Specialist practitioners in disability assessment are referred to as disability analysts, and they may come from a variety of healthcare disciplines.
The disability analyst is concerned with advising about the level of functional and residual ability in people, either in relation to benefit claims or to the work environment. The links with occupational health are therefore strong.
The speciality of disability assessment utilises many of the core values of basic clinical training but with important differences. Disability assessment medicine differs from clinical medicine in several important respects.
The traditional teaching of healthcare practitioners in their approach to a clinical condition is the following progression of actions:
The focus in traditional clinical medicine is to obtain enough information to reach to a correct diagnosis and treatment (Macleod’s Clinical Examination, 2006, Eds Douglas G, Nicol F, Robertson C Churchill Livingstone).
However, the focus in disability analysis is different. As disability analysts, we assess disability by making use of the five steps of disability analysis:
Logical reasoning of the available evidence
Justification of opinions.
There are clearly important similarities and differences in the approaches. The prime objective for the disability analyst is not to diagnose and treat, but to assess the functional effects of a person’s condition on their day-to-day living.
In disability analysis, history-taking focuses on day-to-day living, rather than on a detailed clinical history, although basic clinical information is still required. The precise diagnosis, while useful, is not critical. In terms of the impact on daily life, it is the functional impact of the condition which is more important.
We obtain a functional history based on the individual’s day-to-day activities and any difficulties or restrictions that they have with those activities. That history focuses on an in-depth account of the person’s normal everyday tasks including household chores, social activities and holidays. We call this the ‘typical day’ approach.
This typical day approach is a very useful way of obtaining information about the individual’s regular daily activities and habits.
It gets away from the usual focus within a clinical setting, when we find out about the symptoms and signs related to a particular illness. Although we use the term ‘typical day’, we do not limit the history to a single day, but also refer to less frequent activities, occurring weekly, monthly or sometimes even annually.
When we assess people, we make sure that we use good listening techniques. We remember that appropriate eye contact and suitable body language leave a lasting impression we use clear, familiar and understandable language and we show an interest in the individual. We attempt to allow them to express their needs as fully as possible and we explain what we are doing throughout the assessment.
During the assessment, we summarise, review and clarify we note the manner in which something is said, as well as what was actually said. We use a mainly open questioning style, using closed questions to clarify fact, or to redirect the interview after a possible diversion. We attempt also to use positive body language throughout the assessment.
We place an emphasis on observed behaviour. The observation process starts as soon as we meet the individual. For example, information could be gathered on their hearing ability (when their name is called at the reception area or whether or not they hear the doorbell at a home visit).
Further observation could provide evidence about other areas such as lower limb function (when rising from a chair and walking, for example), upper limb function (when carrying a bag or opening doors), and other areas of functional ability.
Similarly, the examination in disability analysis has a different focus from that used in traditional clinical medicine. Our examination is used to assess the degree of function, rather than to derive the diagnosis of the condition present (although it is important to take the diagnosis into account).
We apply familiar examination techniques, but we use those techniques in a different way to gain information regarding the functional ability. Our physical examination is focused on a functional area (for example the lower limbs, rather than just a single joint of one leg).
Disability analysts do not have a therapeutic role in assessments and we do not provide ongoing care to the individual.
Our responsibility is to provide an impartial report. In most instances this will be used in relation to a claim to benefit or insurance benefits. Any decision on entitlement is taken by a decision maker who may well be non-medical. They make their decision about entitlement in accordance with benefit legislation or the terms of the particular insurance scheme. We provide them with appropriate advice, which is given on the balance of probability.
We are able to give this reasoned advice by using our knowledge of the history and effects of the conditions present to predict the likely effects on the individual’s function. We use logical reasoning to assess all the evidence available to us (functional history, observations, examination and any other information such as a report from the GP), and then give a justified opinion to the decision maker.
Let us consider an example: A 45-year-old man has a 12-month history of back pain and sciatica found to caused by a prolapsed inter-vertebral disc. He has been called for an examination by a disability analyst. The disability analyst would use the five steps while carrying out the assessment.
