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Whereas in psychiatry and psychology the process by which the historical data, excluding purely clerial intake data, e.g., patient identifier information, is collected is an intimate component of the psychiatric examination, collection of such information b any person other than doctoral level trained psychiatrist or psychologist is not accepable. The doctoral level trained psychiatrist or psychologist who authors the report must collect the historical information via the interview process. The use of other clinicians or non-clinicians cannot substitute for the evaluating clinician, and such reports are deficient. Furthermore, the use of other than the examiner to review the records and edit/write reprots is unacceptable. Not uncommonly, the psychiatric examiner reviews personnel files, military records, educational documents and other administrative reports that must not be delegated to the purview of others. Similarly, the nuances of psychiatric diagnosis and formulation of dunamic issues related to the crucial question of returning the employee to the work force must not come from other than a licensed doctoral level practitioner.
The psychiatrist or psychologist who examines an applicant for Worker's Compensation on the basis of alleged psychiatric injury must conduct a careful interview of the applicant addressing elements of the outline for the evaluation report. To complete the interview almost always will require at least one to three hours of direct contact with the applicant by the examiner. In the case of applicants who have significant wxpressive/receptive English language deficits, interpreters may be used by the examiner. However, it is preferable that such applicants bay evaluated by examiners who can speak and also administer psychologial tests in the primary language. The use of interpreters may lead to distortion of the facts and misinterpretation of the data.
Where, the psychologist is in the role of a consultant in the medical-legal assessment process, the duplication of certain efforts between the psychologist and the psychiatrist should not typically occur unless warranted by specific circumstances. It should not be necessary for the consultant to duplicate efforts at reviewing records and obtaining historical information in most cases. It may be necessary in the most comples cases where psychologist assessment is required that certain records and some portion of the history will need to be addressd by the consulting psychologist. A consulting psychologist is allowed to take a history if it is necessary. However, this is not a typical situation and in the routine case a thorough assessment by one clinician of the records and the obtaining of historical information should suffice. An explanation must br given when duplictive services are provided.
The examiner should conduct such interviews as may be appropriate and possible and should review the psychologist assessment findings, the medical and employment and other documents or records [FN1] of the applicant, and other referral documents. When all this information is assembled, it should be documented in the report with a detailed description of the cognitive, effective, and behavioral signs/symptons of the applicant, as well as the psychological assessment scores and interpretations.
It should be noted that the following outlines are more suggestive than prescriptive. The content of reports will vary with the referral questions, the nature of the applicant's presenting problems, and, to some extent, the practice of individual clinicians. The suggested headings are not required, but a systematic, quasistandardized report including all the relevant facts is likely t be most usefull to judges.
[FN1] Employment and other documents or records, if reviewed, should be made available to applicant or his or her counsel at the same time.
A. EVALUATION REPORT FOR PSYCHIATRY DISABILITY
(To be used by psychiatrist and psychologist examiners.)
1. Identifying information
a. Date, place, and duration of examination
b. Reason for referral and referral questions
c. Names and fucntions of others taking part in the examination, including use of interpreter
d. Applicant (patient/client)
1. Date of birth
2. Date of alleged industrial injury
3. Date of last worked
e. Sources of facts (Include collaterals, if interviewed)
2. Description of applicant interview
a. Appearance (Do not omit obvious physical aberrations)
b. Demeanor, general behavior
c. Apparent effective state, based on observation
d. Stream of speech
e. Interaction with interviewer
3. Descriptions of applicant's current complaints
a. Subjective complaints
b. Applicant's view of the impairment created by the complaints
4. History of present illness
a. Applianct's description of industrial stressors, onset of complaints, and alleged injuries or illness asocaited with onset
b. Psychological response to alleged injury situation
c. History of mental health problems since alleged injury
d. History of treatment since alleged injury
e. Current treatment and medication, including medication taken one day of interview
5. Occupational history (Distingiush baseline, injury concurrent, and postinjury events)
a. Educational level and professional, technical, or vocational training
b. Sequential description of occupations pursed (including military service)
1. Training and skills required
2. Supervisory responsibilities
3. Career mobilty (upward, downward, lateral)
c. Difficulties and/ or accmplishments in each occupational setting
6. Past mental health history and relevant medical history
7. Family history
a. Family of origin
1. Parent's age, education, occupational history
2. Sibling's age, education, occupationl history
3. Composition of family during applicant's childhood and youth
4. Mental health history and relevant history or family members
5. Family response to illness
6. Relevant social history of family members
7. Quality of family relations
b. Family or procreation
1. Present marital status
2. Spouse's age, education, occupational history
3. Number of offspring (Obtain same data for abult offspring as for spouse)
4. Mental health history and relevant medical history of family members
5. Relevant social history of family members
6. Quality of family relations
c. History of previous marriages
8. Development history
9. Social history (Distinguish baseline, injury, concurrent, and postinjury findings)
a. Interpersonal relationships
b. Previous life changes (external stresses and losses) and response to these
c. Educational history
d. Legal history, when applicable (Include previous workers' compensation and personal injury claims, with the circumstances and outcome)
e. Criminal history which is relevant to diagnosis and/or disability
f. Substance use and abuse
g. Applicant's description of a typical day
10. Mental Status Examination (Include relevant negative findings)
a. Level of consciousness
b. Mood, e.g.:
(1). Depression
(2). Liability
(3). Elation
(4). Anxiety
(5). Inappropriateness
c. Cognition/thinking
(1). Orientation
(2). Estimation of intelligence
(3). Memory dysfunction
a. Recall/short-term memory
b. Remote memory
(4). Perceptual and communication disorders (agnosias and aphasias)
(5). Thought content
(6). Thought disorder, e.g.:
a. Ideas of reference
b. Looseness of associations
c. Delusions
d. Perceptual disorders, including hallucinations
e. Intrusive thought/obsessive thinking
(7). Evidence of deficit in
a. Learning
b. Problem solving
c. Judgment
(8). Insight (Include applicant's perception of relationship between injury and psychological condition.)
