Title: Functional Outcomes and Physical Impairment Rating Tools in Orthopedic Trauma
1Functional Outcomes and Physical Impairment
Rating Tools in Orthopedic Trauma
- David Hubbard, MD
- West Virginia University, Morgantown, WV
- Created March 2004 Revised June 2006
2Definition of Terms
- Disability
- Permanent impairment
- Handicap
3Definitions
- Disability
- assessed by non medical means
- represents an alteration of an individuals
capacity to meet personal, social, or
occupational demands or to meet statutory or
regulatory requirements.
4Definitions
- Permanent Impairment
- any anatomic loss or functional abnormality
persisting after maximum medical improvement has
been achieved.
5Definitions
- Handicap
- disadvantages that limit fulfillment of the an
individuals usual role.
6Your Role as Physician
- Identify objective findings
- Sole responsibility of the physician to determine
permanent impairment - Most impairment is caused by musculoskeletal
injuries
7Role 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
8Third-Party Payers
- Often request impairment evaluations
- Use this information to determine settlement of
claims - Examples state workmans compensation boards,
private insurance companies, Social Security and
Veterans Administration - Each has their own rules and regulations
9Third- Party Payers
- Will ask specific questions about permanent
impairment - Physicians usually send letters directly to these
payers to provide updates
10Work 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 patients responsibility to find the
appropriate job
11Work 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
12Work 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
13Work 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.
14Work 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.
15Modern Impairment Scales
- Most widely used
- AMAs Guide to the Evaluation of Permanent
Impairment - AAOSs Manual for Orthopedic Surgeons in
Evaluating Permanent Physical Impairment
16AMAs 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.
17AMAs 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
18AAOS Manual
- This considers loss of motion like the AMAs
guide but also takes into account pain separately - Four grades of pain Mild to severe
19AAOSs 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
20Temporary Impairment
- Temporary total disability
- Temporary partial disability
21Temporary Total Disability
- Starts at time of injury
- Lasts until patient achieves a reasonable degree
of mobility and independence, can perform ADLs
reasonably - Patient must be off narcotics
- Must be evaluated by physician periodically to
document/update progress
22Temporary 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
23Fractures 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
24Fractures and Associated Impairments
- 5) Infection
- 6) intra articular involvement
- 7) Associated neurological injury
- 8) Preexisting osteoarthritis
- 9) Spine fractures
25Functional 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
26Functional Outcomes
- Disadvantage is that they do not consider the
patients opinion of the success or failure of
treatment
27Functional 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!
28Functional 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.
29Functional 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
- ADLs
30Functional Outcomes
- Health-related functions are the patients
perception of how they are functioning based on
their overall health.
31Clinical 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
32Clinical 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
33Clinical Outcomes in Trauma
- Unrealistic to collect functional outcome data on
all trauma patients - Multicenter studies are the wave of the future
for outcomes research
34Health-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
35Quality-of-Life Instruments (cont)
- Quality of Well-Being Scale (QWB)
- Musculoskeletal Functional Assessment (MFA)
- AAOS Instruments
36Summary
- Our goal should be to fairly identify our
patients impairments, assist in disability
evaluation, and begin assessing patients
outcomes based on their perceptions as well as
our objective findings
37Thank You
If you would like to volunteer as an author for
the Resident Slide Project or recommend updates
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