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Disability Evaluation, 2nd Ed.,

Jones, Gabrielle

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Newport News, VA

Disability Evaluation, 2nd Ed., S. L Demester, G.B.J. Andersson. St. Louis, MO, Mosby, 2003, hard cover, 939 pp, illustrated, $89.95.

This extensive reference book now in its second edition was revised to follow and further explain the fifth edition of the AMA Guides to the Evaluation of Permanent Impairment, which was published in 2001. Seventy-one contributors have prepared 69 chapters and three appendices. The text is divided into four parts. The first provides introductory material on disability and impairment, the second includes chapters on impairment ratings, the third is focused on disability, and the fourth includes a set of appendices. This second edition includes information on disability and return to work. There is also a new chapter in the introductory section of the book on evidenced-based medicine and causality providing a basis for the legal aspects of disability medicine.

Part I is comprised of 11 chapters that introduce fundamental concepts presented in the book and then elaborate on impairment rating. In the first chapter, Demester defines both impairment and disability, definitions compatible with those used in the AMA Guides. This section then includes chapters on the history of disability programs in the United States, the economic cost of disability, federal and state worker's compensation programs, and social security disability programs. In the description of the SSI benefit programs the insurance benefits for children who are disabled is described, including the concept of Functional Equivalency and the Individualized Functional Assessment. The statutory definition of disability as it relates to children is given and the process of evaluating children for SSI benefits is presented. The final four chapters in this part address medical legal issues.

The first chapter in Part II describes the impairment oriented evaluation and report. The remainder of this part of the book is divided into fours sections: musculoskeletal impairment assessment, internal medicine impairment assessment, neurological impairment assessment, and psychiatric impairment assessment. Section A on musculoskeletal impairment assessment includes nine chapters. Beginning with a chapter on range of motion evaluation, the section then includes a chapter of radiologic imaging in the evaluation of orthopedic impairments, and chapter on cumulative trauma. The remainder of the section includes individual chapters on the joint systems including hand and wrist, shoulder and elbow, knee and hip, foot and ankle, cervical spine, and the thoracic and lumbosacral spine. The chapters on the upper limb describe common conditions such as carpal tunnel syndrome, and rotator cuff injury. No specific mention of impairment assessment is made, and these two chapters present a standard medical examination and treatment programs rather than emphasizing the impairment report. In contrast, the chapter on the knee and hip include specific reference to the AMA Guides and calculation of impairment ratings. The evolving nature of the rating systems is mentioned and the authors look to the future when accuracy will improve, with fair and consistent awards to workers. Chapter 19, on foot and ankle disorders is also focused on impairments and the potential for the development of permanent impairment. The chapter on the cervical spine focuses on clinical presentations, physical examination findings, and radiographic imaging studies that can be used to discriminate among causes of neck and arm pain, but again fails to discuss an impairment assessment report. The chapter on the thoracic and lumbosacral spine recommends two major classification systems to rate impairment and disability and criticizes the AMA symptom-based classification system.

Section B, Internal Medicine Impairment Assessment, includes 11 chapters. The first five address pulmonary and cardiac impairments including diagnostic techniques for the pulmonary and cardiac systems. The chapter on pulmonary diagnostic technique describes pulmonary function tests in detail and notes that greater reliance is placed on pulmonary function tests than on history or physical examination in impairment rating. Chapter 23 provides a review of the accuracy and reliability of tests used to assess cardiac disease including exercise electrocardiography, exercise stress electrocardiography with nuclear imaging, myocardial viability using nuclear imaging, stress electrocardiography with echocardiographic imaging, and catheterization laboratory evaluation. The authors mention the importance of knowing sensitivity, specificity, and positive and negative predictive values as well as overall accuracy of various diagnostic tests. Chapter 24 presents an overview of cardiopulmonary exercise stress testing. Pulmonary and cardiac impairments are described in chapters 25 and 26, respectively. In both of these chapters criteria for impairment ratings are presented. Chapter 27 on peripheral vascular impairments presents criteria for rating impairment due to disease of the aorta, valvular heart disease, and extremity impairment due to peripheral vascular disease. Chapter 28 on dermatologic conditions discusses the use of the AMA guide in preparation of an impairment report and provides explicit examples of language that might be incorporated into a report. The final four chapters describe endocrinological, gastrointestinal, genitourinary and hematologic and oncolgic impairments. With the exception of the chapter on gastrointestinal impairment assessment, each of the chapters provides rating systems of impairments.

