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Disability

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  1. Determine whether a specific decline in functioning (e.g., social, physical, emotional) is a disability for that specific patient.

  2. Screen elderly patients for disability risks (e.g., falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.

  3. In patients with chronic physical problems (e.g., arthritis, multiple sclerosis) or mental problems (e.g., depression), assess for and diagnose disability when it is present.

  4. In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).

  5. For disabled patients, offer a multi-faceted approach (e.g., orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.

  6. In patients at risk for disability (e.g., those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (e.g., exercises, braces, counselling, work modification).

  7. Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is only part of the plan).

See Elderly.

  • Impairment: Structural or functional abnormality/loss - eg. disease (eg. spinal cord injury)

  • Disability: Activity limitation for individual - eg. job (eg. unable to walk)

    • Limitation: Can do but not at usual force, pace, duration

    • Restriction: Cannot or should not do (risk to self/others)

  • Handicap: Social disadvantage - fulfill "normal" role (eg. being a father)

Screening for Disability Risks

  • Falls

  • Immobilization

  • Vision impairment

  • Hearing impairment

  • Cognitive impairment

  • Poor nutrition, weight loss

  • Polypharmacy

  • Medical comorbidity (arthritis, diabetes, heart disease, obesity)

  • Psychiatric comorbidity

  • Psychosocial stressors

Assessment of disabled patient

  • History

    • Occupational history

    • Pre-injury function

    • Job demands

    • Insurance plan

    • Medication, substance

    • Psychosocial factors (stress, dissatisfaction, relationship)

  • Physical exam

    • Functional assessment of affected region

  • Diagnostic tests

  • Referrals (Physiotherapy, occupational therapy, psychologist, specialist consultant)

  • ADL/IADLs

  • Ability to do work-related activities

    • Physical (stand, carry, lift, handle)

      • Sensory (hearing, vision)

    • Psychiatric (judgment, stress)

    • May use a validated questionnaire (eg. SF-36, pain questionnaire)

  • Risk assessment

    • Does this injury pose a risk to patient or others at workplace

  • Formal and informal supports, Family support

  • Financial

Treatment of Disability

  • Education on diagnosis, treatment, and prognosis

    • Emphasize that pain is part of healing process, return to work should not be delayed until pain resolved

  • Recommendations and duration

    • Capabilities, limitations, restrictions (functional and anatomical, eg. cannot lift right arm above shoulder height, cannot drive until impairing medications not required)

      • AVOID getting involved in career planning

        • "S̶h̶o̶u̶l̶d̶ ̶n̶o̶t̶ ̶w̶o̶r̶k̶ ̶w̶i̶t̶h̶ ̶b̶o̶s̶s̶" → "Conflict with boss is factor in present illness"

        • "D̶i̶f̶f̶e̶r̶e̶n̶t̶ ̶j̶o̶b̶ ̶w̶o̶u̶l̶d̶ ̶b̶e̶ ̶b̶e̶t̶t̶e̶r̶" → "Need for rehab"

    • Limited time off work, modified work, part-time work (schedule modifications, eg. reduced hours)

      • Plan return-to-work at first visit

    • Early mobilisation, physical activity

      • Physiotherapy, occupational therapy

      • Orthotics, walking aid

    • Specialist, rehabilitative

    • Psychological services if

      • Minimal functional gains by 8-12w post-injury

      • Somatic symptoms with few objective findings

      • Poor adherence to prescribed treatment

      • Excessive use of medication

      • Psychological indicator (mood, anxiety, anger, substance use)

      • Social indicator (conflict in workplace, life stresses, history of prolonged disability)

  • Community support

  • Treatment of medical/psychiatric comorbidities

  • Reviewing medication (polypharmacy)

Prevention of Disability

  • Increasing physical activity

  • Improved diet and nutrition

  • Immunization

Falls

  • 1/3 of people over 65yo have a fall per year

DDx

  • Visual impairment

  • Peripheral neuropathy

  • CVA

  • TIA

  • Joint instability

  • Deconditioning

  • Medication

  • Environmental or home hazards

  • Orthostatic hypotension

Assessment

  • Falls in past year

  • Problems with gait or balance

    • Surrounding circumstances

    • Associated symptoms

    • Medications

    • Acute/chronic medical problems

    • Mobility level and cognitive and functional level

  • Physical examination

    • Gait

    • Sensory (hearing and vision)

    • Orthostatic vital signs

    • Neurological and musculoskeletal assessment

    • Depression and cognitive impairment screen

    • Review footwear and gait aids

Prevention

  • Screen/treat osteoporosis

  • Vitamin D 1000 units per day

  • Individualized exercise program (strength, gait, balance)

  • Gait aids

  • Home safety assessment (lighting, fix floors, anti-slip shoe devices, hip protectors)

  • Medication review / Deprescribing medications

  • Cardiac pacing where indicated

 

References:

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