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TheGuidesNewsletter
Expert advice, practical information, and current trends on impairment evaluation September/October 2003 Also in this issue Grip Strength: An Uncommon Impairment Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating
In upcoming issues Cervical Fusions: A Paradox in the Fifth Edition Neuropsychological Testing Assessing Credibility Iatrogenic Disability State by State Use of AMA Guides Web Sites for the Rating Physician
© 2003 American Medical Association. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.
Impairment Rating in Traumatic Brain Injury by Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CIME, Michael F. Martelli, PhD, Mark C. Bender, PhD Traumatic brain injury (TBI) affects 1.5 million individuals per year. TBI accounts for 50,000 deaths annually and approximately one third of all injury deaths. It is a common cause of death or disability. Its most frequent cause is motor vehicle accidents and its most frequent victims are males between 15 and 24 years of age. At least 5.3 million Americans live with disabilities resulting from TBI1 with approximately 80,000 people incurring long-term or lifelong disabilities from TBI each year. Reported prevalence and incidence data are likely underestimates due to failures to present for evaluation or treatment; presentation for other serious injuries that preclude or overshadow diagnosis of TBI; or misdiagnosis or inadequate diagnosis.2 TBI is usually described in terms of severity of the initial neurologic insult and defined by the Glasgow Coma Scale (GCS) score; presence and duration of amnesia (retrograde and anterograde); and presence and duration of alteration in or loss of consciousness. These variables classify the severity of brain injuries and, along with other factors, predict anticipated outcome, both short and, to a somewhat lesser extent, long term. Initial injury severity is generally defined by initial GCS scores3 as mild (13-15), moderate (9-12), and severe (3-8). Traditionally, mild TBI (MTBI) is associated with a period of loss of consciousness (LOC) of no greater than 30 minutes if LOC is present at all. More severe injury tends to be associated with greater risk of protracted LOC, anterograde amnesia (also referred to as post-traumatic amnesia), abnormal neuroimaging and electrophysiologic studies (eg, EEG and evoked potentials), as well as, need for operative intervention.4,5 Notably, MTBI-which can be associated with a variety of cognitive, behavioral, and somatic symptoms-was addressed in a previous issue of the Guides Newsletter.6
Assessing Moderate and Severe TBI As per the Guides (5th ed, 21-22), the evaluating clinician should include the following: ● ● ● ●
A narrative history Results of the most recent clinical evaluation Assessment of current clinical status Plans for future treatment, including rehabilitation and re-evaluation
The Guides Newsletter Advisory Board Editor Christopher R. Brigham, MD Brigham & Associates
Associate Editor James B. Talmage, MD Cookeville, Tennessee
Editorial Board Gunnar B.J. Andersson, MD, PhD Rush-Presbyterian-St Luke’s Medical Center Gerald Aronoff, MD Charlotte, North Carolina William Blair, MD Occupational Orthopaedics Margit L. Bleecker, MD, PhD Center for Occupational and Environmental Neurology William Boucher, MD Workwell, Southern Maine Medical Center Charles N. Brooks, MD Bellevue, Washington Lorne K. Direnfeld, MD, FRCP(C) Maui Occupational Health Center Anthony Dorto, MD, DC Disability Assessment Center PA Leon H. Ensalada, MD, MPH Waitsfield, Vermont Robert H. Haralson III, MD, MBA Southeastern Orthopaedics Frank Jones, MD Tennessee Orthopaedic Alliance Edwin Klimek, MD St Catharines, Ontario, Canada James Luck, MD Orthopaedics Hospital Kathryn L. Mueller, MD, MPH University of Colorado
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Diagnosis and clinical impressions An estimate of time for full or partial recovery
The clinician must also analyze the findings relative to explanation of the impact of the medical condition(s) on life activities, static or stabilized nature of the medical condition, or chance of sudden or subtle incapacitation as a result of the medical condition. The risk of injury, harm, or further impairment with activity needed to meet personal, social, or occupational demands must also be addressed. The clinician should also elaborate on any restrictions or accommodations for performing required activities to meet life demands. The medical condition in question must be stable before permanency can be established and/or rated. “An impairment is considered permanent when it has reached maximum medical improvement (MMI), meaning it is well stabilized and unlikely to change substantially in the next year with or without medical treatment” (5th ed, 2). Examiners should note that the concept and/or definition of permanency may differ between the Guides and other disability determination systems or programs. Additionally, examiners should remain cognizant that the Guides occasionally uses disability based criteria to determine certain neurological impairment ratings. Hopefully, future editions will address this current methological limitation. The Guides system, including the Fifth Edition, continues to