MEDICAL ASSESSMENT FRAMEWORK

Transcription

1 MEDICAL ASSESSMENT FRAMEWORK The Department of Social Security March 2001 Contents Page Introduction 2 Assessment of Disablement 4 The Diagnosis of Prescribed Diseases 11 Conditions of the Vertebral Column 13 Vibration White Finger 24 Mental Health Conditions 29 Annex I Decision Makers Medical Glossary March

2 MEDICAL ASSESSMENT FRAMEWORK (MAF) INTRODUCTION The Medical Assessment Framework (MAF) has been designed to provide guidance to Medical Advisers on the assessment of percentage disablement in respect of Industrial Injuries Disablement Benefit (IIDB) and Severe Disablement Allowance (SDA) claims, in those conditions/functional areas for which there is no direct correlation with prescribed degrees of disablement as laid down in Schedule 2 to the Social Security (General Benefit) Regulations 1982 [ Scheduled assessments ]. It is guidance which aims to relate non-scheduled injuries to those listed in the schedules, which form the basis of this guidance. Just as the scheduled assessments may be varied (ie. increased or decreased) dependent on the individual aspects of the case, the guidance in the MAF may be varied in accordance with the specific aspects of the case. The underlying principle must be that the assessment of disablement is made by reference to a person of the same age and sex whose physical and mental condition is normal. The information contained in the MAF is not stand alone. It should be read in conjunction with the relevant legislation and with other guidance specific to the IISB, and the general guidance given in the training in disability assessment medicine. The objectives of the MAF are to enhance the consistency of medical advice on the assessment of disablement, and help Decision Makers to understand more clearly the reasoning underlying medical advice on percentage assessment The guidance contained in the MAF is not prescriptive, nor is it in any way binding on Medical Advisers or Decision Makers. The suggestions contained therein are merely indicative of the level of disablement likely to arise from the clinical and/or functional effects described. Medical Advisers will still be required to exercise clinical judgement in formulating advice on appropriate assessment in the individual case. This will be important especially for disabilities at the lower end of the scale, where Medical Advisers will need to make a careful distinction between what is physiological/normal and what is pathological/abnormal, taking into account the claimant s age and sex. Medical Advisers are still required to justify their advice to Decision Makers. It is particularly important when suggested assessments are very different to those suggested by the scheduled assessment that the Medical Adviser explain the basis of their opinion, and reasons, in the case in question, for that opinion. Reports prepared by Medical Advisers must be readily understandable to claimants without them needing recourse to consulting documents, such as the MAF, which are not readily available. It is not, therefore, acceptable for Medical Advisers to quote a paragraph in the MAF as opposed to writing their clinical findings and reasons in full. 2

3 Although the MAF is intended to help Decision Makers as well as Medical Advisers, it has been written primarily for the latter, and therefore contains medical terminology. Where possible, medical terms with which Decision Makers are not likely to be familiar are included in the Decision Makers Medical Glossary (See Annex I). However, the use of medical terminology in the MAF does not automatically mean that Medical Advisers can quote the MAF in writing reports for Decision Makers. This version of the MAF covers those conditions/functional areas which are most commonly encountered. Further guidance will subsequently be developed to cover other functional areas. It must be remembered that the MAF is designed to be used by doctors who are trained disability analysts, and who are therefore able to make use of the guidance in the context of their specialist training in this field. The MAF must be considered in the context of all the other evidence relating to each individual case which the doctor will have gathered. To use it in any other way could be potentially misleading. Also, it must be remembered that doctors do not make decisions on benefit entitlement: they provide advice to Decision Makers, who are also required to consider that advice in the context of all the evidence, and are not bound to accept it. Factors important to remember in the Industrial Injuries Scheme Benefits (IISB) 1. The medical diagnosis of a condition or disease does not automatically mean that a Prescribed Disease is diagnosed. The diagnosis of the medical condition will not require the strict legal criteria to be fulfilled as is the case with PDS. For example a person may have vibration related white finger, but until it reaches the severity as laid out in the prescription of the PD, PDA11 will not be diagnosed. 2. Relevance and causation are important factors in IISB. For example the disability must be related to the accepted accident; in order for the PD to be diagnosed it must be related to a prescribed occupation. Summary The MAF has been designed to provide guidance to Medical Advisers on the assessment of percentage disablement in respect of Industrial Injuries Disablement Benefit (IIDB) and Severe Disablement Allowance (SDA) claims, in those conditions/functional areas for which there is no direct correlation with prescribed degrees of disablement as laid down in Schedule 2 to the Social Security (General Benefit) Regulations 1982 [ Scheduled assessments ]. The MAF is for guidance purposes only. The advice is not prescriptive. The MAF is designed to be used by doctors who are trained disability analysts, and who are therefore able to make use of the guidance in the context of their specialist training in this field. 3

