disability medicine

28 Pages·2002·0.26 MB·English

Vol. 2 No. 2 April-June 2002
DDIISSAABBIILLIITTYY MMEEDDIICCIINNEE
The Official Periodical of the American Board
of Independent Medical Examiners
Editorial Board Contents
PAGE
Editorial:
Editor-in-Chief
Perils of Being an Independent
Mohammed I. Ranavaya, MD, MS, FFOM,
Medical Edxaminer
FRCPI, FAADEP, CIME 38
. . . . . . . . . . . . . . . . . . . . . . . . . .
Assistant Editors
Original Research Article
Thomas A. Beller, MD, FAADEP, CIME Classifying Fibromyalgia:
Taxonomic Lessons from the
J. True Martin, MD, CIME, FAADEP
Icelandic Disability
Rebecca McGraw-Thaxton MD
Registry
39
. . . . . . . . . . . . . . . . . . . . . . . . . .
Editorial Advisory Board
Alan L. Colledge, MD, CIME Neuropsychological Assessment:
Psychometric and Clinical Issues
Stan Bigos, MD 46
. . . . . . . . . . . . . . . . . . . . . . . . . .
Gordon Waddell, FRCS, Glasgow,UK
Charles N. Brooks, MD, CIME Facial Pain
An Overview of Evaluation
Pete Bell, MD, CIME
and Treatment
Peter Donceel, MD, Belgium . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Sigurdur Thorlacius, MD, PhD, Iceland
Book Review
Clement Leech, MD, Ireland
Independent Medical Evaluations
Jack Richman, MD, Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Cristina Dal Pozzo MD, Italy
Book review
Richard Sekel, MD, Australia
Interactive Spine Software CD
William H. Wolfe, MD, MPH, FACPM, CIME 59
. . . . . . . . . . . . . . . . . . . . . . . . . .
Charles J. Lancelotta, Jr., MD, FACS
Letter to the Editor
Kevin D. Hagerty, DC, CIME 60
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sridhar V. Vasudevan, MD
Frank Jones, MD, CIME Letter to the Editor
62
Alan K. Gruskin, DO . . . . . . . . . . . . . . . . . . . . . . . . . . . .
William Shaw, MD
Jan von Overbeck MD, Switzerland
James Becker, MD
Altus vanderMerwe MD, Switzerland
Jerry Scott, MD
Chet Nierenberg, MD
Charles Clements, MD
Kendal Wilson, DO
John Shimkus, MD
Brian T. Maddox,Managing Director
American Board of Independent Medical Examiners
E :
DITORIAL
Perils of Being an Independent
Medical Examiner
BOARD OF DIRECTORS
Thomas A. Beller, MD, CIME
President
Kansas City, Missouri
Mohammed I. Ranavaya, MD, CIME Hostility exists in Worker’s Compensation course of the examination. Arizona
President Elect/Secretary and in Litigation arenas where Supreme Court said it best1. “If an IME
Chapmanville, West Virginia
Independent Medical Evaluations are practitioner’s evaluations, opinions, and
Alex Ambroz, MD, MPH, CIME
Donald L. Hoops, PhD commonly used. This hostility is age old, reports could lead not only to vehement
Prospect Heights, Illinois and it is born naturally from a situation disagreement with and vigorous cross-
John D. Pro, MD, CIME where a legal bias to represent one’s client examination of the practitioner in the
Kansas City, Missouri
in the light most favorable to the client claims or litigation process, but also to his
Brian T. Maddox
Executive Director exists. This issue of Disability Medicine or her potential liability for negligence, the
Barrington, Illinois
carries a letter from Mr. Tom DiGrazia , resulting chilling effect would be severe.
BOARD OF ADVISORS Esq. underscoring this hostility. The To permit such an action by expanding the
Robert N. Anfield, MD, JD review in this issue of the book concept of duty in this type of case would
Chattanooga, Tennessee
Independent Medical Evaluations sheds be, at best, ill-advised.”
