JohnsHopkinsUniversity

Baltimore,Maryland

MohamedM.Panjabi,PhD

YaleUniversity

NewHaven,Connecticut

ArunPerkash,MD

StanfordUniversity

Sunnyvale,California

DanteJ.Pieramici,MD

JohnsHopkinsUniversity

Baltimore,Maryland

CarrieRedlich,MD,MPH

YaleUniversity

NewHaven,Connecticut

RobertD.Rondinelli,MD,PhD UniversityofKansas KansasCity,Kansas

CecileS.Rose,MD,MHP Denver,Colorado

HenryJ.Roth,MD Denver,Colorado

SpencerRowland,MD SanAntonio,Texas

BrianSchulman,MD Bethesda,Maryland

MarciaScott,MD Cambridge,Massachusetts

WilliamShaw,MD Denver,Colorado

ElizabethSherertz,MD

WakeForestUniversity

Winston-Salem,NorthCarolina

PriscillaShort,MD

AmericanMedicalAssociation Chicago,Illinios

EmilyA.Spieler,JD WestVirginiaUniversity Morgantown,WestVirginia

GordonSteinagle,DO Buffalo,NewYork

Henry(Hal)LeeStockbridge,MD,MPH Olympia,Washington

WilliamM.Swartz,MD Pittsburgh,Pennsylvania

JamesTalmage,MD Cookeville,Tennessee

MarcT.Taylor,MD SanAntonio,Texas

MichaelI.Vender,MD ArlingtonHeights,Illinois

GregWagner,MD Morgantown,WestVirginia

MaryWarren,OT KansasCity,Missouri

American

MedicalAssociationStaff

ProfessionalStandards

ClairM.Callan,MD,MBA

VicePresident DivisionofScience,QualityandPublicHealth

ArthurElster,MD DirectorofClinicalandPublicHealthPracticeandOutcomes

LindaCocchiarella,MD,MSc

SeniorScientist

AMAMedicalEditor Guides to the Evaluation of Permanent Impairment,FifthEdition

ThomasHouston,MD DirectorofScienceandPublicHealthAdvocacyPrograms

PriscillaShort,MD DirectorofGeneticMedicine

JonathanVanGeest,PhD EthicalStandards

RyanBergin,EditorialAssistant

CynthiaColvin,SeniorSecretary

MaryHaynes,AdministrativeSecretary

MaryWilborn,AssistanttotheDirector

AMAPress

TonyFrankos,VicePresident,BusinessProducts

MaryLouWhite,EditorialDirector

BarryBowlus,SeniorAcquisitionsEditor

JeanRoberts,Director,ProductionandManufacturing

RegSchmidt,MarketingManager

RosalynCarlton,SeniorProductionCoordinator

RonnieSummers,SeniorPrintCoordinator

MaryAnnAlbanese,ImageCoordinator

OfficeoftheGeneralCounsel

B.J.Anderson,JD

BruceBlehart,JD

AndreaCooper-Finkel,JD

KarlaKinderman,JD

TableofContents

Chapter1

Philosophy,Purpose,andAppropriateUseofthe Guides

1.1 History

1.2 Impairment,Disability,andHandicap

1.3 TheOrganSystemandWholeBodyApproachtoImpairment

1.4 PhilosophyandUseoftheCombinedValuesChart

1.5 IncorporatingScienceWithClinicalJudgment

1.6 Causation,ApportionmentAnalysis,andAggravation

1.7 Useofthe Guides

1.8 ImpairmentEvaluationsinWorkers’Compensation

1.9 EmployabilityDeterminations

1.10 RailroadandMaritimeWorkers

1.11 ThePhysician’sRoleBasedontheAmericanswithDisabilities Act(ADA)

1.12 Summary Chapter2

PracticalApplicationofthe Guides

2.1 DefiningImpairmentEvaluations

2.2 WhoPerformsImpairmentEvaluations?

2.3 Examiners’RolesandResponsibilities

2.4 WhenAreImpairmentRatingsPerformed?

2.5 RulesforEvaluation

2.6 PreparingReports

Chapter3