4 The MAF must be considered in the context of all the other evidence relating to each individual case which the doctor will have gathered. To use it in any other way could be potentially misleading. Doctors do not make decisions on benefit entitlement: they provide advice to Decision Makers, who are also required to consider that advice in the context of all the evidence, and are not bound to accept it. Medical Advisers are still required to justify their advice to Decision Makers Reports prepared by Medical Advisers must be readily understandable to claimants without them needing recourse to consulting documents, such as the MAF, which are not readily available. It is not, therefore, acceptable for Medical Advisers to quote a paragraph in the MAF as opposed to writing their clinical findings and reasons in full. 4

5 ASSESSMENT OF DISABLEMENT General The assessment of the individual is made by comparing the person with a person of the same age and sex whose physical and mental condition is normal. Special circumstances such as loss of earnings or the effect of the disablement on hobbies etc, are not considered in the assessment of disablement. Prescribed degrees of disablement for certain conditions are laid down in the Regulations. (The Scheduled assessments or Schedules ). However there is the discretion to increase or decrease these assessments where it is appropriate. When advising on the assessment of disablement not covered by the Schedules the doctor will endeavour to equate the disablement to the Schedules. A rough guide to assessment is as follows: less than 1% virtually no disablement 1-5% minimal, eg loss of a toe through the metatarso-phalangeal joint. 6-10% very mild, eg loss of two phalanges of the middle finger 11-20% mild, eg loss of the index finger 21-30% mild/moderate, eg loss of vision of one eye, without complications or disfigurement, the other being normal 31-50% moderate, eg below knee amputation 51-80% moderately severe, eg amputation below hip with stump not exceeding 13 cms in length measured from tip of great trochanter 81%+ severe, eg loss of both hands or amputation at higher sites. It is important to recognise that IIDB and SDA are governed by different legislative requirements. For SDA, all disabling conditions are taken into account in arriving at an assessment of percentage disablement. For IIDB, only disablement relevant to the accident or prescribed disease is taken into account. Therefore, for benefit purposes the same degree of disability in medical terms may quite properly result in a different percentage disablement, depending on whether the claim is for IIDB or SDA. In the following pages guidance is given in the assessment of common conditions which are not directly covered by the Scheduled Assessments, but which have been extrapolated from the 5

6 Schedules over the years by Adjudicating Medical Authorities and confirmed by Medical Appeal Tribunals. Identification and determination of relevance The chain of causation giving rise to a right to disablement benefit is: an accident or prescribed disease arising out of and in the course of employment, resulting in an injury, resulting in a loss of mental or physical faculty, resulting in one or more disabilities, resulting in disablement Advising on the assessment: The nature of the injury The Medical Adviser (MA) has to give advice on the nature of the injury resulting from the industrial accident and record this as specifically as possible, avoiding general descriptions (eg fracture of (L) radius rather than injury to (L) arm; detached retina (L) eye rather than injury to (L) eye). A consequent injury is one which results directly from the accident and must be treated as part of the relevant injury. The loss of faculty The MA has first to be satisfied that it is more probable than not that the claimant has suffered a loss of faculty (the relevant loss of faculty RLOF) as a result of the relevant accident, before it can go on to advise on the assessment of disablement. The MA is not bound in any way by a the advice of an earlier Adjudicating Medical Authority (AMA), MA, Medical Appeals Tribunal (MAT) or Appeals Tribunal (AT). It is for the MA to consider the disablement question afresh each time, to reach his own conclusions on the results of the accepted accident during the period with which it is concerned, and to give advice accordingly. Where an MA reaches conclusions different from those already expressed by a previous MA or AT, or from those given by a doctor who has reported on the claimant, it is helpful if the MA draws attention to this in its report and states the reasons for taking a contrary view. If the case should subsequently go to AT, both the claimant and the AT will wish to know the reasons for these views. However, the MA should not concern itself with what decision should have been given for any period earlier than the period referred for advice. 6

7 There is deemed to be no loss of faculty if the resulting disablement is assessable at less than one per cent. However, the Commissioner has pointed out that it is desirable to distinguish between cases where there is no relevant loss of faculty and those where there is a relevant loss of faculty, but the resultant disablement does not amount to one per cent. Moreover, the MA is required to determine whether or not there is a loss of faculty before it goes on to consider whether any disablement has resulted from it. Therefore, if the MA decides that there is a loss of faculty, but that the resulting disablement amounts to less than one per cent, it should record an affirmative answer to the loss of faculty question and enter the loss of faculty. It should then advise that the assessment of disablement is less than 1%. The MA should record the relevant loss of faculty by specifying what power or function of an organ or part of the body has been affected by the injuries resulting from the relevant accident; for example, loss of vision of left eye ie. the relevant loss of faculty should be described as locally as possible and reflect the loss of function of the injured part. Where the claimant is suffering from a psychological or psychiatric condition, the MA must decide whether or not this condition was caused or materially aggravated by the relevant accident. If it was, it should be shown as a relevant loss of faculty. The disabilities Once an MA has stated that there is a relevant loss of faculty resulting from the accident or prescribed disease, he should consider whether any disability results. The MA should record the disability suffered by the individual as a result of the accident or prescribed disease, by specifying any disability, resulting from any relevant loss of faculty, described globally with reference to the function of the organs or limbs involved. The MA should consider whether any other conditions, not resulting from the industrial accident or prescribed disease contribute to the disability. If so, the MA should record the disability as only partly relevant to the industrial accident or prescribed disease and record the conditions which are the other effective causes of the disability. Conditions present in the organs or limbs, unrelated to the industrial accident, while not contributing to disability at the time of the examination, but which the MA expects would have begun to cause disability within the period under consideration, even if the accident had not occurred, should also be entered as other effective causes of the disability. If the conditions pre- dated the industrial accident they should be described as O(Pre). However, if the conditions developed after the date of the industrial accident, provided they are not a consequence of the accident, they should be described as O(Post). Care must be take not to describe conditions developing as a consequence of the industrial accident as O(Post) since the disability arising from these conditions should be attributed to the accident. It should be noted that the descriptions, O(Pre) and O(Post), of the other effective causes of disability, relate to the date the conditions existed, rather than the date they gave rise to disability. A proneness to a disability (eg to detached retina in a high myope) cannot be regarded as another effective cause of disability unless it is considered by the MA that it would have caused disability within the period under consideration, even if the accident had not occurred. When there is clear evidence of pathology present before the relevant accident, but not 7