admonish against the use of impairment ratings for direct financial awards, as a sole measure of disability (5th ed, 12) or even as an estimate of disability (5th ed, 13). Yet, practitioners and the legal system continue to use the Guides in these inappropriate applications, which we consider a potential disservice to persons with neurodisabilities, society, and the disability determination system. When an individual presents with brain disease or damage, there may be impairments involving several parts of the body, as well as, several parts of the nervous system, eg, the brain, spinal cord, cranial nerves, and/or peripheral nerves. Associated impairments to the ear, nose, and throat (Chapter 11) or visual (Chapter 12) systems may also be involved. These impairments are assessed using Chapter 13, The Central and Peripheral Nervous System. The Fifth Edition revisions include the addition of an impairment evaluation summary (Table 13-25 of the Guides) at the end of Chapter 13 to allow easy access to the neurologic impairment in question, as well as, brief discussion of ancillary tests with some of their indications, greater guidance in the assessment of several impairment categories, and additional illustrative cases. There are numerous relevant sections in Chapter 13 that all clinicians must be familiar with in order to rate impairment associated with central nervous system dysfunction as is seen with TBI (see Table 1 on page 3 for a summary). Individual impairments should be separately calculated and their wholeperson values combined using the “combined values chart” in the Guides (5th ed, 604-606). In general, only the medical condition causing the greatest impairment should be evaluated. The Guides also divides the assessment of the most severe central nervous system (CNS) impairments, based on neurologic evaluation and relevant clinical investigations, into 4 categories: ●
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State of consciousness and level of awareness (whether permanent or episodic) Mental status evaluation and integrative functioning Use and understanding of language Influence of behavior and mood
Henry J. Roth, MD Integrated Health Management
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William S. Shaw, MD Integrated Health Management
“The most severe of these four categories should be used to determine a cerebral impairment rating” (5th ed, 308). Sensorimotor systems, gait and coordination, cranial nerve function, spinal cord impairments, peripheral nervous system problems, and chronic pain are then combined with the most severe impairment. As per the Guides, the evaluation of sensory and motor impairments due to cerebral disorders should be based upon the examinee’s ability to perform activities of daily living (again potentially confounding impairment and dis-
Dennis Turk, PhD University of Washington Laura Welch, MD Washington Hospital Center 2
The Guides Newsletter, September/October 2003
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Table 1. Assessing Impairment of the Central Nervous System
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Section (page) Select the most severe of these 4 categories: Consciousness and awareness (whether permanent or episodic)
Mental status and integrative functioning Aphasia or communication Emotional or behavioral disturbances
Table (page)
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13.3a (309) 13.3b (311) 13.3c (317)
13-2 (309) 13-3 (312) 13-4 (317)
13.3d (319) 13.3e (322)
13-5 (320) 13-6 (320) 13-7 (323)
13.3f (325)
13-8 (325)
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Combine the previously chosen category with the following categories, as applicable: Cranial nerve impairment
Station, gait, and movement disorders Upper extremity disorders related to central impairment Spinal cord and related impairments
Chronic pain Peripheral nervous system, neuromuscular junction, and muscular system
13.4a (327)
13.5 (336) 13.6 (338) 13.7 (340)
13.8 (343)
13.9 (344)
ability rating in the process of an intended impairment rating system). Sensory disturbances may be related to thalamic pain, phantom limb pain, complex regional pain syndrome (causalgia), disorders of stereognosis, and disturbances of 2-point and position sense. Motor disturbances may occur with or without associated weakness. Non-paretic motor deficits may include movement disorders, tonal aberrations, and restrictions in expression of motor behavior, such as in bradykinesia and ataxia. Impairments due to aphasia or dysphasia (Section 13.3e, 5th ed, 322-325) are based upon gradations of impairment severity and on the results of specific language/communication-based testing. Some objective assessment strategies include object naming by sight or description after reading about them, repeating speech, following oral and written commands, reading and comprehending, writing, spelling, and demonstrating the use of an object (a test for aphasia). As with other impairments, the combined values chart should be used to calculate the whole person impairment. Mental status and integrative functions (Section 13.3d, 5th ed, 319-322) are typically determined based on bedside assessment of the following 10 “traditional” measures of cognitive function:
