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Medical Articles »Krzysztof Izdebski, Ph.D.
The Challenge of Determining Work-Related Voice / Speech Disabilities in California
Krzysztof Izdebski, Ph.D.
Voice-Speech Pathophysiology
Krzystof Izdebski, E. David Manace, and Janice Skiljo Haris
The California Workers’ Compensation System (CWCS) is a no-fault, medically-driven benefit system which requires a state-appointed, Qualified Medical Evaluator to determine whether a worker should receive benefits that include lost wages, permanent disability award payments, future medical treatment, and vocational rehabilitation. California employers face challenges with their work injuries because the increasing cost of disability claims (indemnity claims) continues to increase. The California Workers’ Compensation Rating Bureau, which reviews employer-insured data, estimated disability losses increased from 55.9 billion in 1997 to $6.4 billion in 1998. Since 1993, the average cost of an indemnity claim has risen by 51% (1). These claims recently cost California employers billions more for insurance costs, claims payments, legal costs, medical costs and other workers’ compensation-related fees. Although work-related voice / speech injury claims are less common than back injuries or noise-induced hearing loss, voice / speech claims are expected to grow exponentially over the next decade. Increasingly, more workers are using their voice on the job and because new technologies such as voice-activated computers utilizing human voice are rapidly being incorporated into the work place.
Work injuries involving hearing loss, spine, knee and cardiac conditions all have established guidelines under the California Schedule for Rating Permanent Disability, in order to assist the physician in determining the worker’s level of permanent impairment and limitations. In contrast to other occupational injuries, objective criteria to determine voice/speech disability are lacking. Moreover, evaluation of the voice claims are typically conducted solely by an ear nose and throat (ENT) surgeon or general practitioner, who, although may have experience in evaluating injured workers, typically lack, by virtue of education and training, the necessary expertise to assess communication disorders.
This paper presents our model for the medical-legal evaluation of voice / speech injuries in the assessment of permanent disability in California. The purpose of conducting this type of evaluation is primarily to provide all parties (employee, employer, insurance examiner and / or attorneys) with a thorough assessment of the alleged injury, and also objectively to determine any residual permanent disability.
The Multi-Disciplinary Voice / Speech Evaluation Model
According to the California Labor Code, permanent disability is a permanent medical or mental condition, which results in an inability or reduced ability to compete in the open labor market (2). Factors of disability are the terms used to describe legal permanent disability, which takes into consideration objective and subjective factors. Objective factors of disability are those findings on physical examination that can be directly measured, observed or demonstrated, and are not under the control of the patient (3). Currently, there are no scheduled medical criteria for speech disorders to measure objective factors. For California disability rating purposes, subjective factors of disability refer to pain only, and involve factors that are within the control of the patient and cannot be observed, measured or controlled.
Physician determination of final voice / speech permanent disability must not only take into consideration objective findings and subjective factors, but also follow the state guidelines reflected in the Schedule for Rating Permanent Disabilities for injuries occurring on or after April 1, 1997. This was developed under the provisions of the California Labor Code regarding speech injuries, which are inadequate in our opinion. Specifically, there are only two ratings of this in the current Schedule for Disabilities Affecting Speech, Section 5.2: 1. Complete loss of speech, subsection 5.21, lists a 50% standard disability rating; 2. Difficulty in speaking (hoarseness, indistinct articulation, etc.) lists a 10% standard disability rating (4). A professional rating specialist from the California Disability Evaluation Unit determines and assigns the percentage of permanent disability, while the Qualified Medical Evaluations physician presents the disability factors or determines work restrictions based upon the examination findings.
In the CWCS, subjective findings are limited to pain complaints and the physician’s ability to characterize those complaints. The physician must characterize pain complaints in terms of both intensity and frequency levels. There are four descriptions of ‘intensity,’ or the level of pain that the Qualified Medical Evaluations must use to characterize the subjective factor of disability for pain: "minimal," "slight," "moderate," and "severe." Minimal pain would constitute an annoyance and would cause no handicap in the performance of a particular activity, slight pain can be tolerated but would cause some handicap in the performance of the activity precipitating the pain, moderate pain can be tolerated but would cause a marked handicap in the performance of the activity precipitating the pain, while severe pain precludes the activity precipi-tating the pain.
Additionally, there are four descriptions or "frequency," or how often the pain occurs, that the Qualified Medical Evaluations must use to characterize the subjective factor of disability for pain: "occasional," i.e., approximately 25% of the time; "intermittent," i.e., approximately 50% of the time: ‘'frequent," i.e., approximately 75% of the time; and "constant," i.e., 90-100% of the time (3) (5). We use these systems when describing odynophonia (6-7).
