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A new approach to the objective evaluation of physical disability
J. chron. Dis. Vol. 15, pp 105-112. Pergamon Press Ltd. Printed in Great Britain
A NEW APPROACH TO THE OBJECTIVE EVALUATION OF PHYSICAL DISABILITY*: JACK SOKOLOW, M.D., JOHN E. SILSON, M.D., EUGENE J. TAYLOR, M.A., ANDERSON, M.A. and HOWARD A. RUSK, M.D.
EDWARD T.
New York University-Bellevue Medical Center (Received 25 June 1961)
MUCH has been said in the last decade of the outstanding
advances of medicine and surgery, and, as a direct result, of the prolongation of life. Persons with formerly fatal congenital deformities, disease, or injury, were saved. So also were those suffering from acute infections kept alive. Further, the fact that people lived longer meant more people were reaching the age group where the chronic degenerative and disabling conditions were prevalent. Concomitant with these developments was the enormous expansion of industry, spurred by the war and the development of new technological processes. The result of expanded and more complex industrial processes together with the advances in medicine has been a great rise in the number of chronically ill and disabled persons as well as a large addition to this number yearly. Thus, every physician and especially those in contact with industrial medicine, sooner or later must concern himself with disability evaluation. That proper evaluation represents a problem of major proportions is attested to by the fact that the Journal of the American Medical Association has recently begun to publish a series of guides to the determination of medical impairment [l]. Disability is differentiated from impairment by the fact that “disability” includes socio-economic factors in addition to the purely medical. Many types of schedule have been devised to permit evaluation of disability but these have all been based on anatomic loss alone, probably due to the difficulty Although the physician is not responsible for of measuring socio-economic factors. determinations in the socio-economic areas, he is often a member of a team where these considerations are raised. The rising tide of disability has to a great degree been responsible for legislation in the fields of vocational rehabilitation, social security, workmen’s compensation, etc. However, these attempts to handle the problem have only been partially successful because similar cases might be judged totally disabled in one state, partially in another, or not at all, from a vocational point of view, in a third. *Project supported by a grant from the Office of Vocational Rehabilitation, and Welfare, Washington, D.C. tThis article was read at the Pan American Medical Association
105
Department
of Health, Education
meeting in Mexico City in May 1960.
106
JACK SOKOLOW,
JOHNE. SIL.WN,EUGENEJ. TAYLOR,EDWARD T. ANDERSONand HOWARD A. RUSK
These inconsistencies made apparent the great need for a method of evaluation that could be standard and easily understood. It was also obvious that a medical evaluation alone could yield information only regarding the medical impairment. Since disability determination really means establishing a person’s ability to function in daily life, factors other than medical-such as social, vocational and psychological-which determine this function to a large extent, must be considered. The physician is of basic importance in this process, since he must determine physical function in areas of daily living as well as permissible activity. To assist the physician as well as agencies concerned, we have devised a method of evaluating disability from a functional, rather than anatomical, point of view, which considers the medical, social, psychological, and vocational factors. It is not meant to replace a history and physical examination and cannot give meaningful data unless the sum total of all the data is considered. This has previously been reported in the J.A.M.A. [2]. The form for recording is so arranged that the data can be transferred to I.B.M. cards for compactness, comparison of different patients for statistical analyses, selection of patients with similar impairments, and for determining patient progress by serial cards. In a pilot test on 124 patients, the forms were found to be consistent, reliable, and practical (when the examiner was familiar with the form). Certain revisions followed these tests [3] aimed at obtaining more information, better arrangement of material, correction of errors, and insertion of material previously omitted. A new trial has been carried out on about 1000 patients and the following statistics covering about 500 of these cases show the enormous possibilities inherent in the form. These statistics are based on 466 patients (a total of 644 forms, including 188 patients for whom we have admission and discharge forms). Ease of use of the form, validity as a method for gauging disability, and use as a source for