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Wong-Baker Pain Scale & Workers’ Compensation

Posted on October 4, 2020 by Edward Singer

Frequently Injured Workers, when attending workers’ compensation evaluations and treatment are asked to fill out a lot of questions and forms. One of these forms that they may have to fill out is the Wong-Baker FACES® Pain Rating Scale.

These Scales can impact an Injured Worker’s industrial claim.

This article will discuss the Wong-Baker FACES® Pain Rating Scale, how It is used in a Workers’ Compensation claim, and how it can impact an Injured Worker’s claim.

What is the Wong-Baker FACES® Pain Rating Scale?

The Wong-Baker Pain Rating Scale is a tool which is used to allow for patients to provide a self- assessment of their pain. It was created by Donna Wong and Connie Baker in 1983 to help children communicate about their pain. .

Part of the goal is to improve the assessment by using the scale for the purposes of assisting in pain management. The Wong-Baker Faces Foundation indicate that the Scale is self-assessment tool [that] must be understood by the patient, so [that[ they are able to choose the face that best illustrates the physical pain they are experiencing. The Foundation note that the Scale is “not a tool to be used by a third person, parents, healthcare professionals, or caregivers, to assess the patient’s pain. There are other tools for those purposes”.

What Does the Scale Look Like? How It is Scored?

The picture above is a version of the scale. This picture was taken off of the Wikipedia article. The Scale is copyrighted. The Scale is proprietary. Therefore, if you are interested in the material you should contact the Foundation.

The instructions for its usage is to “explain to the person that each face represent a person who has no pain(hurt), or some, or a lot of pain.” “Face 0 doesn’t hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little bit more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have his worst pain.”

The person is asked to choose the face that best depicts the pain they are experiencing. Supra.

Besides the Scale, the Patient may be asked to “to mark their areas of pain on a drawing of a human figure then rate each area using the faces scale.”.

What Was This Scale Designed for? What is Your Opinion Concerning It?

Originally, it was designed for children to help them communicate their pain.

In California, there are a number of Injured Workers who do not speak English. There are some Injured Workers who are illiterate. Some are illiterate even in their language of origin. This type of Pain Scale can assist these individuals express themselves with respect to their pain. It is noted by the Foundation that for children there was “considerable difficulty using any scale with unfamiliar words or scales based on numbering or ranking concepts. The use of the Numeric Rating Scale [were] growing in popularity at this time, but young children had trouble using the numbers.” Thus, this type of scale is of some value with certain Injured Workers.

With respect to other workers, the Scale is more problematic. In the world of workers’ compensation, there is a focus on activities of daily living and how an injury impacts them. This particular scale, while it may be effective with respect to ascertaining pain information for other reasons, does not provide information used for disability assessment in the workers’ compensation system.

With respect to Adults, pain is viewed must differently than with children. Adults react to pain as an irritation, a distraction, frustration, and may generate anger and upset. Adults do not necessarily cry because of their pain. Most adults, however, can understand how the scale signifies a range from no pain to extreme pain. In sum, its inquiry is superficial. Again, this is not an indictment of the Scale, it is simply the problem that occurs when it is employed for something it was not intended for.

How Can The Wong-Baker Scale Be Used For In Workers’ Compensation?

In my opinion, the Scale may have some credibility value. Also, it may document the trajectory of an Injured Worker’s condition. If this Scale is used on multiple occasions, one can look to see how consistent the reporting it. Also, it can possibly bring light to possible exaggeration. Scores at level 10 may give rise to suspicion of exaggeration.

Any Advice Concerning the Scale?

It is very important for Injured Workers to try to be accurate with respect to the score. While providing a “10” may be a “cry for help,” I would suggest that the Injured Worker actually “cry for help” and tell the evaluator or treater that they are experiencing some level of frustration with respect to their treatment and their relief from the pain. This will prevent an allegation of exaggeration.

What If I Need Advice?

If you would like a free consultation concerning any workers’ compensation case, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 28 years. Contact us today for more information.

THE OWESTRY DISABILITY INDEX(ODI) AND WORKERS’ COMPENSATION: BACK INJURIES, EVALUATIONS, TREATMENT AND INDEXES: WHAT YOU NEED TO KNOW

Posted on August 14, 2020 by Edward Singer

Injured Workers are frequently given questionnaires and indexes to fill out as part of their workers’ compensation treatment and evaluations. These questionnaires and indexes can play an important role with respect to workers’ compensation benefits.