8 causing disability, and unlikely to do so during the period under consideration, this condition should be considered as unconnected. Any other conditions found, which have no effect upon the disability resulting from the relevant loss of faculty, should be recorded as unconnected. But if those conditions subsequently deteriorate and produce disability during the period under consideration they should then be considered as O(Pre) or O(Post). The MA should bear in mind that the relevance of disability can change with time, as the effects of the accident wane, and the effects of other effective causes wax and wane. The disablement Once an MA has stated that there is a relevant loss of faculty resulting from the accident, it should consider whether any disability results and, if so, proceed to assess the disablement arising in accordance with the principles in Schedule 6 to the Contributions and Benefits Act The MA should describe how the relevant disabilities, as affected by other effective causes disable the customer in the ordinary activities of life. For example, where the disability is altered function of lower limbs, particulars of gait and carriage should be given together with details of how far the claimant can walk, whether they use an aid, whether they wear an appliance, whether they can use stairs etc. The effect of the law is: (a) (b) (c) (d) (e) the assessment of disablement has to be made without reference to the special circumstances of the claimant other than age, sex and physical and mental condition. Inability to follow a particular occupation, loss of earnings or additional expense because of the effects of the accident does not affect the assessment of disablement the disabilities to be taken into account are all the disabilities incurred as a result of the relevant loss of faculty to which the claimant may be expected to be subject during the period taken into account by the assessment. the period of assessment is that period over which the average assessment of disablement is expected to remain constant. Should there be any significant fluctuation in the level of disablement (eg as a result of surgery), separate assessments should be made for the appropriate periods (split assessment) where there are other effective causes of the relevant disabilities any disablement to which the claimant would have been subject in any event (ie if the accident had never happened) because of some congenital defect, injury or disease not directly attributable to that accident, should be excluded from the assessment of disablement; but where relevant disability is worsened by the presence of some congenital defect, injury or disease not directly attributable to that accident the assessment may, in specified 8

9 circumstances, be increased to take account of such worsening in arriving at the assessment of disablement. The C & B Act requires that an assessment of disablement shall be expressed as a percentage which shall not be more exactly specified than is necessary to determine claimant s entitlement to disablement benefit. For payment purposes assessments between 14 and 100 per cent which are not multiples of 10 are rounded in accordance with legislation and treated as multiples of 10. This rounding is a task reserved exclusively for the Decision Maker and the MA should assess the individual disabilities and the total assessment of disablement should be recorded as an exact percentage. This enables later Authorities to appreciate how the total assessment was determined, which would not be apparent from a rounded figure alone. Scheduled assessments Schedule 2 of the General Benefit Regulations sets out certain degrees of disablement for specified injuries (referred to as scheduled assessments). These amounts were prescribed, on the recommendation of a Committee, on the assumption that the injury had been caused to an otherwise healthy person and had resulted in an uncomplicated and stable condition. Although the schedule contains an assessment for total deafness the Prescribed Diseases Regulations also contain specified assessments for PD A10. The effect on assessment of conditions other than the relevant loss of faculty O (Pre) conditions If the conditions giving rise to another effective cause of the disability pre-date the relevant accident or prescribed disease, and the MA is satisfied that, even if the accident or prescribed disease had not occurred, the claimant would have been disabled to an assessable extent during the period under consideration, then it should be described as O(Pre) and the extent of that disability be excluded (offset) from the assessment. However, any worsening effect due to the interaction of the O(Pre) condition and the relevant condition may be considered. O (Post) conditions If the conditions giving rise to another effective cause of the disability post-date the relevant loss of faculty, they should be described as an O Post provided they are not a consequence of the relevant accident or prescribed disease. Greater disablement due to the interaction of the O Post condition can only be considered if the net assessment arising from the relevant loss of faculty and any O Pre condition is first assessed at 11% or more. 9