Stan Bigos, MD
San Diego, California light as well on the perspectives of
Niall J. Buckley, BSc, MD, CIME plaintiff and defendant, i.e., on the bias In an inherently biased and hostile
Halifax, Nova Scotia, Canada itself. environment, it is of utmost importance
Pieter Coetzer, MB, ChB, BSc, CIME
for society in general that Independent
Capetown, South Africa
Paul W. Goodrich, Esquire Unfortunately, as part of the IME process, Medical Evaluators on both sides are not
Boston, Massachusetts physicians are affected by this bias, and discouraged from reporting what they
J. Frederic Green, MD because of the hostility of this consider the truth, and that they be
Moline, Illinois
environment, this bias makes involvement allowed to speak their mind without the
Jane C. Hall, RN, MPA, CCM
San Francisco, California in the IME process potentially dangerous fear of reprisal. The Colorado Supreme
Clement Leech, MD for physicians. Parties who do not like the Court summed it up2: “Simply put, the
Dublin, Ireland
message of the opposing side’s social utility of allowing physicians to
Christine M. MacDonell
Tucson, Arizona independent medical examiner, sometimes conduct IME’s without fear of liability to
Presley Reed, MD, CIME resort to tactics to harass and intimidate the examinee substantially outweighed the
Past President
Boulder, Colorado physicians who try to be intellectually benefit of allowing such claims.” Judicial
Lester L. Sacks, MD honest, and who speak what they consider views such as these should be reassuring
Hartford, Connecticut the truth. Particularly in cases involving to Independent Medical Evaluators on
William Shaw, MD controversial diagnoses, the risk of action both sides and require Independent
Denver, Colorado
Randall Short, DO against physicians is increasingly Medical Evaluators to maintain
Chapmanville, West Virginia common; some have even called intellectual honesty despite bias of the
Alfred Taricco, MD Independent Medical Evaluation a full requestor of the IME. It is in this way, by
Manchester, Connecticut
contact sport. The goal of these militant maintaining this intellectual honesty, that
Gordon Waddell, DSc, MD, FRCS
Glasgow, Scotland actions against Independent Medical the physician can best function to
John J. Wertzberger, MD Evaluators is to discourage physicians – at maintain the integrity of the process.
Scottsdale, Arizona
best well meaning, good, and honest – on While the ride through legal terrain – such
Karen Wielde, RN, BSN, CCM
Marietta, Georgia both sides from speaking their minds. One as cross-examination, and, in some cases,
such tactic would be the filing of a worse – can be rough for Independent
complaint with a Medical Licensing Medical Evaluators, with legal precedents
Board; another would be legal such as described, there is hope that in
maneuvering that squanders a physician’s the end, despite bias and hostility,
time and money . intellectual honesty can prevail.
Most of the jurisdictions have consistently
Rebecca McGraw, MD
held that Independent Medical Evaluators
Mohammed I. Ranavaya, M.D., M.S.,
do not owe an examinee a duty of care,
FRCPI, FFOM, FAADEP, CIME,
and more generally that a physician has
Editors
no liability to an examinee for negligence
or professional malpractice absent a
Reference
physician-patient relationship, except for
1Hafner v. Beck, 916 P.2d 1105,1107 (Az. App. 1995):
physical injuries incurred during the 2Martinez v. Lewis, 969 P.2d 213 (Col. 1998)
38
Original Research Article
Classifying Fibromyalgia: Taxonomic Lessons
from the Icelandic Disability Registry
Sigurdur Thorlacius1,2, Mohammed I. Ranavaya3, Sigurjon B. Stefansson1,4, Robert Walker3,
1State Social Security Institute of Iceland, 2Faculty of Medicine, University of Iceland, 3Joan C.Edwards School of Medicine, Marshall University
Department of Family and Community Health, Division of Disability Medicine, Huntington, WV, USA and 4Department of Neurology, National University
Hospital of Iceland
Correspondence address:
Sigurdur Thorlacius
Tryggingastofnun rikisins
Laugavegur 114, 150 Reykjavik, Iceland
Tel: [phone]
Fax: [phone]
E-mail: [email protected]
Introduction
Myositis, unspecified, or “Fibromyositis pensioners with the primary diagnosis
NOS”.15This classification, widely used of FMS.
