Top 10 Disability Durations · 2015. 8. 30. · Top 10 Disability Durations J Mark Melhorn MD...

Top 10 Disability Durations

J Mark Melhorn MD Clinical Associate Professor

Section of Orthopaedics, Department of Surgery University of Kansas School of Medicine - Wichita

or11861

•[email protected]

Declare • The Hand Center • MAP Managers, owner of CtdMAP • PHI = Physical Health Index – Health Assessment • Books: Physician's Guide to Return To Work, Guides

to the Evaluation of Disease and Injury Causation, etc

• Professional Organizations: ABA, AMA, AADEP, AAOS, ACOEM, ASSH, AAHS, IAIABC, SDPM, etc

• Organizations: MDA, ODG, SEAK, etc • Speaker: multiple national and state level

organizations • Reviewer: multiple journals and books • Any other task or job that will improve outcomes for

injured workers

Our Goal Should Be To

• Prevent “NEEDLESS” Disability

• Preven Cost Shifting

• We all loose in the end

The Challenge

• Americans employed directly in manufacturing

• 1979 = 19.6 million

• 2011 = 12 million = 9% of workforce

Messenger

• I am only the messenger

• If you don’t like guidelines or disability durations

• Please reframe from blaming the messenger

Causation

Return to Work

Disability Duration

Causation

Table 3-1 Steps for Concluding a Causal Association Exits

Causation Table 3-2

1. Identify evidence of disease 2. Review and assess the available epidemiologic evidence for a causal relationship 3. Obtain and assess the evidence of exposure 4. Consider other relevant factors 5. Judge the validity 6. Form conclusions about the work-relatedness of the disease in the person undergoing evaluation

Return to Work Guides

• Return to work by body region

• Contains much of the MDGuidelines Data

Return to Work

1. Capacity = physical ability based on the injury and the current medical condition

2. Risk = possibility of reinjury or worsening of the medical condition

3. Tolerance = decision by the patient to endure the pain in exchange for the benefits of returning to work (modified by education and communication)

Return to Work

Patient 1. Tolerance 2. Risk 3. Capacity

Physician 1. Capacity 2. Risk 3. Tolerance

• Friction = Unnecessary Disability

Dictionary of Occupational Titles

• United States Department of Labor • Also called DOT

• Not very helpful web site

• http://www.occupationalinfo.org/

http://www.occupationalinfo.org/�


• Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.


• Light Work • Exerting up to 20 pounds (9.1 kg) of force

occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. If the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.


• Medium Work

Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.


• Heavy Work

Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects


• Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.


Sedentary work - max 10 lbs lift/carry; occasional lift/carry Light work – max 20 lbs lift/carry; frequent at 10 lbs Light medium work – max 35 lbs lift/carry; frequent at 20 lbs Medium work – max 50 lbs lift/carry; frequent 35 lbs Medium heavy work – max 75 lbs lift/carry; frequent at 35 lbs Heavy work – max 100 lbs lift/carry; frequent 50 lbs

U.S. Dept Labor Occup Titles

Demand Occasional 0 to 33%

Frequent 34 to 66%

Constant 67 to 100

Energy METS

Sedentary 10 lbs Negligible Negligible 1.5 - 2.1

Light 20 lbs 10 lbs Negligible 2.2 – 3.5

Medium 50 lbs 20 lbs 10 lbs 4.6 – 6.3

Heavy 100 lbs 50 lbs 20 lbs 7.1 – 7.5

Very Heavy > 100 lbs > 50 lbs > 20 lbs > 7.5


• Work

• Job tasks not just weight

• Lift or carry

UE - Work Guides - Form

Disability Durations

• Symptoms • Signs • Job description • Essential functions of job • Accommodation options • Employer willingness • Employee willingness

Disability Duration

• Duration guides are only Guides - but • Many factors influence length of disability

for a specific diagnosis or procedure • Impossible to take into account all factors

affecting recovery • Important factors to consider follow • You will be judged, measured, evaluated

Disability Duration Sources

Permission was granted by MDGuidelines Official Disability Guidelines (ODG) The Hand Center


MDGuidelines http://www.mdguidelines.com/ Official Disability Guidelines (ODG) http://www.disabilitydurations.com/ The Hand Center J. M. Melhorn and S. M. Seaman. Working With Common Upper Extremity Problems. In: The Guides to the Evaluation of Work Ability and Return to Work, edited by J. B. Talmage, J. M. Melhorn, and M. H. Hyman, Chicago, IL: American Medical Association, 2011, p. 177-228.

http://www.mdguidelines.com/�

http://www.disabilitydurations.com/�


MDGuidelines Official Disability Guidelines (ODG) The Hand Center ICD-9-CM Grouping Data in - out


lumbosacral neuritis or radiculitis, unspecified ICD-9-CM is it 724.2 or 724.4 or 724.5

WC - Injury Types

• ICD-9 = pain in limb = 729.5 • 729.51 = pain in shoulder • 729.52 = pain in arm • 729.53 = pain in forearm • 729.54 = pain in hand • 729.55 = pain in ass or pelvis


MDGuidelines

• Duration tables • Duration trends data • Predicative model by – age, gender,

job class, co-morbidity, work comp status, zip code


Official Disability Guidelines (ODG)

• RTW “Best Practice” • Adjustment Factors for Age • Comorbidity Calculator • Claims Data • Graphs


The Hand Center • Data from my office • Reflects unusually effort • Employer education • On site job evaluations • Special programs www.CtdMAP.com

