关于《道路交通事故受伤人员伤残评定》中若干技术难题的处理办法(下)

由于《道路交通事故受伤人员伤残评定》中许多条文的规定比较笼统和原则,在理解和掌握上尚有一定的困难。为此,作者参考国家有关鉴定标准和临床医学有关器官功能障碍分级方法,并结合作者在伤残评定中所积累的经验,提出有关评定标准的细则,旨在推动鉴定工作的统一和规范,确保鉴定结论的公正和科学。     

关于《道路交通事故受伤人员伤残评定》中若干技术难题的处理办法(上)

由于《道路交通事故受伤人员伤残评定》中许多条文的规定比较笼统和原则,在理解和掌握上尚有一定的困难。为此,作者参考国家有关鉴定标准和临床医学有关器官功能障碍分级方法,并结合作者在伤残评定中所积累的经验,提出有关评定标准的细则,旨在推动鉴定工作的统一和规范,确保鉴定结论的公正和科学。     

《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。     

Survey of methods for the rating of psychiatric impairment in Australia

One of the enduring clinical issues in the assessment of plaintiffs in personal injury and workers' compensation claims, as well as applicants for social security and disablement benefits, is that of the evaluation of impairment and work incapacity. Many writers on this topic confuse the concepts of impairment and disability, and similar confusion is reflected in a number of the rating methods that purport to evaluate impairment but in reality assess disability. In Australia there are 20 distinct statutory schemes for workers' compensation, motor accident compensation, and social security and other benefits, which utilise a variety of methods for the rating of psychiatric impairment. Recent legislative changes designed to restrict access to personal injury compensation at common law, which in two Australian State jurisdictions require the use of impairment rating scales, also specify the rating methods to be used in the assessment of psychiatric impairment. This article discusses the concepts of impairment and disability as defined by the World Health Organisation, and reviews the various methods for the rating of psychiatric impairment that are specified by statute in the federal and State jurisdictions in Australia.     

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.     

Erratum to: Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses on current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

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.     

慢性疼痛与残疾评定——以《永久性残损评定指南》为背景

疼痛是一种具有感觉、情感、认知和社会成分的不愉快经历,慢性疼痛可对个体日常生活造成影响。本文以美国《永久性残损评定指南》为背景,对慢性疼痛的概念、神经机制、生物-心理-社会模型及负面影响进行概述,并简要介绍了《永久性残损评定指南》第6版中疼痛伤残评定的原则、方法及争议等内容。以期为慢性疼痛纳入我国残疾评定体系提供方向与思考。     

Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing commentary for practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

Motor Vehicle Collisions and Their Consequences—Part II: Predictors of Impairment and Disability

A significant number of persons involved in motor vehicle collisions (MVCs) evidence persistent changes in physical, psychosocial, and cognitive functioning consequent to physical injury. While post-injury impairment and disability can sometimes be predicted with knowledge of injury type and injury severity, post-injury experiences of pain, psychological distress, cognitive dysfunction, and role disruption have been determined to contribute to injury-related impairment and disability. This article represents the second part of a two-part review of MVCs and their consequences. In part I of the review, research findings related to physical, psychosocial, and cognitive changes that occur consequent to injury-causing MVCs are described. In this article, measures used to document the severity of physical injuries are reviewed, along with the most widely accepted definitions of impairment and disability. Models that have been proposed to explain the progression from injury to impairment and disability are reviewed, including a more recently proposed model created specifically to guide the assessment and management of MVC-related outcomes. The greater part of this article is devoted to the review of findings related to physical, psychological, and cognitive predictors of post-MVC impairment and disability. The relation of these predictors to post-MVC impairment and disability is described across three specific injury contexts: (1) whiplash-associated disorders, (2) traumatic brain injury, and (3) polytrauma. In each context, findings related to recovery of function in the form of return to work are summarized, along with findings related to the contribution of compensation to injury-related symptoms and impairments. Although not characterized as a physical injury, chronic pain serves frequently as the post-injury symptom that persists beyond all injury management and rehabilitation efforts and that contributes significantly to MVC-related functional impairment, disability, and emotional distress. It is appropriate, therefore, to include in this review a discussion of those MVC studies that specifically address impairment and disability occurring in relation to chronic pain. The article ends with the identification of ongoing research challenges and future directions for both the study of MVCs and their associated sequelae and clinical practice with persons who are experiencing the consequences of MVC-related injuries.     

