The first five editions of The Medical Disability Advisor have established it as the best known, most used, and most accurate data source for predicting disability duration, and thus return to work time for many diseases and injuries. The Sixth Edition improves further on this established product by adding additional data on diagnoses from physician-coded claims data.

Probably the best model to use in considering an individual's readiness for return to work involves the consideration of “risk,” “capacity,” and “tolerance.” (1)

“Risk” is a basis for physician-imposed activity restrictions. Most return-to-work forms sent to physicians have a line on which the physician can state “restrictions” that may pose a risk to the individual or to others (e.g. co-workers, the general motoring public, etc.). Risk, in this regard, means the person should not do something, even though he/she may actually be capable of doing the activity. For example, individuals with uncontrolled seizure disorders are not permitted to work as commercial airline pilots or bus drivers based on risk. The concept of “risk” most closely conforms to the “Minimum” column of disability duration in the consensus tables in this edition.

“Capacity” is the basis for physician described activity limitations, and means the individual is not yet physically capable of an activity. Many of the return to work forms sent to physicians have a line on which the physician can state “limitations” based on capacity evaluation. For example, after a wound into the biceps muscle mass of the arm, an individual may not yet have the strength to permit lifting a certain amount of weight; or after a fracture of the shoulder, an individual may not yet have enough shoulder motion for his/her hand to reach the overhead control on a factory press. In the disability duration tables the “Optimum” column indicates when the average person with the average speed of recovery and few comorbidities will return to work.

“Tolerance” is the issue with which doctors, employers, employees, and insurers struggle. Tolerance is the ability to put up with the symptoms (like pain or fatigue) that accompany doing work tasks in order to gain the rewards of work (income, self-esteem, health benefits of work, etc.). Tolerance means the ability to tolerate the symptoms produced by doing an activity the individual clearly can do. Tolerance is not a scientific concept, and tolerance is not scientifically measurable. Early after major injury or surgery physicians have fair agreement on work guidelines based in tolerance issues, but for chronic problems studies have shown physicians cannot agree on work guidelines based in tolerance issues. People (patients) consider factors like income and finances, job satisfaction, need for employer provided health insurance benefits, availability of disability or workers’ compensation insurance to maintain income, ability to switch to physically easier careers, etc. when deciding whether the rewards of working are to them worth the “cost” of working.

This method, which effectively brings into consideration the main elements that involve work loss, works well in conjunction with the MDA disability duration tables.

The “Maximum” column of the disability duration table reflects current physician consensus of what the vast majority of individuals will tolerate. From the data set of actual observed durations, probably 90% or more of individuals have already returned to work by the time listed in the “Maximum” column. There will be some individuals who will not return to work in their prior career because of risk (e.g. heavy work with avascular necrosis of the femoral head), and some who permanently lack the capacity for their former career (e.g., heavy work after a major heart attack that caused permanent congestive heart failure). Cases of this type will also be in the category of those who have not yet returned to their prior careers at the date listed in the “Maximum” column. Thus, for those who seem to have the capacity to return to their prior career with no serious risk issues, but have yet to return to work by the “Maximum” date listed, either multiple and serious co-morbidities, unusually low symptom tolerance, or malingering would logically be present. Thus physicians, employers and insurers would want to look closely at cases nearing the “Maximum” disability duration.

There is a large and growing body of scientific evidence that return to work usually provides significant overall health benefit, and staying off work needlessly results in poorer overall health outcomes.(2) Thus, employers, employees (patients), and insurers all benefit from individuals returning to work in usual time periods.

As medical care improves, the disability durations for many conditions have shortened, and this is reflected in the current revisions to the consensus tables, as well as in the data sets that helped influence the revisions. This is particularly noticeable in the case of minimally invasive surgery (e.g. arthroscopic surgery instead of open joint surgery, laparoscopic surgery instead of open abdominal surgery, etc.). These advances are reflected in a comparison of early editions of The Medical Disability Advisor compared to the current edition and its immediate predecessor, the Fifth Edition.

In summary, the Sixth Edition of The Medical Disability Advisor with its enhanced data set, updated consensus recommendations, and thoroughly revised topics will be a valuable resource for all who are interested in helping individuals achieve their maximum potential.

April, 2009

James B. Talmage MD
Occupational Health Center, Cookeville, TN
Adjunct Associate Professor, Meharry Medical College

1. Talmage JB, Melhorn JM. Physician’s Guide to Return to Work. AMA Press, Chicago, 2005
2. Waddell GA, Burton AK. Is Work Good for Your Health and Well Being? The Stationery Office, London, 2006

Warning: These guidelines are not to be used for the diagnosis and treatment of any medical condition. Diagnostic and treatment methods are constantly changing and improving. The final opinion regarding any medical condition should rest with the treating or consulting healthcare professional.

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