statistical information were well demonstrated. Statistics obtained from this trial are appended. Table 1 shows age and sex of this patient group. It is easily seen that the 45-70 year age group is predominant by far. Table 2 shows the etiologies involved in the principal disabilities. Vascular, traumatic, and degenerative Neurological, musculo-skeletal, and cardioetiologies were by far the most numerous. vascular were the most frequent organ systems involved. Table 3 compares degree of ambulation for several types of impairment and is typical cross-tabulation. An interesting finding here that hemiplegia or hip fracture appears to limit ambulation much more severely than amputation. For valid and complete evaluation, however, further cross-tabulation by factors such as age, time since onset of disability, amount of rehabilitation received, and motivation should be made. Information was also obtained by comparing admission and discharge forms for 188 patients. Table 4 shows the change in degree of independence between admission and discharge. There was a great increase in the ambulatory group from 36 per cent to 54 per cent. Finally, a system for percentage evaluation has been worked out. This is still in tentative form and is under test at this time. This method operates as follows: There are five major factors which will be multiplied to give a total percentage. These are: medical, neuro-musculo-skeletal, special senses (and genito-urinary), psychiatric, and environmental adjustment. The total percentage number will be correlated with actual cases for resealing. Our number may run low but a logarithm conversion table can be set
A New Approach
to the Objective Evaluation
of Physical Disability
107
up to offset this. We will attempt to scale our numbers in terms of presently accepted scales, i.e., present idea of what a given per cent disability means. However, our number will have taken socio-economic, psychiatric, and vocational factors into account and has been considered from a functional point of view. The scales in all five major factors should be comparable and this will be worked out after testing so that a 50 per cent in the medical factor will mean approximately an equal degree of functional impairment as a 50 per cent in the neuro-musculo-skeletal factor. The tentative scales are appended and are presently being tested for validity and replicability. As can be seen, minute grading in fractions of a per cent,as used in current assessments of physical impairment,is avoided as meaningless in terms of the individual’s total disability. An attempt has been made to integrate all factors into a formula which considers their inter-relationships. For example, a complete quadriplegic with a normal heart is fully disabled, as is a IV-E cardiac with a normal musculo-skeletal system. Thus it makes no sense to assign a portion of the disability index to each of these factors. On the other hand, a patient with hemiparesis and heart disease, neither fully incapacitating in itself, might be totally disabled by the combination. Since the cardiac disability acts upon the residual neuro-musculo-skeletal function, multiplication of the factors rather than addition is being used in most instances. The relative importance of each factor can then be adjusted in the formula by weighting constants. However, in some cases addition or subtraction within a major factor is used. For example, in the medical factor the physical activity of a patient will depend largely on cardio-respiratory function. However, other organ systems do have an effect on this system and physical activity. Thus, impairment of other organ systems is subtracted from the rating given the cardio-respiratory system, depending on the degree of impairment. Certainly most physicians in industry are frequently confronted with the problem of evaluation of disability, and further, of a patient’s ability to function not only in daily life, but in a job as well. It is hoped that this method will prove valuable to physicians and agencies concerned with evaluation of disability and rehabilitation.
REFERENCES 1. Guides to the Evaluation of Permanent Impairment, J. Amer. med. Ass., 15 Feb. 1958 (special issue); 27 Sept. 1958, (special article); 5 March 1960 (special article). 2. SOKOLOW,J., SILSON,J.E., TAYLOR,E. J., ANDERSON,E. T. and RUSK, H.A.: Functional Approach to Disability Evaluation, J. Amer. med. Ass. 167, 1575, 1958. 3. SOKOLOW,J., SILSON,J. E., TAYLOR,E. J., ANDERSON,E. T. and RUSK, H.A.: A Method for the Functional Evaluation of Disability, Arch. Phys. Med. R&b. 40,421, 1959.
108
JACK SOKOLOW,JOHNE. SILSON,EUGENEJ. TAYLOR,EDWARDT. ANDERSONand HOWARDA. RUSK TABLE1.
SEX Female
Male
-4s o-4
5-9 l&14 15-19 20-24 25-29 30-34 35-39 4@44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
No.
o/oof males
1
0.4
12 13 16 19 15 25 23 26 27 21 29 13 10 4
5.0 5-1 6.3 7.5 5.9 9.8 9.1 10.1 10.5 8.3 11.4 5-l 3.9 1.6
Total males Total females Total
No.