d. Behavior
1. Motor : Retardation or hyperactivity
2. Appropriateness in interview
e. Evidence of physiologic disturbance
1. Skeletal muscle system
2. Autonomic
3. Somatoform or conversion symptom
11. Findings from psychological assessment (Attach complete psychological report)
12. Review of medical record
13. Interviews with collateral sources and Review of Employment or Personnel records (Compare descriptin of industrial stressor with applicant's account)
14. Diagnosis using DSM-IV terminology and criteria
15. Summary and conclusions (Provide source for all information cited as evidence.)
a. Brief summary of relevant history and findings
b. If any disability, present and justify an opinion concerning the current cause(s), whether or not they are related to the work place. Consider:
(1). The relationship f work exposure to disability
(2). Nonindustrial clauses of disability, including pre-existing causal factors
(3). Aggravating or accelerating factors (industrial and non-industrial)
(4). Natural progression of pre-existing disorder
(5). Active or passive contribution of the workplace to the disability. (See Twentieth Century Fox Film Corporation v. W.C.A.B. and Kevin Conway (1983) C.A. 3rd 778, 190 CA: Rptr 560, 48 C.C.C. 275 and also Georgia Pacific Corporation v. W.C.A.B. and Robert H. Byrne (1983) 144 C.A. 3rd 72, 192 Rptr. 643, 48 C.C.C. 443.)
(6). Applicant's subjetive reaction to stress at work, if relevant. (See Albertson's Inc. v. W.C.A.B (Bradley) (1928) 131 Cal.App.3d 308, 182 Cal. Prtr. 304, 47 C.C.C. 460.)
Indicate whether actual events of employment were predominant as to all causes combined of the pyschiatric injury (see Laboe Code Section 3208.3(b)(1) or, if applicable, whether they were a substantial cause (see Labor Code Section 3208.3(b)(2)(3)).
c. Indicate diagnostic entities which were work-disabling prior to the alleged industrial injury and provide evidence.
d. State whether the disability is temporary or has reached a permanent and stationary status and cite evidence. If the condition is permanent and stationary, state on what date it became so and cite evidence. Consider the natural history of the disorder, the response to treatment. If the condition is not yet permanent and stationary, state when you expect it will be so. If you think further reasonable medical treatment will improve the condition, describe the treatment and its expected benefits.
e. If the disability is permanent and stationary, present an opinion regarding the nature and severity of the disability. Describe the disabling symptoms (subjective and objective factors in disability) according to Chapter II. Cpmplete to Work Function Impairment Form (Exhibit "A") citing symptoms, mental status finding, psychological test data, and history as supporting data. (Descriptions of work functions in Exhibit "B") If there is a non-psychiatric disability, a specialist in the area affected.
f. Make an advisory apportionment of disability. In order to do this, describe the disability that would exist at this time in the absence of the work place injury. Cite the evidence on which the estimated preinjury level is based. Use a separate Work Function Impairment Form. (Exhibit "A")
g. Indicate recommended treatment and/or rehabilitation, if any. State whether the employee, the effects of whose injury, whether or not combined with the effects of a prior injury, whether or disability , if any. is permenently precluded or likely to be precluded from engaging in this or her usual and customary occupation or the postion in which he or she was engaged at the time of injury.
h. Respond to all referral question and/or to questions and issues raised in referral reports.
B. PSYCHOLOGICAL ASSESSMENT REPORT FOR PSYCHIATRIC DISABILITY AND GUIDELINES OF
PSYCHOLOGICAL TESTING
(To accompany an Evaluation Report for Psychiatric Disability)
1. Identifying information
a. Applicant's name, age, birthdate, phone number, and social security number
b. Date of alleged injury or exposure
c. Date last worked
d. Description of alleged injury or exposure
2. Referral information
a. Date of referral
b. Referral source: name and role in evaluation/litigation process
c. Nature or referral and referral questions
3. Behavioral observation and personal characteristics
a. Description of physical appearance, mode or dress
b. Speech, hearing, vision, R/L handedness
c. Other apparent physical cognitive or emotional impairments, including history of unconsciousness, high or protracted fever, seizure acitivity
d. Literacy, educational level, and whether English is first language
e. Ethnic origin, marital status, occupation, socioeconomic status
f. Self-presentation of applicant by relevant observations, test scores, and history (Comment on such qualities as motivation, candor, spontaneity, reliability, consistency of performance, tendency to exaggerate or malinger, and presentation of self in an overly positive light.)
