Disability is a significant public health and social issue in the United States. The number of Americans who experience disability, activity limitations secondary to chronic illnesses, or impairments has increased, whereas mortality has decreased. A U.S. Census Bureau report found in 2010 that of a total population of 303.9 million, approximately 56.7 million (18.7%) individuals reported some degree of mental or physical disability. Although this represents an increase from the 54.4 million who reported a disability in 2005, the percentage remained statistically unchanged. In the 2010 report, 38.3 million people—or 12.6% of U.S. residents—were classified as severely disabled. Given these findings, disability ranks as the largest public health problem in the United States.
The growing numbers of Americans with disabilities present new medical, social, and political challenges. The major activity limitations found in those with disabilities include an inability to manage personal care, the inability to work and be financially self-supporting, and the inability to integrate socially and enjoy leisure. These limitations have medical, behavioral, social, and economic implications. To help those with disabilities restore functional capacity, prevent further deterioration in functioning, and maintain or improve their quality of life, programs of any type should emphasize rehabilitation and prevention of secondary conditions. These programs must respect disability as multifaceted and foster an interdisciplinary approach to treatment.
Within the medical arena, the specialty of physical medicine and rehabilitation has been concerned with the establishment of physiologic, psychological, and social equilibrium for people with disabilities. According to Rusk, “a rehabilitation program is designed to take a disabled person from his bed back to his job, fitting him for the best life possible commensurate with his disability and more importantly with his ability.” To help all people with disabilities achieve their maximum level of independence, avert further deterioration in functioning, and maintain or improve their quality of life, the physiatrist and the medical rehabilitation team must appreciate the multifaceted character of disability. The physiatrist and the medical rehabilitation team must accept the responsibility to initiate appropriate referrals to other collaborating programs that can support these goals beyond the medical arena. One such program is vocational rehabilitation.
This chapter describes the employment of people with disabilities. Specifically, we
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Discuss the concept of disability
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Review national data on disability and employment
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Consider the economic impact of disability
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Review policies supporting employment of people with disabilities
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Discuss economic assistance strategies
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Discuss vocational rehabilitation strategies
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Enumerate the incentives and disincentives for returning to work
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Postulate that vocational rehabilitation serves as a rehabilitation treatment and disability prevention strategy for people with disabilities
Concept of Disability
Disability itself is not always quantifiable. In the Americans with Disabilities Act (ADA) of 1990, an individual with a disability is defined as a person who has a physical or mental impairment that substantially limits one or more major life activities. The concept of disability differs among people who consider themselves to have a disability, professionals who study disability, and the general public. This lack of agreement is an obstacle to all studies of disability, as well as to the equitable and effective administration of programs and policies intended for people with disabilities.
The World Health Organization (WHO) has a mandate to develop a global common health language, one that is understood to include physical, mental, and social well-being. The International Classification of Impairments, Disabilities, and Handicaps (ICIDH-2) was developed by the WHO as a tool for classification of the “consequences of disease.” The ICIDH-2 reflects the biopsychosocial model of disablement, viewing disablement and functioning as outcomes of an interaction between a person’s physical or mental condition and the social and physical environment. Human functioning is characterized at three levels: the body or body part, the whole person, and the whole person in social context. Disablements are the dimensions of dysfunctioning that result for an individual at these three levels; these include impairment, losses or abnormalities of bodily function and structure, limitations of activities, and restrictions of participation.
This biopsychosocial model regards functioning and disablement as outcomes of interactions between health conditions (disorders or diseases) and conceptual factors such as social and physical environmental factors and personal factors. The interactions in this paradigm are dynamic, complex, and bidirectional ( Figure 6-1 ).
Dimensions of dysfunctioning are defined as follows:
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Impairment is the loss or abnormality of body structure or of a physiologic or psychological function.
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Activity is the nature and extent of functioning at the level of the person.
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Participation is the nature and extent of a person’s involvement in life situations in relation to impairment, activities, health conditions, and contextual factors, and can be restricted in nature, duration, and quality.
The 2001 World Health Assembly subsequently endorsed a revised system, the International Classification of Functioning, Disability, and Health (ICF). This is a classification of health and health-related domains, which are classified from body, individual, and societal perspectives with a list of body functions and structure, as well as a list of domains of activity and participation. The ICF also includes a list of environmental factors to provide context for the disability. The ICF provides a common transcultural language across health care systems and is intended to allow comparison of international data and the measurement of health outcomes, quality, and cost, as well as health disparities.