Orientation Recent recall Forward and backward digit repetition Serial subtraction (7s from 100 or 3s from 20) Simple calculations Repetition of 3 unrelated words Spelling a word forwards and backwards Short paragraph repetition Appreciation of proverbs or abstract thought Judgment
These tests can only be performed in the absence of significant aphasia. 13-9 (328) In the presence of both significant 13-10 (328) communication and mental status 13-11 (331) disturbance, the greater of the 2 13-12 (332) impairment estimates should be used. 13-13 (334) Because bedside assessment may 13-14 (334) underestimate the extent of more subtle but functionally significant cogni13-5 (336) tive deficits, the Fifth Edition recommends consideration of using the 13-16 (338) clinical dementia rating (CDR) scale 13-18 (341) in conjunction with a standardized 13-19 (341) mental status test such as the Mini13-20 (342) Mental State Exam. Once again, the 13-21 (342) Guides requires the examiner to grade 13-22 (343) mental status impairment based on the ability to do activities of daily living; thereby, confounding impairment 13-23 (346-7) and disability assessment procedures. 13-24 (348-9) In cases where evaluation of potentially more subtle neurocognitive and/or neurobehavioral impairment and where more comprehensive assessment of impairment and function is necessary, clinicians should consider neuropsychological testing. Such testing provides a more sensitive and reliable measure and currently represents the gold standard for objective assessment of cognitive-behavioral function after TBI.6 Given the importance of these assessments, evaluating clinicians should be familiar with the sensitivity, specificity, validity, reliability, and limitations of these assessments. Appropriate neuropsychological assessments should include consideration of the following: ●
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Pre-injury intellectual function estimates (standardized scores, adjusted statistical procedures) Objective collateral information (pre- and/or post-injury status) Premorbid medical and psychological history Other factors potentially influencing test results (eg, pain, emotional issues, vestibular symptoms, medications, and especially, motivation/response bias) Appropriately referenced normative group comparisons and actuarial based cut-off scores and comparisons with Continued on page 5 The Guides Newsletter, September/October 2003 3
Traumatic Brain Injury (continued) Continued from page 3
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base rates of symptoms in peers without TBI Measures of validity, simulation and/or dissimulation Initial degree of neurologic insult (eg, GCS score, presence and duration of altered consciousness) compared to symptom severity and onset and temporal correlation of impairment Symptom pattern consistency with anticipated recovery curves for similar magnitude injuries and neuropsychological test results Generalization of test results to specific real world functioning with consideration and indication of limitations in predicting real world performance.5,6,7
Emotional and behavioral disturbances (Section 13.3f, 5th ed, 325-327) are again rated based upon the relative degree of impairment in “daily functions” ranging from mild to severe. The disorders that may fall under this category of impairments include depression, emotional lability, mania, pathologic laughing or crying, psychosis, disinhibited behavior, and others. As with many other impairment measures, a significant degree of subjectivity exists within each category of impairment relative to the percentage of impairment assigned. Assessment may be more difficult if psychologic diagnoses such as post-traumatic stress disorder or depression are present. Only emotional impairments that are directly caused by the brain trauma should be rated in this area. Disturbances in the level of consciousness and awareness (Section 13.3a, 5th ed, 309-311) are rated based on ability to care for oneself relative to the overall level of altered consciousness with “persistent vegetative state” or “irreversible coma” correlating with a 70% to 90% impairment rating. Notably, the Fifth Edition uses older nomenclature (eg, irreversible coma is a misnomer as coma does not usually exceed 4 weeks) instead of current terminology (eg, coma, vegetative state, permanent vegetative state, minimally conscious state) in describing low-level neurologic states. Brief repetitive or persisting alterations in state of consciousness that limit ability to perform usual activities correlate with an impairment rating of 0% to 14%. The impairment criteria for disturbances in consciousness and awareness do not apply to seizure disorders, syncope (neurogenic or cardiogenic), or sleep-wake cycle disturbances. Episodic neurologic disorders (Section 13.3b, 5th ed, 311-317) include 3 main subcategories: syncope with alteration in awareness, convulsive disorders, and sleep and arousal disorders. As these disorders may relate to other organ systems outside the central nervous system, the impairments should be combined. If a disorder is expected to change to a moderate or greater degree within the next year, then the impairment should not be rated as it is not permanent. This class of disorders should be described relative to onset, duration, associated symptoms, and impact on daily function. Even in the
