|Year : 2006 | Volume
| Issue : 2 | Page : 98-102
Neurological legal disability
Department of Neurology, Osmania Medical College and Osmania General Hospital, Hyderabad, India
Department of Neurology, Osmania Medical College and Osmania General Hospital, Hyderabad
Neurological disorders with a prolonged course, either remediable or otherwise are being seen increasingly in clinical practice and many such patients are young and are part of some organization or other wherein their services are needed if they were healthy and fit. The neurologists who are on the panel of these organizations are asked to certify whether these subjects are fit to work or how long they should be given leave. These certificates may be produced in the court of law and may be subjected to verification by another neurologist or a medical board. At present there are no standard guidelines in our country to effect such certification unlike in orthopedic specialty or in ophthalmology. The following is a beginning, based on which the neurologist can certify the neurological disability of such subjects and convey the same meaning to all neurologists across the country.
Keywords: Certificate, law, neurological disability
|How to cite this article:|
Radhakrishna H. Neurological legal disability. Ann Indian Acad Neurol 2006;9:98-102
The views expressed in this article are purely the author's opinion and do not carry the approval of the editorial board or the Indian Academy of Neurology. The journal would encourage the readers to comment on this scoring system or the issues at large through the 'Letter to the Editor' section.We intend to forward the discussion on this paper to the Indian Academy of Neurology and to the concerned legal departments of the Government of India for appropriate
Majority of the neurological disorders have prolonged course and even with treatment, many surviving subjects are left with a significant disability. Patients with progressive degenerative disorders like spinocerebellar ataxia, motor neuron disease and Alzheimer's disease have very little prospect to return to normalcy and such disorders are generally considered as incurable. Many of these diseases affect the older population and the impact of their disability on the family or society at large is not given the due importance. But, economic burden due to these chronic neurological disorders on the society is gaining more attention. There are also a good number of stroke and neuro-trauma patients who recover and return to their work so that these subjects need to be certified properly. Currently there are several scales that measure disability. Rankin scale (Appendix-I), Glasgow outcome scale (Appendix-II) and Barthel index (Appendix-III), Mathew scale and NIH stroke scale are a few of them. Some of them are general purpose scales while others are scales developed for use in rigid research settings. These assessments are definitely useful for follow-up and in planning of further treatment; but may not be very helpful for deciding the fitness of a person for a job. Statements like 'a patient of motor neurone disease is unfit for any job', can be a very simplistic approach to the problem if we do not specify the precise deficit, handicap and the job requirements. For example a person suffering from pure bulbar weakness may have considerable disability as a receptionist but may not have much disability with an office job involving typing or other hand functions.
Many of the existing scales describe functional deficits only and do not give the exact percentage of deficit. Some of them are disease-specific e.g., NIH stroke scale, Kurtzke's disability status scale for multiple sclerosis etc. Hence these scales cannot be applied universally to all the neurological disorders. Hence, there is a need to develop a measuring instrument that can be applied to all neurological disorders, useful in quantitative assessment of the deficit and can be applied to Indian circumstances.
The orthopedic specialty, which deals with patients of trauma, amputations or joint replacements, has come out with guidelines from this view point. Like the original American version, it can assess and certify the degree of disability to the requirement of the law-enforcing authorities and the employers. However these guidelines are not suitable for patients with say, dystonia, ataxia, aphasia or Parkinson disease where the subject is normal to the external appearance but is functionally deficient. The orthopedic patient, for whose assessment a standardized disability scale exists, is different in the sense that an amputated or fractured limb is totally deficient in function, while in a neurological patient the limb may still have some kind of retained function, e.g., foot drop affects dorsiflexion at the ankle alone but plantar flexion is absolutely normal, a patient with myopathy may have significant proximal weakness with normal distal power, a dystonia patient cannot be assessed by the orthopedic scale at all. Thus the orthopedic assessment scales cannot be applied 'as it is' to neurological patients though they can be taken as guidelines for neuro-scales. WHO international classification of impairments, disabilities and handicap measures the impact of the disease and is oriented towards rehabilitation of the patients (www.who.int/icidh/). It measures what activities the patients can or cannot do. There are disease-specific scales (e.g., united Parkinson disease rating scale) and generic scales (e.g., 10-item Barthel index, 18-item functional independence measure). They measure mainly the burden of care needed by the patients and have variable sensitivity to change, especially when used during outpatient care. A person who suffered a stroke may be unable to perform any useful work and may be unfit for his job in the initial few weeks or months, but can improve to be near-normal when his disability scores are better [Table - 1].
