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Functional Sequelae and Disability Assessment
Introduction
Advances in acute burn care during the past 25 years in terms of decreased mortality and decreased length of hospital stay have been truly remarkable. Current and historical perspectives on burn mortality can be found in preceding chapters. In almost every burn unit in the United States, the length of stay has decreased from nearly 3 days/% burn to less than 1 day/% burn. The success can be stated simply: patients with larger, more severe burns are surviving.
But if patients with larger and more severe burns are surviving, this has created new problems for patients' quality of life. Although the problems are magnified in massively burned patients, they exist also in smaller burns. These problems are demonstrated in a pediatric burn patient with a 95% total body surface area (TBSA) burn ( Fig. 63.1 ). Cultured keratinocytes were utilized to achieve wound coverage. The child survived; however, when we examined the patient's current and future reconstructive needs, they totaled 33 potential reconstructive procedures. Thus the reconstructive problems are monumental in a child with very few donor sites. With regard to survival, the results of this patient are impressive; however, we must ask the question: “Has the medical expertise in terms of survival progressed past the ability to reconstruct and rehabilitate patients?” Unfortunately the answer is clearly “yes.” Are we returning our patients to a society that is not ready financially, psychologically, or socially to accept them? Again, unfortunately, the answer is clearly “yes.”
Under Titles II and XVI of the Social Security Act, adult disability is defined as “the inability to engage in any substantial gainful activity, by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has or can be expected to last for a continuous period of not less than 12 months.” For children, the definition differs slightly, “a child under the age of 18 will be considered disabled if she or he has a medically determinable physical, mental, or combination of impairments that causes marked and severe functional limitations and that can be expected to cause death or last for a continuous period of not less than 12 months.” These guiding principles of functional assessment require a further definition. “Medically determinable impairment” means that the impairment(s) can be demonstrated, witnessed, or otherwise known and described by some third-party means. These may include laboratory tests, physical examination demonstrating signs of the underlying disease process, and disease-specific historical information elicited during the interview. When impairment results from two or more systems, the ratings should be combined according to a combined values chart or its underlying formula. Using the American Medical Association (AMA) formula, the first diagnosis-based impairment is subtracted from a 100% whole person, and each subsequent impairment is subtracted as a percentage of the remaining, or fractional, unimpaired person. Disability ratings can only be performed after a patient has reached maximal medical improvement. This concept is unfortunately both subjective and undefined but retains its utility when applied with equal measures of common sense and medical judgment.
Postburn System-Based Disability Assessment
Description of an alleged impairment should begin before physician introduction. Careful observation of general appearance: how an individual is groomed, enters the building, comports himself while waiting, interacts with clinical staff during check-in, and completes initial paperwork all provide useful, global insight into how his life has been impacted by burn injury and how he has adapted to it. A whole person's impairment depends on disruption of organ system function. For each system, impairment is categorized into five classes: 0 (no impairment), 1 (minimal), 2 (moderate), 3 (severe), and 4 (very severe). Generally, these correspond to function and symptoms, where 0 is no symptoms despite strenuous activity, 1 is symptoms only with strenuous activity, 2 is symptoms with normal activity, 3 is symptoms with minimal activity, and 4 is unabated symptoms. In cases where an objective measure is widely accepted to correlate with experiential symptoms, this objective measure becomes the key factor (e.g., see the section on respiratory function, which uses the results of pulmonary function tests as a key factor).
This classification allows assignment from no impairment to complete impairment of the system being evaluated, which can be expressed as a percentage of whole-person impairment. Within each diagnosis-based impairment class, impairment can be modified up or down based on additional clinical information or supplementary diagnostic tests. These vary somewhat for each condition (for full details please refer to the individual chapters in the most recent edition of the AMA's Guides to the Evaluation of Permanent Impairment ). The assessment of typical postburn sequelae is described in the following sections.
Constitutional
Body mass, composition, and growth curves in children provide important objective data regarding the overall magnitude of the postburn systemic insult. The weight trend, particularly compared with a preinjury weight, is helpful in estimating the loss of lean body mass, although confounding by body compositional changes does occur. In general, loss of 10–30% of body mass correlates with increasingly severe manifestations of malnutrition and catabolism, namely impaired wound healing, pressure sores, and pneumonia. Losses approaching 40% of preinjury body mass (in survivors seen for disability assessment) indicate a near-fatal systemic insult of malnutrition combined with postinjury hypermetabolism.
