Major U.S. disability and compensation systems graphically compared.

This article offers the reader a "bullet" overview of the principal systems of disability determination. The reader is referred to other sources for more in-depth coverage and a detailed historical background and overview of these systems.

Goniometric techniques for range-of-motion assessment.

The authors hope that this article promotes greater understanding of the methodology available for measuring and recording joint ROM and fosters movement towards the eventual adoption of a single integrated goniometric system for the evaluation and recording of musculoskeletal impairment and disability. Towards this end, the authors have focused on applications of the Neutral-Zero Measuring Method and SFTR documentation and Recording System, and have highlighted the advantages of this system when compared to more conventional approaches. Examination and recording procedures have been described briefly, and examples of appropriate instruments and their applications have been illustrated. The reader is referred to more extensive discussions elsewhere of the measurement techniques themselves.

Impairment rating and disability evaluation of the pulmonary system.

An increasing number of patients are being seen by physicians for impairment and disability of the pulmonary system, partially because of the increasing prevalence of chronic obstructive pulmonary disease and increased awareness of industrial and environmental hazards to the respiratory system. As legislative efforts and social expectations towards entitlement and compensation become more permissive, an increasing number of individuals with respiratory impairment are claiming disability and seeking compensation. Consequently, the physician whose practice includes pulmonary rehabilitation may be expected to evaluate and rate impairment and disability of the pulmonary system. Fortunately, for respiratory disorders, excellent objective measures of pulmonary function exist that are readily applicable to the process of disability assessment. This article highlights the diagnostic procedures and assessment criteria of choice for pulmonary disability determination.

Impairment and disability rating in low back pain.

This "how-to" guide for the examination of impairment and disability resulting from low back pain examines Workers' Compensation, Social Security, The Americans with Disabilities Act, and the American Medical Association's Guides to the Evaluation of Permanent Impairment. The medicolegal interface is addressed, and specific recommendations are made to assist the physician involved in an independent medical evaluation.

Industrial rehabilitation medicine. 1. Why is industrial rehabilitation medicine unique?

This self-directed learning module is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Industrial rehabilitation medicine encompasses injuries and illnesses that occur in the workplace and are covered under workers' compensation. The central thesis of this article is that industrial rehabilitation medicine is a unique area because the workers' compensation system influences the behavior of injured workers. The article is divided into three sections. The first briefly reviews the history of workers' compensation in the United States, and describes eight key features of compensation systems. The second explores several hypotheses to explain why injured workers frequently have less favorable outcomes than noncompensation patients with similar medical conditions. Some explanations focus on dysfunctional psychologic reactions such as "compensation neurosis" and "disability syndrome." Others focus on contextual factors, including return to work policies by employers and financial incentives or disincentives for return to work. The third section outlines reasons why the physiatrist is often the "preferred provider" in industrial rehabilitation medicine. One crucial consideration is that many of the most important disabling work injuries are those with which physiatrists are familiar. Also, physiatric training and philosophy prepare the physician to focus on function, to work with a rehabilitation team, and to be sensitive to psychologic factors that might impede an injured worker's recovery. All of these skills are important in the treatment of injured workers.

Industrial rehabilitation medicine. 2. Case studies in occupational low back pain.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The evaluation and management of patients presenting with low back pain are skills that practicing physiatrists need to acquire. This chapter gives a step-by-step format, along with the thought processes involved, for managing patients with three types of low back pain presentations.

Industrial rehabilitation medicine. 3. Case studies in upper extremity cumulative trauma disorders.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section contains three case studies discussing nerve, joint, and soft tissue pathology and work disability due to upper extremity pain. New areas of interest covered in this section include the controversy regarding the work causality of upper extremity disorders, a detailed review of the impact of upper quadrant postural dysfunction on symptom perpetuation, and the assessment and nonsurgical management of thoracic outlet syndrome.

Industrial rehabilitation medicine. 4. Strategies for disability management.

This self-directed learning module provides a practical overview of the general rehabilitative management of work disability. It is the fourth of four articles on the topic of industrial rehabilitation medicine for the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section includes an algorithm to highlight strategies for early involvement of the physiatrist in the comprehensive management of injured workers. It also examines the broader role of the physiatrist as independent medical examiner. Finally, it explores the complexities surrounding case closure for the chronically disabled injured worker.

A simulation of hand impairments: effects on upper extremity function and implications toward medical impairment rating and disability determination.

OBJECTIVES: To determine whether simulation of significant impairment of the hand will have a predictable impact on degree of functional loss at the wrist and hand. DESIGN: Single subject repeat measures using before-after trial comparisons and healthy volunteer subjects. SETTING: Occupational therapy section of a large academic medical center. OTHER PARTICIPANTS: Twenty adult volunteer student subjects from an occupational therapy education (OTE) department were included. All were between ages 18 and 43 years, right hand dominant, and in excellent general health. There were 19 women and 1 man, reflecting gender distribution of the OTE student body. INTERVENTION: A simulated fusion of the carpometacarpal (CMC) joint of the thumb was achieved by immobilization in an individually fabricated splint designed to maximally restrict motion at the first CMC joint. Impairment ratings (baseline vs splinted) according to the AMA Guides were obtained by Greenleaf testing, and upper extremity function was quantitatively assessed before and after splinting. MAIN OUTCOME MEASURES: Measures of upper extremity function included grip and pinch strength, wrist torque, and speed of performance on the Valpar Small Tools test, Jebsen Hand Function test, and an exploratory measure, the Functional Life Activity Test (FLAT). RESULTS: Significant impairments were achieved for all subjects after splinting and according to Greenleaf testing. Splinting resulted in significant reductions in grip and pinch strength, wrist torque, and significant slowing of performance on the Valpar, Jebsen, and FLAT tests. Regressions of degree of impairment on degree of functional loss after splinting, and according to each of the above measures, were not significant. CONCLUSIONS: Impairment of the hand was simulated to a mild-to-moderate degree as measured according to the AMA Guides. This imposed significant reductions in motion at key joints of the wrist and hand as well as significant reductions in grip and pinch strength and wrist torque. A corresponding and significant slowing of performance on a variety of measures of upper extremity function of an industrial and nonindustrial nature was also seen. However, and for the first time, correlation and regression reveals that it is not possible to predict degree of functional loss attributable to degree of impairment for the hand. It thus appears that, for mild-to-moderate clinical impairments, the associated impairment rating is a poor estimator of functional loss at the hand and should be used cautiously, if at all, as a criterion for disability determination.

