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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.

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 ...

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