worst-case scenario, the highest level of impairment would be 70% (whole person) for this class of disorders. Cranial nerve impairment assessment is performed using Section 13.4 (5th ed, 327-335). The forebrain assessment should also include cranial nerves 1 and 2 without neglecting to assess cranial nerve 1, which is responsible for olfactory function. Olfaction can be tested with easily recognized odors such as coffee, chocolate, and the roselike aroma of the compound phenylethyl alcohol. To determine whether the problem is unilateral or bilateral, each nostril is tested separately. Dysosmia (the altered sense of smell) may occur in the form of parosmias (distortion of the sense of smell) or cacosmias (subjective perception of nonexistent disagreeable odors) which should be considered in the impairment rating. Olfactory impairment may be partial or complete. The maximum impairment rating for loss of smell is 5% of the whole person. Taste is typically tested with weak solutions of sugar, salt, and acetic acid (or vinegar). The patient must keep the tongue protruded and respond to questions either by pointing to names of the tastes written on cards or nodding the head. Taste may be perceived by the examinee to be altered when, in fact, only the sense of smell has been perturbed. Formal chemosensory evaluations are available through a few established national testing centers. Optic nerve impairments relative to decreased visual acuity should be combined with any other visual system impairment. Table 12-7 (5th ed, 290) assists in rating impairment due to visual field loss. The remaining Guides rated central nervous system structures include the midbrain, pons, medulla, and spinal cord. Midbrain injury resulting in extra-ocular muscle dysfunction related to cranial nerves 3, 4, and 6 may produce diplopia. The extent of diplopia in the various directions of gaze is determined in an arc perimeter at 33 cm or with a bowl perimeter. Pontine dysfunction may result in vestibulo-cochlear nerve aberrations. Tinnitus in the presence of unilateral hearing loss may impair speech discrimination and adversely influence ability to conduct daily activities. Up to 5% hearing loss may be added because of impaired speech distortion due to tinnitus to an impairment estimate for severe unilateral hearing loss. Vestibular dysfunction may be unilateral or bilateral. Vertigo is rated as a single entity, without reference to its many potential associated symptoms. Impairment ratings range from 1% to 70% of the whole person. Disorders of station and gait may result from a variety of conditions involving the central as well as the peripheral nervous systems. Whole person impairments for gait disturbance range from 1% to 60%. Altered libido can be rated under sexual impairment criteria and receives a whole person impairment rating from 1% to 9%. The examiner should attempt to quantify any pain complaint, including that of headache, and the impact on functional skills as part of the evaluation. Section Continued on page 8 The Guides Newsletter, September/October 2003 5
Traumatic Brain Injury (continued) Continued from page 5
13.8, Criteria for Rating Impairments Related to Chronic Pain, focuses on causalgia, post-traumatic neuralgia, and reflex sympathetic dystrophy. Chapter 18 regards pain rating and is entirely revised and updated in the Fifth Edition. The need for assessing the 8 Ds (ie, the diagnostic characteristics of chronic pain) is still important although not presented in the Fifth Edition. If the pain condition is to be rated it must be stable and unlikely to change in the future despite therapy. Given the frequency of pain complaints, examiners should be aware of the aforementioned assessment techniques, as well as, the Guides section on pain impairment evaluation (5th ed, 565-591). The latest edition provides a worksheet for calculating the “total pain-related impairment score” based on a qualitative 6-step process. The score is then converted into 1 of 5 qualitative impairment categorizations. Quantitative assessment of pain is limited to certain situations and 3% whole person permanent impairment. When present, pain issues should be integrated with the other observed impairments before making an overall impairment rating (5th ed, 576-577). Evaluation of impairment following TBI often presents a significant differential diagnostic challenge. The Guides rating system has limitations for rating most of the deficits associated with these disorders. Further, the accurate determination of diagnosis and neurologic sequelae and symptom source relies on the assessment of important potential confounds and obstacles.7,8-12 Examiners should be familiar with the full range of potential confounds. The presenting symptoms of brain injury or disease must be differentiated from other conditions including, but not limited to, concurrent unrelated and related psychiatric and neuropsychiatric diagnoses. Clinical psychological and psychiatric conditions such as depression (reactive and/or organic), pain disorders, and/or post-traumatic stress disorder need to be appropriately considered in both litigating, as well as non-litigating, individuals. Less commonly, clinicians may encounter examinees with somatoform disorders, factitious disorders, as well as other response biases and malingering. These must be considered in the differential diagnosis of the individual, particularly when there is readily apparent secondary gain as with litigation, avoidance of work, identification with sick roles, access to