Fibromyalgia Syndrome (FMS) has
for billing, would thereby classify FMS
defied consistent classification by This study utilized the disability
as a disease of muscle. Since disease
physicians and remains controversial.1-4 registry of the State Social Security
classification can be important in
Uncertain classification has implication Institute of Iceland (SSSI) because the
determining etiology, disability criteria
for consultation, treatment, research, Icelandic population is relatively narrow
and clinical research, many attempts
and determination of impairment and in genetic and cultural variation
have been made to suggest and justify
disability. The etiology of the condition compared to that of other nations. This
various ways to classify FMS.16-20Since
is unclear and some question the registry provided primary and
the etiology is unknown and no
existence of fibromyalgia as a distinct secondary diagnoses and information
consistent biochemical marker has been
clinical entity.5-12Depending on one’s on sex and age for all recipients of full
identified, attempts at classification
clinical specialty or research interest disability in Iceland on December 1,
often compare types of attendant or
FMS may be variously categorized 2001.28-30Since previous studies of
secondary diagnoses between
under rheumatology, neurology, chronic fibromyalgia have been criticized
categories20-25as well as numbers of
pain, sleep disorder, or psychiatry.13-14 because of wide genetic and cultural
diagnoses.26-27This study employed a
diversity across subjects access to
The International Classification of unique data set to compare types of
Icelandic population data was especially
Disease, Ninth Revision (ICD-9) has no numbers of secondary diagnoses and
useful to this study.20, 26The citizens of
specific code for fibromyalgia, and the determine the most compatible disease
Iceland are considered to represent a
condition is often coded as 729.1, category for a group of disabled
group of relatively narrow genetic and
corresponding to “Myalgia and
cultural diversity. In addition, a
39
previous nationwide study had Comparisons were made between the distribution of numbers of secondary
determined the prevalence of the study and control groups in the diagnoses.
diagnosis of FMS in Iceland.31 percentage of pensioners with single
Results
versus multiple diagnoses as the basis
Materials and Methods
for disability and in the distribution of
On December 1, 2001, 10,588 people,
categories of illness of secondary
Data from the disability registry from including 6268 women and 4320 men,
diagnoses. The FMS (study) group was
SSSI was used to form two age-matched with full disability pension were
also compared to three groups of
groups. Since over 93% of disability registered at the SSSI. FMS was listed
disabled pensioners with one of three
pensioners with FMS were female, only among the diagnoses of 766 disability
serious, disabling diseases as their
females were included in the study pension recipients, totaling 716 women
primary diagnosis, including a
groups. The study group consisted of and 50 men. Since previous studies have
neurological diagnosis (multiple
female pensioners with FMS as one of also shown that FMS is far more
sclerosis), a rheumatologic diagnosis
their listed diagnoses. The comparison prevalent in women, only women with
(rheumatoid arthritis), and a psychiatric
group consisted of the consecutively that diagnosis were included in the
diagnosis (schizophrenia) in terms of
encountered disabled pensioner with a study. An age-matched comparison
number of secondary diagnoses. As a
date of birth which matched that of the group was identified (Table 1) because
result of initial findings, the FMS
index case within 90 days and who did the FMS group (index group) could not
(study) group was also compared to
not have a listed diagnosis of FMS. be accurately compared to remaining
disabled pensioners with the primary
Statistical significance was determined women with full disability pension due
diagnosis of anxiety/depression in
using the chi-square test.32 to a wide age variation between groups.
Table 1: Age distribution of women with full disability pension.
Age Index group (with FMS) Comparison group All women
(in years) Number Percentage Number Percentage Number Percentage
16-19 0 0.0 0 0.0 80 1.3
20-24 2 0.3 2 0.3 174 2.8
25-29 6 0.8 6 0.8 266 4.2
30-34 29 4.0 29 4.0 333 5.3
35-39 77 10.8 77 10.8 611 9.8
40-44 109 15.2 109 15.2 739 11.8
45-49 121 16.9 121 16.9 728 11.6
50-54 115 16.1 115 16.1 816 13.0
55-59 136 19.0 136 19.0 911 14.5
60-64 100 14.0 100 14.0 1015 16.2
65-66 21 2.9 21 2.9 595 9.5
Total 716 100.0 716 100.0 6268 100.0
40
Table 2 compares the distributions of the Table 3: Diagnoses according to selected main
groups of diseases registered for two groups of
number of diagnoses for each pensioner
women with full disability pension, one with (index
in the FMS (study) and comparison
group) and the other without (comparison group)
groups. In the FMS (study) group, FMS
the diagnosis of FMS.
was the only diagnosis in only 6.8%
pensioners, while 38.3% of the control
Groups of diseases* Women with FMS Women without FMS
group had a single listed diagnosis. The
(n = 716) (n = 716)
percentages of multiple diagnoses in the Number % Number %
FMS (study) group exceeded those of
Infections 6 0.8% 13 1.8%
the control for each number of
Malignant neoplasms 3 0.4% 30 4.2%
diagnoses reported.