Total
% of females
No.
0.5 3.8 3.3 3.8 5.7 2.4 7.0 10-8 10.8 12.7 15.6 9.9 6.1 3.8 3.3 0.5
i 7 8 12 5 15 23 23 27 33 21 13 8 7 1 254 212
‘A males ‘A females
466
%
1
0.2
1 20 20 24 31 20 40 46 49 54 54 50 26 18 11 1
0.2 4.3 4.3 5.2 6.7 4.3 8.6 9.9 10.5 11.5 11.5 10.7 5.6 3.9 2.4 0.2
54.5 45.5 100.0
TABLE2.
Etiologies of principal disabilities
No.
o/0of patients
Vascular Traumatic Degenerative Infection Non-specific inflammation Metabolic and endocrine Congenital Malignant tumor Benign tumor Toxic Allergic Not specified
186 152 97 30 26 23 15 19 13 3 1 2
39.9 22.6 20.8 6.4 5.6 4.9 3.2 4.1 2.8 0.6 0.2 0.4
Total etiologies
567
Total patients
466
% of total
A New Approach
to the Objective Evaluation
TABLE3.
of Physical Disability
109
LEVELAMBULATION BY DISABILITY
Total
Partial
Complete
None
Type of disability
No.
%
No.
%
No.
%
No.
%
Hemiplegia Paraplegia Quadriplegia Other paralysis Amputations Hip fractures All other fractures, osteomyelitis and shortening of leg All other disabilities
167 78 48 19 47 22
35.8 16.7 10.3 4.1 10.1 4.7
33 9 5 6 23 5
28.4 7.8 4.3 5.2 19.8 4.3
64 24 5 4 13 7
43.0 16-l 3-4 2.6 8.7 4.7
70 45 38 9 11 10
35.0 22.5 19.0 4.5 5.5 5-O
18 67
3.9 14.4
5 30
4.3 25.9
8 24
5.4
5
16-l
12
2.5 6.0
Total
466
116
24.9
149
32-O
200
42.9
100.0
% of
%of
total number
%of
total number
total number
One other disability had no ADL test.
TABLE 4. Admission Degree of independence
No.
Bedridden Wheelchair with assistance Wheelchair independent Ambulatory Total ____~___ -.__.
16 76 27 69 188
METHOD
% 8.5 40.4 14.4 36.7 100.0
No.
%
9 41 34 103 187
4.8 21.8 18-l 54.8 99.5
(l-expired)
FOR THE QUANTITATIVE FUNCTIONAL EVALUATION OF DISABILITY
The main areas that interact upon each vocational. These are broken down to: (1) (2) (3) (4) (5)
Discharge
other
are medical,
social,
psychiatric,
and
Medical. Neuro-musculo-skeletal. Special senses and genito-urinary. Psychiatric. Environmental adjustment--consisting of activities of daily living, social situation, and vocational situation. These three groups depend almost wholly on patient’s ability to function within a given setting. Thus they are synthesized in the group titled “environmental adjustment” indicating the patient’s relation to his own environment. For each of these areas scales as shown below have been developed and these scales must be comparable from group to group since they will be multiplied. Thus a 5 in the medical group should mean approximately the same degree of impairment as a 5 in the neuromusculo-skeletal or special sense group.
110
JACK SOKOLOW,JOHNE. SILSON,EUGENEJ. TAYLOR,EDWARD T. ANDERSONand HOWARD A. RUSK
The five factors are multiplied, giving a number which, in this trial run, will be correlated with actual cases for resealing. Our number may run low-this can be corrected with the use of a logarithm conversion table. We plan to scale our numbers in terms of presently accepted scales but with a functional, rather than organic, definition.
(1) Medical (a) Cardio-pulmonary-No
limitation 10. Mild impairment of function 7. Moderate impairment of function 4. Severe impairment of function 0.
Subtract one point for mild impairment of other organ systems. Subtract two points for moderate impairment of other organ systems. Subtract three points for severe impairment of other organ systems. It is because the physical activity depends almost wholly on the integrity of the cardiopulmonary system that it is given a decisive part in the scale. On the other hand, other organ system impairments may act on the cardio-pulmonary but they rarely are in themselves disabling. Therefore, a maximum of three points to be subtracted from the cardiopulmonary figure is allowed for each organ system in the medical group.