4. Clinical interview (Cf. Chapter I, Subchapter A, the Evaluation Report for Psychiatric Disability, sections 2-9, pages 4-6) Since this Psychological Assessment Report accompanies an Evaluation Report for Psychiatric Disability, a brief review or relevant history is sufficient.
5. Revords avilable/reviewed. Including job descriptions and performance evaluations.
(Identify as to before or after alleged injury/exposure.)
6. Prior psychological assessment (from records). List, including:
a. Date
b. Test (Inculed from used.)
c. Scores and interpretion
7. Guidelines for psychological testing
Psychological testing is an additional source of information which can be combined with other elements such as reocrds review and clinical interview to arrive at opinions concerning diagnosis, symptom exaggeration and disability. Psychological testing includes self-administered inventories such as the MMPI which can be used to evaluate the clinical presentation of the patient. Psychological testing also includes the projective tests such as the Rorschach Test. Psychological testing also includes neuropsyhological tests which are used to identify and measure strenghts and weaknesses in case of suepected organic brain disorder. If psychological testing is included as part of the evalutation, these guidelines are to be followed:
a. Routime Screening Battery
Time: 2 to 5 hours
Purpose: This category of psychological testing encompasses a routine Workers' Compensation case. This tesing may be done in conjunction with the Initial Comprehensive Evaluation. The purpose of this testing is to evaluate potentially disabling psychological factors. This psychological testing will look at self-reported symptoms such as depression and anxeity. This type of testing may also explore such issues as personality and possible exaggeration of symptoms.
Types of Tests Used: This category of testing utilizes primarily self-administered questionnaires such as the MMPI and MCMI. Other standard test measures which are appropriate and necessary may be utilized.
Persons Authorized to do the Psychological Testing: Psychiatrist, psychologist and registered psychological assistants with doctorate. within their respective areas of competence with respect to attained education, training, supervision and experience, are the individuals who will interpret psychological tests. Psychaitrists and psychologist are responsible for the production of psychological reports.
b. Complex Psychological Testing
Time: 6 to 10 hours
Purpose: Here the referring evaluator who is conducting the Intial Comprehensive Examination requests more extensive psychological testing. Complex psychological testing gives an in depth view of the patient. Routine testing relying upon self administered inventories may be insufficient in cases where elaboration; reading, language and intellectual barriers; or confusional state exist. This level of testing can be used to explore more thouroughly issues of personality, cognition, and malingering and/or exaggeration.
Types of Tests Used: Here the psychological testing is more extensive. Projective tests such as the Rorchach Test may be used. More extensive personality tesing may be utilizied. The Wechsler Adult Intelligent Scale may be utilized. Other standard test that are necessary and appropriate outside of these measures should be used.
Persons Authorized to do the Psychological Testing: Complex psychological testing utilizes a psychologist or a registered psychologist. When a registered psychological assistant is utilized in the administration or scoring of some of the tests, this id done under the direct supervision of a licensed psychologist. The licensed psychologist is responsible for interpretation of complex testing and the production of the psychological testing report.
How to Request Cpmplex Psychological Testing: Complex psychological testing is done at the discretion of the evaluator doing the Initial Comprehensive Evaluation. In the body of the Initial Comprehensive Report the evaluator must document that complex psychological testing which goes beyond te usual routine screening battery is indicated. The justification for the more thorough battery must be detailed by the disability evaluator in his/her report.
c. Neuropsychological Testing
Time: 8 to 15 hours
Purpose and Criteria Warranting Testing: There are instances where the neuropsychological approach to assessment is indicated to help determine the role an orfanic mental disorder plays in disability. This is not a routine type of evaluation in Workers' Compensation cases and, when used, must be justified by the report. Typically there is a specific head injury, toxic exposure or some other situation that raises the issue of organic brain syndrome. Here the patient often registers impairments on the mental status examination and there is a history consistent with serious congnitive dysfunction.
A condition such as depression, anxiety, and chronic pain may cause a complaint of congitive difficulties but this type of situation would not necessarily warrant neuropsychological testing. The mere report from the patient that there is difficulty with recent menory in and of itself cannot justify extensive neuropsychological testing.
Types of Tests Used: This category of testing utilizes a number of cognitive tests in the form of an organic testing battery. Test such as the Luria Nebraska or the Halstead Reitan may be utilized by not always required in a neuropsychological testing evaluation. The neuropsychological test battery may incluede other standard measures such as the MMPI beyond those used exclusively for assessing cognition.
