This book is an important resource for all physicians involved in the assessment of patients seeking disability compensation. It has a strong North American bias, but most of the text is very relevant to physicians and surgeons everywhere, particularly those involved in occupational health. Lawyers in the field also will find much valuable material. I strongly recommend the book to all of these groups and to medical libraries. The text is well presented, and I came across only one misprint.
The text is divided into three sections. The first section deals with definitions of impairment, disability, and handicap, which also are summarized in an appendix. There is an interesting chapter on the evolution of legal systems for disability compensation. The focus of the middle chapters is on the American and Canadian systems of disability compensation. The section ends with chapters on medicolegal issues, and much of this information is generally applicable.
The second section covers organ systems in thirty-three chapters, thirteen of which are related directly to the musculoskeletal system. Orthopaedic surgeons will find useful material on neurological and psychiatric assessment, particularly in an excellent chapter on chronic pain, by Aronoff.
The third section deals with resources for the evaluation of disability, with the focus on facilities in the United States. However, the chapter on fitness for duty also will be useful to physicians in other countries. I was disappointed that the chapters on physical and vocational rehabilitation contained little more than platitudes regarding the efficacy of these programs.
From the orthopaedic point of view, the book contains much information on the assessment of range of movement and little on the measurement of deformity. The terms valgus and varus cannot easily be substituted with use of "simple" Anglo-Saxon terminology and are not well understood by other physicians or by lawyers. These terms are scarcely mentioned and are not defined. Deformity may have a major impact on an individual and cannot be defined simply in terms of loss of motion.
Inevitably, there is an emphasis on back pain, which is a major contributor to the costs of any disability system. The nonorganic signs of Waddell are described in detail, although their use and application are not. Waddell has reported often on the abuse of these signs, particularly in the medicolegal environment (most recently, in Spine, 23: 2367—2371, 1998).
Interestingly, the chapters on musculoskeletal disorders eschew any condition-specific outcome scoring system (other than the Harris hip score). This may be the correct approach for assessing individuals, but I could not find any discussion of the topic. Questionnaire-based assessment systems are described and recommended in the chapters on psychological disorders and pain. Many such instruments are used in the musculoskeletal field, although how applicable they are to an individual as opposed to a group of individuals is debatable. The chapter on the central nervous system is not helpful in distinguishing among mild, moderate, and severe injuries, and there is little information, either here or elsewhere in the book, to help in the evaluation of a patient who has a spinal cord injury.
From a more general point of view, I was left with a strong feeling of dissatisfaction after reading this book. Developed countries have devised various complex systems to compensate citizens who have disabilities. Unfortunately, most if not all of these systems are abused because they encourage claims of disability when none exists. The financing and organization of these systems is an important area of political conflict, with no good solutions in sight.
Almost without exception, the authors of the chapters in the second section describe the complexity of disability assessment in their particular field. Some seem to be looking enviously over the fence at disability assessment in other specialties. For example, the orthopaedic surgeon merely has to measure range of movement, whereas the internal-medicine physician can select from a range of physiological and biochemical tests and the psychiatrist and the psychologist have access to a battery of well formulated instruments. However, all run into difficulties when it comes to the overall assessment of their patients. Most of the chapters conclude with clinical examples showing how the occupational physician magically converts disability into a percentage impairment.
We still have a long way to go before we have satisfactory and fair systems of assessment. This book tells us where we are now, and it is essential reading for all who are involved in the field.
Jeremy Fairbank, M.D., F.R.C.S.
Nuffield Orthopaedic Centre
Oxford, United Kingdom