《永久性残损评定指南（第六版）》基础概念评介

美国医学会第六版的《永久性残损评定指南》,代表了残损评定领域最新的、革命性进展。《永久性残损评定指南》旨在完善残损等级评定方法、提高评定的准确程度、增强评定结论的可信度,并使评定系数标准化,为残损评定提供稳定的、完备的方法。《永久性残损评定指南》最终目的在于,使利用该指南进行残损等级评定的结论具有权威性、公正性,并为评定所涉及的各方所认可。《永久性残损评定指南》的检查方法、术语以及分析架构以世界卫生组织的《国际功能、残疾和健康分类》为基础,涵盖了当今美国及国际社会最新有关残损等级评定研究成果,包括更为复杂、广泛的医学诊断手段,和更为准确功能丧失系数的解释说明等内容。所有的这些更新内容均有利于帮助鉴定人,在残损等级评定过程中消除争议,提高评定准确率。本文简要介绍了《永久性残损评定指南》第六版的基础概念,为我国法医临床学研究、借鉴《永久性残损评定指南》进行伤残评定提供依据。     

《永久性残损评定指南（第六版）》实践应用指南

本文以美国医学会《永久性残损评定指南（第六版）》为基础,介绍了在美国司法实践中,应用功能丧失比例评价人体功能丧失程度的关键概念、原则和基本原理。以期为我国法医临床学研究、借鉴《永久性残损评定指南》进行残损评定提供依据。     

《永久性残损评定指南》与美国工伤赔偿

在美国工伤赔偿体系中,美国医学会的《永久性评定指南》是强制性使用标准,全美各州均在使用第3版、第4版、第5版和第6版的《永久性评定指南》.但由于《永久性评定指南》相对复杂、难于理解,而且有很多可以引起法律争议内容.因此本文通过介绍《永久性评定指南》在美国工伤赔偿体系中的适用情况,期为我国法医临床学研究、借鉴《永久性残损评定指南》进行残损评定提供依据.     

《永久性残损评定指南》下肢残损评定原则

本文对《永久性残损评定指南》有关下肢致残残损评定原则进行研究。介绍了GEPI下肢评定中区域残损、循诊残损和校正因子等新概念,并对最大医疗改善的评定时机和人体整体功能转化等进行了说明。为完善我国的伤残评定体系提供借鉴。     

《永久性残损评定指南》下肢关节活动度评定原则

本文对《永久性残损评定指南》有关下肢致残残损评定原则进行研究。介绍了GEPI下肢评定中活动度评定的理念,并对活动度检查和评定过程进行了说明。为完善我国的伤残评定体系提供借鉴。     

《人体损伤致残程度分级》和GEPI关于髋关节评定比较研究

本文对《人体损伤致残程度分级》和《永久性残损评定指南》有关下肢髋关节评定进行比较研究。从条款分布、评定方法等方面对二者进行比较,并以《永久性残损评定指南》髋关节评定的残损值为参照,计算并分析《人体损伤致残程度分级》下肢髋条款致残率合理性,为《人体损伤致残程度分级》的修订提供建议。     

《劳动能力鉴定》标准与GEPI对手功能评定的比较

本文对我国《劳动能力鉴定职工工伤与职业病致残等级》(GB/T16180-2014)与美国医学会制定的《永久性残损评定指南》(第6版)在手功能评定方面的规定进行比较研究。从解剖结构缺损功能缺失、运动功能丧失、感觉功能丧失和综合评定等方面分析两者的异同,并评析手功能评定的理论和方法。     

肢体伤残评介(Ⅲ)--下肢功能评定标准

本文主要依据《永久残损评定指南(第五版)》介绍下肢肢体功能障碍评定标准。     

肢体伤残评介(Ⅱ)--上肢功能评定标准

本文主要依据《永久残损评定指南(第五版)》介绍上肢肢体缺损评定、感觉功能障碍评定、运动功能障碍评定以及外周神经损伤后遗留功能障碍评定等标准。     

泌尿生殖系统伤残评定

本文主要依据美国《永久残损评定指南》(第5版)关于泌尿生殖系统损伤残损功能评定的标准进行介绍。主要阐述标准是关于泌尿系统及男女生殖系统系统性残损对全身功能的影响以及个体完成日常生活活动的能力。     

Pain, Impairment, and Disability in the AMA Guides

Physicians use the American Medical Association's Guides to the Evaluation of Permanent Impairment, 5th edition to evaluate millions of disability applicants each year. As major contributors to the chapter in the Guides devoted to assessing impairment associated with pain, we confronted the difficulties of incorporating pain into the Guides' overall evaluation system. Analysis of these difficulties is complicated by the paucity of research on the Guides, and by ambiguities and contradictions that pervade it. We propose that the ambiguities can be reduced if impairment is consistently defined in terms of organ or body part derangement, and disability in terms of activity limitations at the level of the whole person. We also propose a distinction between objective factors that may influence a person's ability to perform activities following injury. We suggest that when physicians examine disability applicants, they should evaluate both objective measures of organ or body part dysfunction and subjective reports of applicants -- especially ones regarding pain. We conclude that a comprehensive medical evaluation of disability applicant encompasses more than an impairment assessment.     