References 1. Center for Disease Control. Traumatic Brain Injury. Available at: http//www.cdc.gov/ncipc/factsheets/tbi.ht m. Accessed June 2003. 2. Thurman D, Alverson C, Dunn KA, Guerrero J, and Sniezek J. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil. 1999;14(6):602-615. 3. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a
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insurance benefits, financial gain, desire to gain or fear of losing access to privileges, etc. An important obstacle to valid impairment assessment is response bias. The frequently significant consequences of impairment determinations undoubtedly explain the sometimes high estimates of response bias in this population. Although most commonly conceptualized as deliberate exaggeration of difficulty, response bias exists on a continuum that extends from (1) denial or unawareness of impairments through (2) symptom minimization, (3) normal or average symptom presentation, (4) sensitization to subtle or benign symptoms or problems, (5) exaggeration or symptom magnification, and up to (6) frank malingering. Especially in medicolegal evaluations, assessment of response bias is critical to ensure accurate determination of diagnosis; symptom severity and source; and appropriate treatment and compensation decisions as well as prevention of iatrogenic complications. As much as possible, reports of interference in activities of daily living should be collaborated and assessment of motivational issues should integrate information from a variety of sources rather than relying on individual indicators.
Conclusions The presented information on the Guides is at best a brief introduction to its utility, as well as limitations, for rating impairment in persons with brain-based injury or disease. Impairment and disability evaluation is by no means a simple undertaking for any clinician regardless of specialty. Clinicians must take the time to familiarize themselves with the variety of disability and impairment evaluation protocols and understand their limitations relative to the specific clinical condition being assessed. Presently, there is no ideal system for rating impairment and disability associated with brain-based disorders.13 Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CIME, is the chief executive officer and medical director of Concussion Care Centre of Virginia and Tree of Life Services, Glen Allen, Virginia. Zasler can be reached at
[email protected]. Michael F. Martelli, PhD, is the director of Rehabilitation Neuropsychology for the Concussion Care Centre of Virginia and Tree of Life Services, Glen Allen, Virginia. Martelli can be reached at
[email protected]. Mark C. Bender, PhD, is a staff rehabilitation neuropsychologist for Concussion Care Centre of Virginia and Tree of Life Services, Glen Allen, Virginia. Bender can be reached at
[email protected].
practical scale. Lancet. 1974;2:81-84. 4. Zasler ND. Prognostic indicators in medical rehabilitation of traumatic brain injury: A commentary and review. Arch Phys Med Rehabil. 1997;78:S12-S16. 5. Zasler ND. Physiatric assessment in traumatic brain injury. In: M Rosenthal, ER Griffith, JS Kreutzer, B Pentland, eds. Rehabilitation of the Adult and Child with Traumatic Brain Injury. 3rd ed. Philadelphia, Pa: FA Davis; 1999:117-130. 6. Zasler ND, Martelli MF. Assessing mild
traumatic brain injury. Guides Newsletter. November/December 1998:1-5. 7. Martelli MF, Zasler ND, Grayson R. Ethics and medicolegal evaluation of impairment after brain injury. In: M Schiffman, ed. Attorney's Guide to Ethics in Forensic Science and Medicine. Springfield, Ill: Charles C. Thomas; 1999:194-236. 8. Martelli MF, Zasler ND, Nicholson K, Hart RP. Masquerades of brain injury, I:
Continued on page 9
Impairment Tutorial: Upper Extremity Pain (continued) Continued from page 4 Given the range, evolution, and discovery of new medical conditions, the Guides cannot provide an impairment rating for all impairments. Also, since some medical syndromes are poorly understood and are manifested only by subjective symptoms, impairment ratings are not provided for those conditions. The Guides, nonetheless, provides a framework for evaluating new or complex conditions. Most adult conditions with measurable impairments can be evaluated under the Guides. In situations where impairment ratings are not provided, the Guides suggests that physicians use clinical judgment, comparing measurable impairment resulting from the unlisted condition to measurable impairment resulting from similar conditions with similar impairment of function in performing activities of daily living. The physician’s judgment, based upon experience, training, skill, thoroughness in clinical evaluation, and ability to apply the Guides criteria as intended, will enable an appropriate and reproducible assessment to be made of clinical impairment. Clinical judgment, combining both “art” and “science” of medicine, constitutes the essence of medical practice (5th ed, 11).