One of the indexes that an Injured Worker may encounter is the Owestry Disability Index. This article will discuss the Owestry Disability Index (ODI), what it is used for, how is it scored, problems with scoring, and how it is used for in the workers’ compensation setting.

Why Are Indexes Used?

Indexes are a quick way of address one’s disability state. Sometimes, simple questions can provide an accurate picture as to an Individual’s physical state and their capabilities. In Workers’ Compensation, due to the employment of the American Medical Association Guide to the Evaluation of Permanent Impairment, 5^th Edition, there is a focus on an Individual’s “Activities of Daily Living.” For an article on Activities of Daily Living, click here.

What is the Oswestry Disability Index?

“The Oswestry Disability Index (ODI) is one of the most commonly used outcome measures for individuals with low back pain (LBP)”Psychometric properties and clinical usefulness of the Oswestry Disability Index, Michael Vianin J Chiropr Med. 2008 Dec; 7(4): 161–163.

doi: 10.1016/j.jcm.2008.07.001 PMCID: PMC2697602 PMID: 19646379

“The ODI is a self-administered questionnaire that requires 5 minutes to complete and 1 minute to score. Scores are associated with degree of disability ranging from minimal to bedbound. The ease of administering, scoring, and interpreting renders the ODI a potentially meaningful tool in clinical practice.” Supra.

What is the Owestry Disability Index Used For?

As noted above, the Owestry Disability Index is used to make assessments for Low Back Injuries. Essentially, it is the self-reporting of the Patient.

For workers’ compensation purposes, functional status is important in assessing a variety of workers’ compensation issues. These issues can include disability status- temporary total, permanent and stationary, permanent total disability, and credibility. Credibility can speak towards the truthfulness of the Injured Worker’s complaints versus possible malingering. A physician encountering malingering may use that finding as a basis to cut-off temporary disability benefits or assign a low level of impairment/permament disability.

“The ODI is a valid, reliable, and responsive condition-specific assessment tool that has withstood the test of time and scrutiny.³ So far, it has been used mostly in chronic and severely disabled populations, but shows good indicators for the assessments of less severe complaints.” Supra.

How Does Owestry Approach Back Injuries?

The Owestry Disability Index looks at the Injured Worker’s ability to perform Activities of Daily Living. The Index focuses on 10 sections designed to make such an assessment. Each section is scored with a 0-5 number. 0 being the least disability and 5 being the greatest.

What Are The Questions Asked in the Owestry Disability Index?

PAIN INTENSITY

I can tolerate the pain I have without having to use pain killers

The pain is bad but I manage without taking pain killers

Pain killers give complete relief from pain

Pain killers give moderate relief from pain

Pain killers give very little relief from pain … Pain killers have no effect on the pain and I do not use them

PERSONAL CARE (e.g. Washing, Dressing)

I can look after myself normally without causing extra pain

I can look after myself normally but it causes extra pain

It is painful to look after myself and I am slow and careful

I need some help but manage most of my personal care

I need help every day in most aspects of self care

I don’t get dressed, I was with difficulty and stay in bed

LIFTING

I can lift heavy weights without extra pain

I can lift heavy weights but it gives extra pain

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table

Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned

I can lift very light weights

I cannot lift or carry anything at all

WALKING

Pain does not prevent me walking any distance

Pain prevents me walking more than one mile

Pain prevents me walking more than ½ mile

Pain prevents me walking more than ¼ mile

I can only walk using a stick or crutches

I am in bed most of the time and have to crawl to the toilet

SITTING

I can sit in any chair as long as I like

I can only sit in my favorite chair as long as I like

Pain prevents me from sitting more than one hour

Pain prevents me from sitting more than ½ hour

Pain prevents me from sitting more than 10 minutes

Pain prevents me from sitting at all

STANDING

I can stand as long as I want without extra pain

I can stand as long as I want but it gives me extra pain

Pain prevents me from standing for more than one hour

Pain prevents me from standing for more than 30 minutes

Pain prevents me from standing for more than 10 minutes

Pain prevents me from standing at all

SLEEPING

Pain does not prevent me from sleeping well

I can sleep well only by using medication

Even when I take medication, I have less than 6 hrs sleep

Even when I take medication, I have less than 4 hrs sleep

Even when I take medication, I have less than 2 hrs sleep

Pain prevents me from sleeping at all

SOCIAL LIFE

My social life is normal and gives me no extra pain

My social life is normal but increases the degree of pain

Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. dancing, etc.