(2) Neuro-musculo-skeletal (a) Muscle test-Good and normal 1. Fair l/2. Below fair 0. (b)
Range qf motion-Full
1. Partial l/2. None 0.
The value of the muscle test is added to the range of motion test value giving a range of O-2 for each extremity and the trunk. Thus we have a total value ranging from 0 to 10. Any half-digits may be dropped from the total. Since the environmental adjustment and neuro-musculo-skeletal groups interact, the social, A.D.L., and vocational groups will reflect in the total number and thus neuromusculo-skeletal impairments may be validly expressed, from a functional point of view, in terms of muscle and range of motion tests.
(3) Special senses and genito-urinary (a) Vision-Normal vision 5. Mild impairment with best correction 4. Moderate impairment with best correction 3. Severe impairment with best correction 2. Legally blind with best correction I. Complete blindness 0.
A New Approach to the Objective Evaluation of Physical Disability
(b)
Hearing-Normal hearing 5. Mild impairment 4. Moderate impairment 3. Severe impairment 2. Complete deafness 1.
(c)
Speech-Normal speech 10. Mild defect 9. Moderate defect 8. Severe defect 7. Global aphasia 0.
(d)
Genito-urinur~-Complete control, no pathology 10. Complete control, with pathology 9. Partial control 7. No control 5.
111
These scales have different values because a complete impairment in one of these areas does not usually cause total disability. Thus persons with total blindness are often quite independent and thus a maximum of five is assigned. This applies to hearing as well. For speech, the range must be 0 to 10 since global aphasia is completely disabling. On the other hand, for the genito-urinary system, complete incontinence is not necessarily totally disabling. Thus the range is 5 to 10. These factors are combined as follows: (Vision+hearing) x Speech x G.U. (4) Psychiatric and psychological-Normal 5. Slight psychoneurosis 4. Moderate psychoneurosis Severe psychoneurosis.2 Slight psychosis 3. Moderate psychosis 2. Severe psychosis 0. Inability to learn 2.
3.
Add 5 for good motivation. Add 3 for fair motivation. Add 0 for poor motivation. Slight psychoneurosis or psychosis is defined as a case where function is slightly impaired, e.g., a case under treatment with medication and/or psychotherapy, who can function. The same defkitions are applied to moderate and severe cases but with moderate and severe impairment of function, respectively. A patient who has inability to learn is generally quite difficult to rehabilitate or retrain and is frequently quite impaired. Thus the low value is assigned. On the other hand, motivation is so important that up to 50 per cent in this category has been assigned to it.
112
(5)
JACK SOKOLOW,JOHNE.SUSON,EUGENEJ.TAYLOR,EDWARDT.ANDERSON~~~ HOWARDA.RUSK
Adjustment (a)
to environment
Social-Homeless or institutional dwelling ... Lives with family (or adequately alone)
.. . ...
2 3 2 or 3
(b)
Vocation&-Continue in present occupation Can do other occupation without Retrainable ... ... .. . Limited retraining potential No retraining potential ...
... training . .. . .. ...
. .. . .. . .. ...
4 3 2 1 0 o-4
(c)
Activities
of daily living-Self-care Transfer Ambulation Travel
None 0 0 0 0
Partial
Complete 1 1 1 1
l/2 l/2 l/2 l/2 o-4
If digit is not whole (i.e. 69 the half may be dropped in the final calculation. Thus the total range of “adjustment to environment” is 2-10. Finally, the factors are multiplied-Medical x Neuro-musculo-skeletal x Special Senses (and Genito-Urinary x Psychiatric x Adjustment to Environment= % Disability. The total percentage figure is to be compared in each tested case with the disability evaluation of experienced examiners in an attempt to determine whether this system is workable (whether or not constants or a conversion table are necessary). In any case, we can then define this total figure in terms of total function. Seventy per cent disability can then mean that consideration of physical, psychiatric, social, and vocational factors leads to the conclusion that the patient is severely disabled functionally rather than that he has a 70 per cent disability due to a severe organic impairment, for example.