Endocrine, nutritional 98 13.7% 79 11.0%
and metabolic diseases
Table 2: The number of
Mental disorders 415 58.0% 329 45.9%
diagnoses registered
Diseases of the nervous system 71 9.9% 101 14.1%
for women with full
Diseases of the circulatory system 76 10.6% 86 12.0%
disability pension, with
(index group) and Chronic obstructive pulmonary diseases 82 11.5% 63 8.8%
without (comparison Diseases of the digestive system 50 7.0% 44 6.1%
group) the FMS Diseases of the skin/subcutaneous tissue 20 2.8% 19 2.7%
diagnosis. Diseases of the musculoskeletal system
other than fibromyalgia 321 44.8% 318 44.4%
Diseases of the genitourinary system 25 3.5% 20 2.8%
Number Women Women
of with without Injury and poisoning 53 7.4% 83 11.6%
diagnoses FMS FMS
Other diagnoses 20 2.8% 34 4.7%
per person (n = 716) (n = 716)
* from the International Classification of Diseases
1 49 (6.8%) 274 (38.3%)
2 233 (32.5%) 184 (25.7%) category. The groups are statistically groups were compared in terms of the
3 205 (28.6%) 120 (16.7%) significantly different (p<0.0001). distribution of numbers of diagnoses
4 125 (17.5%) 85 (11.9%) Among individual categories of disease, per pensioner. This comparison is
5 62 (8.7%) 35 (4.9%) the only category showing significance shown in Table 4. The distribution
6 27 (3.8%) 12 (1.7%) was that of “Mental Disorders.” The pattern between the two groups is
7 7 (1.0%) 3 (0.4%) FMS (study) group listed a significantly similar, with the “anxiety/depression”
8 5 (0.7%) 2 (0.3%) (p<0.0001) higher percentage of group showing a slight tendency toward
9 3 (0.4%) 0 (0.0%) diagnoses in this category (58.0%) than increased numbers of secondary
10 0 (0.0%) 1 (0.1%) the control group (45.9%). Because of diagnoses.
this, the FMS (study) group was
Table 5 compares the distribution of
compared to the 968 disabled female
Table 3 compares the two groups in
numbers of secondary diagnoses in the
pensioners listing “anxiety/depression”
terms of the numbers and percentages
FMS (study) group to schizophrenia,
as their primary basis for disability. The
of secondary diagnosis by disease
41
Table 4: The number of diagnoses registered for women with full disability
pension and anxiety/depression or FMS as first (primary) diagnosis as basis
for disability claim.
Number of diagnoses Anxiety/depression FMS
per person as primary diagnosis as primary diagnosis
Number Percentage Number Percentage
1 170 17.6% 49 16.6
2 270 27.9% 116 39.2
3 242 25.0% 80 27.0
4 146 15.1% 27 9.1
5 89 9.2% 13 4.4
6 27 2.8% 7 2.4
7 14 1.4% 3 1.0
8 7 0.7% 1 0.3
9 2 0.2% 0 0.0
10 1 0.1% 0 0.0
Total 968 100.0% 296 100.0
Table 5: The number of diagnoses registered for women with full disability
pension and three serious, disabling diseases as first (primary) diagnosis as
basis for disability claim.
Number of Schizophrenia Multiple sclerosis Rheumatoid arthritis
diagnoses Number Percentage Number Percentage Number Percentage
1 83 66.7 96 79.3 119 51.1
2 34 18.6 16 13.2 51 21.9
3 15 8.2 6 5.0 33 14.1
4 9 4.9 3 2.5 18 7.7
5 2 1.1 0 0.0 7 3.0
6 0 0.0 0 0.0 3 1.3
7 1 0.5 0 0.0 2 0.9
Total 183 100.0 121 100.0 233 100.0
Discussion
multiple sclerosis, rheumatoid arthritis, conditions showed a similar tendency
three serious disabling conditions with toward fewer secondary diagnoses,
Everything about Fibromyalgia
widespread effects and uncertain unlike the distribution patterns of FMS
Syndrome (FMS) engenders controversy
etiologies. Distributions in these three and “anxiety/depression.”
except for the suffering it causes and the
42
isolation, frustration, and sclerosis, and rheumatoid arthritis are women, especially when such factors
marginalization of FMS patients need to poor matches for the pattern seen with are important in the culture studied.39,40
be addressed by the clinicians. Because FMS and GAD.