Persons Authorized to do th Psychological Testing: This type of evaluation is done by a clinical psychologist with experience in evaluation organic mental disorders. A registered psychological assistant with doctorate may participate in the test administration and data interpretation.
8. Evaluation procedures. Refers to Chapter I, subchapter A, section 11, "Ranges for Psychological testing". List instruments when used in the following order. Indicate date and total administrative time. (This is a reporting format and does not necessarily imply that procedures be administered in this order.)
a. Objective tests measuring general cognition
b. Neuropsychological tests if indicated
c. Objective (standardized and normed) tests relating to personality and emotional state
d. Self-report inventories relating to emotional state
e. Projective devices
f. Interview
9. Results and discussion
a. Describe assessment findings, providing test scores and documentation sufficient to permit other psychological examiners to review issues raised and opinions rendered. (Indiacte if computer scored/interpreted and give score.) Relate test findings to observations and relevant history, with emphasis on the vocational sphere.
b. Relate all assessment findings to DSM-III diagnosis on Axis I, Axis II and, when appropriate, Axis III. (Note: It is inappropriate for a psychologist of offer independent Axis III diagnosis.)
c. Current findings and inferecnes relative to work injury and job-related impairments. (The psychologist should follow "XV. Summary and Conclusions" in the Evaluation Report for Psychiatric Disability, but should include the additional information below.)
(1). Distinguish between transient/situational conditions and enduring/ permanent condition.
(2). Where appropriate describe and document with test findings and range and severity of psychological impairment with respect to ability to work in the same job or to compete on the open job market.
(3). Describe and document with test findings what types of intervention are required to return applicant to the same job or to rehabilitate applicant for other emplyoment with amounts of time involved.
Chapter II
CLINICAL EVALAUTION OF PERMENENT PSYCHISTRIC DISABILITY
In evaluating an applicant with an alleged psychiatric disability, the examiner should first decide: (1) whether or not there is any emotional or mental condition which handicaps the applicant in competing on the open job market, (2) whether or not this disability is to any degree work-related, and (3) whether or not the disability is permanent and stationary, that is, whether or not the applicant can receive further benefit from treatment at this time. If it is the examiner's opinion that there is psychiatric disability which is to some degree work-related and that maximum beneift from treatment has ben reached, then the applicant may be evaluated for permanent psychiatric disability. (California Casualty Ins. Co. v. W.C.A.B. (Jackson) (1985) 50 C.C.C. 262, 264; 167 Ca. App. 470, 476, 213 Cal. Rptr. 420) The examiner will proceed to evaluate the extent and nature of the disability and to describe the prognosis according to the guidelines presented in this section. The examiner will indicate whether or not actual events of employment were responsible for at least 10% of the total causation from all sources contributing to the psychiatric injury.
The guidelines ask the examiner (1) to diagnose the applicant to DSM-III [FN2] to evaluate the applicant's ability to perform specific work funcions, and (3) to provide information concerning the applicant's prognosis. To assist the examiner and the court, schedules for summarizing relevant information are provided. The values in these schedules are not substitutes for the discussion described in the Summary and Conclusions, Chapter I, A., 16. They are vallues to be used in documenting or supporting the conclusions.
A. Evaluation of the Nature and Severity of Impairment
This subchapter provides the examiner an outline with which to describe the nature and severity of the applicant's mental or emotional impairment. This subchapter provides for Axis I and Axis II diagnoses, and also an Axis III diagnoses were occupationally disabling prior to the alleged injury and support the opinion.
This subchapter also provides that the examiner list all symptoms related to the Axis I diagnosis or diagnoses and to state whether they are constant, intermittent, or occasional. Next the examiner is asked to evaluate the level of impairment in the applicant's ability to perform eight work functions. The Work Functions Impairment Form (Exhibit "A") provides a convenient way to summarize this information. The eight work functions are listed in Exhibit "B" hereto. The evaluation is performed as if there were no question of apportionment, even when apportionment is suggested by the examiner's assessment of the etiology.
[FN2] The use of Diagnostic and Statistical Manual of the Mental Disorders 3rd Edition (DSM-III) includes referral to all subsequent revisions and/or editions as they become available and appropriate to the evaluation.
1. DSM-III diagnosis
a. Axis I
b. Axis II
c. Axis III
2. List all diasbling symptoms and state whether each is constant, intermittent, or occasional. ("Intermittent" means present half time; "occasional", less than half the time.)
3. Using the levels defined in a.(1)-a(5) below, describe the extent to which disabling symptoms lead to impairment on the eight work funcions shown in b. below.
a. Level of impairment:
(1). Minimal (discomfort, but not disabling)
(2). Very slight (detectable impairment)
(3). Slight (noticeable impairment)
(4). Moderate (marked impairment)
(5). Severe (unable to perform work function)
b. Work function: Document those symptoms which impair each of the following work functions and the levels of impairment on the Work Function Impairment Form on page. (See Exhibit "B" for descriptions of the work funcions.):
(1). Ability to comprehend and follow instructions
(2). Ability to perform simple and repetitive tasks
(3). Ability to maintain a work pace appropriate to a given workload
(4). Ability to perform complex or varied tasks
(5). Ability to relate to other people beyond giving and receiving instructions
(6). Ability to influence people
(7). Ability to make generalizations, evaluations or decision without immediate supervision
(8). Ability to accept and carry out responsibility for direction, control, and planning
Information on severity of symptoms in referenced in 2 above will assist the Court to determine the level of severity of impairment of work function (factors of disability).
