WorkCover state the AMA guide does not recognise chronic pain

IME-and-pain

We received an email overnight from an injured worker pointing to a submission as recently made to the Joint Committee into the workers compensation NSW scheme. The submission raises interesting and very important questions, namely that WorkCover states the AMA guide does not recognise (rate) chronic pain and how does this impact injured workers who, for example suffer from -yes, really-debilitating complex regional pain syndrome (CRPS)?

WorkCover state the AMA guide does not recognise chronic pain

 

Submission to the inquiry into workers compensation NSW scheme

 

View the submission in a scalable popup frame (as displayed on the parliamentary website)>>

A few weeks ago, a severely injured worker, Soula, posted on our blog that notwithstanding that she suffers from an extremely painful pudendal nerve injury (for which she even has a spinal stimulator inserted!) she scored ZERO percent impairment at the Medical Panel. Soula is unable to work and lives is debilitating pain!

Fact is, under the current workers compensation system (even in Victoria) “pain does NOT rate”.

Under the WorkCover legislation physical injuries must be assessed in accordance with the fourth edition (VIC) of The American Medical Association Guides For The Evaluation Of Permanent Impairment. And that, folks, is the real sh*tty problem!

Although these Guides are now in their sixth edition, the WorkCover legislation requires the fourth edition to be used. They are just about 20 years old and they are banned in civilised countries such as Canada and the USA.

The Guides have been modified by the legislation which basically removes the pain chapter – how SICK! Pain is NOT ratable! The Guides have therefore been the subject of significant criticism because they also provide relatively worthless impairment assessments for musculoskeletal injuries particularly spinal injuries.

The use of the AMA guide (4th Edition) is based on pseudo science and designed to do only one thing: to stop people — especially the most vulnerable  — from being fairly compensated.

AMA Guides and Pain

According to the AMA 4th Edition, “some tables require the pain associated with a particular neurological impairment to be assessed. Because of the difficulties of objective measurement, assessors should make no separate allowance for permanent impairment due to pain, and chapter 15 of the AMA 4 Guides should not be used”

Pain in the 4th Edition AMA guidelines: issues

  • In general pain is taken into consideration within all the ratings contained within the organ system chapters
  • There is a Pain Chapter (15) – which is not to be used (how convenient)
  • The Pain Chapter contains text which addresses pain related impairment based upon theoretical models
  • Difficult to analyze exactly what the chapter authors were attempting to communicate

What is Chronic Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy, is a chronic neurological syndrome characterized by:

  • severe burning pain
  • pathological changes in bone and skin
  • excessive sweating
  • tissue swelling
  • extreme sensitivity to touch

There are Two Types of CRPS – Type I and Type II

  • CRPS Type I (also referred to as RSD) – cases in which the nerve injury cannot be immediately identified
  • CRPS Type II (also referred to as Causalgia) – cases in which a distinct “major” nerve injury has occurred
  • CRPS is best described in terms of an injury to a nerve or soft tissue (e.g. broken bone) that does not follow the normal healing path
  • CRPS development does not appear to depend on the magnitude of the injury. The sympathetic nervous system seems to assume an abnormal function after an injury.
  • Since there is no single laboratory test to diagnose CRPS, the physician must assess and document both subjective complaints (medical history) and, if present, objective findings (physical examination).

Criteria for Diagnosing

Complex Regional Pain Syndrome Type I (RSD)

  • The presence of an initiating noxious event, or a cause of immobilization
  • Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event
  • Evidence at some time of edema, changes in skin blood flow (skin color changes, skin temperature changes more than 1.1°C difference from the homologous body part), or abnormal sudomotor activity in the region of the pain
  • This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

Complex Regional Pain Syndrome Type II (Causalgia)

  • The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve
  • Evidence at some time of edema, changes in skin blood flow (skin color changes, skin temperature changes more than 1.1°C difference from the homologous body part), or abnormal sudomotor activity in the region of pain
  • This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.

[Read more about CRPS on www.RSD.org>>]

CRPS in the 4th Edition AMA guidelines

  • RSD
  • Causalgia
  • CRPS type 1
  • CRPS type 2

4th Edition CRPS rating

  • Establish diagnosis
  • When diagnosis is made it is usually wrong
    • 6th edition quote [is made]
  • For purposes of the Guides, objective criteria points are important

 

 

[also see: http://www.aadep.org/documents/resources/PDF__08_400p_AMA_Guides_4th_edition_E165409E1E416.pdf]

So, what hat we do know, from our own personal experiences, is that, in Victoria (and in states where they use the AMA 4th edition) that CRPS (complex regional pain syndrome, also known as reflex sympathetic dystrophy) is ratable (albeit very poorly) under “CAUSALGIA” under the AMA 4th edition guidelines.

