Impairment and Medical Evaluation

Samuel Bierner, MDProfessor, PM&R

UT Southwestern Medical Center

Why should PM&R physicians care about this?

PM&R and disability/impairment

Impairment Ratings for– Worker compensation– Third party liability

– Independent Medical Examinations– Rehabilitation Assessments for Vocational

Planning

International Classification of Function

World Health Organization• Clinical and epidemiological use• In clinical settings ICF is used for functional status

assessment, goal setting & treatment planning and monitoring, as well as outcome measurement. Countries, which already use ICF in a variety of clinical settings include Australia, Italy, The Netherlands….. At international level WHO is exploring the use of ICF to measure health outcomes and guide disability management in infectious disease programs

Disability

What is disability?– Different Definitions– SSA: “the inability to engage in any substantial

gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted for a continuous period of not less than 12 months.”

Other Definitions of DisabilityAMA Guides

“an alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment.”

Impairment

AMA Guides says: Loss of use, or derangement of any body part, organ system, or organ function.

World Health Organization Definition:

Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions.

Definition:

• An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations.

WHO Definition:

• Thus disability is a complex phenomenon, reflecting an interaction between features of a person’s body and features of the society in which he or she lives.

Disability

• 10% of the world’s population experiences disability.

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes• Injuries

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes• Injuries• Mental illness

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes• Injuries• Mental illness• Malnutrition

Disability

• 10% of the world’s population experiences disability.

• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes• Injuries• Mental illness• Malnutrition• HIV/AIDS; other infectious diseases

Disability

• 10% of the world’s population experiences disability.• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes• Injuries• Mental illness• Malnutrition• HIV/AIDS; other infectious diseases

• World Report on Disability and Rehabilitation, WHO, 2009

Disability Assessment Schedule II

Function and Pain

• Domains of functioning assessed by the WHODAS II include

Function and Pain

• Domains of functioning assessed by the WHODAS II include

• Understanding and communicating

Function and Pain

• Domains of functioning assessed by the WHODAS II include

• Understanding and communicating • Getting around

Function and Pain

• Domains of functioning assessed by the WHODAS II include

• Understanding and communicating • Getting around • Self care

Function and Pain

• Domains of functioning assessed by the WHODAS II include

• Understanding and communicating • Getting around • Self care • Getting along with others

Function and Pain

• Domains of functioning assessed by the WHODAS II include

• Understanding and communicating • Getting around • Self care • Getting along with others • Household and work activities

Function and Pain

• Domains of functioning assessed by the WHODAS II include

• Understanding and communicating • Getting around • Self care • Getting along with others • Household and work activities • Participation in society

Function and Pain

• Domains of functioning assessed by the WHODAS II include

• Understanding and communicating • Getting around • Self care • Getting along with others • Household and work activities • Participation in society

• Source, World Health Organization

Disability

What is disability?– Different Definitions– SSA: “the inability to engage in any substantial

gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted for a continuous period of not less than 12 months.”

Other Definitions of DisabilityAMA Guides

“an alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment.”

Impairment

AMA Guides says: Loss of use, or derangement of any body part, organ system, or organ function.

History Taking

• Social History• Support system (family and friends)• Substance abuse• Vocational activities• Income maintenance• Recreation/leisure activities/interests• Exercise • Spirituality and belief system• Pending litigation issues

Physiatric Examination

Physiatric Examination

Mental Status assessment

Physiatric Examination

Mental Status assessmentCranial nerve examination

Physiatric Examination

Mental Status assessmentCranial nerve examinationMotor control—strength, tone

Physiatric Examination

Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ Sensation

Physiatric Examination

Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ SensationMusculoskeletal examination

Physiatric Examination

Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ SensationMusculoskeletal examinationSupplementary Tests:

Physiatric Examination

Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ SensationMusculoskeletal examinationSupplementary Tests:

Electrodiagnostic studies (EMG, NCV, SEP)

Physical Examination

Muscle StrengthMRC Rating 0-5: shoulder/arm/hand;thigh; leg. Calf raises; walking on heels

Deep Tendon Reflexes: Biceps, triceps, brachioradialis;Patella, Achilles, medial hamstring

Sensation: Pin prick, light touch, cold, vibration

Strength

Balance

Flexibility

MSK Exam

Spurling’s testStraight leg raise test (seated and supine)FABER test (aka Patricks’ test)Bursal tenderness (Greater trochanter, knee, shoulder)Shoulder impingement signs (Neer’s, Hawkins-Kennedy sign, Speed’s test, Jobe’s test)Knee examROM of all major jointsSpinal ROM: LUMBAR: FLEX, EXT, LAT BEND

Schober test CERVICAL: FLEX, EXT, LAT ROTATE, LAT BENDTHORACIC: LATERAL ROTATIONGait: Heel and toe walkingStance: one-legged standing; Trendelenberg sign

Evaluating MSK Disability

Standardized Questionnaires

Clinical uses: PDQ= Pain Disability Questionnaire (Gatchel et al.)Oswestry Back Disability IndexDASH- Disabilities of Arm, Shoulder, and HandWOMAC- (Knee osteoarthritis index)McGill Pain Questionnaire

Short Form Version 2Pain Drawing (completed by patient)--identifies widespread pain; unmentioned locations of pain

Topics to be addressedDiagnosis

Causation

Need for further treatment

Impairment

Activity Limitations

Functional Capacity

Work Ability

DiagnosisHistory

Physical Examination

Laboratory Tests

Imaging Studies

Physiological Studies (EMG/NCV, etc.)

Patient Reported OutcomesDASHPDQWOMACODIPROMIS

Causation

• Injury versus Ordinary Disease of Life

• Degenerative changes commonly found with aging

Injury

Degenerative disease of life

Ordinary aging/senescence

Obtain previous medical records and imaging

Need for treatment

• Maximum medical improvement

• Four phases of care:– Acute/emergency – Medical/Surgical (*Curative)– Rehabilitative– Palliation

Emergency CareMedical CareSurgical Care

Rehabilitative

Palliative

Impairment

• Apportionment for the need for care

• Apportionment for impairment

• Apportionment for disability

• “Were it not for the index injury, on a more probable than not basis, what would be the patient’s current impairment?”

Apportionment

Obtain a functional history

Ability to perform ADL’s and iADL’s

Vocational Activities before injury

Recreational Activities

Judging Credibility of this functional history

Activity Limitations

• Functional Capacity Evaluation

• Limitations– Poor effort– Non-physiological indicators

Look at both home and work activitiesRecreation

Is it logical?

Is there evidence of conscious effort to deceive the examiner?Waddell’s signsNon-physiological grip strength (bell-shaped curve)Inadequate aerobic effort on FCE

Ability to Work

• Take excellent work history (previous types of jobs held; salary or wage scale previously earned)

• Is there job instability?• Biggest predictor of return

to work is?– Answer: Job Satisfaction

Get a written job description from employer whenever possible

Have patient give job description of essential physical functions

Physical Demand Level (US Dept of Labor) Classification System

US Olympic team London 2012

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