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

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.

in AMA Guides® Newsletter
James Robinson
,
Dennis C. Turk
, and
John D. Loeser

Abstract

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, stresses that impairment assessment should be based on objective evidence of organ dysfunction. Using this model, pain-related impairment (PRI) such as migraine headache not associated with definable organ dysfunction is difficult to reconcile with patients’ reports of limitations in their activities of daily living (ADL). Chapter 18 of the AMA Guides, Fifth Edition, systematically addresses PRI and differs from previous editions by allowing examiners to award both quantitative and qualitative impairments. PRI is challenging to integrate with other chapters of the AMA Guides, which provide conventional impairment ratings (CIR) based on objectively measurable organ dysfunction. Examining physicians should consider PRI when performing an impairment evaluation on an individual who has a condition associated with pain, including almost any orthopedic condition and most neurological conditions. The examiner must determine if an individual's PRI should be considered as incorporated in the CIR or if the PRI increases the burden of illness above that acknowledged in the CIR—and only in the latter case should the physician use Chapter 18. This chapter distinguishes ratable vs unratable PRI, but better terminology may be uncontroversial and controversial PRI, respectively. Ten steps are involved in a PRI assessment and require the examining physician to use a multiaxial approach, synthesize information from multiple sources, and carefully assess the individual's credibility and pain behavior.

in AMA Guides® Newsletter
James P. Robinson
,
Dennis C. Turk
, and
John D. Loeser

Abstract

This article clarifies important conceptual issues associated with the assessment of pain and considers reasons why pain should be considered in impairment and disability ratings. The authors address conceptual issues rather than specific pain assessment methods and limit the discussion to the musculoskeletal and neurologic injuries seen most frequently during impairment disability evaluations. Several groups of experts worked on the AMA Guides, and little is known about which elements of the AMA system are well substantiated and which need revision. In addition, the AMA Guides, as actually used, often differ from the guides as written. Self-reports that disability applicants provide about their experiences provide a first-person perspective that, in principle, may be important to assessors. Pain and “unbearable” sensations cannot be incorporated into impairment evaluations in the AMA Guides because pain is inherently subjective and because pain and its effects must be analyzed at the level of the whole person. In summary, although the AMA Guides, Fifth Edition, seems to support including pain in impairment ratings, this support is vitiated by inconsistencies in the conceptualization of impairment, contradictory information about how examiners should interpret pain, and inadequate guidance about how examiners should combine subjective and objective data.

in AMA Guides® Newsletter