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Shaw Chiropractic
A Medical-Legal Newsletter for Personal Injury Attorneys
by Dr. Steven W. Shaw

AMA Impairment Guides:5th Edition, Part 4

Pain has always been a controversial topic when determining it’s relationship to permanent impairment rating. Parties with defense concerns have stated that pain is subjective and therefore not ratable. Plaintiff concerns have pushed the opposite direction indicating that all pain represents impairment. The AMA Guides have always considered pain a ratable condition and have now expanded it’s assessment criteria to quasi-objectify what has always been a difficult area of assessment. In this 4th newsletter on the new AMA Guides I will discuss permanent impairments resulting from pain from the perspective of the 5th edition.

Pain is subjective and cannot be readily validated or objectively measured. In part, this is because pain is often times not related to a specific identifiable pathology. For example, 85% of individuals who report back pain have no identifiable pain producing pathology; conversely, as many as 40% of asymptomatic individuals have significant pathology on MRI or CT scans. Therefore, we know that pain can exist in the absence of tissue damage and tissue damage can exist in the absence of pain.

To make things worse pain has significant social and economic consequences. Over 70 million doctor visits occur as a result of pain each year. In 1988 there were over 150 million lost work days from chronic low back pain alone. Headaches are also a major cause of lost work. Medical expenditures for pain assesment and treatment, indemnity costs, loss of productivity and loss of tax revenue are estimated to be $125 billion each year in the United States.

Pain has elements which are very much individualized. There are cognitive factors and coping skills which need to be considered. Ethnic, racial, social, financial and cultural influences all play a role in how an individual perceives their own pain. This pain perception plays a critical role in each individuals ability to function. In other words, different people with the exact type of pain may have very different abilities to function due to a number of factors which cannot be quantified.

As our understanding of pain increases the difficulty in it’s assessment is becomes more complicated. We now have explanations of pain which include centralization of pain to spinal, thalamic and cortical origins. We also have pain theories regarding nutritional, endcrinological and chemical imbalances which are too subtle to measure. Theories regarding sensitization of central and peripheral nervous systems have been repeatedl demonstrated by neuroscience research.

Complicating things further is the evaluating physician’s background. For example, in some circles, fibromyalgia is still considered a factitious disorder. Depending on the physician’s orientation a diagnosis may vary widely in conditions which have no measure of biological assessment. An example would be the spine mechanical dysfunctions treated by chiropractors and practitioners of manual medicine.

The Guides is clear to point out that the inherent subjectivity of pain is incongruent with their attempts to assess impairment by objective measures or organ dysfunction. Therefore, they have developed criteria to quasi-objectify that which is not objectifiable. This is done by a protocol which, while burdensome, seems to be reasonable. I have summarized the protocol below:

1. After evaluating in the "usual" fashion, determine if the pain experience appears to be encompassed in the impairment.

2. If the pain burden seems increased slightly more than expected the rating can be increased up to 3%.

3. A formal pain impairment should be performed if: a) The pain experience is substantially greater than expected for the condition rated; b) the condition is well accepted but not measurable as a function of an organ system or body part; c) the patient’s pain syndrome is identifiable as an organ system AND is associated with a unpredictable pain presentation which is not captured in the "usual" rating method.

4. The examiner will need to classify the rating severity and determine whether it is ratable or unratable using the below method.

I have attached Table 18-4 which is a pain questionnaire to be used with all pain assessments. The results of the questionnaire are considered with the Global Pain Behavior score from Table 18-5 which helps assess patient credibility. The numbers are compiled and a pain severity determination is made. Reporting of a pain rating should specifically address how much of the rating is for the organ system or body rating and how much is for the pain rating.

What does all this mean from a practical point of view? Patients should not be routinely rated for pain. The pain component is above and beyond the pain expected for an injury impairment or ROM inpairment. If a rating will be increased for pain the doctor should follow the protocols established by the AMA to substantiate the increase and report it accordingly. I perceive the value of the pain ratings to be useful in the context of a patient with multiple traumas with pre-existing impairments from the same body part. The condition may not in and of itself warrant an increased impairment but the pain component an dit’s affect on ADLs may substantiate a slight increase using a pain impairment approach