WORK FUNCTION IMPAIRMENT FORM
WORK FUNCTION LEVEL SUPPORTING
OF DATA
IMPAIRMENT (Cite
Findings)
-------------------------------------------------------------------------------
1. Ability to comprehend and follow
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2. Ability to perform simple and repetitive tasks
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3. Ability to maintain a work pace appropriate to a
given work load
-------------------------------------------------------------------------------
4. Ability to perform complex or varied tasks
-------------------------------------------------------------------------------
5. Ability to relate to other people beyond giving
and receiving instructions
-------------------------------------------------------------------------------
6. Ability to influence people
-------------------------------------------------------------------------------
7. Ability to make generalizations, evaluations or
decisions without immediate supervision
-------------------------------------------------------------------------------
8. Ability to accept and carry out responsibility for
direction, control and planning
-------------------------------------------------------------------------------
Note:
When completing this form consideration is given to Descriptions of Work
Functions - Functional Manifestations (see Exhibit "B").
EXHIBIT "A"
DESCRIPTIONS OF WORK FUNCTIONS
FUNCTIONAL MANIFESTATIONS
The following is a list of the functional manifestations of each of the eight work functions to be evaluated. The examiner should consider these factors in evaluating each work function, using clinical observations and objective supporting data.
1. Ability to comprehend and follow instruction
Consider:
the ability to maintain attention and concentration for necessary periods;
the ability to understand written or oral instructions; and
the ability to do work requiring set limits, tolerances or standards.
2. Ability to perform simple and reptitive tasks
Consider:
the ability to ask simple questions or request assistance;
the ability to perform activities or a routine nature; and
the ability to remember locations and work procedures.
3. Ability to maintain a work place appropriate to a given work load
Consider:
the ability to perform acitivities within a schedule, maintain regular attendance and be punctual; and
the ability to complete a normal work day and/or work week and perform at consistent pace.
4. Ability to perform complex and varied tasks
Consider:
the ability to synthesize, coordinate,l and analyze data; and
the ability to perform a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.
5. Ability to relate to other people beyond giving and receiving instructions
Consider:
the ability to get along with co-workers or peers;
the ability to perform work activities negotiating with, explaining, or persudaing; and
the ability to resond appropriately to evaluation or criticism.
EXHIBIT "B", PAGE 2 OF 2 PAGES
6. Ability to influence people
Consider:
the ability to convince or direct others;
the ability to understand the meaning of words and to use them appropriately and effectively; and
the ability to interact appropriatley with people.
7. Ability to make generalizations, evaluations or decisions without immediatre supervision
Consider:
the ability to recgnize potential hazards and follow appropriate precautions;
the ability to understand and remember detailed instructions;
the ability to make independment decisions or judgements based on appropriate information; and
the ability to set realistic goals or make plans independent of others.
8. Ability to accept and carry out responsibility for direction, control and planning
Consider:
the ability to set realistic goals or make plans independently of others;
the ability to negotiate with, instruct or supervise people; and
the ability to respond appropriately to change in the work conditions.
EXHIBIT "B", PAGE 2 OF 2 PAGES
Note: Authority cited: Section 139.2(j)(4), Labor Code. Reference: Sections 139.2(j)(4) and 4628, Labor Code.
s 44. Method of Evaluation of Pulmonary Disability.
The method of measuring the pulmonary elements of disability shall be as set forth below in the "Guidelines for Evaluation of Pulmonary Disability" as adopted by the Industrial Medical Council on December 4, 1997.
STATE OF CALIFORNIA
GRAY DAVIS, GOVERNOR
DEPARTMENT OF INDUSTRIAL RELATIONS
INDUSTRIAL MEDICAL COUNCIL
395 Oyster Point Blvd., Ste. 102
South San Francisco, CA. 94080
Tel: (650) 737-2700 Fax: (650) 737-2980
ADDRESS REPLY TO:
P.O. Box 8888
San Francisco, CA 94128-8888
Guidelines for Evaluation of Pulmonary Disability
Adopted December 4, 1997
I. PURPOSE
This document defines the following:
1. Criteria to be used for establishing the presence or absence of respiratory impairment;
2. Criteria for selecting appropriate use of laboratory data and for indentifying inappropriate testing;
3. A method for the quantitative and objective assessment of the extent or respiratory disability.
4. Guidelines regarding the content of medical-legal reports for assessing respiratory disability.
II. GENERAL PRINCIPLES
A. Aproach
1. Evaluation of subjective (dyspnea) must be subject to collateral evidence and the internal consistency of the history. The dyspnea criteria are used for rough estimates and cannot by themselves establish a level of impairment without one or more of the physiologic determinants listed below in the same class of impairments.
