Disability ManagementDisability Management- an overview - - an overview -

Dr. Jill CalderDr. Jill CalderPhysical Medicine & RehabilitationPhysical Medicine & Rehabilitation

February 8, 2015February 8, 2015

A bit of background: PhysiatryA bit of background: Physiatry

Physical Medicine & Rehabilitation (PM&R) = USA / Canadian term

Physiatrist = British / old Canadian term

“fizz-i-a-trist” not “si-ci-a-trist”

Born from challenges Born from challenges of the 20of the 20thth century: century:

WarsWW I TBI, PTSD, AmputeesWW II Field surgeonsKorea MASHVietnam Air evac

EpidemicsParkinson’s the comaPolio survivable paralysisAging boomers . . .

Current epidemicsOur highways,

guns and violence,work and leisure pursuits, ageing.

Symptoms History Physical Symptoms History Physical signssigns

Urine tests Blood tests Xrays Urine tests Blood tests Xrays US US

CT scans MRI AngiogramCT scans MRI Angiogram

The Medical Mind:The Medical Mind:

DiagnosisDiagnosis

The Rehabilitation Mind:The Rehabilitation Mind:

DiagnosisDiagnosis

Functional DiagnosisFunctional Diagnosis

Joint range Speech Cognition

Strength Swallow Behaviour

Sensation Communication Emotion/Mood

Control

Self care School

Bowel Home care Work

Bladder Community access Driving

Sexual Function Finances

What is a Disability, or Challenge?What is a Disability, or Challenge?

The same impairment leads to different The same impairment leads to different disabilities / activity limitations . . .disabilities / activity limitations . . .

Handicap?Handicap?

• Handicap used to be a compliment!

• The better the horse, the more weight added to even up the race.

Modern English keeps changing:Modern English keeps changing:

• Handicap is not a positive word anymore.

• REPLACED BY -

““CHALLENGED”CHALLENGED”

““Participation Restriction” has not caught Participation Restriction” has not caught on but good for reports.on but good for reports.

English English Medical Medical Legal language: Legal language:

Terry Fox – ordinary guy, who fought cancer. Amputation is a visible disability.

Rick Hanson – ordinary guy who suffered a spinal cord injury. Paraplegia is a visible disability.

Christopher Reeves – Superman, super actor, suffered a high spinal cord injury. Quadriplegia is a very visible disability.

Their disabilities were not THEM, not really WHO they were. Their disabilities were their challenges by as they lead their lives.

Visible disabilitiesVisible disabilities

Invisible disabilities:Invisible disabilities: Complex Brain FunctionsComplex Brain Functions

Tom Cruise – learning disabled?

Paul McCartney –Paul McCartney – music impaired? music impaired?

Wide range of patients, and systemsWide range of patients, and systems

Gradations of Disability / Return Gradations of Disability / Return to Work conceptsto Work concepts

1. Return to previous work without limitations

2. Return to previous work with modifications

3. Graduated return to work– Modified by duration, intensity– Example:

• 3 half days alternate• 5 half days• 3 full two half . . . etc.

4. New job, same employer

5. New job, new employer

Gradations of Disability Gradations of Disability

1. “temporarily partially disabled”

2. “temporarily totally disabled”

3. “permanently partially disabled”

4. “permanently totally disabled”– “from all gainful employment”

“disabled” = “restricted from required activity”

Disability by payer systemDisability by payer system

• Canada Disability Pension (CDP)– Permanent– Total– Any job

• Persons with Disabilities of BC (PWD BC)– Prolonged– Total– Re-trainable / partial work supplemental to $800.00/mo.

• WorkSafe BC– Gradations to claim and programmatic interventions– Permanent from prior job– Retraining concepts– Pension based on “percentage total body disability”

Maximal Medical Improvement =Maximal Medical Improvement =

• Reached when further formal medical input, diagnostic testing or treatment, is no longer expected to have a favourable effect on patient outcome

• Does not mean the patient’s symptoms have completely resolved

• State whether or not patient’s condition is likely to be chronic or permanent

• Most payers are justifiably searching for “Medical Closure” – be clear.

Handicap / Handicap / Participation Participation RestrictionRestriction

• A patient may be medically able to seek alternate employment, but return to work may be problematic due to societal factors

• Employer won’t rehire until patient is “100%”

• Patient’s age is often a barrier

• Language – especially ESL

• Rural / remote communities, lack of employers

• Small employer unable to accommodate “light” job

Prosthetics, Orthotics, Prosthetics, Orthotics, and Assistive Devices and Assistive Devices

Role of rest, exercise, and spiritRole of rest, exercise, and spirit

• Rest– very specific to injury tissue and recovery for that lesion– Targeted “rest” of the lesion only

• Assistive devices, braces• Ambulatory aides

– Walkers . . . Crutches . . . Canes . . .

