Impairment and medical evaluation
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Impairment and Medical Evaluation
Samuel Bierner, MDProfessor, PM&R
UT Southwestern Medical Center
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Why should PM&R physicians care about this?
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PM&R and disability/impairment
Impairment Ratings for– Worker compensation– Third party liability
– Independent Medical Examinations– Rehabilitation Assessments for Vocational
Planning
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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
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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.”
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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.”
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Impairment
AMA Guides says: Loss of use, or derangement of any body part, organ system, or organ function.
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World Health Organization Definition:
Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions.
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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.
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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.
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Disability
• 10% of the world’s population experiences disability.
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Disability
• 10% of the world’s population experiences disability.
• 650 million people/ 200 million children
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Disability
• 10% of the world’s population experiences disability.
• 650 million people/ 200 million children• Cardiovascular diseases
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Disability
• 10% of the world’s population experiences disability.
• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases
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Disability
• 10% of the world’s population experiences disability.
• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer
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Disability
• 10% of the world’s population experiences disability.
• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes
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Disability
• 10% of the world’s population experiences disability.
• 650 million people/ 200 million children• Cardiovascular diseases• Chronic respiratory diseases• Cancer• Diabetes• Injuries
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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
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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
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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
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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
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Disability Assessment Schedule II
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Function and Pain
• Domains of functioning assessed by the WHODAS II include
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Function and Pain
• Domains of functioning assessed by the WHODAS II include
• Understanding and communicating
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Function and Pain
• Domains of functioning assessed by the WHODAS II include
• Understanding and communicating • Getting around
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Function and Pain
• Domains of functioning assessed by the WHODAS II include
• Understanding and communicating • Getting around • Self care
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Function and Pain
• Domains of functioning assessed by the WHODAS II include
• Understanding and communicating • Getting around • Self care • Getting along with others
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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
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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
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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
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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.”
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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.”
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Impairment
AMA Guides says: Loss of use, or derangement of any body part, organ system, or organ function.
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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
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Physiatric Examination
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Physiatric Examination
Mental Status assessment
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Physiatric Examination
Mental Status assessmentCranial nerve examination
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Physiatric Examination
Mental Status assessmentCranial nerve examinationMotor control—strength, tone
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Physiatric Examination
Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ Sensation
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Physiatric Examination
Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ SensationMusculoskeletal examination
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Physiatric Examination
Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ SensationMusculoskeletal examinationSupplementary Tests:
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Physiatric Examination
Mental Status assessmentCranial nerve examinationMotor control—strength, toneDeep tendon reflexes/ SensationMusculoskeletal examinationSupplementary Tests:
Electrodiagnostic studies (EMG, NCV, SEP)
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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
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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
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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
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Topics to be addressedDiagnosis
Causation
Need for further treatment
Impairment
Activity Limitations
Functional Capacity
Work Ability
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DiagnosisHistory
Physical Examination
Laboratory Tests
Imaging Studies
Physiological Studies (EMG/NCV, etc.)
Patient Reported OutcomesDASHPDQWOMACODIPROMIS
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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
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Need for treatment
• Maximum medical improvement
• Four phases of care:– Acute/emergency – Medical/Surgical (*Curative)– Rehabilitative– Palliation
Emergency CareMedical CareSurgical Care
Rehabilitative
Palliative
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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
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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
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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
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US Olympic team London 2012
Thanks for your attention