Physical medicine and rehabilitation approach to evaluation of impairment and understanding World Health Organization definition (ICF).

1. Impairment and Medical
Evaluation
Samuel Bierner, MD
Professor, PM&R
UT Southwestern Medical Center

2. Why should PM&R physicians care
about this?

3. PM&R and disability/impairment
Impairment Ratings for
– Worker compensation
– Third party liability
– Independent Medical Examinations
– Rehabilitation Assessments for Vocational
Planning

4. 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

5. 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.”

6. Other Definitions of Disability
AMA Guides
“an alteration of an individual’s capacity to meet
personal, social, or occupational demands or
statutory or regulatory requirements because
of an impairment.”

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

8. World Health Organization Definition:
Disabilities is an umbrella term, covering
impairments, activity limitations, and
participation restrictions.

9. 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.

10. 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.

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

12. Disability
• 10% of the world’s population experiences
disability.
• 650 million people/ 200 million children

13. Disability
• 10% of the world’s population experiences
disability.
• 650 million people/ 200 million children
• Cardiovascular diseases

14. Disability
• 10% of the world’s population experiences
disability.
• 650 million people/ 200 million children
• Cardiovascular diseases
• Chronic respiratory diseases

15. Disability
• 10% of the world’s population experiences
disability.
• 650 million people/ 200 million children
• Cardiovascular diseases
• Chronic respiratory diseases
• Cancer

16. Disability
• 10% of the world’s population experiences
disability.
• 650 million people/ 200 million children
• Cardiovascular diseases
• Chronic respiratory diseases
• Cancer
• Diabetes

17. Disability
• 10% of the world’s population experiences
disability.
• 650 million people/ 200 million children
• Cardiovascular diseases
• Chronic respiratory diseases
• Cancer
• Diabetes
• Injuries

18. 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

19. 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

20. 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

21. 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

22. Disability Assessment Schedule II

23. Function and Pain
• Domains of functioning assessed by the
WHODAS II include

24. Function and Pain
• Domains of functioning assessed by the
WHODAS II include
• Understanding and communicating

25. Function and Pain
• Domains of functioning assessed by the
WHODAS II include
• Understanding and communicating
• Getting around

26. Function and Pain
• Domains of functioning assessed by the
WHODAS II include
• Understanding and communicating
• Getting around
• Self care

27. Function and Pain
• Domains of functioning assessed by the
WHODAS II include
• Understanding and communicating
• Getting around
• Self care
• Getting along with others

28. 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

29. 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

30. 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

31. 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.”

32. Other Definitions of Disability
AMA Guides
“an alteration of an individual’s capacity to meet
personal, social, or occupational demands or
statutory or regulatory requirements because
of an impairment.”

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

34. 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

35. Physiatric Examination

36. Physiatric Examination
Mental Status assessment

37. Physiatric Examination
Mental Status assessment
Cranial nerve examination

38. Physiatric Examination
Mental Status assessment
Cranial nerve examination
Motor control—strength, tone

39. Physiatric Examination
Mental Status assessment
Cranial nerve examination
Motor control—strength, tone
Deep tendon reflexes/ Sensation

40. Physiatric Examination
Mental Status assessment
Cranial nerve examination
Motor control—strength, tone
Deep tendon reflexes/ Sensation
Musculoskeletal examination

41. Physiatric Examination
Mental Status assessment
Cranial nerve examination
Motor control—strength, tone
Deep tendon reflexes/ Sensation
Musculoskeletal examination
Supplementary Tests:

42. Physiatric Examination
Mental Status assessment
Cranial nerve examination
Motor control—strength, tone
Deep tendon reflexes/ Sensation
Musculoskeletal examination
Supplementary Tests:
Electrodiagnostic studies (EMG, NCV, SEP)

43. Physical Examination
Muscle Strength
MRC 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
Balance
Flexibility
Strength

44. MSK Exam
Spurling’s test
Straight 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 exam
ROM of all major joints
Spinal ROM:
LUMBAR: FLEX, EXT, LAT BEND
Schober test
CERVICAL: FLEX, EXT, LAT ROTATE, LAT BEND
THORACIC: LATERAL ROTATION
Gait: Heel and toe walking
Stance: one-legged standing; Trendelenberg
sign

45. Evaluating MSK Disability
Standardized Questionnaires
Clinical uses:
PDQ= Pain Disability Questionnaire (Gatchel
et al.)
Oswestry Back Disability Index
DASH- Disabilities of Arm, Shoulder, and
Hand
WOMAC- (Knee osteoarthritis index)
McGill Pain Questionnaire
Short Form Version 2
Pain Drawing (completed by patient)
--identifies widespread pain; unmentioned
locations of pain

46. Topics to be addressed
Diagnosis
Causation
Need for further treatment
Impairment
Activity Limitations
Functional Capacity
Work Ability

47. Diagnosis
History
Physical Examination
Laboratory Tests
Imaging Studies
Physiological Studies (EMG/NCV, etc.)
Patient Reported Outcomes
DASH
PDQ
WOMAC
ODI
PROMIS

48. • Injury versus Ordinary
Causation
Disease of Life
Injury • Degenerative changes
commonly found with
Degenerative disease aging
of life
Ordinary
aging/senescence
Obtain previous
medical records and
imaging

49. • Maximum medical
Need for treatment
improvement
Emergency Care
Medical Care
Surgical Care
Rehabilitative
Palliative
• Four phases of care:
– Acute/emergency
– Medical/Surgical (*Curative)
– Rehabilitative
– Palliation

50. • Apportionment for the
Impairment need for care
Apportionment • Apportionment for
Obtain a functional history
impairment
• Apportionment for
Ability to perform ADL’s and
iADL’s disability
Vocational Activities before • “Were it not for the index
injury injury, on a more probable
Recreational Activities than not basis, what would
be the patient’s current
Judging Credibility of this
functional history impairment?”

51. • Functional Capacity
Activity Limitations
Evaluation
Look at both home and work activities
Recreation
• Limitations
Is it logical?
– Poor effort
Is there evidence of conscious effort to
– Non-physiological indicators
deceive the examiner?
Waddell’s signs
Non-physiological grip strength (bell-
shaped curve)
Inadequate aerobic effort on FCE

52. • Take excellent work history
Ability to Work
(previous types of jobs
Get a written job description from
employer whenever possible
held; salary or wage scale
previously earned)
Have patient give job description of
essential physical functions
• Is there job instability?
Physical Demand Level (US Dept of
Labor) Classification System • Biggest predictor of return
to work is?
– Answer: Job Satisfaction

53. US Olympic team London 2012
Thanks for your attention