PAIN-RELATED IMPAIRMENT IN THE AMA GUIDES

PAIN-RELATED IMPAIRMENT IN THE AMA GUIDES James P. Robinson, M.D., Ph.D.

OVERVIEW • AMA Guides - general features • History - PRI and the 5th edition of the Guides • Description of PRI system in Ch. 18

GENERAL FEATURES • Published by AMA - 1st edition 1971 • 5th edition - November, 2000 • Emphasizes role of MDs - Contrast with SSA • Comprehensive 1) 600 pages; all organ systems 2) Musculoskeletal, peripheral nervous system = majority

GENERAL FEATURES • Emphasizes objective, reproducible findings 1) But - Permits subjective data • Impairment = “A loss, loss of use, or derangement of any body part, organ system, or organ function”

GENERAL FEATURES • Severity of impairment 1) Quantitative 2) Measured by ADL deficits 3) = disability in daily activities?

GENERAL FEATURES • Whole person impairment 1) Common metric for all conditions 2) From 0% to 100% 3) Combine specific impairments

GENERAL FEATURES • Used by insurance companies, workers’ comp 1) Emphasis on objective findings 2) Quantitative impairment needed to provide benefits

AMA GUIDES - 5TH • 11/15/99 1) Guides ready to go to press (?) 2) Linda Cocchiarella asked Dennis Turk if UW team could do the chapter - in 4 weeks

AMA GUDES - 5TH • 11/15/99 - 12/28/99 1) Dennis Turk, Ph.D., John Loeser, M.D., Jim Robinson, M.D., Ph.D. 2) No contact with authors of other chapters

AMA GUIDES - 5TH • February 2000 - August 2000 1) Input from other pain groups 2) AMA as referee 3) Most of our ideas accepted 4) But multiple drafts; several changes • 11/2000 - AMA 5th available. Pain Ch = Ch 18

AMA GUIDES - 5TH • Later activities 1) Workshops 2) Master the AMA Guides 3) AMA Guides Newsletter 4) International Association of Industrial Accident Boards and Commissions

LIMITED GOALS • Chapter on PRI existed in AMA 4th • Technical goal - improve methods for rating PRI • Don’t address broad question - should PRI be rated?

KEY FEATURES • Systematic protocol 1) Follow decision-making process of MD 2) Inter-rater reliability • Consider patients’ self-reports 1) Needed to assess pain-related impairment (PRI) 2) Dimensions to assess - ADLs, pain intensity, associated emotional distress

KEY FEATURES • Self-reported ADL restrictions 1) Central to subjective burden of illness 2) AMA gold standard for impairment • Balance self-reports with observations + MD judgment 1) Pain behaviors 2) Credibility

KEY FEATURES • Move cautiously 1) PRI cannot be assessed in all settings 2) Define settings in which PRI can be assessed 3) PRI assessment should be done only when pain increases burden of illness substantially

KEY FEATURES • Blend pain-related impairment (PRI) with conventional impairment rating (CIR) system 1) Give quantitative PRI 2) Combine PRI with CIR 3) Fit in with format and time of CIR system - 60-90 minute office exam

BLENDING PRI WITH CIR • No contact with authors of other chapters 1) PRI not discussed in other chapters • Ch 18 = last chapter of Guides 5th 1) No discussion in the beginning about blending PRI with CIR

BLENDING PRI WITH CIR • “Physicians recognize the local and distant pain that commonly accompanies many disorders. Impairment ratings in the Guides already have accounted for commonly associated pain, including that which may be expected in areas distant to the specific site of pathology” (Guides 5th, p. 10)

“TYPES” OF PAIN • Adequately encompassed by CIR • Stems from well-accepted medical condition; not adequately encompassed by CIR • Dissociated - Chronic pain syndrome? • Dissociated - psychogenic

RATABLE CONDITIONS 1. Condition typically associated with pain + objectively ratable impairment, but patient has “excess pain”. Ex - lumbar radiculopathy 2. Well-established pain syndrome that typically does not cause measurable organ dysfunction. Ex - headache

RATABLE CONDITIONS 3. Pain syndromes with the following: a. Occurs as a component of a condition that is objectively ratable b. Only some patients with the ratable condition have the associated pain syndrome c. The conventional impairment rating system does not capture the added burden of illness borne by patients with the pain syndrome. Ex - phantom limb pain

UNRATABLE CONDITIONS • Vague or controversial conditions 1) Inherently controversial - fibromyalgia 2) Condition diagnosed is in principle ratable, but relation between findings and diagnosis is unclear

UNRATABLE CONDITIONS • Does NOT mean patient is lying, or pain is unreal • Reflects limits in ability of MDs to interpret patients’ pain complaints, and disagreements within medical community

WORKSHEET • Developed after AMA 5th - for workshops • 10 Steps • Systematize PRI assessment

MD JUDGMENTS 1. Does it appear that PRI > CIR? a. Slightly greater? b. Substantially greater? 2. Do a formal PRI assessment (Steps 4-7)? a. PRI >> CIR b. Individual sufficiently credible

MD JUDGMENTS 3. What is patient’s credibility rating? 4. What is patient’s pain behavior rating? 5*. Is PRI ratable?

MD JUDGMENTS 6a*. For ratable PRI 1) Does PRI increase pt’s burden of illness slightly? If so, how much discretionary impairment? 2) Does PRI increase pt’s burden of illness substantially? 6b. For unratable PRI - Does PRI increase patient’s burden of illness substantially?

CRITIQUE • Contains key features we wanted 1) Specific 2) Incorporates subjective data; balances them with MD observations 3) Blends PRI with CIR 4) Cautious - doesn’t address all kinds of PRI

CRITIQUE • Complicated 1) Largely because of need to fit in with overall AMA system • Many chronic pain patients have unratable PRI • No method for rating psychogenic pain

FUTURE DIRECTIONS • Collaborate with orthopedists and neurologists - integrate PRI into CIR • System for pain that is dissociated from well-accepted medical disorder • System for psychogenic pain

PAIN-RELATED IMPAIRMENT IN THE AMA GUIDES