History of back pain, treatments, employment. The effects on daily living.
Observation of movements seen informally and formally.
Examination of spine, lower limbs.
Logical reasoning to assess all the available evidence.
Justified opinion based on the evidence and giving explanations.
As disability analysts, we are aware of the various models of disability we use the bio-psychosocial model (Models of Disability, 2002, Waddell G, Royal Society of Medicine Press).
This model of disability reconciles and extends beyond the medical and social models, taking into account biological, mental health issues, and social factors. It recognises there are multiple facets to disability that need to be acknowledged fully to understand its effects and focus any rehabilitation efforts. This model supports the approach to otherwise medically unexplained symptoms. We therefore take a totally holistic approach.
In our clinical work, we have all come across patients who have exactly the same disease process or impairment, but the degree of disability is completely different.
Some are rendered housebound by arthritis of their hips, while others appear to continue their normal activities. Some of the differences can be identified in relation to personality and motivation, but the local environment, personal and emotional factors are all important in the response to any impairment.
We also realise that diagnosis and age play a role in the level of disability resulting from a similar impairment we are aware that the effects of other co-existing disabilities have to be considered. When undertaking a disability assessment, the ‘whole person’ and the environment have to be considered.
So it is clear that disability analysis is distinct from other branches of medicine. As such, we need specialists in this area of clinical practice.
Disability analysts assess the functional effects of a person’s disability. Diagnosis and treatment are important, but these are usually the starting point in disability analysis, whereas they are often the end result in more traditional clinical medicine.
Dr Peter Ellis is medical training developer at Atos Healthcare. Atos healthcare is a provider of specialists in disability assessment.
CPD quiz: Disability asessment
Life-long learning and continuing professional development (CPD) are the processes by which professionals, such as nurses, develop and improve their practice.
There are many ways to address CPD: formally, by attending courses, study days and workshops or informally, through private study and reflection.
Reading articles in professional journals is a good way of keeping up to date with what is going on in the field of practice, but reflecting on what you have learned is not always easy.
These questions are designed to help you identify what you have learned from studying the article. They will also help you to clarify what you can apply in practice, what you did not understand and what you need to explore further.
1 By what name are specialist practitioners known as in disability assessment?
a) Disability nurses
b) Disability doctors
c) Disability analysts
d) Disability therapists
2 How many steps are there in disability analysis?
3 Which of the following is NOT one of the disability analysis steps?
a) Functional history
b) Logical reasoning and justification of opinions
c) Observation and focused examination
4 What do they call the focus on day-to-day living?
a) Typical day approach
b) Day-to-day assessment
c) Hobby and outside work assessment
d) Overall approach
5 What does disability assessment place an emphasis on?
a) Therapeutic analysis
b) Individuals’ diagnosis
c) Observed behaviour
d) Clinical history
6 What is the examination used to assess?
a) Degree of function
c) Further observation
7 What role does the disability analyst NOT have in disability assessment?
a) History taker
8 What model do disability analysts use?
9 In disability assessment, what else needs to be considered besides the whole person?
a) The employer
b) The family
c) The job
d) The environment
10 In the case study, what physical examination was undertaken?
a) Ears and eyes
b) Spine and lower limbs
c) Cervical spine
d) Spine and upper limbs
1. c – Disability analysts may be doctors, nurses or other healthcare professionals who have received specific training. Consider if you have the necessary knowledge and skills to undertake disability analysis in your OH role.
2. b – Review the five steps and consider how they differ from the traditional approach to clinical assessment. How relevant is this approach to OH and is it a useful approach?
3. d – A diagnosis has already been made by another clinician so there is no need to repeat the process.
5. c – Consider what skills are needed here, make a list and discuss with your professional mentor or a respected colleague how well you perform with these skills.
6. a – Start to check yourself observing your clients from the time you first meet them. Then after a week or two consider whether since reading this article you make more observations about your clients.
8. c – What do you know or understand about the bio-psycho-social model? Use some of the other resources listed to explore and find out more or undertake an internet search for more information.