10 Multiple injuries embracing scheduled assessments A Tribunal of Commissioners has indicated that multiple injuries, not themselves constituting any specific item in the schedule of prescribed injuries, are not to be regarded as a scheduled injury merely because they constitute an aggregate of injuries each of which is specified in the schedule. Thus the disablement arising from such multiple injuries is not necessarily the sum of the assessments for the separate scheduled injuries. For example, where an industrial accident results in loss of index finger (scheduled degree of disablement 14 per cent) and two phalanges of the middle finger (scheduled degree of disablement 9 per cent), the assessment for the disablement resulting from these injuries is not necessarily the aggregate of the assessments for the separate scheduled injuries (23 per cent) which would amount to more than the scheduled degree of disablement for the loss of two fingers (20 per cent). It is for the MA to advise the appropriate assessment of disablement in the particular circumstances of the case. 10

11 The Diagnosis of Prescribed Diseases 1. Some diseases, when caused by occupational exposure, are indistinguishable from the same disease in someone who has not been exposed at work. Prescribed Disease A11 (PDA11) is an example, but there are many others (probably the majority of the Prescribed Diseases), eg Tuberculosis (B5), Carpal Tunnel Syndrome (A12), Chronic Bronchitis and Emphysema (D12). 2. When considering advising the Secretary of State that a disorder be prescribed the Industrial Injuries Advisory Council (IIAC) will consider whether the attribution to an occupation on the balance of probabilities, based on the epidemiological evidence, that work in the job or occupational exposure increases the risk of developing the disease by a factor of two or more - doubling of risk. 3. Once a disease is prescribed, in an individual case, particularly in a condition such as white finger which is very common in the population as a whole, and which can have many different causes (please see Annex I), care must be taken to ensure the disease is due to the occupational exposure, and not due to some other cause. This requires the doctor to take a detailed occupational history; to take a history of all occupational exposures which may have resulted in a sufficient degree of exposure to cause the disease; to take a detailed social history (to exclude for example, a hobby which could cause the disease either wholly or partially);to take a detailed family history (to exclude inherited causes of the disease which cause the disease wholly or partially); to take a full personal past medical history; and perform a careful examination of the claimant. 4. It is very common for a disease to be diagnosed medically, but the Prescribed Disease not to be diagnosed: There may never have been occupational exposure so the medical condition cannot be attributed to the job. Occupational exposure may have been so limited as to make it improbable that the disease was due to a factor at work. The disease may be inherited. An inherited disease does not have to be present from birth or childhood. Often inherited diseases do not become apparant until adult life. The disease may be present from a medical point of view, but not to a degree of seriousness to fulful the legal criteria required to reach the diagnosis of the Prescribed Disease. eg. (i) D12 not only must there be a certain severity of the disease, the person must fulfil a certain degree of occupational exposure. (ii) White finger would be diagnosed medically when only a tip of one finger 11

12 was affected in winter. However the Prescribed Disease would not be diagnosed until the severity reached that laid down in the regulations. Thus to be diagnosed medically as having a disease is not the same as to diagnose a Prescribed Disease. 5. The date of onset of a Prescribed Disease is not the same as the date the disorder may be diagnosed from a medical point of view: In some cases the date of onset of the Prescribed Disease can be readily determined. For example Prescribed Disease A3 where there is a history of rapid ascent or descent causing barotrauma. In Prescribed Disease A10 (Sensorineural hearing loss) the date of onset is taken to be the date of claim. In some Prescribed Diseases the date of onset has to be determined by careful history taking on the part of the Medical Adviser. 6. Even if diagnosed from a legal point of view, the Prescribed Disease may not result in a loss of faculty, or the loss of faculty may amount to less than 1%. For example, a very small patch of dermatitis may be assessed at less than 1%. As a result of a Commissioner s Decision (R(I) 6/61) Medical Advisers distinguish between cases where there is no loss of faculty and those where there is a loss of faculty but the resultant disablement does not amount to 1%. 7. Before advising the Decision Maker that the medical condition present is or is not a Prescribed Disease, the Medical Adviser will have recorded a detailed history and examination. 8. Industrial Injuries Disablement Benefit Records are kept indefinitely. If a claim for a Presribed Disease fails on the diagnosis question, the records will be kept, and, should there be a later claim for the same or a different Prescribed Disease or an accident, the records will be made available to the Medical Adviser advising the Decision Maker in order that they can compare the history being given and the clinical findings. 12

13 CONDITIONS OF THE VERTEBRAL COLUMN The vertebral column comprises three distinct functional areas: the cervical, thoracic, and lumbar spine. In addition, conditions affecting the vertebral column may, through nerve root irritation or dysfunction, result in disability in the separate areas of upper or lower limb function. Assessment in these latter functional areas can more readily be related to the scheduled assessments for the upper and lower limbs respectively. The assessment framework for the functional areas relating to the vertebral column refers to disability affecting the vertebral column (neck or back) only, in the absence of any neurological effect on limb function. Medical Advisers are required to exercise clinical judgement, for example in identifying and assessing the effect of any conscious or unconscious exaggeration of symptoms by the claimant ( inappropriate/illness behaviour ). The clinical findings described vary in the degree of objectivity which they represent. Medical Advisers will need to exercise particular care in evaluating those which are less objective, such as the degree of SLR achieved, and will have to draw attention in their report to their conclusions. 13

