Functional Outcomes and Physical Impairment Rating Tools in Orthopedic Trauma

1
Functional Outcomes and Physical Impairment
Rating Tools in Orthopedic Trauma

• David Hubbard, MD
• West Virginia University, Morgantown, WV
• Created March 2004 Revised May 2011

2
Definition of Terms

• Disability
• Permanent impairment
• Handicap

3
Definitions

• 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.

4
Definitions

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

5
Definitions

• Handicap
• disadvantages that limit fulfillment of the an
  individuals usual role.

6
Your Role as Physician

• Identify objective findings
• Sole responsibility of the physician to determine
  permanent impairment
• Most impairment is caused by musculoskeletal
  injuries

7
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

8
Third-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

9
Third- Party Payers

• Will ask specific questions about permanent
  impairment
• Physicians usually send letters directly to these
  payers to provide updates

10
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 patients responsibility to find the
  appropriate job

11
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

12
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

13
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.

14
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.

15
Modern Impairment Scales

• Most widely used
• AMAs Guide to the Evaluation of Permanent
  Impairment
• AAOSs Manual for Orthopedic Surgeons in
  Evaluating Permanent Physical Impairment

16
AMAs 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.

17
AMAs 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

18
AAOS Manual

• This considers loss of motion like the AMAs
  guide but also takes into account pain separately
• Four grades of pain Mild to severe

19
AAOSs 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

20
Temporary Impairment

• Temporary total disability
• Temporary partial disability

21
Temporary 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

22
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

23
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

24
Fractures and Associated Impairments

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

25
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

26
Functional Outcomes

• Disadvantage is that they do not consider the
  patients opinion of the success or failure of
  treatment

27
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!

28
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.

29
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
• ADLs

30
Functional Outcomes

• Health-related functions are the patients
  perception of how they are functioning based on
  their overall health.

31
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

32
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

33
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

34
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

35
Quality-of-Life Instruments (cont)

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

36
Summary

• 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

37
Thank You
If you would like to volunteer as an author for
the Resident Slide Project or recommend updates
to any of the following slides, please send an
e-mail to ota_at_aaos.org
Return to General/Principles Index
E-mail OTA about Questions/Comments