Data: Impairment and Disability
The U.S. Census Bureau provides extensive information on the number and characteristics of people with disabilities. Data from the Americans with Disabilities Report of 2010 indicate that 56.7 million people, or 18.7% of the U.S. population, have some level of disability. Among those 6 years or older, 12.3 million individuals or 4.4% needed assistance with one or more activities of daily living without an assistive device. This represents an increase in both the number and percentage that needed assistance in 2005.
Impairments resulting from chronic disease have become increasingly significant risk factors of disability. Table 6-1 lists the 15 conditions with the highest prevalence of functional compromise or disability. The prevalence of disability with these conditions appears to be attributable to the prevalence of the condition itself and the chance that the condition will cause a disability. Table 6-2 shows the ranking of people, by percentage of specific conditions, who have functional limitations secondary to that condition. In general, many of the conditions that are significant risk factors for disability are low in prevalence. For example, multiple sclerosis has a low overall prevalence but is a significant risk factor for disability. Examination of this ranking shows 7 of the top 10 disabling conditions are conditions frequently managed by the physiatrist and the rehabilitation team. These conditions or diseases are typically chronic, requiring a lifetime of rehabilitative management to have an effect on the disabling process, prevent secondary conditions, and maintain quality of life.
| Percentage | |
|---|---|
| Main Cause | |
| Orthopedic impairments | 16.0 |
| Arthritis | 12.3 |
| Heart disease | 22.5 |
| Visual impairments | 4.4 |
| Intervertebral disk disorders | 4.4 |
| Asthma | 4.3 |
| Nervous disorders | 4.0 |
| Mental disorders | 3.9 |
| Hypertension | 3.8 |
| Mental retardation | 2.9 |
| Diabetes | 2.7 |
| Hearing impairments | 2.5 |
| Emphysema | 2.0 |
| Cerebrovascular disease | 1.9 |
| Osteomyelitis or bone disorders | 1.1 |
| All Causes | |
| Orthopedic impairments | 21.5 |
| Arthritis | 18.8 |
| Heart disease | 17.1 |
| Hypertension | 10.8 |
| Visual impairments | 8.9 |
| Diabetes | 6.5 |
| Mental disorders | 5.6 |
| Asthma | 5.5 |
| Intervertebral disk disorders | 5.2 |
| Nervous disorders | 4.9 |
| Hearing impairments | 4.3 |
| Mental retardation | 3.2 |
| Emphysema | 3.1 |
| Cerebrovascular disease | 2.9 |
| Abdominal hernia | 1.8 |
| Chronic Condition | Number of Conditions (in 1000s) | Causes Activity Limitation (%) | Rank | Causes Major Activity Limitation (%) | Rank | Causes Need for Help in Basic Life Activities (%) | Rank |
|---|---|---|---|---|---|---|---|
| Mental retardation | 1202 | 84.1 | 1 | 80.0 | 1 | 19.91 * | 9 |
| Absence of leg(s) * | 289 | 83.3 | 2 | 73.1 | 2 | 39.0 * | 2 |
| Lung or bronchial cancer | 200 | 74.8 | 3 | 63.5 | 3 | 34.5 * | 4 |
| Multiple sclerosis * | 171 | 70.6 | 4 | 63.3 | 4 | 40.7 * | 1 |
| Cerebral palsy * | 274 | 69.7 | 5 | 62.2 | 5 | 22.8 * | 8 |
| Blind in both eyes | 396 | 64.5 | 6 | 58.8 | 6 | 38.1 * | 3 |
| Partial paralysis in extremity * | 578 | 59.6 | 7 | 47.2 | 7 | 27.5 * | 5 |
| Other orthopedic impairments * | 316 | 58.7 | 8 | 42.6 | 8 | 14.3 † | 12 |
| Complete paralysis in extremity * | 617 | 52.7 | 9 | 45.5 | 9 | 26.1 * | 6 |
| Rheumatoid arthritis * | 1223 | 51.0 | 10 | 39.4 | 12 | 14.9 * | 11 |
| Intervertebral disk disorders * | 3987 | 48.7 | 11 | 38.2 | 14 | 5.3 * | — |
| Paralysis in other sites (complete or partial) * | 247 | 47.8 | 12 | 43.7 | 10 | 14.1 † | 13 |
| Other heart disease disorders ‡ | 4708 | 46.9 | 13 | 35.1 | 15 | 13.6 * | 14 |
| Cancer of digestive tract | 228 | 45.3 | 14 | 40.3 | 11 | 15.9 † | 15 |
| Emphysema | 2074 | 43.6 | 15 | 29.8 | — | 9.6 * | 15 |
| Absence of arm(s) or hand(s) * | 84 | 43.1 | — | 39.0 | 13 | 4.1 * | — |
| Cerebrovascular disease * | 2599 | 38.2 | — | 33.3 | — | 22.9 * | 7 |
* Conditions frequently managed by physiatrists.
