AMA Guides® Newsletter - Issue Archive

Articles

1. Chapter 14 or 18 for Pain Complaints? Avoiding the Common but Mistaken Dichotomy of Psychological vs Organic

   Robert J. Barth, Christopher R. Brigham

   Pages 1–3, 10-11

   DOI: 10.1001/amaguidesnewsletters.2005.JanFeb01

   Abstract

   In accordance with the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Chapter 18, Pain, pain that is attributable to mental illness does not also qualify for an additional pain-related evaluation. Evaluators must discriminate between presentations of pain that represent mental illness vs those that do not and must decide whether to rate using Chapter 18 or 14. Dichotomous thinking often opposes the notion of psychological vs physiological-organic presentations, but all presentations of pain include psychological aspects, and all mental illnesses include physiological aspects. One type of illustrative mental illness involves conditions that are overtly mental but have been found via extensive scientific study to have a physiological basis (eg, schizophrenia and Alzheimer's disease). Another presentation that is claimed to be of a medical nature actually overlaps with psychological issues (eg, complex regional pain syndrome, type 1 [CRPS-1] and fibromyalgia). Further, the AMA Guides summarizes the lack of a strong correlation between tissue damage or physiology and pain: Pain can exist without tissue damage, and tissue damage can exist without pain. Pain, chronic pain, and impairment from pain are largely, even primarily, psychological phenomena. Accordingly, the determination whether to rely on the pain chapter or the mental/behavioral chapter in the evaluation of a pain presentation cannot be reduced to a misleading dichotomy of psychological vs organic pain.
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2. Legal Update: Apportionment and California Workers’ Compensation Reform

   Phil Walker

   Pages 4–5

   DOI: 10.1001/amaguidesnewsletters.2005.JanFeb02

   Abstract

   In April 2004, California implemented workers’ compensation reforms to reduce workers’ compensation premiums for California employers while speeding medical treatment for injured workers. The new law requires the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, particularly regarding apportionment analysis for impairment; the AMA Guides does not directly evaluate disability. Under the new California law, the following are clear: apportionment of permanent disability is based on a) causation and requires both the overall percentage of permanent disability caused by the industrial injury, and b) the percentage of permanent disability due to all other factors, including previous injuries. Less clear about the new law are the following: does apportionment to “causation” mean the physician should apportion out preexisting “pathology” even if it was not disabling prior to aggravation; what happens if a worker fails to disclose a prior injury; and are the standards of the AMA Guides on apportionment similar to those in California's new Labor Code? In the AMA Guides, the discussion of causation, apportionment analysis, and aggravation is different from the legal precedent for disability in California. New in the law is the explicit statement that the employer shall be liable only for the percentage of permanent disability directly caused by the industrial injury. Legal decisions are expected to clarify the interpretation of apportionment.
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3. Clinical Update: The Impairment Impact Inventory: Comparison of Responses by Treatment-seekers and Claimants Undergoing Independent Medical Examinations

   Dennis C. Turk, James P. Robinson, Mary Aulet

   Pages 6–7

   DOI: 10.1001/amaguidesnewsletters.2005.JanFeb03

   Abstract

   In the adversarial setting of an independent medical evaluation (IME), claimants may be incentivized to exaggerate the severity of their problems. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) describes a protocol for assessing impairment associated with chronic pain, including the Impairment Impact Inventory (I³) that consists of 26 items that assess the burden of illness in three domains: pain intensity, interference with activities of daily living, and emotional distress. A study was performed to establish preliminary norms for the I³ and to compare responses of claimants undergoing IMEs with those of treatment-seeking chronic pain patients: 183 patients completed the I³, including fibromyalgia syndrome patients (FMS group), 35 multidisciplinary pain center patients (PC group), and 72 claimants undergoing IMEs. Patients in the latter two groups had a variety of chronic pain problems (and hypothetically may be more likely to exaggerate their problems). The three groups had similar mean scores on the total I³ and for each of the FMS, PC, and IME groups. Results support the hypothesis that participants, in aggregate, do not exaggerate their pain when they undergo IMEs, although some quite possibly do. These results are a step toward establishing a scientific basis for the impairment rating system described in the AMA Guides from consensus-based rules to an evidence-based system for making decisions about impairment.
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4. Special Feature: Referral Letter for the Performance of an Independent Medical Evaluation

   Christopher R. Brigham, Phil Walker

   Pages 8–9

   DOI: 10.1001/amaguidesnewsletters.2005.JanFeb04

   Abstract

   Clients who request an independent medical or impairment evaluation are more likely to obtain a quality report from an evaluating provider if they request the appropriate evaluator, provide needed information, and clarify the specifics of their referral. The referral should identify the information needed for the assessment, define the standards for the evaluation, and provide detailed questions to be answered. Failure to provide this information often will result in a poor outcome. The article includes a sample generic referral letter to an impairment evaluator; this example letter can be modified based on the specifics of a case. For example, a workers’ compensation case in California could include the question, What is the overall percentage of permanent disability caused by the industrial injury, and what is the percentage of permanent disability due to all other factors, including prior injuries? The generic referral letter instructs the evaluator to use the standards in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition and refers the evaluator to Chapter 2, Philosophy, Purpose, and Appropriate Use of the AMA Guides. The article includes a sample paragraph that could be included in the generic referral letter and includes specific questions that address statutory requirements under California law, along with instructions about apportionment decisions and documentation.
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