Impairment Tip of the Week

This week we will discuss the problems we are seeing with rating sleep disturbances, and provide practical guidance.

The purpose of the Guides is provide a consistent and reliable acquisition, analysis, communication, and utilization of medical information through a single set of standards. Two physicians, following the methods of the Guides to evaluate the same patient, should report similar results and reach similar conclusions (page 17). We are seeing the use of approaches that are not supported by the methodologies in the Guides and result in erroneously inflated ratings.

An example of inappropriate application of the Guides is rating of the spine, and including additional impairment for sleep. This issue was addressed in the current issue of the Guides Newsletter.

Question:
My patient has had sleep disturbance since his back injury. Would it be appropriate to rate him per section 13.3c, Arousal and Sleep Disorders?

Answer:
No. Chapter 13 provides criteria for evaluating permanent impairments due to documented dysfunction of the brain, cranial nerves, spinal cord, nerve roots and/or peripheral nerves and muscles, as explained on page 305. All the criteria for Table 13-4, Criteria for Rating Impairment Due to Sleep and Arousal Disorders, require that there be reduced daytime alertness. The Guides notes it is expected that the diagnosis of excessive daytime sleepiness has been supported by formal studies in a sleep laboratory. Pain induced sleep disturbances are common, but, absent a separate brain disorder, the sleep disruption from back pain would not be ratable by Chapter 13. Sleep is an Activity of Daily Living listed in Table 1-2. As such, it is already included in the rating for back pain in the various DRE categories or ROM Method calculations. When choosing an impairment percentage from the available range for a DRE category, the rating physician would include the effect of spinal pain on sleep when considering how symptoms impact activities of daily living.

We were subsequently asked three questions relating to sleep disturbance. The answers provided were jointly authored by James Talmage, MD, Associate Editor of the Guides Newsletter, Robert Haralson, MD III, MD the Chair of Chapter 15, The Spine, and Tom Mayer, MD the Contributor to the Chapter 15, the Spine and Chair of the Spine Chapter in the Sixth Edition, and myself (Editor of the Guides Newsletter); therefore they should be considered as a definitive response by the leading experts on spine impairment evaluation.

Question 1:
Will a disc injury or diagnostically confirmed radiculopathy support a chapter 13 sleep disorder?

Answer:
No, this is not an appropriate application. Interference for sleep is reflected in the value assigned within a DRE Category range. Furthermore, typically a “sleep disturbance” associated with back pain is usually not permanent in nature. Sleep is an ADL listed on page 4 in Table 1-2, and as such it is already factored into the DRE rating. Examples of central nervous system diseases that are appropriately rated for sleep impairment are found on page 317, column 2, paragraph 2.

Question 2:
Is a sleep study required for any Class of sleep disorder on Table 13-4. Or, will the Epworth Sleepiness Scale suffice (see page 317 of the Guides) and is excessive daytime sleepiness the same as reduced daytime alertness (table 13-4)

Answer:
In rating for sleep disturbance, there should be objective documentation of a sleep disorder, not merely a self-report. This is stated on page 317, column 2, paragraph 2, the last sentence states it is expected that the diagnosis of excessive daytime sleepiness has been supported by formal studies in a sleep laboratory.

Question 3:
If the sleep disturbance results from the actual radicular pain or numbness, will this be enough to support a Chapter 13 impairment rating.

Answer:
No, this is not appropriate.

The use of Chapter 13, The Central and Peripheral Nervous System, is to rate injury or illness involving this system. This chapter should not be misapplied to situations that are not appropriate. Impairment ratings must be accurate and unbiased.