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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 due to chronically
painful conditions.1 Much of these costs are related
to the disability process including workers’ compensation,
litigation, personal indemnity, lost productivity, and Social Security Administration
(SSA) payments. There has been a 73% increase in workers’ compensation
costs as a percentage of payroll 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 likely reflects state policy changes with more aggressive case
management.3 Given that during this same period
applications for SSI and SSDI rose by greater 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 than health care professionals
who treated these patients with a functional restoration approach.5 Perhaps
we demand too little from our chronic pain patients, therefore contributing
to increased disability.
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One question that is often raised is, what distinguishes those
individuals with chronically painful conditions that are disabled
from those that 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 for validation.
To illustrate the difficulty, it is all too common for a patient
with severe congenital scoliosis who has undergone spinal fusion with
instrumentation at multiple levels to have no pain and little in
the way of functional limitations. Contrast this to another typical
patient with a remote history of low back injury, minimal findings
on examination and imaging studies, and yet, who has, by self-report,
severe disabling pain. Many of the instruments used to predict outcome
that utilize the self-report of the patient in various ...