Disability Evaluation of Patients with Chronic Pain
James P. Robinson
Lee Glass
Issues related to the evaluation of work disability claims by patients with chronic pain have been considered in the third and fourth editions of Bonica’s Management of Pain. The purpose of this chapter is to build on the concepts and data provided in the earlier chapters. In particular, we hope to shed light on issues related to the evaluation of disability in chronic pain patients by contrasting the approaches to the problem taken by two disability agencies—the Social Security Administration (SSA) and the Washington State Department of Labor and Industries (DLI).
Basic Concepts
Many societies have programs of financial support for individuals with medical conditions that render them incapable of working. The agencies that administer these programs differ in many respects, but their broad mandate is to evaluate claims for disability benefits made by their constituents and decide whether to accept or reject the claims.
Agencies that administer disability benefits in the United States include the SSA, the Department of Veterans Affairs, the Department of Defense, the Office of Personnel Management, the Department of Labor, workers’ compensation carriers, welfare programs, and private disability insurance companies. These agencies have somewhat different eligibility criteria, but they all must answer the following questions when evaluating someone who applies for work disability benefits.
Does the applicant have a medical condition that might interfere with his or her ability to work? If so, what is the diagnosis?
How severely impaired is the body part or organ due to the person’s medical condition?
What kinds of activity limitations might the person reasonably be expected to have because of his or her impairment?
How do these expected activity limitations compare with the essential activities required by various jobs?
In addressing these issues, disability agencies generally emphasize the significance of objective medical evidence. They apply their conclusions regarding the facts of a case to the rules in their respective jurisdictions to determine whether a claimant is actually disabled. The basic challenge in the evaluation of chronic pain patients is that incapacitation that may be alleged is at least in part inherently subjective. This challenge was succinctly summarized in a monograph about the evaluation of pain for purposes of the SSA:
The notion that all impairments should be verifiable by objective evidence is administratively necessary for an entitlement program. Yet this notion is fundamentally at odds with a realistic understanding of how disease and injury operate to incapacitate people. Except for a very few conditions, such as the loss of a limb, blindness, deafness, paralysis, or coma, most diseases and injuries do not prevent people from working by mechanical failure. Rather, people are incapacitated by a variety of unbearable sensations when they try to work.1(p28)
Thus, the challenge for disability agencies is to reliably and consistently determine the extent to which “unbearable sensations” affect individuals who apply for benefits. If they discount “unbearable sensations” completely, they are likely to deny benefits to applicants who are actually unable to maintain employment. If they rely too heavily on statements of “unbearable sensations,” they might encounter two adverse outcomes: First, they might give preference to patients who communicate their struggles very effectively over more stoic patients who actually have more severe medical conditions. Second, because it is possible to feign severe pain, the agencies might award disability benefits to individuals with completely fraudulent claims.2,3,4,5
Conceptual and Empirical Issues
In order to study the role that chronic pain plays in work disability awards, observers and researchers must consider several issues. These were discussed in detail in the fourth edition of Bonica’s Management of Pain and will be summarized only briefly here.
IMPAIRMENT AND DISABILITY
Two concepts that are central to the functioning of agencies that administer disability programs are “impairment” and “disability.” Unfortunately, these terms do not have unique definitions because different disability agencies define them in slightly different ways.
Impairment
The definition of impairment given by the SSA is “anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.”6(p3) This definition captures essential features of the concept. A key point is that impairments are construed as biomedical abnormalities that can be analyzed at the level of organs or body parts. In fact, a critical distinction between impairment and disability is that they address limitations at different levels of analysis. Impairment refers to a limitation in the function or structure of an organ or body part, whereas disability refers to a limitation in the behavior of a person. This distinction is reflected in the syntax used to describe impairments and disabilities. For example, one would say “Ms. Smith’s right leg is weak because of her polio” to describe her impairment and “Ms. Smith is unable to walk up stairs” to describe her consequent disability. In summary, impairment can generally be considered to be a medical issue—typically, the presence of an abnormality that interferes with an individual’s normal functional ability.
