Functional Assessment for Adults with Disabilities (2019) / Chapter Skim
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7 Selected Impairments and Limitations in Functional Abilities Relevant to Work
7 Selected Impairments and Limitations in Functional Abilities Relevant to Work
Pages 295-334
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the spectrum of changes to functional abilities relevant to work requirements related to the progression of common disease processes in example impairments," which "could include, but are not limited to back disorders, cardiac impairments, or depression." Chapter 7 addresses this charge for several common conditions. These illustrations of disease trajectory, treatment, and related disability are provided as though each condition is present in isolation.
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In addition to back disorders, cardiac impairments, and depression, the committee elected to address traumatic brain injury (TBI) because of its prevalence and complexity and the associated high rates of cognitive impairment and work disability.
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. Other factors found to be associated with a poor prognosis for recovery from back pain include older age, sciatica, functional disability, poor general health, increased psychological stress, negative cognitive characteristics, poor colleague relations, heavy physical work demands, and the presence of compensation (Hayden et al., 2010)
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is typically noninvasive, consisting primarily of nonpharmacologic treatments such as exercise; general physical rehabilitation; and such modalities as acupuncture, progressive relaxation, and biofeedback. Nonpharmacologic treatments for chronic low back pain, including exercise, yoga, psychological therapies, and acupuncture, have demonstrated clinical effectiveness (Chou et al., 2017)
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Huysmans and colleagues (2018a) conducted a systematic review of the medical literature to identify the factors that influence the duration of an individual's absence from and eventual return to work.
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A Cochrane database of systematic reviews by Schonstein and colleagues (2003) found evidence that physical conditioning programs that included cognitive-behavioral therapy coupled with intensive physical training by a physiotherapist or a multidisciplinary team encompassing aerobic capacity, muscle strength and endurance, and coordination was associated with reduced number of sick days due to chronic low back pain.
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or secondary impairment of heart function that can arise from multiple causes, most commonly coronary artery disease. To encourage awareness, the current American College of Cardiology/American Heart Association staging system for heart failure defines an asymptomatic Stage B that can be detected as decreased heart function, usually left
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Improvement also can occur with correction of a structural abnormality, such as heart valve disease, or a functional abnormality, such as a persistently rapid heart rhythm. Even without such correctable causes, establishment of the recommended regimen of medications and pacing devices can improve heart function and functional capacity in some individuals even after years of heart failure symptoms, with about 15 percent improving to near-normal levels of function (Cleland et al., 2017)
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. Current SSA listing criteria for cardiac functional impairment for both heart failure and ischemic heart disease can be met with inability to perform 5 METS of activity (IOM, 2010, pp.
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Most individuals with potentially limiting symptoms resulting from coronary artery disease undergo procedural interventions to enlarge significantly narrowed coronary arteries or surgery to bypass them, assuming they have no comorbidities that limit eligibility for major cardiac surgery.
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. Nonetheless, while coronary artery disease can lead to functional impairment due to angina or myocardial infarction or after cardiac surgery, much of the disability resulting from coronary artery disease relates to a progressive decrease in heart function after myocardial infarction, which is the most common cause for heart failure (Cahill and Kharbanda, 2017)
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. Cardiac rehabilitation is routinely recommended for patients after myocardial infarction or coronary artery bypass surgery and more recently approved for patients with heart failure.
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. Depression occurs in 20 to 40 percent of patients with heart failure and in a similar proportion of individuals with coronary artery disease (Bush et al., 2005; Mbakwem et al., 2016)
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. In understanding where along the spectrum of depression severity an individual's ability to perform functions relevant to work requirements is affected, it is important to consider how depression can affect job performance.