TheCardiovascularSystem:HeartandAorta

3.1 PrinciplesofAssessment

3.2 VavularHeartDisease

3.3 CoronaryHeartDisease

3.4 CongenitalHeartDisease

3.5 Cardiomyopathies

3.6 PericardialHeartDisease

3.7 Arrhythmias

3.8 CardiovascularImpairmentEvaluationSummary

Chapter4

TheCardiovascularSystem:SystemicandPulmonary Arteries

4.1 HypertensiveCardiovascularDisease

4.2 DiseasesoftheAorta

4.3 VascularDiseasesAffectingtheExtremities

4.4 DiseasesofthePulmonaryArteries

4.5 CardiovascularImpairmentEvaluationSummary

Chapter5

TheRespiratorySystem

5.1 PrinciplesofAssessment

5.2 SymptomsAssociatedWithRespiratoryDisease

5.3 TobaccoUseandEnvironmentExposureAssociatedWith RespiratoryDisease

5.4 Examinations,ClinicalStudies,andOtherTestsforEvaluating RespiratoryDisease

5.5 Asthma

5.6 ObstructiveSleepApnea

5.7 HypersensitivityPneumonitis

5.8 Pneumoconiosis

5.9 LungCancer

5.10 PermanentImpairmentDuetoRespiratoryDisorders

5.11 RespiratoryImpairmentEvaluationSummary

Chapter6

TheDigestiveSystem

6.1 PrinciplesofAssessment

6.2 UpperDigestiveTract

6.3 Colon,Rectum,andAnus

6.4 EnterocutaneousFistulas

6.5 LiverandBiliaryTract

6.6 Hernias

6.7 DigestiveSystemImpairmentEvaluationSummary

Chapter7

TheUrinaryandReproductiveSystems

7.1 PrinciplesofAssessment

7.2 TheUrinarySystem

7.3 UpperUrinaryTract

7.4 UrinaryDiversion

7.5 Bladder

7.6 Urethra

7.7 MaleReproductiveOrgans

7.8 FemaleReproductiveOrgans

7.9 UrinaryandReproductiveSystemsImpairmentEvaluation Summary

Chapter8

TheSkin

8.1 PrinciplesofAssessment

8.2 Disfigurement

8.3 ScarsandSkinGrafts

8.4 ContactDermatitis

8.5 NaturalRubberLatexAllergy

8.6 SkinCancer

8.7 CriteriaforRatingPermanentImpairmentDuetoSkinDisorders

8.8 SkinImpairmentEvaluationSummary

Chapter9

TheHematopoieticSystem

9.1 PrinciplesofAssessment

9.2 Anemia

9.3 PolycythemiaandMyelofibrosis

9.4 WhiteBloodCellDiseaseorAbnormalities

9.5 HemorrhagicandPlateletDisorders

9.6 ThromboticDisorders

9.7 HematologicImpairmentEvaluationSummary

Chapter10

TheEndocrineSystem

10.1 PrinciplesofAssessment

10.2 Hypothalamic-PituitaryAxis

10.3 Thyroid

10.4 Parathyroids

10.5 AdrenalCortex

10.6 AdrenalMedulla

10.7 Pancreas(IsletsofLangerhans)

10.8 Gonads

10.9 MammaryGlands

10.10 MetabolicBoneDisease

10.11 EndocrineSystemImpairmentEvaluationSummary

Chapter11

Ear,Nose,Throat,andRelatedStructures

11.1 PrinciplesofAssessment

11.2 TheEar

11.3 TheFace

11.4 TheNose,Throat,andRelatedStructures

11.5 Ear,Nose,Throat,andRelatedStructuresImpairmentEvaluation Summary

Chapter12

TheVisualSystem

12.1 PrinciplesofAssessment

12.2 ImpairmentofVisualAcuity

12.3 ImpairmentoftheVisualField

12.4 ImpairmentoftheVisualSystem

12.5 VisualAcuityMeasurementatNear(ReadingAcuity)

Chapter13

TheCentralandPeripheralNervousSystem

13.1 PrinciplesofAssessment

13.2 CriteriaforRatingImpairmentDuetoCentralNervousSystem Disorders

13.3 CriteriaforRatingCerebralImpairments