Disability
In its broadest meaning, disability refers to an inability to carry out necessary tasks in any important domain of life because of a medical condition. Several distinctions need to be made regarding it.
First, a distinction needs to be made between self-reported disability and disability as a social construct. In medical research, it is common for investigators to use self-reported disability as an outcome variable. For example, patients might
be asked to complete the Roland-Morris scale, which assesses the extent to which they are limited in activities of daily living (ADLs) because of low back pain.7 In this sense, disability is specific to the individual and is often closely linked to impairment: “Because of her knee injury, Ms. Smith is unable to walk up stairs.” In contrast, “disability” for insurance purposes reflects a very different meaning. Government-regulated disability insurance systems, including workers’ compensation and Social Security, all to a greater or lesser degree reflect a societal view of what benefits should be awarded to an individual: “Because she cannot walk up stairs, Ms. Smith should be awarded X dollars.” This linkage of a term that refers at one level to something very specific to an individual, but at another level to a societal determination that is applied to all covered individuals, is often not fully recognized and is often the source of great consternation. Moreover, two different government systems, which may exist in the same geographical area, which offer benefits to the same covered populations, but whose benefits flow from decisions made by two separate and distinct legislative bodies, may offer greatly distinct benefits for what at the individual level may be the same disability.
be asked to complete the Roland-Morris scale, which assesses the extent to which they are limited in activities of daily living (ADLs) because of low back pain.7 In this sense, disability is specific to the individual and is often closely linked to impairment: “Because of her knee injury, Ms. Smith is unable to walk up stairs.” In contrast, “disability” for insurance purposes reflects a very different meaning. Government-regulated disability insurance systems, including workers’ compensation and Social Security, all to a greater or lesser degree reflect a societal view of what benefits should be awarded to an individual: “Because she cannot walk up stairs, Ms. Smith should be awarded X dollars.” This linkage of a term that refers at one level to something very specific to an individual, but at another level to a societal determination that is applied to all covered individuals, is often not fully recognized and is often the source of great consternation. Moreover, two different government systems, which may exist in the same geographical area, which offer benefits to the same covered populations, but whose benefits flow from decisions made by two separate and distinct legislative bodies, may offer greatly distinct benefits for what at the individual level may be the same disability.
If a disability agency determines that a patient is eligible for benefits, he or she is granted the social status of being disabled. As a consequence of this determination, he or she is exempted from selected customary societal obligations. If the type of disability in question is work disability, the individual may receive financial support to compensate for lost income.
An obvious but important point regarding disability as a social construct is that the process of disability evaluation starts when a person applies to an insurance company or disability agency. That is, the person alleges that he or she is disabled. The insurance company or disability agency then has the task of evaluating the claimant and deciding whether to accept or reject the allegation of disability.
A second distinction relates to the domain(s) in which activities are limited. For example, a C5 quadriplegic is disabled in the sense of being unable to carry out many basic ADLs. Such an individual might need an attendant to assist in the performance of ADLs. A person with early Alzheimer might be unable to manage financial affairs responsibly and thus might need a relative or friend to assume power of attorney. Individuals with a wide range of medical conditions might be disabled from work. Different disability agencies may include or exclude benefits for disability in these domains, depending on their legislative or contractual mandates.
Finally, there is a distinction between short-term and longterm disability. For example, injured workers who believe they are unable to work due to symptoms they consider to be work-related typically apply for benefits under a workers’ compensation claim. Most of these “time loss” claims are resolved within a matter of a few weeks because most workers return to work after a short period of disability.8 In contrast, some medical conditions produce limitations that continue for an individual’s entire life, so that the disability agencies to which they apply must decide whether to grant permanent disability benefits.
This chapter focuses on long-term or permanent work disability as a social construct.