In Osmania General Hospital, Hyderabad, we have been seeing candidates coming for 'certification by a neurologist' for hemiplegia, muscular dystrophy, aphasia or a variety of other neurological illnesses. The certificate is useful to them to obtain a bus-pass, railway concession, a telephone outlet, a job or an admission to an educational course designated for the physically handicapped or for income tax concessions. Precise quantification of the disability in terms of certain percentage is obligatory for this purpose. For example certain institutions permit voluntary retirement on medical grounds for their staff if their disability exceeds 40%. (Appendix IV and V). The neurologists may have to face criticism or cross examinations for certifying a subject to a certain degree of disability. It has become imperative that we have clear and reproducible guidelines for such certification which can be followed in any institution in our country and convey the same meaning to other neurologists and administrators alike.
The following proposal is an attempt in this direction and it is hoped that this scale may lead to wider discussions and possible refinements.
Neurological legal disability
1. The person in question is referred to as 'subject' and not as 'patient' as he had not approached for treatment of his/her problem.
2. Intermittent/ periodic illnesses do not qualify for any permanent physical disability. e.g., epilepsy, hypokalemic periodic paralysis, myasthenia gravis. However, if there is a persisting disability, as in case of fracture or mental retardation in a patient with epilepsy, generalized myasthenia or hemiplegia-hemiatrophy-epilepsy syndrome, these subjects may qualify for permanent disability. It must also be noted that subjects working at crucial places like drivers, machine operators, under-water workers or underground mine workers should be dealt with separately. For e.g., A person with active epilepsy should not be permitted to carry on such hazardous jobs as driving a public transport vehicle. The existing laws (Motor Vehicle Act, 1939, 1988 or 1994) do not prohibit persons with epilepsy from driving.) It may be possible that under current circumstances a doctor who had certified the fitness of a driver can be taken to court in the event of an accident while driving, that caused injury to the driver himself and/or the passengers. The Indian Epilepsy Association had also highlighted the need for a structured prohibition of driving.
3. Disability shall be assessed after removing any prosthesis, walking aids or any other assisting devices but not avoiding the medication.
4. Any 'persistent' disability of more than 75%, qualifies for permanent invalidation.
5. Neurological disability of less than 2 years duration continuously, cannot qualify for 'persistent' status.
6. Combination of two disabled body parts does not automatically amount to an arithmetical sum of the percentages together. The neurologist can use his/ her discretion while arriving at a reasonable figure in this situation. For e.g., paraplegia with grade 0/5 power and sphincter involvement qualifies for >75% disability, while the aggregate disability of paralysis of two lower limbs and sphincters amounts to 65%.
7. Motor power of a limb of grade 3/5 and less indicates total (for certifying purpose only) loss of function while a power of grade 4-/5 and above indicates partial loss of function. Presence of only brisk deep tendon reflexes without motor weakness, as in case of recovering stroke patients, does not qualify for any disability.
8. Post operative cases. e.g., 'Failed back syndrome' cases are to be evaluated in the same way as are non-surgical cases. However, any prospect of further surgical correction should be excluded by a qualified specialist, before declaring the subject as 'disabled'.
9. Sensory loss alone does not qualify for any disability. Only when it is associated with permanent trophic changes such as ulcers or deformities, does it qualify for disability depending on the extent of involvement.
10.Weakness of a limb is taken as the maximum weakness present either distally or proximally. For example, a subject with 2/5 power proximally and 4/5 power distally shall be considered as one who has 2/5 power.