• Restorative exercise– Not just any exercise, specific to the lesion and its domino

• Spirit– Anxiety and depression assess and treat– Resources

• Arthur’s Story https://www.youtube.com/watch?v=qX9FSZJu448

• myfitnesspal.com

A Comprehensive Fall Prevention PlanA Comprehensive Fall Prevention Plan

Education

Assessment Exercise

Environment Equipment

NewtonNewton’’s laws:s laws:

Risk FactorsRisk Factors

• Lower body weakness• Problems with gait and balance• Reduced sight and hearing• Reduced muscle strength,

coordination, and neurologic reflexes

• Urinary dyscontrol, nocturia• Multiple medical conditions• 4 or more medications• Psychoactive medications• Environmental fall hazards

History of falls**

The Role of the The Role of the Family Practitioner?Family Practitioner?

• In a key position to prevent falls

• Assessment of physical function:– Basic level

• Rises from chair without using arms– TUG “time to up and go”

• Step length at least twice foot length• Walks without assistive device

– Timed walk (30 m < 30 sec)– High Level

• Tandem walks at least four to five steps• Descends stairs step-over-step

• Categories– Frail: fails basic level– Transitional: passes basic level, fails high level– Vigorous: passes high level

Supported standing toe rises

Basic squat

Hip abduction

Hams curls

Glut extensions

Geriatric exercise = exerciseGeriatric exercise = exercise

• Range of motion• Progressive resistance• Balance and coordination• Cardio but short / intense blast• Embed in functional activities• Socially and community connected

Story of the LOL who could stork-stand indefinitely

MedicationsMedications

• Patients taking benzodiazepines are 70% more likely to fall than those not taking these medications (Passaro et al., 2000)

• Medication reviews were associated with a significant reduction in falls in a psychiatric hospital (Murdock et al., 1998)

• Psychotropic drug withdrawal has been associated with a reduction in falls in other settings but compliance is problematic

• For patients with a diagnosis of osteoporosis, bisphosphonates have been shown to reduce fracture rates

NutritionNutrition

• Poor nutrition is associated with weak muscles

and low bone density, putting older people at

greater risk of falling and sustaining a fracture

• Studies show that approximately 16% of older

people admitted to hospital are severely

malnourished – many with Vitamin D deficiency

• Vitamin D and calcium supplementation have

been shown to reduce fractures in residential

settings and should be considered in hospital

settings

• Shields placed against the unprotected hip

• Energy absorbing• Energy shunting:

disperse impact across a wider area

(Lips & Ooms, 2000)

Why hip protectors

• Contains a falls section

• User friendly and easy to read

RESIDENTIAL FALLS PREVENTION: STRATEGIES & SOLUTIONSChallenge What Staff Can Do

AcknowledgementsFunding for this pamphlet was provided by the Population Health Planning and Support Unit (PHPSU).A special thanks to the staff and management at Ponderosa Lodge whose support, encouragement and dedication made this program a reality.Rhonda Chisholm, O.T.Charge Occupational TherapistRoyal Inland Hospital, Home and Community CareKamloops

• https://www.youtube.com/watch?v=qX9FSZJu448

DrivingDriving – – “the gut test”“the gut test”

• Department of Motor Vehicles “red book”• Sections:

– Vision– Seizures– Motor control

• Reaction times• Sedation / Medications

• Driving assessments options:– “Senior’s check”– Mandatory road test– Driver rehab programs (have licensed pulled)

• Insight Driving Assessment, Vernon• GF Strong Driving assessment unit

Adapted driving:Adapted driving:

• Any alteration or adaptation must be DMV cleared• Very specific list of “no’s” for Class 1 – 4• Pilots, military, police – all have specific rules

Lawyers and the IMELawyers and the IME

• IME = Independent Medical Examination

• Or “Medical Examination by Non-Treating Physicians”

• Legal, financial or insurance reasons

• CONSENT

• Examination

Medical Legal ReportMedical Legal Report

• Reason for IME referral• CERTIFICATION: Pursuant to the BC Rules of Court, July 1,

2010, Sub rule 11-2(1): I am aware of my duty to the court as an expert witness and hereby certify that I have a duty to assist the Court and not be an advocate for any party. I confirm that I have prepared this report in conformity with that duty. If called upon to give oral or written testimony at trial, I certify that I shall give my testimony in conformity with that duty.

• Documentation of consent• Documents reviewed• Hx PMH Soc/Voc hx • Px (objective physical findings, or lack of findings)• Causality

ObjectivityObjectivity

• Be objective• Evidence-based• References where indicated• Humble• Clear• Don’t own the patient – avoid “sides”

• Don’t refer for unnecessary tests or programs• Say what you can say• Say what no one can say