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Foreword to The Medical Disability Advisor (version 7)

The Medical Disability Advisor, now a part of the MDGuidelines suite, provides the disability-duration guidelines. The first six editions of The Medical Disability Advisor have established it as the best known, most used, and most accurate data source for esimtating disability duration, and thus return to work time for many diseases and injuries. The new version 7 improves further on this established product by adding additional sections on Risk, Capacity, and Tolerance, both in the clinical text and, at times, below the disability duration tables. In addition, the usual re-inspection and revision of the medical topics, along with their durations, have been performed.

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.).

1. Talmage JB, Melhorn JM. A 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

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Revised Topics
  1. Absence Seizures
  2. Acute Necrotizing Ulcerative Gingivitis
  3. Adjustment Disorder with Anxiety
  4. Adjustment Disorder with Depressed Mood
  5. Adjustment Disorder with Disturbance of Conduct
  6. Alcohol Intoxication, Acute
  7. Alcoholism
  8. Alzheimer's Disease
  9. Atrophy, Muscular (Progressive)
  10. Bladder Neck Suspension
  11. Borderline Personality Disorder
  12. Cannabis Use Disorder
  13. Carpal Tunnel Syndrome
  14. Cerebral Palsy
  15. Complex Regional Pain Syndrome
  16. Coronary Atherosclerosis
  17. Cystitis, Acute
  18. Cystitis, Interstitial
  19. Decubitus Ulcer
  20. Delirium
  21. Delusional Disorder
  22. Dependent Personality Disorder
  23. Depersonalization / Derealization Disorder
  24. Dermatitis
  25. Dissociative Identity Disorder
  26. Eating Disorders
  27. Encephalitis
  28. Epilepsy
  29. Factitious Disorder
  30. Functional Neurological Symptom Disorder
  31. General Paresis
  32. Glomerulonephritis, Acute
  33. Glomerulonephritis, Chronic
  34. Glomerulosclerosis
  35. Hematuria
  36. Hernia Repair
  37. Hernia, Inguinal and Femoral
  38. Hernia, Umbilical
  39. Huntington's Chorea
  40. Intermittent Explosive Disorder
  41. Jacksonian Seizure
  42. Keloid
  43. Ligation and Stripping of Varicose Veins
  44. Major Depressive Disorder, Severe, with Psychotic Features
  45. Major Neurocognitive Disorder
  46. Menstrual Disorders
  47. Myelopathy
  48. Narcissistic Personality Disorder
  49. Nephritis, Interstitial
  50. Nephrotic Syndrome
  51. Obsessive-Compulsive Disorder
  52. Obsessive-Compulsive Personality Disorder
  53. Opioid Dependence
  54. Paranoid Personality Disorder
  55. Passive-Aggressive Personality Disorder
  56. Peripheral Neuropathy
  57. Persistent Depressive Disorder (Dysthymia)
  58. Phencyclidine Use Disorder
  59. Polysubstance Dependence
  60. Posttraumatic Stress Disorder
  61. Psychotic Disorder, Brief
  62. Psychotic Disorder, Unspecified
  63. Reactive Arthritis
  64. Salmonellosis
  65. Schizoaffective Disorder
  66. Schizoid Personality Disorder
  67. Schizophrenia
  68. Schizophreniform Disorder
  69. Sedative, Hypnotic or Anxiolytic Dependence
  70. Seizures
  71. Shigellosis
  72. Somatic Symptom Disorder
  73. Somatic Symptom Disorder and Illness Anxiety Disorder
  74. Stimulant-Related Disorders (Amphetamine-Type Substance)
  75. Stimulant-Related Disorders (Cocaine)
  76. Stress Disorder, Acute
  77. Substance/Medication-Induced Anxiety Disorder
  78. Substance/Medication-Induced Bipolar and Related Disorder
  79. Substance/Medication-Induced Depressive Disorder
  80. Substance/Medication-Induced Major or Mild Neurocognitive Disorder
  81. Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
  82. Substance/Medication-Induced Psychotic Disorder
  83. Substance/Medication-Induced Sexual Dysfunction
  84. Substance/Medication-Induced Sleep Disorder
  85. Tendon Sheath Incision
  86. Tenosynovitis
  87. Tenosynovitis, Radial Styloid
  88. Tenotomy
  89. Tension Headache
  90. Tetanus
  91. Thoracentesis
  92. Thoracic Outlet Syndrome
  93. Thrombocytopenia
  94. Thrombophlebitis
  95. Tics
  96. Tinea
  97. Tobacco Use Disorder
  98. Tonic-Clonic Seizure
  99. Toxic Shock Syndrome
  100. Toxoplasmosis
  101. Trachoma
  102. Transcutaneous Electrical Nerve Stimulation
  103. Transient Ischemic Attack
  104. Transurethral Incision of Bladder Neck
  105. Transurethral Removal of Obstruction from Ureter
  106. Traveler's Diarrhea
  107. Trichinosis
  108. Trichomoniasis
  109. Tubal Ligation
  110. Tuberculosis, Respiratory
  111. Tularemia
  112. Typhoid Fever
  113. Typhus Fever
  114. Upper Respiratory Infection
  115. Urethral Catheterization
  116. Urethritis
  117. Vena Cava Interruption
  118. Ventricular Tachycardia
  119. Vocational Therapy
  120. Warts, Genital
  121. Warts, Plantar
  122. Warts, Viral
  123. Wound Infection, Postoperative
  124. X-ray
  125. Yellow Fever