AMA Guides® Newsletter - Issue Archive

Articles

1. Differential Diagnosis for Complex Regional Pain Syndrome

   Robert J. Barth, Robert Haralson

   Pages 1–4, 12-16

   DOI: 10.1001/amaguidesnewsletters.2007.SepOct01

   Abstract

   Complex regional pain syndrome (CRPS) is a controversial, ambiguous, and often unreliable concept that presents significant clinical and rating challenges, to the extent that, for any individual case, many of the differential diagnostic issues provide a far more probable explanation of symptoms than does CRPS. The International Association for the Study of Pain (IASP) introduced CRPS in 1994 specifically to replace “reflex sympathetic dystrophy” [RSD] and “causalgia.” The IASP diagnostic protocol for assessing CRPS has led to overdiagnosis, as well as questions regarding the protocol's reliability, validity, and high error rate during field trials. Using the IASP protocol and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the authors discuss the mental health and general medical evaluations that are part of the differential diagnosis of CRPS, which involves both psychological and general medical components. Finally, examiners should be aware that the probability rates for a diagnosis of CRPS following a thorough and extensive differential diagnosis is very small and is further limited by the general lack of scientific credibility for the concept of CRPS. A diagnosis of CRPS in the absence of ruling out all potential differentials is not credible. A sidebar discusses several chapters that are relevant to rating impairment due to causalgia, RSD, and CRPS.
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2. Impairment Evaluation: Use of the Guides in Ontario for Defining “Catastrophic Impairment”: Challenges and Controversies

   Arthur Ameis, Christopher Brigham, Robert J. Barth, Norma Leclair, Steven Leclair

   Pages 5–11

   DOI: 10.1001/amaguidesnewsletters.2007.SepOct02

   Abstract

   Several Canadian provinces use the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) to adjudicate workers’ compensation claims, and the Province of Ontario uses the AMA Guides, Fourth Edition, to adjudicate motor vehicle accident personal injury claims. This article focuses on controversies that have arisen in Ontario regarding how the AMA Guides is applied and shows some of the challenges that occur in quantifying psychological impairment. In 2004, the Ontario Superior Court found in the Desbiens v. Mordini trial that the AMA Guides did not provide any direct methodology for estimating percentage impairment in this unique circumstance that involved pre-existing paraplegia and subsequent dramatic loss of residual functions. The judge found that, using the information available, a whole person impairment (WPI) score of 40% could be derived, but Ontario requires a minimum 55% WPI before an individual qualifies for catastrophic impairment benefits. In view of the individual's circumstances and a psychologist's recommendation, the judge awarded an additional 25% WPI. The Ontario model has been interpreted to allow subjective complaints (symptoms) to be included in the impairment evaluation process, but this approach eliminates any expectation of objectivity. If a judicial system aims to force impairment percentages onto a situation that in fact does not warrant such ratings, it should not do so by an inappropriate application of the AMA Guides.
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