2. In any evaluation, the physician shall progress from the simple to the more complicated. Start wiht the history and phycial examination, follow with basic pulmonary function test, and then proceed as appropriate to more complicated procedures. Some patients will require only spirometry, but most will require determination of diffusing capacity for carbon monoxide (D<> co), and many will need lung volume measurement. Refer to Chapter 5, "The Respiratory System in "Guides to the Evaluation of Permanent Impairment" of the American Medical Association, 4th Edition, 1993. These guidelines shall be used in conjunction with the determinants discussed below.
B. Evaluation Tests
1. Spirometry
a. Spirometry must be performed according to the 1994 American Thoracic Society Recommendations. Equipment, calibration, and techniques must be according to these American Thoracic Society criteria.
b. A spirogram representing the best effort of at least three attempts is used to calculate FEV<>1 and FVC. The two best efforts must be within 5% of each other, or additional efforts are needed. Hard copies of the spirogram must be incorporated in the report or maintained by the physician for review if needed.
c. If wheezing or other evidence of brochospasm is present or if the FEV<< sub>>1/FVC ratio is reduced, perform test before and after brochodilator. If albuterol, metaproterenol or isoetharine is used, wait 10 minutes or more before testing. The examiner shall comment on what treatment program the subject has been on during the two months before the testing.
A. diagnosis of asthma must be supported by objective evidence of airway hyperresponsiveness such as abnormally low (below the 95% confidence level) FEV<>1 or FEV<>1/FVC ratio , which is reversible, or a positive methacholine challenge test. (Astma may be present and the FEV<>1 and FEV<>1/FVC ratio not reversible, if examinee is on bronchodilator at time of testing.) If FEF 25-75% is abnormal (below the 95% confidence level) in a non-smoker, then asthma may be present, but additional testing such as methacholine or histamine challenge may be performed. Whenever possible, the patient should discontinue aerosol brochodilator treatment at least 12 hours before tesing.
d. Compare test results to the tables of predicted normal values in the Chapter 5 of Guides to the Evaluation of Permanent Impairment of of the American Medical Association, Fourth Edition, 1993. Where FEV<>1 or FVC value is outside the 95% confidence interval, it is considered abnormal. Where FEV<>1/FVC value is less than 0.70 or outside the 95% confidence interval, it is considered abnormal.
e. Analysis should be based on the FEV<>1, FVC, the FEV<>1/FCV ration.
f. Tracings and all data must be submitted with the report or maintained on file for review.
2. Diffusing Capacity
a. Single-breath diffusing capacity forcarbon monoxide (D<>co) shall be performed routinely unless asthma has been established as the sole cause of dyspnea or spirometry alone establishes severe impairment.
b. D<>co measurement must be done according to the 1994 American Thoracic Society Epidemiology Standardization Project Recommendations.
c. D<>co tracings and all data must be submitted with report or maintained on file for review.
d. Either Cotes, Crapo, or methods published in peer-reviewed journals for predicted values may be used.
e. D<>co less than 50% predicted indicates significant impairment. If spirometry is normal, exercise testing may be indicated to determine the extent of impairment.
f. When the D<>co is between 50-70% of predicted impairment, evaluation may require exercise testing.
3. Exercise Testing
a. The minimal requirements for performance of an adequate pulmonary exercise test include the following:
(1) Supervision and interpreation by a physican thoroughly trained in pulmonary physiology and with special expertise in clinical pulmonary exercise physiology.
(2) A standardized quantifiable exercise system (either a treadmill or a bicycle ergometer).
(3) Ability to measure heart rate, respiratory rate, minute ventilation, and oxygen consumption following appropriate quality control and validation procedures. (Note: oxygen consumption must be measured, not estimated, from the level of exercise.)
(4) Equipment for measuring arterial oxygenation by in-dwelling arterial catheter or pulse oximetry, and personnel appropriately qualified in its use. The blood gas measurements (pH, PCO<>2, PO<>2) must be made in a laboratory which successfully passes a professional society's proficiency testing program annually (e.g., program of California Thoracic Society or College of American Pathologists). In many instances, properly performed oximetry (to measure O<>2 saturation of hemoglobin) can be used as a substitute for measurement of arterial PO<>2.
(5) The exercise testing must be performed with cardiac monitoring in a medical facilty capable of handling any complications and, in addition, capable of performing resting lung studies. An experienced physician must be on site.
b. Written interpretation must include answers to the following questions:
(1) Was the test technically satisfactory?
(2) Describe the maximal exercise level achieved as the predicted percent of both heart rate and maximum oxygen consumption (VO<>2max). Include in the report the source of the prediction values used.
(3) What is the estimate of the meximum exercise level which patient can sustain? Include a statement or literature reference which provides the rationale on which this prediction is based.