Pain has restricted my social life and I do not go out as often

Pain has restricted my social life to my home

I have no social life because of pain

TRAVELLING

I can travel anywhere without extra pain

I can travel anywhere but it gives me extra pain

Pain is bad, but I manage journeys over 2 hours

Pain restricts me to journeys of less than 1 hour

Pain restricts me to short necessary journeys under 30 minutes

Pain prevents me from traveling except to the doctor or hospital

EMPLOYMENT/ HOMEMAKING

My normal homemaking/ job activities do not cause pain.

My normal homemaking/ job activities increase my pain, but I can still perform all that is required of me.

I can perform most of my homemaking/ job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming)

Pain prevents me from doing anything but light duties.

Pain prevents me from doing even light duties.

Pain prevents me from performing any job or homemaking chores.

See Fairbank JC, Pynsent PB. “The Oswestry Disability Index.” Spine 2000: 25(22):2940-2952; Fairbank JCT, Couper J, Davies JB. “The Oswestry Low Back Pain Questionnaire.” Physiotherapy 1980; 66:271-273

How It is Scored? Is There a Problem With Scoring?

“The index is calculated by dividing the summed score by the total possible score, which is then multiplied by 100 and expressed as a percentage. Thus, for every question not answered, the denominator is reduced by 5. If a patient marks more than one statement in a question, the highest scoring statement is recorded as a true indication of disability.” Oswestry Disability Index Scoring Made Easy A Mehra, D Baker, S Disney, and PB Pynsent Ann R Coll Surg Engl. 2008 Sep; 90(6): 497–499. doi: 10.1308/003588408X300984

Scoring of the test can be problematic. First, the individual may not understand the questions asked and answer them incorrectly. There can be language or literacy issues that can come into play. Second, the individuals scoring the test may not use the highest score or may calculate the result appropriately. See Oswestry Disability Index Scoring Made Easy A Mehra, D Baker, S Disney, and PB Pynsent Ann R Coll Surg Engl. 2008 Sep; 90(6): 497–499. doi: 10.1308/003588408X300984 (re: Issues concerning staff scoring tests accurately and their training)

What Does the Score Mean?

The scores of ODI are as follow:

0 – 4 No disability

5 – 14 Mild disability

15 – 24 Moderate disability

25 – 34 Severe disability

35 – 50 Completely disabled

See Fairbank JC, Pynsent PB. “The Oswestry Disability Index.” Spine 2000: 25(22):2940-2952 Fairbank JCT, Couper J, Davies JB. “The Oswestry Low Back Pain Questionnaire.” Physiotherapy 1980; 66:271-273

What Do These Disability Terms Mean?

No disability The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting, sitting and exercise.

Mild disability The patient experiences more pain and difficulty with sitting, lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care, sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means.

Moderate disability Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation.

Severe disability Back pain impinges on all aspects of the patient’s life. Positive intervention is required.

Completely disabled These patients are either bed-bound or are exaggerating their symptoms.

Supra.

What Does This Mean In Workers’ Compensation?

The Index can help address the credibility of the Injured Worker. Is the scoring commensurate with the pathology? For example, if someone scores “Completely Disabled” but has a minor back sprain, malingering comes into question. If someone post-back surgery scores as “Moderate”, they would most likely be viewed as credible. In sum, an ODI score can either raise a “red flag” concerning an Injured Work or be a confirmatory basis for assigning impairment, disability status or permanent disability.

What If I Need Legal Advice?

Activities of Daily Living (ADLs) & Workers’ Compensation: What You Need to Know

Posted on September 13, 2018 by Edward Singer

California Workers’ Compensation Law provides for the assessment of Permanent Disability based upon the American Medical Association Guides to the Evaluation of Permanent Impairment 5th Edition. When determining Whole Person Impairment, the AMA Guides employs an analysis of the injury’s impact on Activities of Daily Living.

