When Presley Reed, MD first envisioned these seminal guidelines as “presenting common
standards that can be shared by doctors, patients, and employers,” the World Wide
Web was impossible to foresee. Today, the internet provides the fundamental communication
platform to realize Dr. Reed’s original vision.
With MDGuidelines, we introduce The Medical Disability Advisor as the basis
for a growing collection of content and tools that we consider vital to all stakeholders
in the return to work process. We have many goals for this site: to infuse occupational
medicine into the mainstream of physician education and practice; to provide innovative
Reed Group's Medical Advisory Board members are among the foremost contributors
to the current knowledge in occupational medicine. We are fortunate to have appointed
James Talmage, MD as the current Chair of the Medical Advisory Board. We have also
retained many of our previous members, who have continued to dedicate significant
time and effort to revising the disability duration values that form the foundation
of the MDGuidelines resource. Presley Reed, MD also continues in an important advisory
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.
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,
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.
The MDA Internet now includes Current Procedural Terminology (CPT) © codes.
CPT © 2009 American Medical Association. All Rights Reserved.
No fee schedules, basic units, relative values or related listings are included
in CPT. AMA does not directly or indirectly practice medicine or dispense medical
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the American Medical Association.