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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

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PAIN-RELATED IMPAIRMENT IN THE AMA GUIDES

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

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

  3. 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

  4. 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”

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

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

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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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?

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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)

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

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

  21. WORKSHEET - #1, 2 • Start with conventional IME • Determine conventional impairment rating (CIR)

  22. WORKSHEET - #3 • Do full PRI assessment when: 1)Insurance company requests it OR 2) PRI seems to be substantially greater than CIR AND 3) Pt. credible enough to permit PRI assessment

  23. WORKSHEET - #4 • Have patient fill out Impairment Impact Inventory (I3) 1) Pain intensity 2) Impact of pain on ADLs 3) Associated emotional distress

  24. WORKSHEET - #5 • Credibility 1) Qualitative - Can PRI assessment be performed? 2) Quantitative -10 to +10

  25. WORKSHEET - #6 • Pain Behavior (Range = -10 to +10) 1) -10 - Markedly exaggerated pain behaviors 2) +10 a) Excellent effort; no exaggeration b) Concordant pain behaviors that confirm diagnosis

  26. WORKSHEET - #5 VS. #6 • Credibility - depends mainly on what patient says • Pain Behavior - depends mainly on what patient does during exam

  27. WORKSHEET - #7 • Add Scores from Steps 4-6 • Designate PRI class

  28. SHORTCUTS(from Step #3) • If CIR adequately encompasses patient’s burden of illness, STOP • If PRI makes patient’s burden of illness slightly greater than CIR indicates, skip Steps 4, 5, 6, and 7

  29. WORKSHEET - #8 • Is patient’s PRI ratable according to this system? 1) Does it stem from a well-accepted medical condition? 2) Is it adequately encompassed by CIR?

  30. 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

  31. 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

  32. 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

  33. 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

  34. WORKSHEET - #9 (for ratable PRI) • Does PRI make patient’s burden of illness greater than CIR indicates? 1) Same issue as in #3, but now based on systematic assessment (Steps 4-7) 2) Presence of PRI does not automatically mean that patient should receive extra impairment - conventional system captures typical pain

  35. WORKSHEET - #9(for ratable PRI) 3) Answer depends on type of ratable pain a) “Excess PRI” - burden of illness must be significantly higher than usually seen b) PRI in condition with no objective findings - PRI increases patient’s burden of illness c) PRI in condition such as phantom limb - clinical judgment - Does CIR capture pt’s pain?

  36. WORKSHEET - #9(for ratable PRI) • If PRI makes patient’s burden of illness greater than CIR indicates: 1) Award 1%, 2%, or 3% discretionary impairment if increase is slight 2) Award 3% discretionary impairment if increase is substantial

  37. WORKSHEET - #9(for ratable PRI) • Calculations 1) Combine discretionary PRI allowance with CIR 2) If PRI increases burden of illness substantially, indicate category of PRI (Step 7)

  38. WORKSHEET - #10(for unratable PRI) • If PRI does not make patient’s burden of illness greater than CIR indicates, or makes it only slightly greater: Patient’s total impairment = his/her CIR

  39. WORKSHEET - #10(for unratable PRI) • If PRI makes patient’s burden of illness substantially greater than PRI indicates: 1) Indicate patient’s CIR 2) Indicate class of patient’s PRI (from Step 7), and indicate that it is unratable

  40. 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

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

  42. 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?

  43. 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

  44. 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

  45. 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

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