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CHAPTER OBJECTIVES

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  • Review key terminology (impairment, disability, and handicapped)

  • Review American Medical Association and Social Security Administration guidelines for impairment and disability

  • Contradictions of disability determination in chronic pain

  • Functional assessment methods in pain patients

  • Measuring pain intensity

  • Determining functional impairment

  • The role of diagnostic studies in disability assessment

  • The role of psychological assessment tools in disability assessment

  • Basics of disability evaluation

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OVERVIEW

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Approximately one-third of all Americans have a chronically painful condition; 50% to 60% of these individuals are partially or totally disabled. Cost estimates in the United States run as high as $79 billion a year in direct and indirect expenses, with 40 million physician visits annually because of chronically painful conditions.1 Many of these costs are related to the disability process, including workers’ compensation, litigation, personal indemnity, lost productivity, and Social Security Administration (SSA) payments. In the period from 1980 to 1994, there was a 73% increase in workers’ compensation costs as a percentage of payrolls in the period from 1980 to 1994, and in the same period, the medical costs in compensation cases rose 1.5 times faster than did general health care costs in the United States.2 Although from 1988 to 1996 the length of disability on workers’ compensation decreased by 60.9% and the average cost per claim decreased by 41.4%, this probably reflects state policy changes with more aggressive case management.3 Given that during this same period, applications for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) rose by more than 40% in 1992, one can assume that there may have been a shift from workers’ compensation to federal compensation. Interestingly, pain was a factor in 40% to 60% of these SSA claims.4 The reasons for this dramatic increase are multifactorial; increased social and vocational demands and change in work ethics may have contributed. Health care professionals themselves may be a significant cause of this change. In one study using the Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS), community health care providers had much lower expectations regarding the functional performance of patients with chronic low back pain (LBP) than health care professionals who treated these patients with a functional restoration approach.5 Perhaps we demand too little from our patients with chronic pain, therefore contributing to increased disability.

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One question that is often raised is what distinguishes individuals with chronically painful conditions who are disabled from those who are not. Ideally, one would expect that there would be major differences in disease severity that could be assessed with the use of standard clinical methods. What is frustrating for many physicians dealing with the question of impairment and disability in chronic pain is that there are no generally accepted standards to assess these differences. The pain field lacks the tests and examination techniques that rise to the level of a gold standard to which all other clinical methods can be compared ...

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