Biopsychosocial Factors that Perpetuate Chronic Pain, Impairment, and Disability

The biopsychosocial model provides the most heuristic account of the complex multifaceted nature of chronic pain and its associated impairment and disability. Although chronic pain, impairment, and disability are related, these are three separate constructs. In order to understand how these three constructs are interrelated, the development of pain from the acute to the chronic stage is discussed. Psychosocial factors as barriers to recovery are emphasized, including those that commonly manifest among patients receiving disability compensation. This is complemented by a review of psychometric instruments used to assess these psychosocial factors in chronic pain. Finally, the major delineation in levels of care for chronic pain is highlighted, emphasizing an interdisciplinary approach that is consistent with pain as a biopsychosocial phenomenon.     

道路交通事故精神伤残评定相关问题

近年来,道路交通事故频繁发生,造成严重的人身伤害。许多颅脑损伤患者伤后常出现明显的行为或认知缺陷,创伤性脑损伤患者精神障碍的患病率明显增高,精神伤残的评定日益增多。但同时,关于精神伤残评定的争议也日益激烈。首先介绍国内外精神伤残的相关概念,然后分析道路交通事故精神伤残评定标准存在的不足和缺陷,重点分析道路交通事故中精神伤残程度的影响因素,并介绍精神伤残评定中的检查方法,最后提出解决精神伤残评定分歧的思路。     

Revised medical criteria for determination of disability, endocrine system and related criteria--SSA. Proposed rule

We are proposing to delete "Obesity," from the listing to adjudicate claims for disability under titles II and XVI of the Social Security Act (the Act) when we evaluate claims of individuals at step 3 of our sequential evaluation process. Current medical and vocational research demonstrates that, while many individuals with obesity are disabled, obesity, in and of itself, is not necessarily determinative of an individual's inability to engage in any gainful activity. Instead, individuals with obesity would have their cases reviewed under the listing for an affected body system(s) or, on a case-by-case basis, at the remaining steps of the sequential evaluation process.     

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。     

《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%。     

劳动能力鉴定中无晶体眼的视觉功能评价

无晶体眼视觉功能的评价是劳动能力鉴定中经常遇见的问题。准确评价无晶体眼的视觉功能障碍程度,有利于保证鉴定意见的科学性和客观性。无晶体眼不仅影响视力,亦可影响视野,引起视野缺损。单眼无晶体者较双眼视力对称性降低更易引起立体视锐度的损害。总结多年劳动能力鉴定中涉及视觉功能障碍评定的实践经验,可以紧紧把握劳动能力鉴定标准中＂依视力递减受损百分比进行比较＂这个关键,利用改进的＂对比相乘法＂对无晶体眼的视觉功能进行有效评价。     

《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。     

脑震荡后综合征伤残评定研究进展

由于症状表现的主观性以及当前客观检查方法所能提供证据的匮乏,加之赔偿伴生的症状伪装和夸大等问题,脑震荡后综合征患者的伤残评定鉴定意见一致性不高。在人体损伤赔偿纠纷中,脑震荡后综合征患者的伤残评定成为法医精神病鉴定的争议点和难题。通过对脑震荡及相关术语变化、脑震荡后综合征的发生率、症状表现及诊断标准、脑震荡后综合征客观评价技术以及伤残评定的现状及未来发展方向进行综述,以期提高对脑震荡、脑震荡后综合征的认识,提高鉴定意见的一致性。     

Extension of the expiration data for several body system listings. Final rule

We use the Listing of Impairments (the listings) at the third step of the sequential evaluation process when we evaluate your claim for benefits based on disability under title II and title XVI of the Social Security Act (the Act). This final rule extends until July 1, 2008, the date on which the listings for eight body systems will no longer be effective. Other than extending the effective date of the listings, we have made no revisions to the listings; they remain the same as they now appear in the Code of Federal Regulations. This extension will ensure that we continue to have the medical evaluation criteria in the listings to adjudicate disability claims involving these body systems at the third step of the sequential evaluation process.