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[popup url=’http://www.parliament.nsw.gov.au/Prod/parlment/committee.nsf/0/2945888d02ece0b4ca257a170027d53b/$FILE/0279_Name%20suppressed.pdf’] submission in a scalable popup frame[/popup] (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!
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 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
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.
CRPS in the 4th Edition AMA guidelines
- 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!))
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]
- Impairment rating of neuromusculoskeletal conditions: http://emedicine.medscape.com/article/314420-overview