LETTER TO EDITOR
|Year : 2006 | Volume
| Issue : 3 | Page : 186-187
Department of Neurology, Osmania Medical College and Hospital, Hyderabad, India
Department of Neurology, Osmania Medical College and Hospital, Hyderabad
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Radhakrishna H. Authors' Reply. Ann Indian Acad Neurol 2006;9:186-7
I thank T. Murali et al for providing some more background information regarding the disability issue.
There had already been some deviations from the guidelines pointed out by them. 'Disability certificate can only be issued by a medical board duly constituted by the state / central government.' Income tax authorities require a certificate from a neurologist (and not a Board) regarding the diagnosis, disability percentage and the amount of money spent on treatment -to be countersigned only by the Head of the Institution (edited in the original article).
It is true that at many places the disability certificates are being issued by orthopedic surgeons even for neurological issues. In a country where neurologists are available and the assessment done by orthopedic surgeons is likely to be incomplete, biased and not truly representative of the physical findings, a new strategy is essential. For example, assessment of dysarthria / aphasia or hemiparesis as mild, moderate or severe can only be arbitrary and highly subjective.
'Assessment should be done 6 months after the onset of the disease.' I was not aware of this fact. I proposed 2 years as the minimum period for certifying permanent disability because victims of stroke and acute neuromuscular disease continue to improve with good physiotherapy even up to 1-2 years. Even now I feel that 6 months is too short a period to arrive at 'permanent disability,' and at 6 months a subject can be given only 'temporary partial disability' status.
I had not included altered sensorium in the scoring system as I had not come across any subject coming for certification with this symptom so far. But on re-analysis, subjects with persistent vegetative state as a result of hypoxic ischemic neuronal injury or with traumatic diffuse axonal injury leading to prolonged altered sensorium can be brought in for compensation; this criterion should also be included and I agree that the subject can be awarded 100% disability, whether temporary or permanent, depending on the duration of the symptom.
Intellectual impairment and IQ assessment are in the psychiatrist's domain, while two cranial nerve functions (optic and auditory) are dealt with by the respective specialists.
As one might have observed, I had given importance to objective assessment rather than arbitrary grading (mild, moderate and severe) or subjective symptoms (number of seizures, severity of pain or severity of sensory loss, etc.). Sensory loss alone (including cranial nerves other than optic and auditory) is not associated with any significant disability. Motor power testing using MRC grading is given importance for assessing hemiplegia or paraplegia. A patient with recovering hemiparesis generally has more weakness in the upper limb and assessment must take into consideration the functional disability of individual limbs. A power of grade 3 and below is considered significant and for calculation purposes is taken as 'total.'
A subject with chronic progressive external ophthalmoplegia, according the existing system, will have 100% disability (20% for each motor cranial nerve x 6 nerves) while he/she has no symptom at all. I considered measurement of clinical manifestations and impairment of function to arrive at a conclusion rather than individual cranial nerves. Hence the symptoms of diplopia and dysphagia, which can be assessed at the bedside objectively also, are used to measure the disability of cranial nerves.
Epilepsy being an important and controversial topic, I had lengthy discussions with my colleagues in neurology and other specialties, as well as some lawyers, before arriving at the final conclusion. Epilepsy is not a physical disability at all. The subject can use adequate medication and perform his job. In the existing system, there is subjectivity as regards to the number of attacks per month. For claiming compensation or sympathy, the subject might quote a higher number of seizures, while on examination there usually is no deficit at all. If only there is some neurological deficit or associated mental retardation, he / she may be awarded suitable percentage of disability. I had also pointed out that persons with epilepsy should not be employed as drivers, machine operators, underwater workers or underground mine workers. If a person develops the disease after getting employed, the subject may be shifted to a safer job which would not cause physical injuries and compensation may be only in the form of reimbursement for the anti epileptic drugs prescribed.
Regarding bladder and bowel function - I had seen one subject who had recurrent episodes of urinary and fecal incontinence persisting even 7 years after an attack of myelitis, even though he had recovered completely as far as the paraplegia was concerned. According to the existing system of scoring, he would come under the category 'moderate to severe (50-75%) disability.' Actually he would not merit so much disability as he is attending to his present job (auto-driving) with a few precautions to prevent inconvenience. Hence I had proposed only 25% disability in such cases. However, if the same subject had significant paraplegia too, he could be given 75% (20 + 20 + 25%) disability. Lower limb weakness without sphincter involvement (lower motor neuron type) as seen in hereditary motor sensory neuropathy or muscular dystrophy will have increasing disability as the disease progresses and so in the initial stages may deserve 30% or less disability only. If one observes carefully, subjects with 40-74% disability would come into the same bracket from the certification point of view and would be eligible for the same benefits.
As can be seen from the above discussion, I had not differentiated between upper motor neuron lesion and lower motor neuron lesion; and between spinal, cerebral and peripheral pathologies but had only looked at the clinical effects and the resultant functional disability.
When cases of dementia come for certification, I feel that mini-mental status examination is still a time-tested, bedside, quick quantitative method for grading. Complete neuropsychological examination is useful for localization and planning the investigations and treatment strategies but lacks a uniform standardized scaling instrument.
Parkinsonian syndromes were singled out because of the peculiar clinical features of this disease and the difficulty in including this disease into the scoring system. In particular, bradykinesia in combination with rigidity, rather than rigidity alone, tremor or motor weakness, interferes with the daily life and it cannot be graded otherwise. Thus a person with Parkinsonian syndrome will be eligible for 40-50% disability when he is in Stage II-III and cannot perform his job effectively. The rest tremor of Parkinson disease is not a significant disability at all, while other degenerative diseases can be included in the scoring system as and when the disabling symptoms evolve.
Spasticity is again an interesting subject. In a weak upper limb (as seen in a hemiplegic subject) it interferes with physiotherapy and effective functioning of the limb, while in a weak lower limb, it is useful in locomotion. Again in a lower limb with good power, it interferes with function. Because of these reasons, the scoring for spasticity may need some modification. The scoring may be applied only when spasticity alone is the disabling symptom and not when it is a part of paraplegia or hemiplegia. This is because sometimes spasticity alone can be problematic for the subjects, as seen in cases of hereditary spastic paraparesis, where weakness is minimal and spasticity significantly interferes with activities of daily living.
These are some clarifications which I could not include in the original article. I suppose, still the proposed scoring system has to go a long way before being accepted by one and all.