肘关节损伤致上肢功能障碍程度评价方法的比较

目的 比较我国<道路交通事故受伤人员伤残评定>(简称<道标>)与美国<永久残损评定指南>(简称GEPI)对肘关节活动功能障碍致上肢功能丧失程度的评价结果.方法 对70例肘关节活动功能障碍者分别用上述两种方法评价上肢功能丧失程度,并对两种方法评价结果进行分析比较.结果 两种方法评价结果的差异具有统计学意义.当肘关节屈伸活...     

肩关节损伤致肢体功能障碍程度评价方法比较

目的探讨能客观反映肩关节功能障碍对肢体功能影响的评价方法。方法通过用我国《道路交通事故受伤人员伤残评定》（简称＂《道标》＂）的权重指数法与美国《永久残损评定指南》（Guides to the Evaluation of Permanent Impairment,GEPI）（简称GEPI法）,对133例肩关节损伤后伤残评定案例进行回顾性评价;并用两种评价方法对肩关节不同运动方向及不同活动度对上肢功能影响进行全方位的比较。结果 133例肩关节功能障碍案例,权重指数法达到伤残的总比例高于GEPI法;但在功能丧失不同比例段两者有差异。差异的原因在于,在GEPI法中,肩关节不同运动方向所占的权重不同,前屈上举与外展上举对于肩关节功能相对重要,并考虑关节功能位对肢体障碍程度的影响;而权重指数法,上肢功能的关系与关节活动度呈简单的线性关系,与关节活动方向及功能位无关。结论 GEPI法比权重指数法能更能客观地反映肩关节功能障碍对肢体功能丧失的影响程度。     

Predictive Validity of the Neuropsychological Assessment Battery-Screening Module for Assessing Real-World Disability in Patients with Mild Traumatic Brain Injury

The present study set out to examine the ecological validity of the Neuropsychological Assessment Battery-Screening Module (NAB-S) and to examine more specifically, whether performance on this test battery is related to real-world disability status in patients who have sustained a mild traumatic brain injury (mTBI) as a consequence of a motor vehicle collision (MVC). Seventy-nine patients were recruited from a random sample of litigating patients who incurred an mTBI and were referred for a neuropsychological examination due to subjective complaints of cognitive function. Of the total sample, 54 patients were categorized into the non-disabled group and 25 patients were categorized into the disabled group using the 4th edition of the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (AMA; 1993). A multivariate analysis of variance revealed that performance on the NAB-S significantly differed between the two groups, and that memory and attention domains provided a more discriminative index of disability than general neuropsychological functions. In addition, discriminant function analyses revealed that the NAB-S correctly classified 73% of patients according to their group membership. The current findings provide evidence for the ecological validity of the NAB-S as a reliable index of real-world disability status as defined by the AMA Guides.     

《人体损伤程度鉴定标准》“视力视器损伤”条款解读与分析

《人体损伤程鉴定标准》＂视力视器损伤＂部分,在充分吸纳国内、国外新的损伤理念（如WHO关于盲目的分类、《国际功能、残疾和健康分类（ICF）》,美国医学会《永久残损评定指南（GEPI）》）的基础上,进一步追求标准的科学性、规范性。该标准去除了旧标准中不适当的条款,增加了标准的可操作性,并使得标准更符合国际潮流。与旧标准相比,条款总体变化的情况如下：条目大量增加,条目由旧标准的19条目增加至39条目;条款内容细化;新增了视野缺损条款5个条目。上述变化,需要法医临床学工作者加以关注并正确解读。同时,在司法鉴定实践中,伪盲鉴别、视野检查及其客观评定方面的操作难度将大幅增加,相应的科学研究需同步跟进。本文对本标准运行中存在的技术难点给予了解读;同时详解了＂视野有效值＂的计算方法,即：实测视野有效值（%）=（8条子午线实测视野值之和/500）×100%。     

The Usage of the AMA <Emphasis Type="Italic">Guides</Emphasis> for the Determination of Psychological Injury Within the State and Federal Workers’ Compensation Systems