Section C is comprised of five chapters related to neurologic impairment assessment. The first chapter presents an overview of neurological diagnostic techniques presented in association with disorders of various areas of the CNS. A section of this chapter is devoted to documentation of the loss of function, and verification of subjective complaints (including pain, paresthesias, weakness, and muscle spasm). The next four chapters present CNS impairment, PNS impairment, visual impairment and otolaryngological impairment. Each of these chapters presents clear systems of impairment rating.

Section D of Part II includes five chapters on various aspects of psychiatric impairment assessment. The chapters include evaluation of psychiatric impairment, evaluating and rating pain, evaluating and rating stress, psychological impairment, and functional somatic syndromes. An additional section is included on impairment evaluation in functional somatic syndromes written by Demester. Beginning with information on the DSM-IV, the chapter on psychiatric evaluation describes the five different axes or categories of psychiatric illness. The evaluation of psychiatric impairments is described with reference to a variety of clinical measures. This section is a bit difficult to follow as the variables being evaluated are sometimes not clearly identified. For example, neuropsychological testing is listed with 12 different variables listed, whereas the Incomplete Sentence Blank-Adult Form is listed with a very general description of what the psychiatrist assesses in this test. Chapter 39 presents evaluation and rating of impairment caused by pain. The chapter includes information on chronic pain and psychiatric illnesses, characteristics of patients with chronic pain syndrome, disability intervention, impairment assessments of pain, measuring and rating pain, social issues, and impairment from chronic pain. The author concludes the chapter with a clinical example. Chapter 40 on the evaluation and rating of impairment caused by stress includes sections on problems assessing stress in medical practice, the importance of individual variability in assessing stress, the biological concept of stress, stress immunity and disease, stress and personality function, temperament and the assessment of disability, stress and personality disorders, coping and disability, posttraumatic stress syndrome and the assessment of life events. Also included are discussions of stress and the DSM-IV and stress and impairment. The chapter concludes with six examples of job stress that bring the information presented in the chapter into clear focus. The chapter on psychological impairment in many respects repeats information presented earlier in this section. The AMA guidelines are referenced and the chapter includes 23 small case presentations to illustrate the main points of the chapter. A section on special issues concludes the chapter and provides information on stress, personality disorders, substance abuse, pain and somatization, motivation, desire for compensation, symptom magnification and malingering. A chapter on functional somatic syndromes (FSS) concludes this part of the book with information on fibromyalgia, chronic fatigue syndrome, somatization disorders and multiple chemical sensitivity syndromes.

Part III is focused on disability evaluation. It begins with a section on Introductory Concepts. The first chapter in this section is used to remind the reader that disability and impairment reports are different and that the goal of a disability report is to describe for a third party, what an individual can and cannot do, as well as to describe methods of overcoming limitations. Chapter 44 describes the various personnel that might be involved in disability evaluation including therapists, vocational rehabilitation specialists, industrial hygienists, and human resource management specialists. Chapter 45 presents legal issues including federal law (Family Medical Leave Act, Americans With Disabilities Act, And Social Security Act), state law (Worker's Compensation) and Private Insurance. Chapter 47 provides an overview of the Family Medical Leave Act and the Americans with Disabilities Act. The next chapter provides the US Department of Labor's Guidelines for Job Categorization. Chapter 49 presents the Federal Aviation Administration's disability guidelines and Chapter 50 includes a discussion of fitness to work for Commercial Drivers along with presentation of the Federal Motor Carrier Safety Regulations—Physical Qualifications for Drivers. The next chapter in this introductory section presents a generic functional capacity assessment that the authors indicate can be applied to any organ system. Chapter 52 entitled Can Joe Work? begins with a discussion of the factors of capacity, tolerance and risk. Examples are employed for individuals with Coronary Artery Disease and Low Back Pain. The point of this chapter is that disability evaluation is not an exact science and decisions regarding patients’ levels of disabilities are fraught with bias and anecdotal evidence, rather than science.

