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INTRODUCTION

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Disability and chronic pain commonly co-occur, particularly in the case of diagnoses with controversial etiologies. When disability impacts work, the contributory factors become even more complex, with occupational disability bearing scant relationship to a patient's specific clinical state. Given the weak relationship between medical diagnosis, clinical severity, and work disability, investigators have championed the decade of “yellow flags,” outlining a series of proposed predictors of work disability, including psychosocial, economic, and environmental factors. Identification of these factors in the individual patient can assist the clinician in achieving a better outcome. Conversely, failure to adequately assess can contribute to unnecessary or inappropriate treatment and chronic disability.

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Recent studies note that about 17% of people in the United States have a disability, or 54 million American people.1 Notwithstanding measurement difficulties, studies consistently reveal that people with disabilities are less likely to be employed than people without disabilities (21% vs. 59%), are more likely to live in poverty (34% vs. 15% as defined by less than $15,000 annually), are more likely to not have graduated high school (17% vs. 11%), and are more likely to have a significantly lower quality of life (34% vs. 61%).2 The problem is worldwide, although estimates across countries vary widely, largely because of the variability in the operational definition of disability. In addition, social factors and practice patterns of health care providers result in response bias.

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Even within a given state, work disability rates may show considerable variability over time based on economic conditions or local laws that reinforce changes in behavior. State law may eliminate benefits after a specified time, resulting in dramatically increased work return rates. Some states restrict access to subspecialists, another factor that may directly impact work disability.3 The U.S. Federal Social Security Disability Insurance (SSDI) program reported return-to-work rates that hovered at less than 1% for 25 years, with more recent changes resulting in financial incentives that encourage a return to part-time employment. In many cases, a patient's disability may have little relationship to diagnosis or any “objective” measure of physical impairment.

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Many studies report higher rates of physical disability in underdeveloped countries, particularly when more objective measurements are used.4 Not surprisingly, many individuals may work despite physical disabilities or pain, particularly if the government fails to provide a financial safety net. Conversely, the percentage of people who report chronic pain is significantly lower in developing countries (2.9%); the United States has a rate of 15.5%.5 Patients in developed countries may also expect that they should not or cannot work with chronic pain conditions, a belief system often shared by treating physicians.6 Chronic pain remains one of the leading factors contributing to disability in the United States, regardless of diagnosis or physical impairment.5,712

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Clinicians who care for patients with chronic pain are often fully aware of the high rates of disability. Lacking ...

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