Psychological injuries, like physical injuries, may occur within the workplace. If those injuries are reported to be a result of a triggering event in the workplace, then a workers’ compensation (WC) claim may be filed by the individual. State WC and the federal WC systems have laws and rules in place to address workplace psychological injury claims. However, because each State has its own WC State laws as does the federal WC system, there is no current standardization in defining either psychological injury or in defining disability. This is because each system has its own definitions. A few States allow workplace psychological injury claims. Some States do not accept WC psychological injury claims. The remaining States recognize workplace psychological injuries but with specific limitations. The federal WC system allows WC psychological injury claims. There are problematic issues that occur in the State and federal WC systems. These issues are utilizing outdated terminology, employing outdated diagnostic criteria, and allowing documentation submission and professional opinion that does not comport with current professional standards of care. In addition, the need for a definitive answer to address causation is not always possible to address with regard to psychological injury. These types of issues introduce imprecision into the determination of psychological injuries. To address these concerns, the American Medical Association developed the Guides to the Evaluation of Permanent Impairment as a means to take a more scientific approach to the assessment of impairment. This stance was a move away from the poorly defined term, “disability”. The focus was on evaluating the individual’s functioning in terms of impairment. The AMA holds that this is a more objective method that provides a balance between clinical opinion and the utilization of a more scientific methodology that increased precision in the determination of psychological injury and purported impairment in functioning that may have resulted from the injury. The American Medical Association’s Guides to the Evaluation of Permanent Impairment are utilized by many States and the federal WC systems to assist in the evaluation of psychological impairment in functioning and in the WC claims process. Some States opt to use earlier editions of the Guides. Other States and the federal WC system require the usage of the most current edition of the Guides. A few States opt to forego the usage of the Guides altogether and develop State-specific guidelines. The complexities that arise within the WC systems as well as usage of the Guides to evaluate and assess psychological injury are explored as well as potential solutions to address the imprecision that occurs within the WC systems.     

Disentangling the Disability Quagmire in Psychological Injury: Part 1—Disability and Return to Work: Theories, Methods, and Applications

This paper critically reviews and integrates multidisciplinary literature informing conceptualization and determination of disability and return to work from a psychological injury perspective. It focuses on dissecting and disentangling the ambiguities and complexities of theories and definitions of disability, impairment, and return to work, highlighting the conceptual quagmires that affect both research and clinical methodology in the field. The paper discusses the strengths and limitations of the main theoretical perspectives on disability and return to work—social, medical, and biopsychosocial—and the associated applied perspectives, including the legal/administrative, clinical, and research oriented. It provides a special focus on the Americans with Disabilities Act and the American Medical Association’s Guides for the Evaluation of Permanent Impairment as leading applied perspectives. The paper also highlights the features and methodological implications of the integrative framework of the International Classification of Functioning, Disability and Health (World Health Organization, International classification of functioning, disabilities and health, WHO, Geneva, Switzerland, 2001). Finally, it draws implications for the field of psychological injury in a legal context.     

《人体损伤程度鉴定标准》解读与评析

本文就《人体损伤程鉴定标准》（以下简称《标准》）立法本意、“重伤一级”与残疾等级的对应关系、标准框架、标准中存在的技术问题等内容，予以解读。本文作者认为，（1）《标准》满足了司法审判中对“严重残疾”予以医学界定的需求，其中的“重伤一级”即是对“严重残疾”的明确界定。（2）对比分析显示：“重伤一级”的24个条款中，有23个属“严重残疾”状态，其残疾等级分属“1-4级”。（3）《标准》延续了原重伤、轻伤标准的鉴定原则不变，并修订大量条款，使其更具有可操作性（4）《标准》大量吸纳了国际上ICF、GEPI等残疾分类的新理念，更具有进步性。当然，研究显示，标准亦存在一些技术问题：（1）不符合《中华人民共和国标准化法》对技术标准的形式要件要求；（2）标准条款之间有不平衡、不严谨的现象；等等。预测：在未来的几年内，对《标准》条款的解读、争议、规制，将是中国法医临床学研究的主要内容之一。     

道路交通事故伤残等级评定中的手功能评估

手功能的检查和评估,历来是法医临床学鉴定中的难点和重点问题。GB18667—2002《道路交通事故受伤人员伤残评定》中对手功能评定的规定较为详细,其标准溯源是国际手外科联合协会的“手功能评定标准”和我国临床医学专家据此修订的“手功能评定标准专题讨论会纪要”。手功能检查和评估包括手部缺失的评定、手部运动功能的评定及手部感觉丧失的评定。在计算手功能损害率时,应按照所规定的系数。在缺失、运动障碍及感觉丧失等多种类型并存时,应按照复合计算的方法得出结果。