14 ASSESSMENT BANDS IN CONDITIONS OF THE VERTEBRAL COLUMN AND ASSOCIATED LIMB DISORDERS Conditions affecting the vertebral column, ie neck, upper and lower back [cervical, thoracic and lumbar spine] 1. Lumbar Spine Virtually no disablement Minimal Effects on activity Any symptoms and restrictions are minimal. Very mild occasional local discomfort complained of Mild local discomfort with minimal vertebral dysfunction. No significant effect on day-to-day activities General Clinical Findings There are no objective clinical findings Minimal objective clinical findings. On flexion fingertips reach to mid-shin or more. Full lateral flexion. Straight leg raising may be 40º or more. Very mild Mild/moderate background local discomfort with some limitation of spinal movements. Some restriction of day-to-day activities Mild Moderate discomfort with intermittent exacerbations involving more acute pain. Significant restriction of day-to-day activities, more marked during periods of increased severity Objective clinical findings present. On flexion fingertips reach to tibial tuberosity. Lateral flexion to with 4cm of popliteal crease. Straight leg raising 25º - 40º On flexion fingertips reach upper patellar border. Lateral flexion to within 8cm of popliteal crease. Straight leg raising 10º - 25º. Muscle spasm may be present. Mild/ Moderate Moderate/severe discomfort with few remissions. Very significant restriction of day-to-day activities. Surgery may be under active consideration. These cases tend to be rare and this level of severity shortlived. On flexion fingertips fail to meet upper patellar border. Lateral flexion fails to reach popliteal crease by more than 8cm. SLR very restricted. Likelihood of significant neurological signs in certain cases. Marked muscle spasm often present. 14

15 2. Cervical Spine Virtually no disablement Minimal Very Mild Mild Mild/moder ate Effects on activity Minimal symptoms and restrictions reported. Complaint of mild local discomfort Mild background neck discomfort. Slight restriction of tasks involving rotation or extension of the neck. Mild/moderate neck discomfort. Difficulty in performing tasks such as driving, DIY Moderate discomfort with intermittent exacerbations involving more acute pain. Significant restriction of day-to-day activities, more marked during periods of increased severity Moderate/severe discomfort with few remissions. Very significant restriction of day-to-day activities. Surgery may be under consideration General Clinical Findings Few objective clinical signs. May be slight unilateral restriction of lateral flexion. Objective signs may include: restriction of lateral flexion, slight restriction of rotation; can attain 30º flexion and 45º extension of the neck. Unable to obtain 30º flexion or 45º extension of the neck. Restriction of rotation Marked objective restriction of all neck movements. May be some wasting of accessory muscles. Muscle spasms may be present Neck movements restricted to a few degrees in any direction. Likelihood of neurological signs in the upper limbs in certain cases. Marked muscle spasm often present. 15

16 Thoracic Spine: The disablement arising from thoracic spine problems are unlikely to cause more than mild disablement. Effects on activity General Clinical Findings Minimal to very mild Mild Symptoms are mild to moderate localised pain. Variable effect on day-to-day activities More severe pain which may extend more diffusely from the site of the disease or injury Localised tenderness. Slight/moderate restriction of the thoracic spinal component of flexion/stooping and of rotation while seated. Marked restriction of the thoracic spinal component of flexion/stooping and rotation while seated. Expression of loss of faculty and disability in vertebral column Dysfunction Loss of Faculty: Disability: This will be expressed as Reduced vertebral column movement, or Reduced spinal movement or similar This will be expressed as impaired vertebral column (or spinal) function Any associated effects on the upper or lower limbs will be expressed separately 16

17 Limb disorders associated with vertebral column dysfunction 1. Lower limb Minimal Very mild Mild Effects on activity Any restriction in walking or climbing ability is minimal. Occasional discomfort that does not significantly affect walking speed or distance. Some difficulty in squatting. Any gait problems are minor Objective limitation of movement of lower limb joint(s), or instability. Significant difficulty in squatting. Reduced climbing ability. Some difficulty in walking on uneven ground. Minor problems with gait. Objective limitation of movement of joint(s) to a significant degree; or significant instability. Difficulty walking on level, even ground. Marked problems with gait. General Clinical Findings Objective clinical signs are sparse. Area of altered sensation may occasionally be identified May be distinct area of altered sensation, usually lateral border of foot and/or lateral calf. Slight weakness of dorsiflexion of foot and/or hallux may be present Above accompanied by some muscle wasting. Depression of ankle jerk and/or knee jerk. Significant weakness of dorsiflexion of foot and/or hallux 17

18 2. Upper Limb Effects on activity Minimal Minimal reduction in reaching, handling or manipulating objects. Occasional upper limb discomfort only. Paraesthesia in fingers may be reported General Clinical findings Few objective clinical signs. There may be slight restriction of abduction of the shoulder Very mild Mild Mild/moderate upper limb discomfort causing some difficulty with household tasks involving reaching, pushing/pulling Moderate discomfort with intermittent exacerbations involving more severe pain. Significant reduction of day-to-day activities, more marked during periods of increased severity Some reduction of grip strength may be present, and reduction in triceps or biceps tendon-jerks There may be some wasting of the biceps or triceps. Sensory depression may occur, and muscle fibrillation Expression of loss of faculty and disability in upper/lower limb disorders association with vertebral column conditions Loss of faculty: Disability: Examples include: Reduced power in lower/upper limb; reduced movement in upper/lower limb; altered sensation in lower/upper limb This will be expressed as: Lower/upper limb dysfunction; impaired lower/upper limb function 18