For example, Lisa was diagnosed with SEVERE CRPS (type 1) by a most reputable pain specialist specialised in the condition and treatment of CRPS. Second and third opinions confirmed the diagnosis. Lisa’s entire right arm (elbow to hand) was blue and mottled, she has a measurable temperature difference in the limb of a whopping 5 degrees Celsius and had the visible trophic changes such as increased hair growth and “weird”nails. Lisa had excruciating pain in that arm -anyone who has been diagnosed with CRPS knows just how painful and crippling this condition is. Lisa describes it as “having the feeling that you are constantly being bitten by a blue bottle jelly fish” (as in extreme burning sensation, with the total inability to even tolerate clothes on the arm). She was totally unable to use that arm.

However, despite this crippling and extremely painful condition, Lisa was given 2% impairment for the advanced “causalgia grade 5” (note in Vic you need 30% for a common law claim and 5% to 10% (depending on body part) for a lump sum!))

This means that injured workers who develop this extremely painful and debilitating condition, from a minor injury (CRPS can develop from a very minor injury such as a needle stick or a sprain!)  basically get bugger all (if not zero) percentage impairment rating under the AMA 4th edition guidelines.
They may never be able to work again and yet they will not ever qualify for even a meager “lump sum”, let alone a common law damages claim.

So, unless you have in addition to CRPS, an extremely bad physical (and visible) injury(like Lisa) you will never obtain a “fair” impairment rating under those ancient AMA 4th edition guidelines….

 

And this, folks is the truth and nothing but the painful truth….The 20 year old, totally outdated AMA guides are used for only one reason and that is to deny injured workers a fair assessment and subsequent compensation.

 

This post is dedicated to The Applicant – our warm thoughts are with you 😉

 

[Post entered fully by T on behalf of workcovervictim]

Further reading

 

 



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16 Responses to “WorkCover state the AMA guide does not recognise chronic pain”

  1. It is also important to point out that the current measures used to assess permanent impairment for psychological injuries, according to Associate Professor Gordon Robert Wyndham Davies is neither valid or reliable – I know this from personal experiences – it’s a dodgy art and definitely not a science.  Oh, and insurers cause more damage to injured workers than they do good (shock, horror) – he refers to it as maladministration (bit of an understatement).

     

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    John McPhilbin June 12, 2012 at 6:53 pm
    • Thanks for pointing this out and reminding us – the psych impairment rating issues are also well summarized in the document we used as a source for the CRPS/PAIN (AMA 4th edition): see: http://www.aadep.org/documents/resources/PDF__08_400p_AMA_Guides_4th_edition_E165409E1E416.pdf

      As I said the AMA guided (4th edition) is being used for one reason only and that is to routinely under-rate legit  permanent impairments (and not to pay legit compensation). Why else would workcover use medical guides that are 20 years old? When you open the book (4th Ed) it says on the front page that:

      • They do not — NOT — purport to be “scientifically valid and reliable
      • Impairment ratings in the guides are “merely ‘estimates’ of impairment” based on “consensus” not “scientific evidence”
      • Do not apply to “every type of impairment”
      • That “certain conditions (such as psychiatric reaction to pain) are not explicitly ratable under the Guides”
      • Should “not be used for direct financial awards nor as the sole measure of disability; and
      • Are based “not on science but on ‘legal fiction’, ‘consensus,’ and other unsupported assertions”

      So WHO IS RIPPING OFF WHO?

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      workcovervictim June 12, 2012 at 8:42 pm
  2. Just wanted to point out that it is Complex Regional Pain Syndrome, not Chronic Regional Pain Syndrome – your post contains both terms, which is a bit confusing.
    Very concerning if anyone is using such outdated guidelines for any form of assessment. Have you contacted Pain Australia re this issue?

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    • Thank you for pointing out the spelling/term error, now rectified (entirely my fault but I like to blame it on my cocktail of heavy duty narcotics prescribed for my shoulder injury and, yes, also for my CRPS).

