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)
WORKSHEET
• Developed after AMA 5th - for workshops
• 10 Steps
• Systematize PRI assessment
“TYPES” OF PAIN
• Adequately encompassed by CIR
• Stems from well-accepted medical condition; not
adequately encompassed by CIR
• Dissociated - Chronic pain syndrome?
• Dissociated - psychogenic
WORKSHEET - #1, 2
• Start with conventional IME
• Determine conventional impairment rating
(CIR)
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
WORKSHEET - #4
• Have patient fill out Impairment Impact
Inventory (I3)
1) Pain intensity
2) Impact of pain on ADLs
3) Associated emotional distress
WORKSHEET - #5
• Credibility
1) Qualitative - Can PRI assessment be
performed?
2) Quantitative -10 to +10
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
WORKSHEET - #5 VS. #6
• Credibility - depends mainly on what
patient says
• Pain Behavior - depends mainly on what
patient does during exam
WORKSHEET - #7
• Add Scores from Steps 4-6
• Designate PRI class
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
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?
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 - #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
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?
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
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)
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
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
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