19 Example 1 On the claimant, Mrs B, a 40-year-old auxiliary nurse, was lifting a patient with a colleague when she slipped on a wet patch on the floor, twisting her back. She felt severe immediate low back pain, extending down her left leg. She was X-rayed in the A&E Department and told that she had a slipped disc. She was taken home in a taxi and called her GP. He confirmed the diagnosis and told her that she had sciatica. He advised bed rest at first, for about 5 days, then gentle exercises. She has not returned to work yet (3/9/99) and continues to experience low back pain and pain in her left buttock and down the back of her left leg. She has been prescribed analgesics which help a little, but she is awaiting an orthopaedic appointment. Physiotherapy has not been helpful. She has had trouble with her back on and off since she started nursing, but has lost no time from work with it. An X-ray of her lumbar spine two or three years ago showed wear and tear. She has not had this leg pain before, although she does have trouble with her right knee since a patellar fracture in her teens. It clicks painfully from time to time and occasionally swells up. She says she has difficulty stooping to lift her year-old grandchild and she finds that her walking distance is reduced if the ground is uneven. Her husband has to do any heavy housework. She is receiving Incapacity Benefit and is pursuing a case against the hospital in connection with the accident. Examination Mrs B is a lady of average build. She walks with a slight limp, sparing the left leg. Informal observation of her movements suggest mild/moderate restriction of back movements. Back. Normal spinal curves; erect posture. No tenderness elicited, and no inappropriate clinical signs. There is some lumbar paravertebral muscle spasm. She tiptoes fully, but squats only half-way, complaining of right knee pain. Site of back pain is lower lumbar spine (L4/5 L5/S1) extending down the left buttock and posterior thigh. Movements Forward flexion; fingertips reach to tibial tuberosity (ie just below kneecap). Lateral (sideways) flexion: fingertips 3cm short of popliteal crease 19

20 Extension: nil Rotation: unrestricted Straight Leg raising: Right 60º Left 30º Measurements: Thighs Right 45cm Left 42.5cm Calves 38cm 38cm Knee jerks + + Ankle jerks + absent Plantar responses Loss of power of dorsiflexion of hallux No Slight reduction There is a poorly defined area of diminished sensation over the lateral (outer) border of the left foot and another, also poorly defined, over the outer aspect of the upper third of the left lower leg. There is slight loss of power of eversion (outward rotation) on the left foot. Lower limbs Appearances normal The right knee is tender over the outer aspect (lateral joint line). There is significant crepitus (indicating degenerative change). Extension is full but flexion through 110º only. (Normal > 135º) All other lower limb joints normal. Injury: Loss of Faculty: Soft-tissue injury to lumbar spine with nerve root compression Reduced movements of lumbar spine: reduced power and sensation of left leg Disability: 1. Vertebral column dysfunction F 2. Lower limb dysfunction P Other Effective 3. Degenerative arthritis of right knee O Pre Cause: Serial No Gross Assesssment Offset (percentage & condition) Net assessment % 12% 3) 5% (Pre-existing degenerative condition. Right knee 8% 7 20

21 Example 2 On 1/8/99 Mr B, a plumber, was a passenger in his firm s van when it was struck from behind by another vehicle. Mr B was thrown violently backwards, landing on the floor. He experienced discomfort in his neck and felt stunned, although he was not unconscious. He was taken to Glasgow Royal Infirmary where his neck and skull were X-rayed. He was told that there was no bone injury, but that he was suffering from whiplash. The neck pain worsened a great deal over that weekend and he returned to the hospital where he was given a cervical collar and advised to contact his General Practitioner. He saw his GP the next day, and was given painkillers and advised to stay off work. Things did not improve, and indeed since the accident he has experienced increasing pain in his neck, towards the left and in the shoulder on that side. He also complains of tingling and weakness in his left arm and hand. Painkillers give only temporary relief. Exercised advised by the physiotherapist seem to make the main worse. He says he can no longer drive or do any DIY asked, and gardening is impossible, due to numbness and tingling in the left hand and arm and pain in the shoulder. Things have been made worse by a mishap at home on when he fell, and in putting out his right hand to save himself cut the palm of the hand on a bread knife which was lying on the table. It bled profusely and he was taken to A&E Dept. where severed tendons were diagnosed, involving the right ring and little fingers. He was detained and the tendons repaired under general anaesthesia. Healing was satisfactory, but despite doing exercises the fingers will not straighten fully, thereby adding to his difficulties. No further treatment is planned in connection with this injury. He has not returned to work since the accident. His employers have been supportive and are pursuing compensation on their, and his, behalf. He has no previous history of neck or upper limb problems, apart from minor cuts and bruises in the course of his work. Examination (3/12/99) Mr B is tall (190cm.estimated) and slightly stooped. He gives a clear history and responds normally to history-taking and examination. He holds his neck tilted to the right and moves his shoulders to look to the side. He is right-handed. Cervical spine indicated the site of pain is over the lower cervical spinous processes, where he is tender. There is no loss of cervical lordosis. 21