Sections B, C and D of this part of the book discuss, musculoskeletal, internal medicine and neurological disabilities, respectively. Section B begins with a chapter on Fitness for Duty (FFD) that includes discussions of the history of FFD evaluations, legal background for FFD determinations, employee ability assessment, employer identification of essential job functions, and the FFD determination process. The author reminds the reader that an individual who has a medical condition that limits a major life activity is rendered a disabled person and protected by the ADA with respect to employment decisions, and suggests that legal counsel be sought in contested cases. The next chapter presents a discussion of the ergonomic basis for job-related strength testing. The following chapter presents the functional capacity evaluation (FCE). Beginning with a definition the author then discusses FCE standards of care, presents various types of FCE in current use, and discusses the future of FCE. Chapter 56 by Isernhagen, a physical therapist, presents concepts of work hardening. The final two chapters in this section present orthopedic disabilities of the joints and the spine.

Section C includes eight short chapters on pulmonary, cardiac, peripheral vascular, dermatological, endocrinological, gastrointestinal, renal and hematological and oncological disabilities. Each of these chapters is a segue for reiteration of the characteristics of the common diseases/disorders as well as in some instances very rare disorders that lead to disability, in most instances reference is made to the need to determine job characteristics as part of the assessment of disability. The assessment of disability is often covered in a cursory manner with reference to the impairment ratings and the process of using impairment ratings and applying them to the specific characteristics of the workplace.

Section D presents 2 chapters on neurologic disability: one on disabilities that result from CNS disorders and the other on disabilities due to PNS conditions. The first chapter focuses on outcome scales, those used across conditions and those developed for specific conditions, such as stroke, dementia, traumatic brain injury, and epilepsy. The second chapter on PNS disabilities is disappointing in its approach to the topic of repetitive motion disorders. The possibility of injury prevention is never discussed and the author takes the stand that repetitive motion is a requirement of some jobs, rather than suggesting any form of workplace accommodation. Unlike the chapter on CNS disorders, this chapter does not address predicted outcomes for specific disorders of the PNS.

The final section of this part of the book includes a single chapter on psychiatric disabilities. This chapter is a bit redundant with the initial chapter on psychiatric impairment rating although as is typical for the disability assessment chapters reference is made to assessment of the workplace and tasks required of the individual. Steps in determining a psychiatric disability are outlined including assessment of workplace accommodations. Psychiatric conditions that preclude return to work are listed, and the chapter concludes with a discussion of and outline for disability assessment reports.

Part IV of the book is comprised of three appendices: A. Biostatistics and Epidemiology: A Review of Topics Found in this Book, B. How to Fill out Disability and Return-to-Work Forms, and C. Resource Lists.

This comprehensive text is overly lengthy and occasionally redundant. Designed to follow the AMA Guides on Disability Evaluation, the editors have failed in some instances to require that the authors address fundamental issues related to impairment and disability assessment ratings. Too few references to measurement science are included for what would be a major reference book. The appendix on Biostatistics and Epidemiology is a short 7 pages, with only two of those devoted to the topic of epidemiology. Where science is absent, authors frequently claim that medicine is both an art and a science. However, in this time of evidence based practice, one wonders how long such claims can be made when rendering such significant decisions regarding impairments and disabilities that affect industry and thus have economic import. The fact that legal scholars are moving toward evidence based practice serves as a warning sign that where evidence exists, practice regarding impairment and disability assessment should be in tune with the evidence. Where evidence does not exist, clinicians and researchers alike should be aware of the very real limitations of their decisions. This book goes a good distance in organizing the presentation of information related to disability evaluation, yet the chapters would be stronger if there were a requirement that all authors possess and apply rudimentary knowledge of measurement science in their chapters.

Because children with disabling conditions move from school to the workplace, this book could be of value as a reference for those therapists who provide service to adolescents transitioning to work. However, the lack of specific information related to disabilities associated with common childhood disabilities makes the text of limited utility for pediatric physical therapists. As a result, I would not recommend the text for purchase by physical therapists who work with children. Only in the instance when a therapist is employed to carryout transition to work functions would I suggest that the employer obtain the book as a reference text.

© 2003 Lippincott Williams & Wilkins, Inc.

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