(4) If limitation of exercise is found, what is the cause (pulmonary or non-pulmonary)? In all cases, include a description of the specific symptoms which limited the maximal level of exercise.
c. Indications for Exercise Testing
(1) If spirometry indicates Class 2 or Class 3 impairment (See Table 2) but there is dyspnea two levels higher (Class 4 or Class 5, respectively) and the dyspnea is not explained by tests for episodic bronchospasm, exercise testing may be indicated.
(2) If spirometry establishes Class 4 or Class 4 impairment, exercise testing is contra-indicated.
(3) If tests for airway hyperresponsiveness, exercise induced, antigen induced, or irritant induced episodic bronchospasm are positive and if the degree of impairment can be calculated from spirometric data demonstrating the most severe level of bronchospasm reached during the study, exercise testing is usually not needed since the most severe level of impairment in the presence of the inciting agent is known. The physician must provide specific information on the nature of the bronchospasm inducing agent and its prevalence in the job market.
(4) Exercise testing may be needed in some patients with episodic dyspnea to determine if exercise induced bronchospasm is present. If done for this purpose, spirometry must be performed immediately before and after the exercise.
(5) If spirometry and D<>co are normal but there is marked dyspnea and there are significant clinical findings such as positive x-ray examinations showing interstitial disease (i.e., ILO category 1/0 or greater) or hypoxemia (PO<>2 less than 80, according to the Guidelines for the Use of ILO Int'l Classification Radiographs of Pneumoconioses, Geneva: ILO, 1980. Occupational Health and Safety Services No. 22 Revised), exercise testing may be needed.
4. Airway Hyperresponsiveness Testing
a. Tests of airway hyperresponsiveness are indicated when asthma is a consideration. This is particularly relevant when the patient complains of episodic dyspnea.
b. In such instance, if the FEV<>1/FVC ratio is reduced and the FEV<< sub>>1 is less than 60% of predicted, an aerosolized bronchodilator shall be administered. A consistent response (based on accurate testing and maximal patient effort) with greater than 15% increase in FEV<>1 indicates that airway reactivity is present.
c. If the FEV<>1/FVC ratio is normal or reduced, and the FEV<>1 is greater than 70% of predicted, a provocation challenge test shall be considered if the clinical history suggests the presence of possible disability due to asthma. In such instances, a methacholine challenge or histamine challenge test shall be performed. Such tests shall only be performed by physicians with experience in their conduct. These tests require careful attention to technical detail. In particular, establishment and maintenance of precise concentrations of the methacholine agent is requisite. False positive and false negative tests may occur if not performed well, and therefore spirometry tracings must be retained for review.
d. Additional information about the specific techniques of the methacholine challenge may be determined from standard references.
5. Treatment
A careful history of the nature of ongoing treatment for pulmonary conditions must be obtained by the phsician performing the evaluation. It is particularly important in cases of asthma to express an opinion about whether optimal therapy is being provided. If the examining physican feels that adequate therapy if not provided, this should be stated explictly and suggested alternatives should be indicated. In addition, if the examining physican believes that the patient is not complying with treatment, this should be stated.
The National Institute of Health guidelines ("Medical Care", Vol. 31. No. 3, pp MS20-MS28, Supplement, 1993, "The National Asthma Education Program: Expert Panel Report Guidelines for Diagnosis and Management of Asthma") for the treatment of asthma shall be used as a reference standard for determining the adequacy of treatment. In general, a patient shall be treated with the minimal drug which is necessary to maintain control of the asthma.
Additional guidance is available on the 1993 American Thoracic Society statement on Disability and Impairment from Asthma.
6. Chest Radiography
Chest radiographic examinations are an essential part of most pulmonary disability evaluations. For evaluating possible pneumoconioses (dust diseases of the lung), it is essential that the radiographs be of high technical quality. Over or under penetration can lead to under or over diagnosis of the presence of pulmonary abnormality. The recommendations of the International Labor Organization (ILO) Committee on chest radiography, Guidelines for the Use of ILO Int'l Classification of Radiographs of Pneumoconioses, Geneva: ILO, 1980. Occupational Health and Safety Services No. 22 Revised), shall serve as the reference guideline. The physican interpreting the radiographs must be experienced in evaluating occupational and environmental lung disease (e.g., such as by being an A or B reader as certified by the National Institute for Occupational Safety and Health).
CAT scans are not routinely necessary in the evaluation of dust exposed individuals. Their use shall be limited to those situations where a specific indication exists (e.g., to radiographically evaluate the parenchyma in the presence of extensive pleural abnormality). CAT scans are not indicated for the evaluation of individuals who have been dust exposed but have normal lung function and no symptoms. They are required only if finding the deviation from complete normality will affect the ratable disability.
Table 1. Minimal Historical Information To Be Collected By Examining Physician
Dyspnea Frequency
Severity: At rest, walking on
level, etc.
Constant or Intermittent
Wheezing Patient's description
Associated with dyspnea?
Cough Frequency
Severity: e.g., paroxysmal
Precipitants
Sputum Production Frequency
Timing: A.M./all day, etc.