      I did personally write to Pain Australia in 2006 and to the AMA about this critical issue re the AMA 4th edition guidelines… However it appears that it is “beyond anyone’s power” as it is inbuilt into the legislation… So, an overhaul of the legislation would be needed to incorporate at least the 6th edition of the AMA guidelines.

      Many injured workers that we know of have written to the Minister of WorkCover about this issue (and the AMA 4thedition guides in general), yet nothing ever gets done about it. Fact is it is convenient as it saves millions of dollars in compensation…. It is a rip off and it is scandalous!

      We need to come up with a plan! Perhaps a petition? Any thoughts?

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  3. Ok, thinking back to my high school legal studies…. the laws of Australia can be changed in a couple of ways – legislation, Law Reform Commission (ALRC) & also when judges make decisions in court.

    Looked up the Victorian LRC http://www.lawreform.vic.gov.au/ & read a few things on this site. Maybe this is where we need to direct our stories? Maybe with all the help & increased knowledge of many like minds, a submission could be made?

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  4. So is there anything we can do to fight this? I have been diagnosed with CRPS, and have been getting treatments. But the insurance company are now pushing for me to return to work, and I don’t know if/how I can handle it. I have days where I can barely even walk to the bathroom.

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  5. If your Doctor certifies you unfit, then that is it.

    If your specialist says you are unfit, then even more significant.

    Case managers are not medically qualified, nor are they appropriate to comment on your capacity, even though they may think so.

    They only care about their KIP’s and outcome stats, not you.

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    Worker Advocate June 16, 2012 at 12:19 am
  6. We wish it was that simple, however the truth is that “Advice from the most senior Medical Staff in the country can be overruled by Case Managers, and often Orthopaedic or Neurosurgery is delayed or never done on the whim of a Case Manager “who decides that it is not necessary.”

    The Case Managers, employed by the Insurer, and the Return to Work  Coordinators have the right to withhold treatment recommended by specialists, or to over-rule evidence based treatment based on thorough medical knowledge…”

    See:http://workcovervictimsdiary.com/2012/05/senior-medical-staff-in-the-country-can-be-overruled-by-case-managers/

    Case managers are also trained in the art of doctor shopping – that is: they will send you to IME after IME after IME until they are happy with the biased “report”.

    It has happened to countless seriously injured workers, including me. On one occasion, after just having me unlawfully sacked after 10 years service and from a desk job -on the basis of “disability”, I became extremely depressed and suicidal.I was in full crisis. Yet my case manager not only tries to immediately cease my psych “services” (fr which I had to fight at conciliation in my mental state), but she also sent me to a vocational assessment in a suicidal state. Why I had t undergo a vocational was a mystery given I was well qualified and had been sacked from a senior desk based position! If my employer deemed I was not able to continue my desk job due to my disability, what on earth could I do? My case manager, who had also been repeatedly told that my physical injury had catastrophically deteriorated by my surgeon told me in writing that she was was NOT interested in my physical condition but that I needed to undergo a psych IME to assess “my ability to RTW and engage in rehab’ – WTF! The biased IME, although certified me with NO current work capacity, stated I should undertake “volunteer work”. The IME had also not been given the physical side of the story (the medical reports stating I am unfit for the foreseeable future and that my condition and prognosis was ‘dreadful”). You can just about imagine what this did to me. The vocational came back with “working as a ward clerk” (WTF) (whilst I worked as a senior manager and was deemed unfit based on disability to hold down desk job). Luckily additional reports from other IMEs and my own treaters were enough to barely rescue the situation and I was found unfit to work by the vocational assessor, just….

    The whole process is a f*cking joke. There is NO regard whatsoever for YOUR condition, pain or mental status, and barely for your specialist’s reports. I nearly committed suicide because of all this. (the initial shock of losing my much loved job, the catastrophic deterioration of my physical injury and, in particular added to that, the most inappropriate bullying and intimidating behaviour of my case manager).

     

     

     

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  7. Yep your so right,Recently the same thing happened to me,my work cover agent sent me return to work documents to choose from.this occurred three times to me.I then spoke to my doctor if he received the latest report from (IME),my doctor stated NO I did not.

    I then wrote a letter to my case manager why she did not(Allianz) disclose the IME’s report to my doctor in which it clearly states I am in no condition and in no capacity to do any return to work (pre injury) work or training of any sort shape or form.I clearly stated that I’m a human being that was bullied,exploited,Harrassed,by my employer and that’s why I’m in this situation so now you (the case manager (Allianz) are doing the same to me.I Also stated my employer treated me like a dog and now you are doing the same to me even with all the supporting evidence that the NUMEROUS IME,S HAVE STATED IN ALL THE REPORTS YOU HAVE ASKED FOR,just remember your not a doctor nor do you have the right to force me to do anything over than what the IME’s reports say (STOP BULLYING ME).