With this background, we can examine the assessment of 2 unusual cases.
Ms A: Survivor of a Helicopter Crash Case Presentation Ms A, a 35-year-old woman, sustained multiple injuries in a helicopter crash including multiple compression fractures and a right shoulder injury. In the acute and subacute post-injury period, symptoms included pain radiating from the neck into right upper extremity and numbness in right ring and small fingers, present all of the time. Based on the results of multiple imaging studies and neurophysiologic tests, there was no evidence of neck pathology, or pathology within the right upper extremity itself, to account for her symptoms. Right shoulder subacromial decompression
did not change her right upper extremity symptoms distal to the shoulder. Her treating physicians’ diagnoses included thoracic outlet syndrome for which she underwent resection of the right first rib with right anterior and medial scalenectomy. Postoperatively, her right upper extremity symptoms improved but did not resolve completely, and she experienced an operative complication of right phrenic nerve palsy. At the time of the evaluation, Ms A’s symptoms included intermittent numbness in the right ring and small fingers and a feeling of weakness in the right upper extremity.
Impairment Assessment Approach A (Lorne Direnfeld, MD, Neurologist) In assessing this case, I did use alternative approaches to define impairment based on the premise that there actually was a thoracic outlet syndrome and also on the basis of chronic upper extremity pain, as if there had been a nerve injury. In this rare case, it was my professional opinion that there should be an assignment of permanent impairment, however, the Guides does not provide a direct methodology. Ratings for conditions affecting the brachial plexus are discussed in Section 16.5c, Regional Impairment Determination (5th ed, 489). Table 16-14 (5th ed, 490) provides specific values for maximum upper extremity impairments due to unilateral sensory or motor deficits of the brachial plexus, or to combined 100% deficits. Typically, thoracic outlet syndrome involves the lower trunk of brachial plexus. Table 16-14 indicates this results in a maximum of 20% upper extremity impairment due to sensory deficit or pain and 70% upper extremity impairment for motor deficit. These deficits are graded using Tables 16-10 and 16-11 (pages 482 and 484, respectively) of the Guides. However, how is one to rate a patient with credible symptoms who has undergone first rib resection and whose examination is normal? As the primary problem in this patient's case was Continued on page 10
Traumatic Brain Injury (continued) chronic pain and traumatic brain injury. J Controversial Med Claims. 2001; 8(2):1-8. Available at: http://villamartelli.com. 9. Martelli MF, Zasler ND, Hart RP, Nicholson K, Heilbronner RL. Masquerades of brain injury, II: response bias in medicolegal examinees and examiners. J Controversial Med Claims. 2001;8(3):13-23. Available at: http://villamartelli.com.
10. Martelli MF, Zasler ND, Nicholson K, Hart RP, Heilbronner RL. Masquerades of brain injury, III: critical examination of symptom validity testing and diagnostic realities in assessment. J Controversial Med Claims. 2001;9(2):19-21. Available at: http://villamartelli.com. 11. Heilbronner RL, Martelli MF, Nicholson K, Zasler ND. Masquerades of brain injury, IV: functional disorders. J Controversial Med Claims. 2002;9(3):1-7.
Available at: http://villamartelli.com. 12. Martelli MF, Bender MC, Nicholson K, Zasler ND. Masquerades of brain injury, V: pre-injury factors affecting disability following traumatic brain injury. J Controversial Med Claims. 2002;9(4):1-7. Available at: http://villamartelli.com. 13. Hinnant D, Tollison CD. Impairment and disability associated with mild head injury: medical and legal aspects. Seminars in Neurol. 1994;14(1):84-89.
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