Supporting documentation for patients
of the absence of a known etiology or
There is a body of medical literature to applying for disability pensions
consistent laboratory markers, FMS has
support classification of FMS as a obviously must list diagnoses to justify
been classified in many ways. Since the
psychiatric diagnosis associated with the application. Societal prejudices
most commonly used diagnostic criteria
the anxiety disorders.2,8,23Peer reviewed against mental and behavioral disorders
are based primarily on the elicitation of
literature suggests a strong associations may influence physicians’ decisions to
tender points33 the disease is most
of FMS with co-morbid conditions make the more “respectable” diagnosis
consistently classified as rheumatologic.
which are strongly linked to anxiety and of FMS.6
On-going research suggests to some that
stress, such as irritable bowel syndrome,
the disease represents a dysfunction of Some authors propose new classification
irritable bladder syndrome and
neurological or neuroendocrine systems. systems for FMS and similar conditions.
tympanomandibular disorders.21,22,23,34
The common association of chronic, These include categories such as
debilitating conditions with psychiatric Others document the high prevalence of “functional disorders,” “widespread
diagnoses, and overlapping diagnostic specific mental disorders in patients pain,” “disorders of pain modulation,”
criteria have made classification of FMS with FMS.19,24,27,35,36Other authors have and “functional somatic
as a psychiatric illness difficult and attempted to demonstrate a lack of syndromes.”2,18,19,26It would appear that
controversial. Uncertain classification has correlation of FMS with other diseases such new classifications would be
implication for consultation, treatment, more firmly established as helpful and consistent only if the
research, and determination of impairment rheumatologic.2,25,37 conditions classified shared etiologic or
and disability. laboratory elements.
Classification of FMS must also consider
The data set employed in this study the significant sex difference disparity, This study supports the notion that
lend support to classification of FMS as which is reported consistently by classification of Fibromyalgia Syndrome
a mental disorder, most consistently a researchers and confirmed in this study. should be thoroughly examined using
manifestation of a generalized anxiety Anumber of rheumatologic conditions, available epidemiological tools, data
disorder (GAD). Comparisons of such as rheumatoid arthritis and sets and population studies.
frequency distributions of numbers of systemic lupus erythematosis, show Classifications that are based on legal or
attendant, secondary diagnoses support consistent female predominance. These politically correct construction are ill
a strong association between FMS and are often attributed to underlying serving to patients, physicians, or
GAD. Acomparison of secondary hormonal, genetic, vascular, or society at large. Until a firm etiology or
diagnoses by disease category also most immunologic factors. Aconsistent sex consistent markers are found, the
closely matches the “mental disorder” difference disparity has also been syndrome should be classified on best
category and the Registry classification observed for generalized anxiety available scientific evidence.
of “anxiety/depression.” Frequency disorder.38Sex differences in the rates of
distributions of attendant, secondary these disorders may be related to
diagnoses for schizophrenia, multiple different social roles of men and
43
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Headache Rep 2001 Oct;5(5):412-20 einkenni ororku a Islandi arid 1996 [Disability in
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44
Neuropsychological Assessment:
Psychometric and Clinical Issues
Abstract Neuropsychological
Michael J. Herkov, Ph.D., ABPP
Assessment: Basic
Diplomate in Clinical Psychology
Principles and Clinical
This article represents the first of a two-
American Board of Professional Psychology
Issues
University of Florida part series dealing with psychometric
College of Medicine
and clinical issues of neuropsychological
Brief History of
assessment. The first article focuses on
And Neuropsychology
the underlying principles of
T. Wayne Conger, Ph.D., ABPP neuropsychological assessment and Neuropsychology, which has it origins
Diplomate in Clinical Psychology
includes discussion of brain-behavior in the fields of psychology, neurology
American Board of Professional Psychology
Psychology Associates of Tallahassee relationships, test reliability and and neurophysiology, is best described
validity, and normative data. This article as the study of the brain and its
will also address pertinent issues of relationship to mentation and behavior
neuropsychological assessment (Benton, 2000). The study of brain-
including referral questions, selection of behavior relationships can be traced
a neuropsychologist, establishment of back almost 2000 years (Pagel, 1958).