† Figure has low statistical reliability or precision (relative standard error >39%).
‡ Heart failure (9.8%), valve disorders (15.3%), congenital disorders (15.0%), other ill-defined heart conditions (59.9%).
Socioeconomic Effect of Disability
Disablement has significant socioeconomic consequences for the individual with disabilities and for society. When a person is unable to participate in her or his social role as a worker or homemaker because of a physical or mental condition, that person is said to have a work disability or a work participation restriction. Work participation restriction results in dependency and loss of productivity for that person. Society, in turn, incurs direct and indirect costs.
Direct expenditures include those for medical and personal care, architectural modification, assistive technology, and institutional care, as well as income support for the person with a disability. For the individual, these expenses contribute to impoverishment. Society’s response to the expenditures related to disablement includes disability-related programs such as Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medicaid. In 2008, federal and federal-state programs for working-aged people with disabilities were estimated to cost $357 billion, or 12% of all federal spending of the United States.
Disablement is costly to the individual and to society because of the loss of productivity. People with disabilities are more likely to be unemployed or underemployed and have lower average salaries than their peers without disabilities ( Table 6-3 ). The indirect monetary costs for the individual are reckoned in terms of losses in earnings and homemaker services. A 2006 study by researchers at the University of California, with 1997 as an example year, found that people with disabilities were estimated to spend an average of 4.5 times as much on medical expenses and that the overall net salary loss associated with disability was $115.3 billion, or 1.4% of the 1997 gross domestic product.
| Employment Rate of People 21 to 64 Years Old (%) | Median Monthly Earnings 21 to 64 Years Old ($) | Median Monthly Family Income 21 to 64 Years Old ($) | |
|---|---|---|---|
| No disability | 79.1 | 2724 | 4771 |
| Any disability | 41.1 | — | — |
| Nonsevere disability | 71.2 | 2402 | 3959 |
| Severe disability | 27.5 | 1577 | 2376 |
Disablement is associated with poverty. In 2011, 23% of people with disabilities, aged 5 years and older were below the poverty level as opposed to only 15% of those without a disability. In 2010, people 21 to 64 years of age without a disability had median monthly earnings of $2724. Those with a nonsevere disability had $2402 median monthly earnings, and those with a severe disability had $1577 median monthly earnings ( Table 6-3 ). The indirect monetary cost to society is loss from the labor force. For example, in 1996, spinal cord injury alone was estimated to have cost the U.S. economy $9.73 billion, including $2.6 billion in lost productivity.
Disablement imposes indirect nonmonetary costs to the individual and to society. Fifty-seven percent of people with disabilities thought their disability prevented them from reaching their full potential. Restriction in work participation, in particular, places the individual in a position of dependency on insurance payments or government benefits for income support and medical care. Dependency affects people’s feelings about themselves and their overall satisfaction with life.
Pressure from various customers, and especially the third-party payers, for accountability in medical care focuses attention on outcome and cost-effectiveness. Interventions directed at disablement should be assessed with measures of both outcome and cost-effectiveness. Disablement is more than a medical phenomenon: It is a complex socioeconomic process. Assessment of the outcome and cost-effectiveness of an intervention should take into consideration the quality of life and indirect monetary costs, as well as direct expenditures.
Vocational rehabilitation is an intervention that can limit restrictions in work participation. In 1993, the Social Security Administration estimated that for every dollar spent on vocational rehabilitation services, five dollars in future direct expenditures was saved. A 2006 analysis of spending by the New Mexico Division of Vocational Rehabilitation found a total benefit/cost ratio of 5.63. Although employment is the expected outcome of vocational rehabilitation, the impact of this intervention goes beyond simple employment and saving of direct expenditures. The positive effects of working are demonstrated when the characteristics of working and nonworking people with disabilities are compared. Those who work are better educated, have more money, are less likely to consider themselves disabled, and in general are more satisfied with life.
Comprehensive rehabilitation of people with disabilities should include strategies that reduce work restrictions, such as vocational rehabilitation. The outcomes include increased independence and increased productivity. The cost-effectiveness of comprehensive rehabilitation should be measured in direct and indirect monetary and nonmonetary costs over the lifetime of the individual.