While the gold standard of body compositional analysis is potassium-40 scintillation counting coupled with deuterium oxide dilution measurement of total body water, whole-body dual energy X-ray absorptiometry (DEXA) provides a useful and more readily available surrogate. Whole-body DEXA scans provide bone density measurements of the axial and appendicular skeleton, as well as assessment of peripheral and visceral fat mass, bone mass, and extremity/central lean mass. Bone metabolism is markedly disturbed after severe burn injury; accordingly growth arrest is seen in growing (prepubertal) children. This is attributable to stalled endochondral bone formation. Patients are also prone to fracture from trivial trauma such as ground-level falls, and fracture healing is slowed.
Skin/Integument
As the organ most visibly affected by burn injury, photo-documentation of affected areas can provide efficient insight into the magnitude of the injury and the status of the healing process. Scars from healed burn wounds or skin grafts and donor site morbidity are described by TBSA and location. It is also important to note associated venous congestion, tissue edema, chronic wounds, pain, itch, tissue disfigurement, and distortion of adjacent unburned mobile structures (nipple, umbilicus, and/or genitalia) by burn scar contraction. Large burns (>20% TBSA) can result in homeostatic impairment of the skin. Manifestations may include subjective heat intolerance, impaired thermoregulation, and loss of sweat function in the scars, or cold intolerance owing to loss of adipose tissue insulation. The latter is of particular concern after deep or infected burns with fascial excision or other significant adipose tissue débridement in the course of burn care. While a goal of burn care is rapid, durable wound closure, chronic wounds still occur after burn injury. If present, these should be described including size, depth, location, exudate/odor, and status of the healing process/granulation tissue. Previously applied wound therapies should be described. If a wound has been present beyond 3 months, a more detailed assessment of the reasons for failure of healing is warranted (including malnutrition, pressure, infection/colonization, osteomyelitis, loss of sensation, tension, and lack of blood flow). This assessment may include a search for neoplasia (Marjolin's ulcer) and related examination of the draining lymph nodes because nonbasal cell skin cancer (not in remission) is assigned 58% whole-person impairment. The claimant's history is the key factor in classifying nonfacial skin/scar-related impairment, focusing on the impact of the skin-related conditions on an individual's ability to perform activities of daily living. Whole-person impairment resulting from nonface skin disorders can range from 0% to 58%.
Facial Injuries, Scars, and Ear/Nose/Throat Problems
Burn scars involving the face can be a significant cause of impairment. Beyond aesthetics, these may include cicatricial microstomia (causing weight loss and malnutrition), loss of facial expression, and nasal deformity/tissue loss with associated airway dysfunction and loss of humidification. Air passage deficits, including nasal injuries and vocal cord paralysis, are rated from 0% to 58% whole-person impairment based on the key factor of degree of dyspnea and interference with daily or work activities. Voice and speech impairment is rated at 0–35% of the whole person, based on the key factors of speech audibility, intelligibility, and functional efficiency of speech in everyday communication. Ear loss, in addition to the aesthetic deficit, can compromise sound localization/lateralization and make it difficult to wear glasses or similar headgear that rests on the ears. Auditory function may be compromised in several ways following burn injury. Significant blast injuries are associated with tympanic membrane (TM) rupture. Middle ear infection, often with TM perforation, may complicate convalescence from severe burns; multidrug-resistant organisms are usually observed, and clearance can require prolonged treatment. Resulting TM scarring may reduce auditory acuity. Several ototoxic medications (especially aminoglycosides and furosemide) are routinely used during critical care of the severely burned patient. The key factor for hearing evaluation is decibel threshold sum audiometry using 500, 1000, 2000, and 3000 Hertz sounds. Whole-person impairment from binaural hearing loss ranges from 0% to 35%, with the latter value reflecting complete hearing loss. Facial disfigurement is rated separately from overall skin assessment, and the key factor determining classification is the degree of facial anatomical distortion, loss of expression/facial features, and the degree of difficulty experienced by the patient in social settings due to facial disfigurement. Whole-person impairment resulting from facial scars/disfigurement can range from 0% to 45%.
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