The evaluating physician, who is either a Qualified Medical Evaluations or an Agreed Medical Evaluator, has the duty to provide a written report compiling the relevant medical evidence to be used in the resolution of claims and disputes. As stated before, in the State of California, this may be an ENT, surgeon or a general medical practitioner, both typically lacking the ability to provide objectively measurable expertise in the evaluation of communication disorders. The limitations of the medical evaluator and the sparse guidelines submitted by the Permanent Disability Rating Manual leaves determination of the impairment wide open to a variety of errors and misrepresentation, and may compromise the interests of both parties, worker and employer.
Our response to this evaluation challenge was to introduce a multi-disciplinary voice / speech evaluation model. Our model differs fundamentally from the traditional approach in that it includes a double medical specialty complex evaluation for laryngeal and voice / speech disorders. This is through a complex and combined laryngeal examination by a Qualified Medical Evaluations appointed otolaryngologist, together with special testing that includes phonoscopic (laryngovidcostrohoscopic examination) and acoustic analysis by a voice / speech pathologist, a professional uniquely qualified to evaluate communication disorders. Voice / speech examination by phonoscopy and phonatory analysis includes a complete battery of objective instrumental evaluation and documentation (8-15).
Because our combined report reflects the unique professional education and expertise that pertains to the health and functions of the anatomical parts that make up the act of voice and speech, it inherently complies with the CWCS guidelines for conducting a disability evaluation. These guidelines are reflected in our model (and, in our opinion, are not met when the examination is conducted solely by one professional), because our report covers all objective and subjective factors that CWCS recommends to be addressed during the evaluation process. Our model also addresses work restrictions and the loss of pre-injury capacity.
The objective voice factors comprise parameters that can be directly measured, observed and demonstrated. These include acoustic findings that pertain to voice / speech quality and intelligibility including: pitch, loudness, duration, rate, melody, pausing characteristics, etc. Objective findings also include visualization of vocal / speech mechanics via a synchronized computer-driven, slow-motion stroboscopic illumination technique. This technique is considered to be the only objective means capable of unequivocally describing the mechanism of voice and speech as used by the claimant to generate sound (9) (14).
The combined acoustic-physiological tests conducted by the voice pathologist reflect the range of motion, strength and disfigurement or dysfunction of the act of producing voice and speech. When needed, special tests are utilized. Of specific interest is the test that assesses the vocal fatigue factor, a common factor in a voice injury claim. In such a test, voice production is continuously evaluated over time and pertinent voice parameters are evaluated objectively. This test gives improved understanding of possible malingering issues, and provides the Qualified Medical Evaluations with objective data on how voice changes as a factor of repeated usage over time. When appropriate, a multidimensional acoustic profile is taken at pertinent time intervals. Trends representing change in the signal characteristics are noted. To simulate work noise environment, a variable background noise is introduced during reading. The presence of associated somatic signs, i.e., throat clearing, coughing, etc., are noted. Overall voice quality is scored on a 1-5 point scale for the presence or absence of breathiness (B), overpressure (O), periodicity (A), Tremor (T). The evaluator’s opinion of patient's fatigue factor is also noted on 1-10 point scale (10).
Resultant objective observations are extrapolated to form a functional voice assessment scale of phonatory change over time. For quick overview, the test results are presented in an easy-to-follow, graphic way. To further examine functional and/or compensatory components of alleged voice problems, the delayed auditory feedback voice test is used (16). This test also provides information on functional components of the worker’s voice characteristics. Other tailor-made voice tests are employed when examining professional voices, i.e., singers, teachers, stockbrokers, etc. (17). The aim is to examine voice problems in a setting relevant to the claimant’s voice usage profile. The other objective part of the voice/speech examination includes psychoacoustic (perceptual) judgments of the manner used in voice/speech production, reflecting habitual production mannerisms that must be separated from work-related causes.
Determination of voice / speech permanent disability
The voice pathologist provides the Qualified Medical Evaluations with a written voice pathology report that covers acoustic, psycho-perceptual and physiological parameters of voice and speech production. In this way, the speech pathology findings provide the Qualified Medical Evaluations with complete objective measurements to determine the final level of disability, if any. The Qualified Medical Evaluations incorporates these findings into a report and provides a final opinion regarding permanent disability, together with other medical-legal issues. Overall disability is determined by the experienced Qualified Medical Evaluations physician who takes into consideration the objective findings on examination (including test results) and the subjective pain factors as characterized by that evaluator to determine the overall permanent disability. Overall disability is either discussed in work restriction terms or based upon the objective and subjective findings. For example, the Qualified Medical Evaluations may state that the worker has a disability equal to the objective and subjective actors listed as a speaking difficulty level of moderate hoarseness and pain characterized as intermittent slight to moderate. Or the Qualified Medical Evaluations could determine that the worker’s permanent disability is such that the worker’s voice usage is restricted.