Treatment of the Injured Worker
Workers’ Compensation Medicine
Physiatrists are often the providers of choice for treatment of injured workers, being both well-grounded in musculoskeletal medicine and, generally, conservative in the use of resources, with a preference for nonoperative treatment. Different nations and states vary widely in the rights and responsibilities of both employers and employees after a work-related injury. Obviously knowing the regulations in your practice area is essential. However, the best way to view what can become an adversarial process, particularly when health care is not otherwise provided by the state, is as follows: keep in mind that you are foremost a health care provider and should be devoid of any other interests. If any condition or activity requires any particular treatment, it should be provided. If any particular restrictions or limitations are warranted they should be clearly expressed. However, using your common sense is encouraged. Claims of severe pain following minor events, accompanied by normal diagnostic tests, deserve some scrutiny, particularly if test results, such as the Waddell test , are positive and normal movement about the examination room occurs without difficulty. Many jobs are not that enjoyable and also do not pay particularly well. Not returning to such jobs may not be an altogether unpleasant scenario. In fact, it is well known that the less pleasant the relationship with one’s supervisor was before an injury, the longer a return to work will take. In addition, the longer the worker is out, the less likely is an eventual return to work. With this in mind, instituting brief restrictions to sedentary (0 to 10 lb lifting maximum, occasionally) or light duty work (20 lb maximum, occasionally), but not taking the worker off work, should be done if possible. For individuals who have been out of work for some time, returning part-time for a few weeks initially can be reassuring and allow a gradual reacclimatization to the workplace. Overall, the goal of worker’s compensation medicine is to provide medically necessary care for the injured worker, as well as to work with the patient and his or her employer to facilitate a safe return to work. In most cases, standard medical examination is sufficient but aggressive evaluation and treatment may be required to prevent prolonged and excessive disability. The Functional Capacity Evaluation, Work Hardening Programs, and Functional Restoration Programs are tools that may be indicated in problematic cases.
Functional Capacity Evaluation
A Functional Capacity Evaluation (FCE) is a series of performance-based tests that evaluates an individual’s ability to perform work activities related to his or her participation in employment and a specific job. Capabilities tested can include perception, range of motion, strength, endurance, coordination, ability to lift, assume certain postures, and ability to tolerate standing walking and climbing. Various measures attempt to detect submaximal effort and objectively assess an employee’s ability to meet the demands of a work environment. The tests gauge physical demands and the cognitive demands of the job, and for complicated patients, the tests are used to predict an individual’s return to work.
There is generally no mandate to perform an FCE, and sometimes they are not readily available. The tests are generally not necessary for sedentary workers because there is by definition no lower level of activity. Many workers with only moderately demanding jobs are well aware of their present abilities from simply performing the activities of routine life(i.e., lifting bags of potatoes of set weights). The tests will prove invaluable only when a worker is returning to moderately or heavily strenuous work and the worker is truly uncertain of whether he or she can perform the required activities of their occupation.
Work Hardening Program
Work Hardening is a multidisciplinary “work-oriented treatment program” that consists of work tolerance screening and work capacity evaluation components. It features physical conditioning with job simulation activities combined with psychological treatment to address mild-to-moderate cognitive and behavioral factors accompanying the subacute pain/disability. Patients with complex pain syndromes or psychological comorbidities may benefit from an interdisciplinary pain program. Types of psychological issues commonly addressed include anger at employer, fear of return to work, fear of injury, and interpersonal problems with co-workers. The impact intense physical conditioning for subacute back pain has on the duration of work absence remains unclear owing to conflicting study results.
Functional Restoration Program
Functional Restoration Programs were first described in 1985 by Dr. Tom Mayer and his colleagues at the University of Texas Health Science Center and Productive Rehabilitation Institute of Dallas for Ergonomics (PRIDE) for the treatment of patients with chronic lower back pain. The goal of a Functional Restoration Program is to restore the patient’s physical, psychosocial, and socioeconomic situation. It is a physician-driven interdisciplinary program requiring, but not limited to, the participation of physical/occupational therapists, social workers, and psychologists. These programs emphasize the importance of function over the elimination of pain, with the key concepts being pain acceptance, pain management, and the creation of active coping strategies. Patients are required to participate in intensive exercise sessions where no passive modalities are included. The sessions are then associated with cognitive-behavioral therapy and may be followed by ergonomic therapy sessions.
In a 2007 systematic review by Poiraudeau et al., the authors found that despite the favorable claims of various Functional Restoration Program studies reporting of a 65% to 90% return-to-work rate, many of the studies lacked or had inadequate control groups. In spite of the lack of adequate control groups, the reviewers found that Functional Restoration Programs when coupled with Work Hardening Programs were associated with a double increase in their return-to-work rate. These findings are echoed in a more recent 2013 Cochrane review, which found that the number of sick leave was reduced in workers undergoing Work Hardening activities incorporated into their Functional Restoration Programs. Currently, further studies with proper control groups are needed to accurately indicate if Functional Restoration Programs successfully increase and maintain the vocational outcomes of patients.
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