13.4 CriteriaforRatingImpairmentsoftheCranialNerves

13.5 CriteriaforRatingImpairmentsofStation,Gait,andMovement Disorders

13.6 CriteriaforRatingImpairmentsofUpperExtremitiesRelatedto CentralImpairment

13.7 CriteriaforRatingSpinalCordandRelatedImpairments

13.8 CriteriaforRatingImpairmentsRelatedtoChronicPain

13.9 CriteriaforRatingImpairmentsofthePeripheralNervous System,NeuromuscularJunction,andMuscularSystem

13.10 NervousSystemImpairmentEvaluationSummary

Chapter14

MentalandBehavioralDisorders

14.1 PrinciplesofAssessment

14.2 PsychiatricDiagnosisandImpairment

14.3 AMethodofEvaluatingPsychiatricImpairment

14.4 AssessingImpairmentSeverity

14.5 ExamplesofImpairmentDuetoMentalandBehavioral Disorders

14.6 FormatoftheImpairmentReport

Chapter15

TheSpine

15.1 PrinciplesofAssessment

15.2 DeterminingtheAppropriateMethodforAssessment

15.3 Diagnosis-RelatedEstimatesMethod

15.4 DRE:LumbarSpine

15.5 DRE:ThoracicSpine

15.6 DRE:CervicalSpine

15.7 RatingCorticospinalTractDamage

15.8 Range-of-MotionMethod

15.9 ROM:LumbarSpine

15.10 ROM:ThoracicSpine

15.11 ROM:CervicalSpine

15.12 NerveRootand/orSpinalCord

15.13 CriteriaforConvertingWholePersonImpairmenttoRegional SpineImpairment

15.14 ThePelvis

15.15 SpineEvaluationSummary

Chapter16

TheUpperExtremities

16.1 PrinciplesofAssessment

16.2 Amputations

16.3 SensoryImpairmentDuetoDigitalNerveLesions

16.4 EvaluatingAbnormalMotion

16.5 ImpairmentoftheUpperExtremitiesDuetoPeripheralNerve Disorders

16.6 ImpairmentoftheUpperExtremitiesDuetoVascularDisorders

16.7 ImpairmentoftheUpperExtremitiesDuetoOtherDisorders

16.8 StrengthEvaluation

16.9 SummaryofStepsforEvaluatingImpairmentsoftheUpper Extremity

16.10 ClinicalExamples

Chapter17

TheLowerExtremities

17.1 PrinciplesofAssessment

17.2 MethodsofAssessment

17.3 LowerExtremityImpairmentEvaluationProcedureSummary andExamples

Chapter18

Pain

18.1 PrinciplesofAssessment

18.2 OverviewofPain

18.3 IntegratingPain-RelatedImpairmentIntotheConventional ImpairmentRatingSystem

18.4 BehavioralConfounders

18.5 HowtoRatePain-RelatedImpairment:ASampleProtocol

18.6 PsychogenicPain

18.7 Malingering

18.8 Conclusion

18.9 CaseExamples Appendix

RecordingRange-of-MotionMeasurements

Glossary

CombinedValuesChart Index

ListofTablesandFigures

Chapter1

Philosophy,Purpose,andAppropriateUseofthe Guides

Table11 DefinitionsandInterpretationsofImpairmentand Disability

Table12 ActivitiesofDailyLivingCommonlyMeasuredin ActivitiesofDailyLiving(ADL)andInstrumental ActivitiesofDailyLiving(IADL)Scales

Table13 ScalesforMeasurementofInstrumentalActivitiesof DailyLiving(IADL)andActivitiesofDailyLiving (ADL)

Figure11 TheRelationshipAmongtheConceptsofNormalHealth, Impairment,FunctionalLimitation,andActivityDisability (PerformanceLimitation)

Chapter2

PracticalApplicationofthe Guides

SampleReportforPermanentMedicalImpairment

Chapter3

TheCardiovascularSystem:HeartandAorta