Mental health articles

Appropriate Documentation of Limitations in Objective Impairment/Functioning

Physicians are typically expected to provide employers guidance on every workers’compensation patient as to the employee’s work abilities and restrictions. Unfortunately,almost no medical school and very few medical residency programs teach how todetermine appropriate work restrictions and limitations, so it is not surprising thatphysicians have very different assessments of patients’ work ability (Rainville, Pransky,Indahl, & Mayer, 2005).

Most “return to work” forms physicians are asked to fill out do not define the terms“restrictions” and “limitations.” Many of these forms do not differentiate betweenthese two concepts or the concept of “tolerance.” These terms have been defined(Talmage, 2007; Talmage & Melhorn, 2005).

Risk refers to what the individual clearly can do, but should not do, because ofsignificant risk to self or others. Significant risk is the basis for physician-imposedwork restrictions. Most work status certification forms contain a line on whichphysicians are to enter work restrictions based on risk. If there is no significant riskof substantial harm, physicians logically would leave this line on work ability formsblank. However, many physicians do not understand work ability terminology andthus they inappropriately enter comments about tolerance on this line.

Capacity is a misnomer. Actually, “current ability” is usually what is intended.The current ability can increase up to capacity with exercise or training, or decreasewith inactivity (“use it or lose it”). Most work status certification forms contain a lineon which physicians may enter work limitations based on capacity issues. Currentability can usually be measured to some degree. For example, if a strenuous jobrequires the ability to do sustained work at four METs with frequent exertion to apeak workload of eight METs, and if a prospective employee can only exert to sixMETs on treadmill testing, the employee does not have the current capacity to do that job. Similarly, if a job requires working with hands overhead, and if a prospectiveemployee has a stiff shoulder, the individual lacks the current capacity for that job.Tolerance is the basis for an individual patient’s or worker’s decision to do or notto do a specific task, like work, based on the rewards available for doing the task(like wages) and the cost of doing the task (symptoms like pain, numbness, etc).Tolerance is unique to every individual. Tolerance is not scientifically measurable.Tolerance is not predictable by objective findings. Some patients with severe objectivepathology express symptoms, but remain fully functional while others withminimal apparent pathology refuse to function due to symptoms that seem to be outof proportion to the objective findings. Many individuals are not willing to toleratemild pain from an easy job for a low rate of pay, but are willing to tolerate muchmore pain from a physically demanding job for a high rate of pay. This dramatizesthat tolerance is not a scientific concept that physicians can measure or determine.Most work status certification forms for physicians from employers and insurershave no line on which physicians can comment on tolerance issues. One reason forthis is that tolerance is a subjective issue for a patient decision, but is not an issuefor physician-imposed restrictions or physician-described capacity limitations.When two patients have seemingly similar pathology, and yet very different selfreportedability to tolerate symptoms and work, psychosocial factors probably explainthe discrepancy, since again the pathology is the same.

Physicians can assess pathology, and based on scientific studies or known consequencesmake statements about risk and capacity. The only way to attempt to measuretolerance is by Functional Capacity Evaluation (FCE) conducted usually by a trainedphysical therapist or occupational therapist. This testing shows what a patient is willingto do on the day tested. FCEs have not been shown to correlate with the risk of reinjuryif the patient is reemployed (Gouttebarge, Wind, Kuijer, & Frings-Dresen, 2004; Gross &Battié, 2005, 2006). Thus, they yield some information about whether the patient islikely to return to work (tolerance), but not whether the return to work is safe.

In summary, physician statements on return to work forms should be recognizedas “educated guesses” unless the physician can clearly articulate a logical significantrisk of substantial harm or an objectively measured deficit (loss of range of motion,loss of a body part, reduced exercise capacity due to coronary artery disease, etc.).

Tags: functioning, impairment