A NEW APPROACH TO THE OBJECTIVE EVALUATION OF PHYSICAL DISABILITY*: JACK SOKOLOW, M.D., JOHN E. SILSON, M.D., EUGENE J. TAYLOR, M.A., ANDERSON, M.A. and HOWARD A. RUSK, M.D.
EDWARD T.
New York University-Bellevue Medical Center (Received 25 June 1961)
MUCH has been said in the last decade of the outstanding
advances of medicine and surgery, and, as a direct result, of the prolongation of life. Persons with formerly fatal congenital deformities, disease, or injury, were saved. So also were those suffering from acute infections kept alive. Further, the fact that people lived longer meant more people were reaching the age group where the chronic degenerative and disabling conditions were prevalent. Concomitant with these developments was the enormous expansion of industry, spurred by the war and the development of new technological processes. The result of expanded and more complex industrial processes together with the advances in medicine has been a great rise in the number of chronically ill and disabled persons as well as a large addition to this number yearly. Thus, every physician and especially those in contact with industrial medicine, sooner or later must concern himself with disability evaluation. That proper evaluation represents a problem of major proportions is attested to by the fact that the Journal of the American Medical Association has recently begun to publish a series of guides to the determination of medical impairment [l]. Disability is differentiated from impairment by the fact that “disability” includes socio-economic factors in addition to the purely medical. Many types of schedule have been devised to permit evaluation of disability but these have all been based on anatomic loss alone, probably due to the difficulty Although the physician is not responsible for of measuring socio-economic factors. determinations in the socio-economic areas, he is often a member of a team where these considerations are raised. The rising tide of disability has to a great degree been responsible for legislation in the fields of vocational rehabilitation, social security, workmen’s compensation, etc. However, these attempts to handle the problem have only been partially successful because similar cases might be judged totally disabled in one state, partially in another, or not at all, from a vocational point of view, in a third. *Project supported by a grant from the Office of Vocational Rehabilitation, and Welfare, Washington, D.C. tThis article was read at the Pan American Medical Association
105
Department
of Health, Education
meeting in Mexico City in May 1960.
106
JACK SOKOLOW,
JOHNE. SIL.WN,EUGENEJ. TAYLOR,EDWARD T. ANDERSONand HOWARD A. RUSK
These inconsistencies made apparent the great need for a method of evaluation that could be standard and easily understood. It was also obvious that a medical evaluation alone could yield information only regarding the medical impairment. Since disability determination really means establishing a person’s ability to function in daily life, factors other than medical-such as social, vocational and psychological-which determine this function to a large extent, must be considered. The physician is of basic importance in this process, since he must determine physical function in areas of daily living as well as permissible activity. To assist the physician as well as agencies concerned, we have devised a method of evaluating disability from a functional, rather than anatomical, point of view, which considers the medical, social, psychological, and vocational factors. It is not meant to replace a history and physical examination and cannot give meaningful data unless the sum total of all the data is considered. This has previously been reported in the J.A.M.A. [2]. The form for recording is so arranged that the data can be transferred to I.B.M. cards for compactness, comparison of different patients for statistical analyses, selection of patients with similar impairments, and for determining patient progress by serial cards. In a pilot test on 124 patients, the forms were found to be consistent, reliable, and practical (when the examiner was familiar with the form). Certain revisions followed these tests [3] aimed at obtaining more information, better arrangement of material, correction of errors, and insertion of material previously omitted. A new trial has been carried out on about 1000 patients and the following statistics covering about 500 of these cases show the enormous possibilities inherent in the form. These statistics are based on 466 patients (a total of 644 forms, including 188 patients for whom we have admission and discharge forms). Ease of use of the form, validity as a method for gauging disability, and use as a source for statistical information were well demonstrated. Statistics obtained from this trial are appended. Table 1 shows age