D ETERMINATION OF D ISABILITY

Over 7 million disability assessments are made annually in the United States. Many of which are made by physicians in the field of pain medicine.

Physicians are often asked for their expertise regarding disability or impairment in their patients.

The process of disability assessment can be fraught with subjective bias and the role of determining disability can pose ethical issues for treating physicians.

As healers physicians try to maximize the health and functional potential of patients, but in disability assessment, physicians become advocates for patients financial interests and healthcare resources, which can conflict with the healer role.

Many physicians lack experience or training in the methods of assessing disability.

In theory, the determination of disability should be a transparent, unprejudiced and objective process.

And impairments or functional limitations should be correlated with objective evidence for tissue damage, organ dysfunction, or cognitive dysfunction, and this evidence should be reproducible in examination or diagnostic study.

Knowledge of basic terminology in disability determination is important to the pain specialist.

Disability is an alteration in one’s physical or cognitive capacity to perform a specific task, function, or activity and is highly dependent on individuality and context.

Disability is greatly influenced by education, age, and social and cultural factors, as well as vocational opportunities and training.

There is no universally accepted method for the assessment of disability.

Disability in this context is typically assessed by an administrative judge, not a physician, and is subjective.

In contrast, impairment is an objective term that defines the loss or loss of use or derangement of any body part, organ system or organ function, but can also relate to impairments of cognitive or psychological functioning.

Impairment may be temporary or permanent, and can be reproducibly measured through testing or physician assessment.

Handicap is a legal or policy term used to describe a disability.

An impairment rating or whole person impairment is a specific and objective assessment of a patient’s impairment, and can be derived by using the “American Medical Association’s Guides to the Evaluation of Permanent Impairment”.

This rating defines the impact of an impairment on one’s ability to perform typical activities of daily living, including self-care, personal hygiene, use of hands, ability to communicate, sensory functioning, sexual function, and ability to travel.

The Guides are evidence-based consensus estimates defined by more than 120 experts who relate a particular injury, derangement, or loss of function with changes in functionality or activities of daily living.

For example, an impairment stemming from small disc herniation that causes moderate leg pain would rate a 5% to 8% impairment of the whole person, while a disc herniation that required decompression and fusion, with residual pain, sensory loss, andelectromyography (EMG) abnormalities would render a 25% to 28% rating.

Overall, the greater and more impactful the impairment is, the larger the whole person impairment percentage will be.

It is important to note that an impairment rating should not be assessed until the patient has reached maximal medical improvement (MMI).

MMI is the state at which all potential healing, repair, and treatment has been completed, and the impairment is permanent and unlikely to change significantly within the ensuing 1-year period.

The Social Security Act defines disability as: The inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.

Disability is entirely based on vocational rather than medical issues, although a medical justification is essential.

Four categories of disability are Possible: Temporary partial; Temporary total; Permanent partial; Permanent total.

The work-related injury can be physical or mental.

An independent medical evaluation (IME) is a comprehensive assessment of a patient by a trained physician.

In contrast to most doctor-patient relationships, the evaluating physician for an IME does not provide medical care and does not initiate a therapeutic relationship with the patient undergoing the evaluation.

The purpose of the IME is to objectively assess the impact of an injury and subsequent disability on the patient’s ability to function in a variety of domains, including self care, work duty, leisure, or recreational activity.

The evaluating physician reviews the treatment to date, performs a physical examination, and reviews pertinent diagnostic tests and procedure reports, and then comments on the current clinical status, relevant diagnoses, and whether the patient is at MMI.

The IME report should address causation of the injury and the relationship of the injury to the impairment, and any anatomic, physiologic, or psychological impairments should be identified.

Functional limitations, defined as a lack of ability to perform an activity within a normal human range as the result of a specific impairment, should be specifically addressed in an IME report.

Examples would include an inability to lift more than 25 pounds due to a disc herniation.

Components of an Independent Medical Evaluation Narrative history Current clinical status Results of physical exam and diagnostic studies Causation of injury and relationship to job MMI assessment Pertinent diagnoses Impairments and function limitations Permanence of impairments Analysis of job tasks Assessment of patient ability to perform job tasks

In contrast to an IME, a functional capacity evaluation (FCE) or work capacity evaluation (WCE) are measures of a Patient’s functional ability and are typically performed with a physical therapist or occupational therapist.

Tolerances for sitting, standing, walking, bending, reaching, lifting, and climbing are typically assessed, with a specific emphasis on the ability to lift and carry specific weights.

Due to the nature of painful or disabling diseases, pain specialists must often balance disability evaluation and assessment with disability management.

Disability syndrome is set of dysfunctional and counterproductive attitudes and beliefs that develop over time as an individual adapts to the role of being a disabled person.

The more significant the dysfunction in the patient, the more important the multidisciplinary approach to pain management is necessary.