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: (354) 560-4400 Fax: (354) 560-4461 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 References 17 White KP, Harth M Classification, epidemiology, Iceland 1996: size and characteristics]. Lµknabla- 1 Wright M. Diagnosing fibromyalgia stops doctors and natural history of fibromyalgia. Curr Pain did [the Icelandic Medical Journal] 1998:84:629- from thinking. BMJ 2002:324:300. Headache Rep 2001 Aug;5(4):320-9 635. 2 Nimnuan C, Rabe-Hesketh S, Wessly S, Hotopf M. 18 MacFarlane GJ, Croft PR, Schollum J, Silman AJ. 30 Thorlacius S, Stefansson S, Olafsson S, Rafnsson V. 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Ororkumat fyrir og eftir gildistoku ororku- and sex differences in depression. J Health Soc 15 International Classification of Disease, 9th matsstadals. [Disability evaluation in Iceland Behav. 1981;22:379-393. Revision, Clinical Module, 6th Edition. October before and after introduction of a functional capac- 40 Cleary PD, Mechanic D. Sex differences in psycho- 2001. ity evaluation.] Laeknabladid [the Icelandic logical distress among married people. J Health 16 Gerwin RD. Classification, epidemiology, and natu- Medical Journal] 2001:87: 721-3. Soc Behav. 1983;24:111-121. ral history of myofascial pain syndrome. Curr Pain 29 Thorlacius S, Stefansson S, Olafsson S. Umfang og Headache Rep 2001 Oct;5(5):412-20 einkenni ororku a Islandi arid 1996 [Disability in NEW We have asked attorney Rob Sherman to partner with ABIME in bringing you practical communication tips that you can use immediately. Rob will not only present on trial and deposition techniques, but he will also help you in your presentation to outside groups, who can use your services. The price of $198 is a great bargain to work with one of the nation’s top trainers. Rarely are such skills taught at traditional programs. Space is limited so please sign up today for Rob’s program. Please see our web site www.abime.org for further details or call ABIME at 1-800-234-3490 . 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 45 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. 46