and sex of this patient group. It is easily seen that the 45-70 year age group is predominant by far. Table 2 shows the etiologies involved in the principal disabilities. Vascular, traumatic, and degenerative Neurological, musculo-skeletal, and cardioetiologies were by far the most numerous. vascular were the most frequent organ systems involved. Table 3 compares degree of ambulation for several types of impairment and is typical cross-tabulation. An interesting finding here that hemiplegia or hip fracture appears to limit ambulation much more severely than amputation. For valid and complete evaluation, however, further cross-tabulation by factors such as age, time since onset of disability, amount of rehabilitation received, and motivation should be made. Information was also obtained by comparing admission and discharge forms for 188 patients. Table 4 shows the change in degree of independence between admission and discharge. There was a great increase in the ambulatory group from 36 per cent to 54 per cent. Finally, a system for percentage evaluation has been worked out. This is still in tentative form and is under test at this time. This method operates as follows: There are five major factors which will be multiplied to give a total percentage. These are: medical, neuro-musculo-skeletal, special senses (and genito-urinary), psychiatric, and environmental adjustment. The total percentage number will be correlated with actual cases for resealing. Our number may run low but a logarithm conversion table can be set
A New Approach
to the Objective Evaluation
of Physical Disability
107
up to offset this. We will attempt to scale our numbers in terms of presently accepted scales, i.e., present idea of what a given per cent disability means. However, our number will have taken socio-economic, psychiatric, and vocational factors into account and has been considered from a functional point of view. The scales in all five major factors should be comparable and this will be worked out after testing so that a 50 per cent in the medical factor will mean approximately an equal degree of functional impairment as a 50 per cent in the neuro-musculo-skeletal factor. The tentative scales are appended and are presently being tested for validity and replicability. As can be seen, minute grading in fractions of a per cent,as used in current assessments of physical impairment,is avoided as meaningless in terms of the individual’s total disability. An attempt has been made to integrate all factors into a formula which considers their inter-relationships. For example, a complete quadriplegic with a normal heart is fully disabled, as is a IV-E cardiac with a normal musculo-skeletal system. Thus it makes no sense to assign a portion of the disability index to each of these factors. On the other hand, a patient with hemiparesis and heart disease, neither fully incapacitating in itself, might be totally disabled by the combination. Since the cardiac disability acts upon the residual neuro-musculo-skeletal function, multiplication of the factors rather than addition is being used in most instances. The relative importance of each factor can then be adjusted in the formula by weighting constants. However, in some cases addition or subtraction within a major factor is used. For example, in the medical factor the physical activity of a patient will depend largely on cardio-respiratory function. However, other organ systems do have an effect on this system and physical activity. Thus, impairment of other organ systems is subtracted from the rating given the cardio-respiratory system, depending on the degree of impairment. Certainly most physicians in industry are frequently confronted with the problem of evaluation of disability, and further, of a patient’s ability to function not only in daily life, but in a job as well. It is hoped that this method will prove valuable to physicians and agencies concerned with evaluation of disability and rehabilitation.
REFERENCES 1. Guides to the Evaluation of Permanent Impairment, J. Amer. med. Ass., 15 Feb. 1958 (special issue); 27 Sept. 1958, (special article); 5 March 1960 (special article). 2. SOKOLOW,J., SILSON,J.E., TAYLOR,E. J., ANDERSON,E. T. and RUSK, H.A.: Functional Approach to Disability Evaluation, J. Amer. med. Ass. 167, 1575, 1958. 3. SOKOLOW,J., SILSON,J. E., TAYLOR,E. J., ANDERSON,E. T. and RUSK, H.A.: A Method for the Functional Evaluation of Disability, Arch. Phys. Med. R&b. 40,421, 1959.
108
JACK SOKOLOW,JOHNE. SILSON,EUGENEJ. TAYLOR,EDWARDT. ANDERSONand HOWARDA. RUSK TABLE1.
SEX Female
Male
-4s o-4
5-9 l&14 15-19 20-24 25-29 30-34 35-39 4@44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
No.
o/oof males
1
0.4
12 13 16 19 15 25 23 26 27 21 29 13 10 4
5.0 5-1 6.3 7.5 5.9 9.8 9.1 10.1 10.5 8.3 11.4 5-l 3.9 1.6
Total males Total females Total
No.
Total
% of females
No.