Structured research training in residency training programs. The impact on the level of resident research activity.

A survey was conducted to construct a profile of structured resident research training and experience in physiatric residency training programs. Resident research activity was quantified, and factors that may influence the level of resident research activity were examined. Questionnaires were sent to all 72 residency training program directors, of which 87% responded. To construct the profile of structured training and experience in research that currently exists, descriptive analyses were applied to the survey responses. Resident research activity was quantified according to projects per resident per year over the last 3 yr. Resident research activity was assigned to level I activity (> or = 0.25 projects/resident/year) or level II activity (< 0.25 projects/resident/year). This point of discrimination was chosen because it represents one project per resident per 4-yr graduate medical education cycle. Nonparametric, univariate analyses were used to evaluate the impact of each characteristic in the research training profile on resident research activity. The following characteristics were found to be statistically significant (P < 0.05): (1) the use of mentors outside of the physical medicine and rehabilitation department; (2) the provision of guidelines to residents for choosing a mentor; (3) the provision of responsibility guidelines to mentors; (4) the presence of a classroom curriculum. Mentorship outside of the department, however, had a negative impact on resident research activity, although the other three characteristics had positive impacts. A multivariate analysis using stepwise logistic regression was applied to further determine the capacity of each characteristic to predict independently the level of resident research activity. Only one characteristic simultaneously and independently remained significant (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Further studies on the electrodiagnosis of diabetic peripheral polyneuropathy using discriminant function analysis.

Discriminant function analysis can be useful when applied to multiple nerve conduction parameters for diabetic and nondiabetic subjects to reveal the essential dimension along which key neuropathic differences occur between these groups. In this study, 19 electrophysiologic parameters were used in a stepwise discriminant function analysis to reveal a highly significant dimension of intergroup differences between 67 diabetic and 75 normal adult Japanese-American males. The classification functions thereby derived are more sensitive and specific than those reported previously for this population. Furthermore, when 72 additional subjects with impaired glucose tolerance were examined, they showed considerable overlap with the normal and separation from the diabetic groups, respectively. Their intermediate position between normal and diabetics in the key discriminant dimension indicates that essential neuropathic change is, at most, incipient in this latter group.

Predictors of functional outcome and resource utilization in inpatient rehabilitation.

Consecutive patients (n = 1,289) discharged from two inpatient rehabilitation facilities were prospectively examined to determine the extent to which rehabilitative outcomes, functionally based progress, and associated resource utilization (in terms of rehabilitation length of stay) can be concomitantly predicted using the Tufts/New England Medical Center functional assessment tool and bivariate and multivariate statistical comparisons. A high percentage (greater than 50%) of statistically significant associations between the predictor variables and seven outcome measures were seen. The R2s corresponding to these associations were generally small and resistant to enhancement by commonly accepted statistical manipulations. Consequently, they are, in general, of limited predictive value for determining functional prognosis or resource utilization among rehabilitation inpatients. Although functionally based predictors appear to be the best predictors of functional progress, their effectiveness as predictors of other domains (eg, discharge outcome and rehabilitation length of stay) is variable. The implication is that a prospective payment system using such an array of predictors and directed primarily at cost containment is likely to overlook potentially important gains in functional progress and patient outcome. Furthermore, the functionally based predictors, taken individually, varied in effectiveness as predictors among facilities, and, taken collectively, they varied in effectiveness as predictors for different diagnostic groupings within a facility. The inconsistency of predictions according to the various domains appears to further limit their application to a prospective payment model.

Electrodiagnosis of diabetic peripheral polyneuropathy. A multivariate analytic approach.

Traditional univariate comparisons of nerve conduction data against standard norms may produce conflicting estimates of the presence or absence of a diabetic neuropathy, depending upon the data obtained and the specific nerves sampled. Alternatively, a multivariate analytic approach, using discriminant functions, provides a useful single measure of the degree of neuropathy determined as a weighted combination of the available data. The weights are derived from the linear discriminant function, which maximizes statistical separation of diabetic and nondiabetic subject groups. In this study, 12 electrophysiologic attributes are used to generate a single discriminant function that clearly separates diabetic from nondiabetic subjects and is interpretable as a neuropathic index. Each individual's index of diabetic neuropathy (I) can be quantified as follows: (Formula: see text) where Ai is the original electrophysiologic attribute (i = 12), ai is the coefficient for each attribute that defines the discriminant function and C is a constant specific for that function. For the first time, the degree of diabetic neuropathy can thus be quantified for purposes of comparison and correlation with other quantifiable clinical/somatic measures of diabetes. The index allows for a higher percentage of type II diabetic patients to be classified as neuropathic than previously described and enables determination of degree of neuropathy is affected individuals by an interpolative method.