Duration: months/year
Amount
Quality (Thick/thin, purulence)
Sleep Problems Snoring
Respiratory Infections Frequency
Severity
Medically Diagnosed Lung Asthma
Disease Pneumonia
Other
Allergic History Hay fever
Allergic Asthma
Limitations Due To Dyspnea Work
Home
Other
SMOKING
Current Status
History Starting
Average Intensity (packs/day)
Type: cigarette, pipe, cigar
Use of filters
Periods Of Nonsmoking List years of nonsmoking or
reduced smoking.
If an ex-smoker, list when stopped.
Cessation Efforts Type
Success?
Environmental Tobacco Worksite
Home (e.g., smoking spouse)
Workplace Questions
Chemical Exposures Name
Level
Duration
Dust Exposure Asbestos
Silica
Other
Mitigating Factors Respirator Use
Exhaust Ventilation
Special Exams X-ray
Spirometry
Respiratory Medical History
Chest Trauma
Medical Diagnoses
Tuberculosis History Active Disease
PPD Status
Respiratory Medications Physician Prescribed
Over The Counter
(including inhalers)
Table 2. Impairment Schedule
CLASS 1
The subject may or may not have dyspnea. If dyspnea is present, it is for nonrespiratory reasons or it is consistent with the circumstances of activity.
OR
Tests of ventilatory functions (FVC, FEV<>1, FEV<>1/FVC ratio as percent) above the lower limit of normal for the predicted value is defined by the 95% condicence interval. (See Chapter 5, "The Respiratory System" in Guides to the Evaluation of Permanent Impairment of the American Medical Association, 4th edition, 1993 for methods of calucation.)
OR
VO<>2 Max greater than 25 ml/kg-min).
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CLASS 2
Dyspnea with fast walking on level ground or when walking up a hill; patient can keep pace with persons of same age and body build on a level ground but not on hills or stairs.
AND
Tests of pulmonary function (FVC, FEV<>1, FEV<>1/FVC ratio as percent) below the 95% condifence interval but greater than 60% predicted for FVC, FEV<>1, and FEV<>1/FVC ratio.
OR
VO<>2 Max between 20-25 ml/kg-min).
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CLASS 3
Dyspnea while walking on level ground with person of the same age or walking up one flight of stairs. Patient can walk a mile at own pace without dyspnea, but cannot keep pace on level ground with others of same age and body build.
AND
Tests of ventilatory function (FVC, FEV<>1, FEV<>1/FVC ratio as percent) less than 60% predicted, but greater than:
50% predicted for FVC<
40% predicted for FEV<>1,
40% actual value for FEV<>1/FVC ratio.
OR
VO<>2 Max between 15-20 ml/kg-min).
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CLASS 4
Dyspnea after walking more than 100 meters at own pace on level ground.
AND
Tests of pulmonary function (FVC, FEV<>1, FEV<>1/FVC ratio as percent):
less than 50% predicted but greater than 40% for FVC;
less than 40% predicted but greater than 30% for FEV<>1;
less than 40% predicted but greater than 30% for FEV<>1/FVC;
30-40% predicted for D<>.
OR
VO<>2 Max between 10-15 ml/(kg-min).
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CLASS 5
Dyspnea after walking less than 30 meters at own pace or dyspnea at rest.
AND
Tests of ventilatory functions (FVC, FEV<>1, FEV<>1/FVC ratio as percent):
less than 40% for FVC;
less than 30% for FEV<>1;
less than 30% for FEV<>1/FVC;
less than 30% predicted for D<>co.
OR
VO<>2 Max less than 10 ml/kg-min).
NOTES:
1. To assess lung function for permanent rating purposes, the patient must be receiving optimal therapy.
2. Lung function testing must conform to 1994 American Thoracic Society Epidemiology Standardization Project Recommendation.
3. If oxygen consumption is determined, it must be directly measured, not estimated by treadmill speed and grade (as is commonly done in cardiac stress testing).
Table 3. Impairment Table
Preclusion
CLASS VO<>2 max ml/(Kg-min) Peak METs Equivalent
1 >25 >7 None
2 20 to 25 5.6-7 Very heavy lifting
3 15 to 20 4.2-5.6 Heavy lifting
4 10 to 15 2.8-4.2 Light work only
5 <10 <2.8 Sedentary work only
Table 4
Modifying Factors For Asthma
Medication Need (Documented)
Daily mandatory bronchodilator or
anti-inflammatory medication 0-1 class
High dose inhaled bronchodilator
(>800 ug beclomethasone or equivalent daily)
Plus occasional course of systemic
steriod (e.g., 1-3 year) 0-1 class
Regular systemic steriod use
(e.g., >20 mgm prednisone/day 0-2 class
Noncompliance with proper treatment substract 0-1 class
Airway Hyperresponsiveness
Methacholine Challenge PC<>20
<8 mgm 0-1 class
<0.5 mgm 0-2 class
Exercise Induced Bronchospasm-Decline in FEV<>1
with exercise
>20%0-1 class (continued)