0.5 3.8 3.3 3.8 5.7 2.4 7.0 10-8 10.8 12.7 15.6 9.9 6.1 3.8 3.3 0.5
i 7 8 12 5 15 23 23 27 33 21 13 8 7 1 254 212
‘A males ‘A females
466
%
1
0.2
1 20 20 24 31 20 40 46 49 54 54 50 26 18 11 1
0.2 4.3 4.3 5.2 6.7 4.3 8.6 9.9 10.5 11.5 11.5 10.7 5.6 3.9 2.4 0.2
54.5 45.5 100.0
TABLE2.
Etiologies of principal disabilities
No.
o/0of patients
Vascular Traumatic Degenerative Infection Non-specific inflammation Metabolic and endocrine Congenital Malignant tumor Benign tumor Toxic Allergic Not specified
186 152 97 30 26 23 15 19 13 3 1 2
39.9 22.6 20.8 6.4 5.6 4.9 3.2 4.1 2.8 0.6 0.2 0.4
Total etiologies
567
Total patients
466
% of total
A New Approach
to the Objective Evaluation
TABLE3.
of Physical Disability
109
LEVELAMBULATION BY DISABILITY
Total
Partial
Complete
None
Type of disability
No.
%
No.
%
No.
%
No.
%
Hemiplegia Paraplegia Quadriplegia Other paralysis Amputations Hip fractures All other fractures, osteomyelitis and shortening of leg All other disabilities
167 78 48 19 47 22
35.8 16.7 10.3 4.1 10.1 4.7
33 9 5 6 23 5
28.4 7.8 4.3 5.2 19.8 4.3
64 24 5 4 13 7
43.0 16-l 3-4 2.6 8.7 4.7
70 45 38 9 11 10
35.0 22.5 19.0 4.5 5.5 5-O
18 67
3.9 14.4
5 30
4.3 25.9
8 24
5.4
5
16-l
12
2.5 6.0
Total
466
116
24.9
149
32-O
200
42.9
100.0
% of
%of
total number
%of
total number
total number
One other disability had no ADL test.
TABLE 4. Admission Degree of independence
No.
Bedridden Wheelchair with assistance Wheelchair independent Ambulatory Total ____~___ -.__.
16 76 27 69 188
METHOD
% 8.5 40.4 14.4 36.7 100.0
No.
%
9 41 34 103 187
4.8 21.8 18-l 54.8 99.5
(l-expired)
FOR THE QUANTITATIVE FUNCTIONAL EVALUATION OF DISABILITY
The main areas that interact upon each vocational. These are broken down to: (1) (2) (3) (4) (5)
Discharge
other
are medical,
social,
psychiatric,
and
Medical. Neuro-musculo-skeletal. Special senses and genito-urinary. Psychiatric. Environmental adjustment--consisting of activities of daily living, social situation, and vocational situation. These three groups depend almost wholly on patient’s ability to function within a given setting. Thus they are synthesized in the group titled “environmental adjustment” indicating the patient’s relation to his own environment. For each of these areas scales as shown below have been developed and these scales must be comparable from group to group since they will be multiplied. Thus a 5 in the medical group should mean approximately the same degree of impairment as a 5 in the neuromusculo-skeletal or special sense group.
110
JACK SOKOLOW,JOHNE. SILSON,EUGENEJ. TAYLOR,EDWARD T. ANDERSONand HOWARD A. RUSK
The five factors are multiplied, giving a number which, in this trial run, will be correlated with actual cases for resealing. Our number may run low-this can be corrected with the use of a logarithm conversion table. We plan to scale our numbers in terms of presently accepted scales but with a functional, rather than organic, definition.
(1) Medical (a) Cardio-pulmonary-No
limitation 10. Mild impairment of function 7. Moderate impairment of function 4. Severe impairment of function 0.
Subtract one point for mild impairment of other organ systems. Subtract two points for moderate impairment of other organ systems. Subtract three points for severe impairment of other organ systems. It is because the physical activity depends almost wholly on the integrity of the cardiopulmonary system that it is given a decisive part in the scale. On the other hand, other organ system impairments may act on the cardio-pulmonary but they rarely are in themselves disabling. Therefore, a maximum of three points to be subtracted from the cardiopulmonary figure is allowed for each organ system in the medical group.