    I stated also I’m not a DOG I’m a human being and this letter has also been sent to my Dr,my lawyer,union,Australian medical Association,Australian medical council,Australian medical Board and the health and safety minister of Victoria.In Addition any further correspondence will be done in writing by me as you don’t care about me the injured worker,your just one of many doing your job instructed by your supervisor and insurance lawyer whom are trained to deal with such circumstances.How do I know this?, your own colleagues working for Allianz.

    I’m still waiting for her reply,and soon as I get her reply I will forward it on to this wonderful site.Oh also I stated to the dog the surveillance report you gave to the the IME which discredits me to some genuineness but still supports me is also been tampered with.How do I know this? Because the person in the tape is my cousin from Singapore who stayed at my place on the dates of the surveillance sent to the IME for viewing.So do what ever you want I HAVE PROOF.He is a dead ringer in appearance of me in fact people often mistake him for me (vise versa). The so so called professional investigators should also be named they are SECA and Black widow investigations. I don’t know if the tapes had been tampered with I’m not an expert,but if they have been I’m guessing it’s one of the two (Allianz or Investigators). They have to prove it in court.Also it has been
    known in the past that some insurance companies edit their tapes trying to foul the courts,A KNOWN FACT
    And documented.

    Like the workcovervictim says document everything so you don’t have them discrediting you.I have had help
    writing this by a anti discrimination advocate whom is a doctor in the subject of human studies , human
    resources, and specializes in human rights.I know most would not have this privilege as me but I urge all of
    you take a stand and don’t be bullied by any one SCREAM AND YELL TILL YOUR HEARD we are human
    beings not ANIMALS NOT DOGS.I would also like to express my interests in a joint march of all types of
    workers in Victoria and urge our voices be heard on the foot steps of state parliament even federal
    parliament and the insurance companies that do the wrong thing and be pattered on their backs by people
    like O’Farrell .Bill shorten said he is a bully so “I wonder if he would support our rights and walk along with
    us?). Is Mr Shorten a man of he’s words or just a conjurer of bull shit like the rest of the politicians that want
    our votes but don’t deliver what us citizens ask for,Or are they just full of verbal diarrhea?. Makes you wonder
    Hah,That’s why if we all sign up for it and do it,and not be scared of any body that tries to bully us.After all
    with out us workers that run this country the governments that govern would be in total disarray.I will be the
    first to sign and even be the name behind it,as long as we have the voices and feet to march for our
    rights.PEOPLE POWER CAN MOVE THE COUNTRY EVEN THE WORLD as seen in the recent time gone
    by.I will always comment on this wonderful site but it may be time to take the next steps to make it a reality not
    just words that fail to be heard but merely sited and documented .After all all of us submit stories and replies
    with hidden names don’t we?.

    Please do insult me if I’m wrong in your eyes/ears or what ever you may see invalid,just don’t forget I’ve seen hell and am still living in it as many or all who currently experience this at present.COME ON YELL LIKE MAD, like Erin says.I’ve got the BALLS just need the support.

    Please forgive my spelling and grammar IM ONLY HUMAN,and the formatting as I use a gadget called a IPad
    Which does not have the same applications/editing formats as a normal computer.I can’t afford one on what i Get surviving on.

    Kind regards
    Work cover victim. (Alias Al).