premorbid functioning and However, because of its multiple
identification of factors other than brain origins, the field of neuropsychology,
injury that might affect per se, is relatively new. Prior to its
neuropsychological test scores. The emergence as a new discipline,
second article examines neuropsychology was generally
neuropsychological assessment of subsumed under the umbrella of
specific cognitive processes such as Clinical Psychology. The term
attention, memory, motor, language, “neuropsychology” was first used by
executive, visual spatial and tactile William Osler in 1913 but did not gain
functioning. Finally, the authors will its current association until the 1950s
describe patterns of neuropsychological (Bruce, 1985).
testing associated with common brain
Theoretical Basis of
injuries including traumatic brain injury,
Neuropsychological
anoxia, toxin exposure, and substance
Assessment
abuse.
Neuropsychological testing is a valid
and sensitive measure of brain
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dysfunction. Rather than measuring In addition to confirming the presence statement is made regarding brain
brain structure or metabolism as of brain dysfunction, functioning.
modern radiographic techniques, neuropsychological test scores can also
While this method of assessment allows
neuropsychological testing assesses be valuable in describing the nature of
for the detection subtle changes in brain
brain functioning by examining brain the deficit and how it affects the
functioning, this increased sensitivity
output in terms of behavior and person’s adaptive functioning
can also result in increased false
mentation. By examining how the brain capabilities. Finally, neuropsychological
positives, i.e., reporting of brain damage
deals with various aspects of testing can assist in the development of
where none exists (Retzlaff & Gibertini,
information processing, recommendations for remediation and
1994). For example, central nervous
neuropsychological testing can often rehabilitation (Spreen & Strauss, 1998).
system control of finger tapping speed
detect subtle changes in brain
While the measurement of behavior and for each hand is controlled largely by
functioning sometimes not visible in
mentation provides neuropsychological the contralateral motor area of the brain.
present radiographic techniques. This
assessment with increased sensitivity in Thus, the finding of significant
increased sensitivity can be especially
identifying brain dysfunction, it also can discrepancy in finger tapping speed
important in dealing in cases of mild
also lead to false positive or false between the two hands might be
traumatic brain injury where
negative findings when output is indicative of lateralized brain damage.
microscopic axonal shearing, while
affected by factors other than brain However, finger tapping speed may also
having an impact upon cognition, may
damage. What might be surprising to be influenced by a number of other
not be detectible with traditional
the reader is that while sensitive to factors including motivation (e.g.,
radiographic measures.
brain injury, neuropsychological depression), peripheral nerve injury in
Generally, research involving both assessment does not measure brain the hand or arm, etc. (e.g., neuropathy)
neuropsychological testing and damage, per se; at least not in a direct or other factors. False negatives, i.e., the
radiographic studies indicates a positive manner like that of a brain imaging reporting of no deficits when deficits
correlation between neuropsychological study such as a MRI, CT or SPECT scan. actually exist, is also an area of concern
test findings and radiographic results of Rather, neuropsychological testing and must be considered when
studies (e.g., CT, MRI, PET and SPECT examines cognitive performance or the interpreting neuropsychological test
imaging) of brain lesions (Ichise et al., application of brain functioning to data. Thus, it is important that the
1994;Wallesch, et al., 2001). In fact, in cognition and adaptive functioning neuropsychologist consider a number of
many cases, neuropsychological test abilities. During a neuropsychological factors in addition to test scores in their
results often serve as the established test a person is asked to perform a interpretation of test results. Thus, the
criterion in concurrent validity studies. certain task, (e.g., learn a list of words, results of neuropsychological tests can
In some cases, neuropsychological tap a lever, solve a problem) and, based be influenced by non-brain factors
testing may identify subtle changes in on the quality of their performance and including language, culture,
cognitive functioning not identified in our knowledge of brain anatomy and psychopathology and past experience
radiographic imaging studies. functional organization, a probability (see below) that must be considered by
the neuropsychologist.
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