Conclusions
Our multi-disciplinary and complex testing evaluation approach and report provides the Qualified Medical Evaluations with a quantifiable basis, not only for disability rating, but also for the determination of other benefits to which the worker may be entitled. The comprehensive and complete information assists the Qualified Medical Evaluations in the determination of other complex workers’ compensation-related medical-legal issues, which we were unable to cover in this article. For example, our combined report provides qualified evidence that the legal system needs better answers to the question of whether the injury arose out of employment (causation) or whether it is a ‘derivative’ injury caused by treatment complications secondary to an industrial injury. If the job aggravated a pre-existing disability, the Qualified Medical Evaluations would be asked to determine how much of the final permanent disability would have occurred without the employment, this is also known as legal apportionment and concepts of overlap or duplication (18). The Qualified Medical Evaluations must also determine the appropriate compensation for lost wages on a medical basis, as well as any future medical treatment necessary for the work injury, or whether the worker can return to work, or is eligible for any vocational rehabilitation.
We believe that, with our multi-disciplinary approach, both parties (employer and worker) are served in a qualified, thorough, and unbiased objective professional manner. Hence, the worker’s access to all benefits is appropriate and the employer’s assessment of benefits responsibility is protected. In summary, we believe that our model of examining voice / speech injury claims is the preferred way of complying with CWCS requirements and guidelines. In this way, we secure the access of the worker to all benefits and entitlements, and, at the same time, provide relevant and objective information to the requesting agency.
References
(1) Rising cost of claims drives up workers' compensation losses, but not premium rates; loss ratio to hit 100 for 1998: California Workers' Compensation Reporter, A Monthly Bulletin of Key Developments in Workers' Compensation Law, Vol 27, No 10, Nov. 1999, Berkeley, CA
(2) The Workers' Compensation Laws of California, 1999 ed. New York, NY; Matthew Bender
(3) Physician's Guide to Medical practice in the California Workers' Compensation System, Industrial Medical Council, Department of Industrial Relations, State of California, 1994
(4) Schedule for Rating Permanent Disabilities Under Provision of the Labor Code of the State of California, April 1997, Department of Industrial Relations, Division of Workers' Compensation, Sacramento, CA
(5) Frost RE: Speed Rater, Fremont, CA, USA. 1999
(6) Izdebski K, Dedo HH, Mance ED: Odynophonia: what is it and is there a solution? In: Digest of the Ninth Annual Pacific Voice Conference, San Francisco, CA, San Diego, CA: Singular Publication Press 1997
(7) Izdebski K, Dedo HH, Nobre F: Odynophonia: what is it and can it be treated? In: Proceedings of the 2nd World Voice Conference and 5th International Symposium on Phonosurgery, Sao Paulo, Brazil, February 8-11, 1999, pp 50-51
(8) Izdebski K: the voice load test: an objective acoustic test to assess voice quality as a factor of voice usage over time. In: Proceedings of the 2nd World Voice Congress and 5th International Symposium on Phonosurgery, Sao Paulo, Brazil, February 8-11, 1999, pp 50-51
(9) Leonard R, Izdebski K: Laryngeal impaging with stroboscopy; its value in therapeutic assessment. In: Pais Clemente M (ed) Voice Update. International Congress Series 1997. Amsterdam: Elsevier 1997
(10) Izdebski K, Ward R: Differential diagnosis of ADD-ABDuctor spasmodic dysphonia, vocal tremor and ventricular dysphonia by auditory and phonoscopic observations. In: Pais Clemente M (ed) Voice Update. International Congress Series 1997. Amsterdam: Elsevier 11997
(11) Izdebski K, Saviano M, Baron BC, Klein J, Ross JC, Ward R: Phonatory and non-phonatory voice rest in treatment of soft mucosal lesions. In: Izdebski K (ed) Digest of the Sixth Annual Pacific Voice Conference, San Francisco, CA, San Diego, CA: Singular Publication Press 1993
(12) Morgan DE, Frattali CM, Bosone ZT, Cyr DG, Hayes D, Izdebski K et al: Neurophysiologic intraopenative monitoring. ASHA Suppl 7, 34(3): 34-36, 1992
(13) Izdebski K, Ross JC, Klein JC: Rigid transoral laryngovidscostroboscopy (phonoscopy). Sem Speech Hear Lang 11(1): 16-26, Feb 1990
(14) Izdebski K: Practical techniques of office voice recordings. Otolaryngol Head Neck Surg 91: 338-243, 1983
(15) Izdebski K: Magnetic sound recording in laryngology. Am J Otolaryngol 2: 48-52, 1981
(16) Izdebski K: The usage of delayed auditory feedback in testing of voice disorders. Electron J Occupational Voice Speech Disorder 1: 2000 (submitted). SF, CA, USA
(17) Izdebski K: Simulation of work conditions during evaluation of occupational dysphonia. Electron J Occup Voice Speech Disorder 1:2000 (submitted). www.pvsf.org, SF, CA USA
(18) Kahn ML: Understanding apportionment, overlap, duplication and the combining of successive industrial injuries, Workers' Compensation Quarterly, Workers; Compensation Section of the State of California, Vol 23, No 1, Spring 1999, San Francisco, CA
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