Whole Person Impairment assignment is important for determining Permanent Disability. The purpose of the AMA Guides, within the California framework, is to provide a Whole Person Impairment for each injured body part. This Whole Person Impairment is then placed into a formula to calculate the Injured Worker’s Permanent Disability Percentage. It is that percentage which translates into monetary compensation.

This article is meant to explain what are the Activities of Daily Living, how they are analyzed, and how they can impact the assessment of the Injured Worker’s Whole Person Impairment.

Impairment Ratings and Activities of Daily Living, What is the Relationship?

Per the AMA Guides, “Impairment percentages or ratings developed by medical specialists are consensus-derived estimates that reflect the severity of the medical condition and the degree to which the impairment decreases an individual’s ability to perform common activities of daily living (ADL), excluding work.

Impairment ratings were designed to reflect functional limitations and not a disability. The whole person impairment percentages listed in the Guides estimate the impact of the impairment on the individual’s overall ability to perform activities of daily living, excluding work, as listed in Table 1-2. “Guides to the Evaluation of Permanent Impairment” at Page 4.

The fact that the AMA Guides excludes consideration of work activities provides some irony to the fact that the Guides are used to compensate Injured Workers on their Workers’ Compensation cases by considering the injury’s impact on Activities of Daily Living. In handling California Workers’ Compensation cases, these cases, there is always the concern that an Injured Worker may not be adequately compensated for their inability to perform their occupation, trade or job.

Impairment Ratings and Activities of Daily Living are related. In certain assessments of Whole Person Impairment, there are ranges of Whole Person Impairment within the tables for particular medical conditions. The impact of the injury on ADLs can impact the assessment of the Whole Person Impairment by the evaluating physician. In certain tables, the ranges are not very large. On other tables, the ranges are quite large. If the impact of the medical condition is significant to Activities of Daily Living, it is likely that the Examining Physician will provide a Whole Person Impairment number that is within the high range of either/or the class or table that is applicable.

What are the Activities of Daily Living?

Per the AMA Guides, Activities of Daily Living “include such activities as self-care, personal hygiene, communication, ambulation, travel, sexual function, and sleep. “

How are the Activities of Daily Living broken down?

Per the AMA Guides 5th Edition, Table 1-2, See Page 599, the following are the definitions of each ADL.

Self Care:

Urinating
Defecating
Brushing Teeth
Personal Hygiene
Combing Hair
Bathing
Dressing Oneself
Eating

Communication:

Writing
Typing
Seeing
Hearing
Speaking

Physical Activities:

Standing
Sitting
Reclining
Walking
Climbing stairs
Hearing
Seeing
Tactile Feeling
Tasting
Smelling

Sensory function:

Nonspecialized Grasping
Lifting
Tactile
Hand Activities
Discrimination

Travel:

Riding
Driving
Flying

Sexual function:

Orgasm
Ejaculation
Lubrication
Erection

Sleep:

Restful
Nocturnal sleep pattern

How is Impairment of Activities of Daily Living evaluated?

Limitations are to be judged by the medical disorders and not by other factors. Factors such as lack of money or transportation are not to be considered when addressing ADLs. See AMA Guides.

How is the impact of Activities of Daily Living assessed?

“In the context of the individual’s overall situation, the quality of these activities is judged by their independence, appropriateness, effectiveness, and sustainability. It is necessary to define the extent to which the individual is capable of initiating and participating in these activities independent of supervision or direction.” See AMA Guides at P. 361.

Who makes the Assessment on the impact of Activities of Daily Living and How?

In California Workers’ Compensation Law, the evaluating physician, either the Agreed Medical Examiner, Qualified Medical Evaluator, or Treating Physician, will make the assessment of the impact of activities of daily living.

In many Qualified Medical Evaluations and Agreed Medical Evaluations, the evaluating doctors will either directly ask the injured worker about their ADLs or provide the Injured Worker a written questionnaire to make such an assessment. Per the AMA Guides, “[t]he examiner must assess not simply the number of activities that are restricted but the overall degree of restriction or combination of restrictions.

For example, a person who is able to cook and clean might be considered to have marked restriction of daily activities if he or she were too fearful to leave home to shop or go to the physician’s office.” AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, Page 361.

Where Can I Get Legal Advice?

If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 26 years. Contact us today for more information.