22 Movements Flexion is full. He can touch his chest with his chin. Extension is reduced to half of the expected range (about 30º) Lateral flexion 30º to left, 20º to right Rotation 45º to left and right (Normal 80º) Right upper limb. The right hand bears a ragged palmar scar just proximal to the metacarpal heads, and an associated surgical scar. Both are well-healed, non-tender and featureless. There is significant wasting of the hypothenar muscles. Movements of the thumb, index and middle fingers is full, but the ring and little fingers are held in 45º of flexion at the m-p joint. Flexion at this joint is minimal, and only 15º or so of extension is possible. Grip strength is 50% less than that on the left. Pinch grip and sensation normal. There is no other abnormality in the right upper limb. Shoulder, elbow and wrist movements full. There are no sensory changes. Left Upper limb. Appearance is normal. He indicates the lateral border of the arm and forearm as the site of pain, which extends to his thumb and index. There is no tenderness. He has a full range of movement in all joints, apart from the shoulder, which abducts to 100º only and lacks 30º of internal rotation. These movements exacerbate neck pain. There is a 5cm x 2cm area of reduced sensation over the lateral border of the thumb metacarpal. Pinch grip is 25% reduced, compared with the right. Grip strength is apparently normal. Injury: Whiplash injury to neck Loss of faculty: Disability: Other effective Cause: Reduced movement of neck and left shoulder: reduced power and sensation left hand 1. Vertebral column dysfunction F 2. Upper limb dysfunction P 3. Tendon injury to right hand O Post Serial No Gross Assessment Offset (percentage & condition Net assessment 1. 8% 8% 2. 5% 5% Serial No Additional Assessment 3. 2% 22

23 Decision on Assessment 15% 23

24 VIBRATION WHITE FINGER 1. Vibration is one of the many causes of Raynaud's Phenomenon. 2. Raynaud's Phenomenon is caused by intense vasospasm of the peripheral arteries on exposure to cold. The causes of Raynaud's Phenomenon include the following: (1) Primary Raynaud's Disease: Constitutional, or idiopathic white finger, the cause of which is unknown. It often affects other family members. (2) Secondary Raynaud's Phenomenon: The causes include connective tissue disorder, eg Scleroderma trauma to the extremities or to proximal blood vessels (eg thoracic outlet syndrome) occlusive vascular disease (eg thromboangiitis obliterans, arterial emboli) dysglobinaemias intoxication (eg ergot, nicotine, vinyl chloride) neurogenic (eg poliomyelitis) vibration (referred to as Vibration White Finger - VWF) 3. Raynaud's Phenomenon affects 5% of the population (NB some studies give figures as high as 20% of the population). It is more common in women than men (5:1). Most case are due to Primary Raynaud's Disease. 4. The onset of Raynaud s Disease and Raynaud s Phenomenon is usually gradual over a number of years, with attacks being rare and in winter only. Usually the fingers are affected, (but it can affect the toes and, more rarely, the nose, ears, cheeks and chin), beginning with tingling and/or numbness in the tips of the finger. Later in the progression of the disorder there is well demarcated blanching on exposure to intense cold, at first in the tips of the fingers, but over time this blanching progresses to affect more and more of the finger, and to occur throughout the year in that it can occur on colder summer days. 5. If the cause of the disorder is vibration the disorder will not progress if exposure to vibration ceases. With continued exposure to vibration the disorder may slowly worsen. 6. The colour changes are characteristic. The blanching is an intense whiteness with a well defined demarcation. The blanching may last a few minutes or last up to an hour or two. Sometimes immersion in warm water speeds up recovery. On recovery the fingers may become cyanotic (ie turn a greyish blue colour) or become hyperaemic (ie very red in colour). Blanching is not just a paleness, it is an intense whitening. In severe cases, with the passage of time, there may be trophic changes leading to gangrene of the tips of the fingers. 7. As the symptoms are intermittent, and only occur in cold conditions, it is rare for the clinician to witness an attack. Thus, in a specific case, it is important not only to try to have an accurate description of the symptoms, but also to establish an accurate diagnosis and that the cause is occupational in origin, and not due to another cause. 24