ASSOCIATIONS BETWEEN IMPAIRMENT AND DISABILITY
Disability agencies typically require objective medical data that demonstrate that an applicant has a medical condition that causes impairment. They develop schedules and procedures that allow adjudicators to create linkages between applicants’ medical data and activity limitations that the applicants might reasonably be expected to have. In order to follow these procedures, they rely on the assumption of a strong linkage between impairment and disability. First, they construe impairment as a necessary condition for disability. The logic underlying this requirement is straightforward, especially in relation to work disability. Disability programs are designed to assist individuals who are unable to compete in the workplace because of a medical condition. In essence, disability programs attempt to partition individuals who fail in the workplace into two large groups: those who fail because of a medical condition and those who fail for nonmedical reasons. The distinction is necessary because there are many potential nonmedical reasons that may restrict employment, including a lack of demand for an individual’s skills or lack of motivation on the part of the individual. Disability programs require evidence that an applicant has a medical problem underlying his or her workplace failure. Impairment provides the needed evidence because it can be viewed as a marker that an individual has a medical problem, which diminishes his or her capability. Conversely, if an individual has no identifiable impairment, this implies that employment limitations are not due to a medical condition.
Second, disability agencies typically assume that the severity of a patient’s impairment correlates with the degree and/or probability of his or her being disabled from work. Even when an agency compensates for work disability and not for impairment, it will often seek information about the severity of a patient’s impairment to rationalize its decision about whether or not to award disability benefits.
Despite the administrative need of disability agencies to assume a tight relationship between impairment and disability, there is reason to doubt the strength of the relationship, at least when it comes to work disability. Observers over at least the past 75 years have noted that the ability of an individual to work depends on a host of factors, only some of which are medical.9 The widely held belief that work disability is a product of both medical and nonmedical factors implies that statistical associations between results of medical evaluations and severity of work disability would be expected to be modest.
THE “EMBEDDEDNESS” PROBLEM
One conceptual problem in any discussion of pain-related impairment is that pain is not completely distinct from medical conditions that cause organ/body part dysfunction. Rather, it is usually most appropriate to construe pain as a “component” of a medical disorder. From this perspective, it is arbitrary to examine the significance of pain in isolation from the medical condition underlying the pain, just as it would be arbitrary to evaluate shortness of breath in isolation from congestive heart failure. It would be seem conceptually appropriate to evaluate a medical disorder as an entity with characteristic signs, symptoms (e.g., pain), and pathophysiology. An impairment rating based on such an evaluation would take into account all manifestations of the disorder, including pain. Many disability agencies follow this logic; that is, they construe pain as one of many manifestations of injuries or diseases. This conceptualization involves the implicit and, in some cases, explicit assumption that impairment ratings based on objective evidence of derangement of organs or body parts capture the burden of illness borne by an individual, including the burden imposed by pain.
Unfortunately, this apparently plausible approach to the assessment of pain in the context of impairment ratings can run into either of two complications. First, pain severity may not (and often does not) correlate well with objective indicators of organ/body part dysfunction. In fact, empirical evidence has consistently demonstrated a low concordance between selfreports of pain and behavioral functioning (such as ADLs) or physiologic indices.10,11 In such situations, impairment ratings based strictly on objective findings are likely to fail to capture the burden of illness of the disorder.
A second and even more difficult situation involves conditions that are associated with severe pain but are not amenable
to conventional impairment ratings because they are not associated with unequivocal objective findings. In these conditions, it is not possible to make impairment ratings on the basis of such findings. Common examples include headache disorders and fibromyalgia (FM).
to conventional impairment ratings because they are not associated with unequivocal objective findings. In these conditions, it is not possible to make impairment ratings on the basis of such findings. Common examples include headache disorders and fibromyalgia (FM).
PRACTICAL PROBLEMS IN IDENTIFYING THE ROLE OF PAIN IN DISABILITY DETERMINATIONS
In order for an investigator to determine the role that pain plays in the decisions that a disability agency makes, it is necessary to consider a few basic questions. First, what benefits does the disability agency offer and to what individuals? Second, what methods do adjudicators for the agency follow when they evaluate a disability claim? Third, what are the outcomes of the evaluations? That is, claimants with which types of medical conditions typically receive benefits? Some disability agencies treat both their evaluation methods and the results of the evaluations as proprietary, so that investigators do not have access to either kind of data. Other agencies publish information about their evaluation methods; those used by two disability agencies (DLI and SSA) are discussed in the following text.
