Functional Outcomes and Physical Impairment Rating Tools in Orthopedic Trauma David Hubbard, MD West Virginia University, Morgantown, WV Created March 2004; Revised May 2011

Definition of Terms Disability Permanent impairment Handicap

Definitions Disability –assessed by non medical means –represents an alteration of an individual’s capacity to meet personal, social, or occupational demands or to meet statutory or regulatory requirements.

Definitions Permanent Impairment –any anatomic loss or functional abnormality persisting after maximum medical improvement has been achieved.

Definitions Handicap –disadvantages that limit fulfillment of the an individual’s usual role.

Your Role as Physician Identify objective findings Sole responsibility of the physician to determine permanent impairment Most impairment is caused by musculoskeletal injuries

Role as Physician Care not finished when fractures healed and rehabilitation finished Must participate in the impairment evaluation process Many state/federal laws limit how a physician assigns ratings

Third-Party Payers Often request impairment evaluations –Use this information to determine settlement of claims Examples: state workman’s compensation boards, private insurance companies, Social Security and Veterans Administration –Each has their own rules and regulations

Third- Party Payers Will ask specific questions about permanent impairment Physicians usually send letters directly to these payers to provide updates

Work Restrictions Another role of the physician is to estimate how much and what level of work or activity a patient can safely tolerate The physician assigns impairment and work restrictions but it is the third-party payers’ and the patient’s responsibility to find the appropriate job

Work Restrictions Most commonly used guidelines are those of the Social Security Administration: Consist of differing levels of physical activity –Very heavy –Heavy –Medium –Light –Sedentary

Work Restrictions Very heavy work is that which involves lifting objects weighing more than 100 lb at a time, with frequent lifting or carrying of objects weighing 50 lb or more Heavy work involves the lifting of no more than 100 lb at a time, with frequent lifting or carrying of objects weighing up to 50 lb. Medium work involves the lifting of no more than 50 lb at a time, with frequent lifting or carrying of objects weighing up to 25 lb

Work Restrictions Light work involves lifting no more than 25 lb at a time, with frequent lifting or carrying of objects weighing up to 10 lb. Sedentary work involves the lifting of no more than 10 lb at a time and occasional lifting or carrying of small items.

Work Restrictions Work restrictions should be placed at a level that does not compromise healing or cause too much discomfort during the recovery phase of injury Once maximum medical improvement has been reached if patient is unable to return to previous job then permanent restrictions should be set.

Modern Impairment Scales Most widely used: AMA’s Guide to the Evaluation of Permanent Impairment AAOS’s Manual for Orthopedic Surgeons in Evaluating Permanent Physical Impairment

AMA’s Guide “Whole man” concept Each part of body assigned a percentage of its contribution to the whole Loss of function of an extremity is expressed as percentage of the value of the whole extremity, then the impairment of the whole man is calculated from this.

AMA’s Guide Lower extremity is 40% of whole man Upper extremity is 60% Other than amputation the ratings are based solely on the residual range of motion and does not consider factors like pain, limb shortening, or weakness

AAOS’ Manual This considers loss of motion like the AMA’s guide but also takes into account pain separately Four grades of pain: Mild to severe

AAOS’s Manual Mild pain (Grade I) – does not contribute to impairment Moderate pain (Grade II) – might require treatment and does contribute to a minor degree to impairment Severe pain (Grade III) – pathological changes and clinical findings indicate that pain is contributing significantly to impairment Very severe pain (Grade IV) – physical impairment is nearly complete secondary to pain

Temporary Impairment Temporary total disability Temporary partial disability

Temporary Total Disability Starts at time of injury Lasts until patient achieves a reasonable degree of mobility and independence, can perform ADL’s reasonably Patient must be off narcotics Must be evaluated by physician periodically to document/update progress

Temporary Partial Disability Starts at the end of temporary total disability Lasts until patient back to normal function or a permanent impairment is assigned May return to work with restrictions Must be reevaluated by physician

Fractures and Associated Impairments Increased impairment may be assigned based on the following: 1) Handiness (dominant vs nondominant upper extremity injury) 2) Nonunion 3) Limb length discrepancy 4) Malunion

Fractures and Associated Impairments 5) Infection 6) intra articular involvement 7) Associated neurological injury 8) Preexisting osteoarthritis 9) Spine fractures

Functional Outcomes Traditional orthopedic evaluations in the past have focused on impairment measures These include findings like range of motion, muscle strength, and radiographic healing These findings have the advantage of being easy to measure

Functional Outcomes Disadvantage is that they do not consider the patient’s opinion of the success or failure of treatment

Functional Outcomes The focus of outcomes assessment has now shifted to patient-based subjective assessments of outcome A combination of impairment and patient- based assessment is probably the ideal measure of outcome Patient satisfactions is very important!

Functional Outcomes Up until recently the focus of most orthopedic literature has been based on clinical outcomes Ultimate outcome however, should be a combination of clinical, functional, health- related outcomes, and satisfaction with care.

Functional Outcomes Clinical outcomes are what we are used to (range of motion, union, etc.) Functional outcomes are total patient outcome, not just the injured part. Include: –mental health –social function –role function, –physical function –ADL’s

Functional Outcomes Health-related functions are the patient’s perception of how they are functioning based on their overall health.

Clinical Outcomes in Trauma The trauma registry is the main source of collected data at most institutions. The American College of Surgeons Committee on Trauma has made recommendations on what data should be collected and evaluated

Clinical Outcomes in Trauma One of the key components is measure of ISS (Injury Severity Score) –Not a good measure for most orthopedic injuries OTA has developed their own software to track orthopedic injuries more completely Extensive resources required for appropriate data collection

Clinical Outcomes in Trauma Unrealistic to collect functional outcome data on all trauma patients Multicenter studies are the wave of the future for outcomes research

Health-Related Quality-of-Life Instruments in Common Use for Musculoskeletal Problems Medical Outcomes Study Short Form 36 (SF-36) Sickness Impact Profile (SIP) Western Ontario and McMaster University Osteoarthritis Index (WOMAC) Nottingham Health Profile

Quality-of-Life Instruments (cont) Quality of Well-Being Scale (QWB) Musculoskeletal Functional Assessment (MFA) AAOS Instruments

Summary Our goal should be to fairly identify our patient’s impairments, assist in disability evaluation, and begin assessing patient’s outcomes based on their perceptions as well as our objective findings

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