In Workers’ Compensation reports, it is crucial to provide a comprehensive update on how an injury impacts an injured worker’s day-to-day life. These activities are referred to as Activities of Daily Living, or ADLs. The inclusion of detailed information about ADLs is essential for creating accurate and complete Workers’ Compensation reports.
ADLs encompass a range of physical activities that individuals perform regularly outside of their work environment. While injured workers may have their tasks at work adjusted to accommodate their limitations, their personal lives continue without such modifications. The impact of an injury on an individual’s ADLs can be measured and provides valuable insights into the extent of the injury. The AMA Guidelines Fifth Edition list eight broad categories of ADLs:
- Self-care, personal hygiene
- Communication
- Physical Activity
- Sensory Function
- Non-specialized hand activities
- Travel
- Sexual Function
- Sleep
These categories are further broken down into 34 routine activities that include writing, seeing, hearing, standing, sitting, bathing and dressing.
ADLs are the currency of functional impact, allowing the severity of an injury to be rated within a specific range. For example, if a patient’s condition fits within a 5-10% Whole Person Impairment (WPI) range, this determination is based on impairment to their ADLs.
The impact of an injury on ADLs is measured by two dimensions:
- Endurance: The amount of time an individual can spend on a specific activity.
- Pace: The rate or speed at which the activity can be performed.
There are three ways an injury can affect an individual ADL:
- Limitations: The activity is limited by the injury, altering or diminishing the pace or endurance.
- Pain/Symptoms: The individual experiences pain or other symptoms when performing the activity, but pace or endurance is not altered.
- No Symptoms: There is no pain, nor any inhibition to the activity’s pace or endurance.
Combining Impairment from Multiple Body Parts
Rating permanent disability in the California Workers’ Compensation system is about understanding how the injured worker’s industrial impairment impacts their ADLs. Once a permanent disability rating is calculated for each body part after an injury, these ratings must be combined. The Combined Values Chart (CVC) found in the rating manual is the presumptively correct method to use, allowing for some injuries to be combined but not allowing redundant ratings. The formula used to create the combined values chart is:
% impairment = [A + B(1 – A)] x 100
In this way, a second body part is valued at less impairment than it would be as the only body part injured.
The CVC has two main purposes:
- To Ensure the Ultimate PD Value Does Not Exceed 100%: This ensures that the summary value of impairments does not exceed the whole person.
- To Avoid Overlap of Impact of Injuries on Applicant’s ADLs: This prevents the same or similar impacts from multiple injuries from being counted more than once.
While the CVC is the standard method, other combining methods might yield a more accurate PD rating. For example, some jurisdictions use additive, subtractive, or multiplicative methods based on how impairments affect an individual’s ability to perform ADLs. Some injuries are able to be added with a discussion justifying this, such as contralateral injuries to the same body part that more dramatically affect activities of daily living when the injury is bilateral compared to unilateral; also, ipsilateral injuries may sometimes be added rather than combined to more accurately reflect their impact. More complex cases such as this must cite the Kite Decision, which states that there is a synergistic effect of injury to the same body parts bilaterally versus different body parts, because the body part on the opposite side is not able to fully compensate for the impairment because it is also impaired. The presence of impairment in the same region bilaterally is more disabling and therefore requires a higher impairment rating by addition rather than the Combined Values Chart. Likewise, adjacent body parts are synergistic due to inability to compensate. Adding again allows for calculation of greater impairment than use of the Combined Values Chart.
The accurate documentation of ADLs in Workers’ Compensation reports is vital for a QME to be able to rate impairment. They not only reflect the injury’s impact on the worker’s ability to perform daily activities but also ensure that the impairment rating follows the legal code. Both the standard CVC method and potential alternative methods such as the Kite Decision require substantial medical evidence to ensure the most accurate reflection of the injured worker’s permanent disability. By obtaining a survey of the applicant’s ADLs with each office visit, QMEs play a crucial role in advocating for the injured worker’s overall well-being.
Resources:
- American Medical Association. Guides to the Evaluation of Permanent Impairment, Fifth Edition. Edited by Linda Cocchiarella and Gunna B.J. Andersson. Newburyport: American Medical Association, 2001.
- Athens Administrators v. W.C.A.B. (Kite) (2013). 78 Cal. Comp. Cases 213.