25 8. Particular care needs to be taken in cases where the claimant has left the employment to which they attribute causation. The consensus of opinion is that if symptoms develop more than a year or two after exposure to vibration has ceased, then the cause is not occupational in origin. (In rare cases, symptoms may occur if there are exceptional cold conditions after the cessation of exposure when this did not occur in the latter months of the employment during which vibration occurred). 9. There is no simple, reliable test for Raynaud s Phenomenon, and much of the diagnosis depends on the history and observations during the interview. Loss of sensation, which can be a feature of Raynaud s Phenomenon, such as can be identified by simple tests such as the response to pin-prick, cotton wool etc may not necessarily be disabling, and rely on the patient s responses, and are therefore not very reliable. On the other hand, observation of manual dexterity is relatively easy to test formally, and verify informally through observation during the interview, pre and post examination etc. 10. Because it is rare for the clinician to see the colour changes, and the tests which have been developed are not very reliable (having many false positives and false negative results) the diagnosis of the disorder and its cause are mainly derived from the history from the patient. In cases seeking compensation (eg in the civil courts or under the Industrial Injuries Scheme) it is particularly important to check the patient s history closely. The signs are easily learned, and there has been evidence of coaching to ensure the criteria for diagnosis and causation are fulfilled. Hand Arm Vibration Syndrome (HAVS). There is no universal description of HAVS. It includes elements of Raynaud s Phenomenon, but different authors attribute different entities to HAVS. For example some authors include Carpal Tunnel Syndrome as an element of HAVS, whereas others do not. In IISB carpal tunnel syndrome is a separate prescribed disease. HAVS is a much broader condition than Raynaud s Phenomenon. As with Raynaud s Phenomenon and VWF, HAVS may be diagnosed medically, but the symptoms may not be of a sufficient severity to fulfil the strict qualifying criteria required for the diagnosis of PD A11. Definition of PD A11 PD A11 is defined as: Episodic blanching throughout the year, affecting the middle or proximal phalanges, or in the case of the thumb the proximal phalanx, of : a). in the case of a person with 5 fingers (including thumb) on one hand, any 3 of those fingers, or 25

26 b). in the case of a person with 4 such fingers, any 2 of those fingers, or c). in the case of a person with less than 4 such fingers, any one of those fingers, or as the case may be, the one remaining finger Medical Adviser advice on PD A A medical diagnosis of VWF does not equate to a diagnosis of PD A11. Medically, VWF could be diagnosed when there are minimal neurological and/or vascular symptoms, which may not occur throughout the year. The diagnosis of PD A11 depends on the symptoms having reached a sufficient degree of severity as specified in the legislation. 2. The onset of neurological element of VWF usually pre-dates the onset of vascular problems, but as the diagnosis of PD A11 is restricted to the vascular element of Raynaud s phenomenon only, when advising on the diagnosis of PD A11, the development of vascular symptoms to the extent listed in the legislation should be used to suggest the date of onset of the prescribed disease. Once PD A11 is diagnosed, any disablement arising out of any peripheral neurological problems should be assessed. For clarity it is recommended that the Medical Adviser give advice on the vascular and neurological elements separately. 3. An O(pre) or O(post) relationship should also be considered for any other cause of upper limb dysfunction, such as Dupuytren s contracture, arthritis, peripheral neuropathy of different aetiology etc. Assessment of Disablement 1. Unless the condition is very severe the disablement in PD A11 is not continuous. In general the symptoms and signs occur episodically, and usually the condition affects both hands. Should only one hand be affected, then the resultant disablement will be less than if both hands are affected. 2. Only in very severe cases is the impairment to manual dexterity present all the time. For comparison, the amputation of the tips of all fingers of one hand causes a mild to moderate disablement in the order of 22 to 26%. However, unless there are trophic changes, there is no actual tissue loss and symptoms of PD A11 occur intermittently. These characteristics of the disease must be taken into account when assessing the disablement, and consequently the disablement rarely approaches that which amputations would attract. 3. The upper limb dysfunction identified as the disability will most commonly manifest itself as disordered or reduced manual dexterity. 4. Due to the nature of the condition, by the time the symptoms are sufficiently severe to diagnose the Prescribed Disease, disablement will be at least 1%. Minimal: Occasional episodic (ie less than half the days in a week) blanching affecting 26

27 the middle phalanges of the fingers in both winter and summer, but more frequently in very cold weather. Very mild: Regular episodic (ie occurring on most days in a week) blanching affecting the middle and proximal phalanges of the fingers in both winter and summer, but more frequently in cold weather. If trophic changes are present, then the resultant disablement will depend on the extent of those trophic changes, and an appropriate addition made. For example trophic changes to the tip of the middle finger could equate to the amputation of the tip without loss of bone. 27

28 Example 1: A claimant with occasional episodic (ie less than half the days in a week) blanching affecting the middle phalanges of the index, middle and ring fingers of both hands in both winter and summer, but more frequently in very cold weather could be assessed as follows: Disability: Upper limb dysfunction F Disablement: intermittent peripheral neuropathy 2%... vascular disturbance 2% Example 2: A claimant with occasional episodic (ie less than half the days in a week) blanching affecting the middle phalanges of the index, middle and ring fingers of both hands in both winter and summer, but more frequently in very cold weather who had a pre-existing, non-occupationally caused amputation of the little finger of the left hand, and who has angina, could be assessed as follows: Disability: Upper limb dysfunction P Other effective cause: Unconnected conditions: Amputation of the little finger O Pre Angina Disablement: of 5%. a gross disablement of 12%, offset 7% for the pre-existing condition, giving a net The difference in the assessment of the P relevant condition to that of the F relevant condition reflects the increased disablement due to the worsening effect by the interaction of the pre-existing condition with the relevant condition. 28