Disability Duration Factors

• Psychological factors Motivation Work environment Job satisfaction Pre-exiting psychological conditions Marital status Etc, etc, etc, etc


• Age • Variablity within a Dx • Complications • Medications • Benefit structures • Return to work program • Availabiity of modified work


• Disability managed programs • Workplace factors

• Physician guides • Physician guides • Physician guides

Top 10 Work Comp Claims

By Body Area

• Upper Limb • Spine • Lower Limb


Upper Limb 1. Carpal Tunnel Syndrome 2. Ulnar Nerve Elbow 3. Rotator Cuff Tear/ Shoulder

Impingement 4. Finger Tip Amputation


Spine 1. Low back pain – lumbar strain 2. Lumbar diskectomy 3. Lumbar fusion 4. Neck Pain


Lower Limb 1. Knee Meniscectomy 2. Ankle strain or sprain

Carpal Tunnel

Carpal Tunnel - ODG

• Conservative • - modified work (limit repetitive use of

hand/wrist): 0 days • - regular work (if not aggravating to

disability/use of splint): 0-5 days • - regular work (if work related &

electrodiagnostically confirmed): 28 days • - regular work (with severe nerve

impairment): indefinite

Carpal Tunnel - ODG

• Endoscopic/mini-palm surgery • modified work: 3-5 days • regular work, non-dominant arm: 28 days • regular/repetitive/heavy manual work,

dominant arm: 42 days to indefinite

Carpal Tunnel - ODG

• Open surgery • modified work: 10-14 days • regular work, non-dominant arm: 42 days • regular/repetitive/heavy manual work,

dominant arm: 56 days to indefinite • regular/repetitive/heavy manual work,

bilateral: 84 days to indefinite

Carpal Tunnel - ODG

Carpal Tunnel – MDGuidelines

NIOSH -- Hand Wrist / CTS

Risk Factor Strong Evidence Insufficient No Effect +++ ++ =/0 --

Repetition x Force x Posture x Vibration x Combination x

Data Source

Job Target Tmin Tmax Opt Min Max

Sedentary

Light

Medium

Heavy

V Heavy

•MDG composite,

multiple physicians,

multiple states

•THC Best Practice

Guides

NonSurg CTS


Sedentary 0 0 7 7 0 21

Light 0 0 7 7 0 21

Medium 0 0 12 14 0 28

Heavy 0 0 21 21 0 42

V Heavy 0 0 28 18/28 0 63

Surgery CTS


Sedentary 0 0 7 14 1 42

Light 0 0 7 28/21 1/3 42

Medium 14 0 28 42/28 14 56

Heavy 21 0 42 42 28/21 84

V Heavy 28 3 61 56 28 84/91

Carpal Tunnel Syndrome MDA Duration Table

Low Back Strain

Low Back Strain - ODG

• Mild (grade I), clerical/modified work: 0 days • Mild, manual/heavy manual work: 7-10 days • Severe (grade II-III), clerical/modified work: 0-

3 days • Severe, manual work: 14-17 days • Severe, heavy manual work: 35 days • With radicular signs, see 722.1 (disc disorders) • Obesity comorbidity (BMI >= 30), multiply by:

1.31

Low Back Strain - ODG

Low Back Strain – MDGuidelines


Los Angeles


Wichita, KS total days 27.4 with LA at 35.6 days

Knee Meniscectomy

Scope

Knee Meniscectomy - ODG

Data for Medial Meniscus • Without surgery

– clerical/modified work: 0-2 days – manual/standing work: 21 days

• With arthroscopy – clerical/modified work: 14 days – manual/standing work: 42 days


Data for Medial Meniscus • With arthrotomy

– clerical/modified work: 28 days – manual/standing work: 56 days – With arthrotomy, heavy manual/standing

work: 84 days

Knee Meniscectomy – MDG Medial and Lateral

Knee Meniscectomy – MDG

What do you think? Does meniscus repair require more or less time off from work? Vote

Knee Meniscectomy – MDG Repair = more time off work


Permission was granted by MDGuidelines Official Disability Guidelines (ODG) The Hand Center


The other Top 10

Diagnoses / Conditions are in my handout


Want More? Web search for

AAOS Annual Work Comp CME Course - November

AADEP Annual Meeting - January

SAW/RTW Upper Extremity The Reason We Are Here

SAW/RTW = Costs to Physicians

A good measure of our commitment to something is the amount of inconvenience or discomfort we are willing to endure for it.

Have Fun

• I hope this information will help you Monday morning when you return to the office

J Mark Melhorn MD The Hand Center

625 N Carriage Parkway Suite 125 Wichita, KS 67208-4510

316-688-5656 [email protected]

Top 10 Disability Durations

©J Mark Melhorn MD

[email protected]

General Disclaimer

• All photographs, drawings, figures, and tables remain the property of the first author. The first author grants the use of these materials for this specific publication and all future publications based on this specific article in paper, electronic, or other format.

• 2004 Disclaimer: The academy, editors, course chairs, and authors of this material provide this information for guides for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners and on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly, the above disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guides.

Additional Reading


Upper Limb 1. Carpal Tunnel Syndrome 2. Ulnar Nerve Elbow 3. Rotator Cuff Tear 4. Shoulder Impingement 5. Trigger Finger


Spine 1. Low back pain – lumbar strain

Syndrome 2. Lumbar diskectomy 3. Neck Pain 4. Lumbar fusion 5. ?


Lower Limb 1. Knee Meniscectomy 2. Knee Meniscus Repair 3. Total Knee 4. Knee ACL Repair 5. Ankle strain or sprain

Resources

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