Disability is defined as a "state of being disabled, absence of competent physical, intellectual or moral power, fitness or the like; or an instance of such lack, legal incapacity, incompetence or disqualification" (Webster's dictionary). The later part of the definition can be made use of by the employer to seek neurologist opinion regarding the disability. WHO system of classification defines 'Impairment' as "clinical signs or symptoms resulting from nervous system damage", 'disability' as "limitation on activities of daily living from neurologic impairment" and 'handicap' as "social and environmental consequences from impairment and disability".
Rating (percentage) of disability
The rating of weakness and the grade of the power are not always proportional. The upper limb weakness carries a higher rating of disability than it is for a similar grade of weakness in the lower limb. The thumb (or great toe) weakness carries a higher rating when compared to similar weakness of other fingers (or toes). Similarly proximal weakness of the limbs, as in muscular dystrophies, carries higher rating of weakness when compared to distal muscle weakness.
The final rating of the disability should be the examining doctor's own personal opinion entirely based on his/her own knowledge, experience and the subject's clinical findings. The rating scales can only be guidelines and are not absolute while arriving at the final percentage of disability.
The 'disability certificate' is a document that is producible in the court of law, acts as a reference and needs to be substantiated by the doctor if needed. Hence, a copy of the final assessment should be available with the certifying doctor for any further clarification, to prevent malpractice, for future alteration or re-certification or for his/her own guidance in other cases.
Grading of pain as a subjective symptom
Sometimes subjects with painful neuropathies, headache, low backache or thalamic syndrome are brought for certification. One should be careful to exclude an underlying arthritis as the cause, eg. periarthritis of the shoulder as the cause of brachialgia.
1) Mild: There is only symptom of pain, but no physical findings. It does not constitute any physical impairment.
2) Moderate: There are physical findings that can reasonably explain the degree of pain but can be treated with medication.
3) Severe: When the pathological changes and clinical findings are commensurate with a severe physical impairment requiring treatment and contributing extensively to the physical disability.
This rating was arrived at from examining several clinical scales, published in Indian or western literature, the disabilities coming up for certification and has been satisfactory, consistent and comparable with the rating done by other Neuro-colleagues. However, the requirements of the employer, type of work expected by the present or prospective employer, results of any available relevant investigations and any previous certification should also be taken into account while arriving at a final conclusion. A subject with 40-75% disability can be advised a lighter job as long as the part of the body affected does not interfere with his/ her job. One should not hesitate to ask for reasonable non-invasive investigations like cranial imaging or electrophysiological testing before giving the final certificate. However, invasive tests like conventional four vessel angiography or an open biopsy should be ordered only after careful consideration of the value of the potential information that can be obtained and the risks and the cost involved. There can be objections from the law enforcing authority, the employer or the subjects themselves when costly or invasive insvestigations are recommended.
In cases of ambiguity (where the duration of the illness is not known or the effect of treatment was not examined to the satisfaction of the neurologist or where the patient had undergone treatment with unqualified persons), it is always prudent to certify temporary disability only and advise re-certification after 6-12 months period, as the case may be, to look for the evolution of the disease or the effect of the treatment.
| Acknowledgement|| |
I thank Dr. P. Nagabhushana Rao MD, DM Professor and HOD Neurology, Dr. K. Ashok Kumar MD, DM Professor of Neurology and Dr. P. Viswa Jyothi MD, DM Assistant professor of Neurology for correcting the manuscript, offering suggestions and providing the necessary references.
| References|| |
|1.||Tiwari AK. Manual for orthopedic surgeons in evaluating permanent physical impairment. 1965. |
|2.||IAMA Guide: A guide to the evaluation of permanent impairment of the extremities and back. J Am Med Assoc 1958. |
|3.||Dobkin BH. Principles and Practice of Neurological Rehabilitation - Neurology in Clinical Practice 4th ed. editors: Bradley WG, Daroff RB, Fenichel GM, Jankovic J 2004. p. 1027-40. |
|4.||Arjundas G, Arjundas D. Epilepsy and Indian law. In Epilepsy in India Ed. Singhal BS, Devika Nag: 2000. p. 387-96. |
[Table - 1]
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