AMA Guides® Newsletter - Issue Archive

Articles

1. A Biopsychosocial Model of Sickness and Disability

   Gordon Waddell, A. Kim Burton, Mansel Aylward

   Pages 1–13

   DOI: 10.1001/amaguidesnewsletters.2008.MayJun01

   Abstract

   Despite improvements in objective measures of impairment, health, and working conditions, long-term incapacity and ill-health retirement are major problems in all western societies. This article explores three models that address disability: the medical, social, and biopsychosocial models. The medical model identifies the sequence from disease that causes an impairment to a disability that leads to incapacity; this model works best when identifiable pathology permits objective diagnosis and assessment but is inappropriate for many common health problems, particularly those that are subjective or when treatment is symptomatic and often ineffective. The social model is widely accepted as the basis for social inclusion and antidiscrimination policies but cannot be operationalized as the basis for individual entitlement for incapacity benefits. The biopsychosocial model attempts to tack account of biological, psychological, and social dimensions of health and is reflected in the International Classification of Functioning, Disability, and Health (ICF), which is the contemporary model of disablement used in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Powerful links exist among poor health, disability, social and regional disadvantage, worklessness, and poverty. Vocational rehabilitation, in the biopsychosocial model, reverses the question of why people develop long-term incapacity and instead asks why people with common health problems do not recover as expected. The answer involves addressing the biopsychosocial obstacles that delay or prevent expected recovery and requires a fundamental cultural shift in how we perceive and manage common health problems.
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2. Evaluating the Difficult Pain Patient

   Richard T. Katz, Stacey Lee Smith

   Pages 14–18

   DOI: 10.1001/amaguidesnewsletters.2008.MayJun02

   Abstract

   One of the most difficult aspects of performing independent medical examinations (IME) is the assessment of individuals with pain complaints (eg, neck or low back pain) for which no clear and objective basis can be determined. This two-part article critiques chronic pain models and presents a useful construct based on well-validated psychiatric diagnoses. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) attempts to evaluate pain in the context of the underlying, objectively defined impairment and considers pain to be of secondary importance. Physicians differ sharply concerning the contributions of neurophysiological vs behavioral/psychological factors when pain is present without general medical findings (eg, fibromyalgia). Chronic pain syndrome diagnosed by the “Eight Ds in Chronic Pain” is superficially attractive but seriously inadequate. Evaluators are challenged by poorly validated criteria for certain diagnoses and questions about the accuracy of patient self-reports. The AMA Guides, Sixth Edition, does not use range of motion to determine spinal impairment, and in most cases electrodiagnosis has little to add. Impairment and disability assessment of individuals with pain complaints is one of the greatest challenges encountered by IMEs, and future challenges will involve taking into account both the subjective factors and the difficulties inherent in evaluating another person's subjective experiences.
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