(2) Neuro-musculo-skeletal (a) Muscle test-Good and normal 1. Fair l/2. Below fair 0. (b)
Range qf motion-Full
1. Partial l/2. None 0.
The value of the muscle test is added to the range of motion test value giving a range of O-2 for each extremity and the trunk. Thus we have a total value ranging from 0 to 10. Any half-digits may be dropped from the total. Since the environmental adjustment and neuro-musculo-skeletal groups interact, the social, A.D.L., and vocational groups will reflect in the total number and thus neuromusculo-skeletal impairments may be validly expressed, from a functional point of view, in terms of muscle and range of motion tests.
(3) Special senses and genito-urinary (a) Vision-Normal vision 5. Mild impairment with best correction 4. Moderate impairment with best correction 3. Severe impairment with best correction 2. Legally blind with best correction I. Complete blindness 0.
A New Approach to the Objective Evaluation of Physical Disability
(b)
Hearing-Normal hearing 5. Mild impairment 4. Moderate impairment 3. Severe impairment 2. Complete deafness 1.
(c)
Speech-Normal speech 10. Mild defect 9. Moderate defect 8. Severe defect 7. Global aphasia 0.
(d)
Genito-urinur~-Complete control, no pathology 10. Complete control, with pathology 9. Partial control 7. No control 5.
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These scales have different values because a complete impairment in one of these areas does not usually cause total disability. Thus persons with total blindness are often quite independent and thus a maximum of five is assigned. This applies to hearing as well. For speech, the range must be 0 to 10 since global aphasia is completely disabling. On the other hand, for the genito-urinary system, complete incontinence is not necessarily totally disabling. Thus the range is 5 to 10. These factors are combined as follows: (Vision+hearing) x Speech x G.U. (4) Psychiatric and psychological-Normal 5. Slight psychoneurosis 4. Moderate psychoneurosis Severe psychoneurosis.2 Slight psychosis 3. Moderate psychosis 2. Severe psychosis 0. Inability to learn 2.
3.
Add 5 for good motivation. Add 3 for fair motivation. Add 0 for poor motivation. Slight psychoneurosis or psychosis is defined as a case where function is slightly impaired, e.g., a case under treatment with medication and/or psychotherapy, who can function. The same defkitions are applied to moderate and severe cases but with moderate and severe impairment of function, respectively. A patient who has inability to learn is generally quite difficult to rehabilitate or retrain and is frequently quite impaired. Thus the low value is assigned. On the other hand, motivation is so important that up to 50 per cent in this category has been assigned to it.
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(5)
JACK SOKOLOW,JOHNE.SUSON,EUGENEJ.TAYLOR,EDWARDT.ANDERSON~~~ HOWARDA.RUSK
Adjustment (a)
to environment
Social-Homeless or institutional dwelling ... Lives with family (or adequately alone)
.. . ...
2 3 2 or 3
(b)
Vocation&-Continue in present occupation Can do other occupation without Retrainable ... ... .. . Limited retraining potential No retraining potential ...
... training . .. . .. ...
. .. . .. . .. ...
4 3 2 1 0 o-4
(c)
Activities
of daily living-Self-care Transfer Ambulation Travel
None 0 0 0 0
Partial
Complete 1 1 1 1
l/2 l/2 l/2 l/2 o-4
If digit is not whole (i.e. 69 the half may be dropped in the final calculation. Thus the total range of “adjustment to environment” is 2-10. Finally, the factors are multiplied-Medical x Neuro-musculo-skeletal x Special Senses (and Genito-Urinary x Psychiatric x Adjustment to Environment= % Disability. The total percentage figure is to be compared in each tested case with the disability evaluation of experienced examiners in an attempt to determine whether this system is workable (whether or not constants or a conversion table are necessary). In any case, we can then define this total figure in terms of total function. Seventy per cent disability can then mean that consideration of physical, psychiatric, social, and vocational factors leads to the conclusion that the patient is severely disabled functionally rather than that he has a 70 per cent disability due to a severe organic impairment, for example.