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examined factors related to social and occupational disability, social adjustment, and work disability among individuals with major depressive disorder (MDD)
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. Measuring Depression and Work Impairment Understanding of where along the spectrum of depression severity an individual's ability to work is affected is limited by the fact that most accepted clinical measures of depression do not assess an individual's functional capacity (Harvey et al., 2017)
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. (Persistent depressive disorder, previously called dysthymia, requires fewer depressive symptoms relative to MDD, and is sometimes termed "minor" depression [APA, 2013]
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Data were drawn from a randomized controlled trial of quality improvement for depression that included 938 adults with depressive disorder in 46 managed primary care clinics in five states. At 6 months, individuals with appropriate care had lower rates of depressive disorder (24 versus 70 percent)
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Improvements in cognitive symptoms were less marked during the acute treatment phase. Functional impairment in individuals with MDD was found not only to be associated with severity of depressive symptoms but also to be independently associated with subjective cognitive symptoms
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As discussed further below, Drake and colleagues (2013) found that supported employment services are associated with improved work functioning in people with major depression.
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As individuals with depressive disorders age, those who have certain chronic comorbid conditions (particularly pain, insomnia, musculoskeletal disorders, and diabetes) find that their depressive symptoms further impair their capacity to function.
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. TRAUMATIC BRAIN INJURY Traumatic brain injury (TBI)
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The course and prognosis of TBI are complicated by multiple trauma, such as damage to the spinal cord, orthopedic injuries, and chest trauma. Cognitive impairment may resolve for people with mild TBI within 3 months, but up to 18 percent of those with mild TBI experience persistent symptoms and functional deficits that can last from months to years postinjury, with as many as 18 percent of those who were employed premorbidly remaining unemployed at 12 months post-TBI (Cancelliere et al., 2014)
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. The WHO Collaborating Center Task Force for Mild Traumatic Brain Injury determined that the studies reviewed addressing return-to-work rates in people with TBI were of low scientific quality, and no acceptable studies on return to work addressed physical, cognitive, or emotional barriers (Cancelliere et al., 2014)
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. Successful return to work is aided by having health insurance; receipt of supported employment; tailoring of work duties based on preserved abilities; a socially inclusive work environment; and reduced stress at work, such as avoiding frustration associated with having to relearn prior performed tasks, avoiding the need to multitask, and diminishing the need to learn new skills (Little et al., 2015)
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For cardiac conditions, the severity of deviation from normal capacity can be measured more objectively than for the other conditions discussed in this chapter, as is also the case for pulmonary disorders. Even for cardiopulmonary disease, however, the associated physiologic decrements do not translate directly to work impairment, as multiple other factors affect the ability and the motivation to work with limitations.
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In contrast with the course of musculoskeletal limitations, depression, or most other impairments, the progression of cardiac disease to become the primary limitation to employment is often associated with a decreasing likelihood of surviving the next 2 years. Impacts of Treatment Therapies can treat a condition directly or aid adaptation to the work environment without changing the severity of the condition itself.
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Aging is strongly associated with increasing numbers and severity of comorbidities, including physical, mental, and cognitive limitations. Depression Depression is the most common comorbidity limiting employment for individuals with a wide range of physical and mental impairments, as well as rehabilitation from such events as surgeries and myocardial infarction.
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7-2. Although the likelihood of return to work for a population is cor related with multiple factors that can be ascertained (as is the case for low back surgery and traumatic brain injury)
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7-3. Age, presurgical employment, the physical exertion involved in work, and comorbidities are key factors in evaluating individuals' functional abilities relevant to work requirements.
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2018. Functional assessment of depression and anxiety disorders rele vant to work requirements.
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2014. Systematic review of return to work after mild traumatic brain injury: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.
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2015. Return-to work in patients with acquired brain injury and psychiatric disorders as a comorbidity: A systematic review.
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2018. Functional impairment in patients with major depressive disorder: The 2-year PERFORM study.
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2010. The burden of work disability associated with mild traumatic brain injury in Ontario compensated workers: A prospective cohort study.
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2017. Cognition and return to work after mild/moderate traumatic brain injury: A systematic review.
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2010. Predictors of new-onset depression after mild traumatic brain injury.
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2017. Work related difficulties in patients with traumatic brain injury: A systematic review on predictors and associated factors.
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1997. Functional status in coronary artery disease: 1-year prospective study of the role of anxiety and depression.
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2006. Chronic low back pain in older adults: Prevalence, reliability, and validity of physical examination findings.
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