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    Workcover victim June 20, 2012 at 12:29 pm
  8. I was diagnosed with CRPS after 1 year of suffering pain from bilateral epicondilitis. I wasn’t really convinced that I had this condition, so I changed pain specialist and he diagnosed me with chronic bilateral epicondilitis and complications of my shoulder due to overuse. I developed tears in my left elbow while at work, which forced me to use my right arm only because of the pain. I then had a MRI on my right shoulder and there was tears, tendinopathy and also a degenerative AC joint. My pain specialist said my right shoulder problems were from the overuse of my right side, of course the insurer denied liability for my shoulder. So of to conciliation, failed to reach a decision and was referred to a medical panel. The medical panel stated that I have no medical condition now and the pain in my arms, shoulders and neck is from cervical spine dysfunction “I was thinking to myself that these doctors must have x-ray vision, maybe their superhero’s or something. And to make matters worse the panel agreed with one of the IME doctor’s (Occupational Physician) that basically said this was all in my head, and he stated that psychology wasn’t his area of expertise. I got truly screwed over by the panel, they did not even take into consideration that I tore my left elbow at work forcing me to use my right side of my body for about 4-5 months after I stopped working. They said it had nothing to do with work! They also totally ignored the fact that I had tears in my shoulder and a degenerative AC joint with tendinopathy. I also just received a IME report from another corrupt doctor stating I have CRPS. I now have three different opinions on what my condition is “this is so frustrating”. The funny part is that I rang the insurer to see if they would pay for a MRI on my spine and he said that should be fine. I still can’t get my head around this, because if the insurer is not taking liability for this why would they be paying for a MRI. The insurer has just given me a months notice in regards to ceasing my payments. I have seen my lawyer about the medical panel report, because I wanted to fight it, but she said it would be expensive and I might have to go up before another medical panel. “I feel very uneasy about the decision” I feel very angry, depressed and anxious about this because the panel have totally ignored medical reports given to them by me and also got several things wrong in the certificate of opinion. The thing that gobsmacked me also is the panel agreed with a Occupational Physician rather than a Chronic Pain Specialist who is one of the best in Australia?. The insurer has totally ignored the psychological side of this, yet they still pay for me to see a psychiatrist and psychologist.  I am sick and tired of these doctor’s and insurance agents, they have driven me into a bad depression which is effecting my family as well. Anyone have any thoughts on the medical panels decision?

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    DiagnosisWrong May 2, 2013 at 6:27 pm
  9. Hi, just a few points for you. You are doing the right thing finding this site & trying to learn as much as you can about the WC system & how it operates. I hate to tell you, but your experience is the same if not better (& worse) than some. It all comes down to the $$ & the WC Agent keeping as much of it as possible. Is the system corrupted? shonky? deceptive? full of liars? You bet & are you going to get the help & support you need from the system – not a chance in hell. You need a good lawyer, not an ok 1, so if your not happy with the response, ask about a better lawyer. Problem with the Medical Panel is that it is binding & not able to be appealed. There is no magic answer, but you have to learn as much as you can about others stories, what worked, what didnt work & what your options are moving forward. Just be aware that injured workers are not the only ones to find this site, so try not to be so specific about your conditions as we would hate that your cries for help could be used against you – because your WC Agent will go to any length to get the bonus they get paid for getting you off their books.

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    • Thanks for the tips and I will be doing a lot of reading on this site. I know a medical panel decision is binding, but I thought you could still contest it in court. I really think they have missed some critical points about my injuries, I will get another opinion though. Wish I found this site earlier on.

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      DiagnosisWrong May 3, 2013 at 11:40 am
      • @DiagnosisWrong – Sorry to read about your Medical panel assessment.

        As listed in our WorSafe VIC frequently asked questions:

        The decision of the Medical Panel can only be appealed on very narrow grounds. It is only possible to appeal the decision if the Panel has made legal error.

        It is not possible to appeal the decision of a Panel solely on the basis that it came to the wrong conclusion.

        In order to appeal a decision of a Medical Panel, it is necessary to demonstrate that they have made procedural error. This type of appeal is very technical and must be made to the Supreme Court within strict time limits. If an appeal to the Supreme Court is upheld, the decision of the Medical Panel will be quashed and the matter sent back to the Medical Panel for a further decision. It is normal for the new decision to be made by different personnel at the Medical Panel.

        Time limits

        Appeals against the decision of a Medical Panel are only possible on extremely limited grounds. An appeal against the decision of a Medical Panel must be made to a judge of the Supreme Court of Victoria.

        The time limits are extremely technical as an appeal can be launched either under the provisions of the Administrative Law Act or, alternatively, under the specific orders of the Supreme Court. Under the Administrative Law Act, the period can be as short as 28 days. (This period can be marginally extended more detailed reasons requested from the Panel and those reasons in fact supplied).

        Under the orders of the Supreme Court the normal period for appeal is 60 days from the date of the decision. The Supreme Court, however, has a general discretion to extend this period where it is in the interests of justice.

        There is heaps of info about disputes, medical panels, etc on that page – may be of use.

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        workcovervictim3 May 3, 2013 at 12:48 pm
  10. Thankyou for the links HuntingWorkcover, every little bit of info I can get helps.

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    DiagnosisWrong May 5, 2013 at 12:31 am