Even when information about the methods adjudicators use is available, it is often difficult to obtain and interpret data regarding the results of the evaluations. As discussed earlier, the problem is that pain is embedded in medical disorders in complex ways. For example, a patient with a chronic lumbar radiculopathy might have atrophy and weakness in one lower extremity, along with severe pain. If such a patient were awarded disability, it might not be clear whether the award was made on the basis of the objective evidence of lower extremity dysfunction or on the basis of chronic pain.
In some medical conditions, incapacitation may occur primarily because of pain, so that if disability is attributed to the conditions, it is likely that pain, rather than objectively measurable organ impairment, is the basis for the calculation of the disability. Examples of such conditions include most spine disorders (unless there is evidence of spinal cord injury or cauda equina syndrome), most sprains and strains (unless there is clear evidence of major ligamentous or muscle injury), and complex regional pain syndrome. Moreover, there are at least a few disorders in which pain is the dominant feature, and there is no definable associated organ impairment. The most prominent example of this is FM. A disability agency that allows self-reported pain to serve as a basis for concluding that an impairment exists may conclude that, in a given case, the impairment is of sufficient magnitude to warrant a declaration of disability. The same patient in a system that mandates the presence of a condition that can be verified objectively as a foundation for a declaration of disability may, in the absence of such evidence, be denied such a declaration.
In the following discussion, the aforementioned conditions are considered proxies for disorders in which pain is the major driver of impairment. But seeking such proxies does not necessarily make the role of pain in disability awards fully apparent. Disability agencies may provide only very general information about the medical conditions of claimants who are awarded disability. For example, data from the SSA indicate that 31.7% of Social Security Disability Insurance (SSDI) awards were given for conditions labeled as “Diseases of the musculoskeletal system and connective tissue” (2015 Statistical Report, Table 21).12 No details are given within this broad category, and it is virtually impossible to determine the role that claimants’ pain played in the decisions that the SSA made. For example, a claimant with severe loss of function in both hands due to rheumatoid arthritis is lumped together with a claimant with chronic low back pain.
Somewhat more useful data are available from the Bureau of Labor Statistics (BLS). Data from 2015 reveal that 37% of all work injury claims leading to time off work were coded as “sprains, strains, or tears,” and that an additional 16% were coded as “soreness, pain.”13 If we accept the premise that most of the patients diagnosed with “sprain” or “strain” receive the diagnosis when they present to health care providers with musculoskeletal pain but do not have clear-cut objective findings, it would appear that about 50% of the injuries that lead workers to take time off work involve pain as the major driver of incapacitation. The BLS also provides at least some data on the frequency with which spinal disorders lead to time off work. For example, in 2015, 31% of all time loss claims nationally were coded as musculoskeletal,13 and at least in Arkansas, 46% of musculoskeletal conditions were coded as “back” conditions.14 These data suggest that approximately 14% of claims leading to work disability are attributable to disorders of the spine. These figures are crude and address only short-term work disability. However, they strongly suggest that painful conditions are a major cause of time lost from work and may in many instances serve as the basis for declarations of disability.
Methods for Evaluating Chronic Pain in Applicants for Disability Benefits
The following discussion addresses the methods that adjudicators in two agencies use when evaluating pain in disability applicants—the SSA and the Washington State DLI.
EVALUATION METHODS IN THE SOCIAL SECURITY ADMINISTRATION
The U.S. SSA manages two disability programs—Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). The programs use the same medical criteria when determining whether a claimant is in fact disabled from work but differ in their nonmedical eligibility requirements.
Adults who become disabled after working long enough to meet the SSA’s “work credits” criteria15(p4) are eligible to apply to the SSDI program. The SSI program is available to individuals who do not meet the work credits criterion for SSDI eligibility and have very limited financial resources. It pays substantially less than the SSDI program. Many SSI recipients are children or adults who have been disabled since childhood.16
The present discussion focuses on adults applying for benefits under the SSDI program. For these claimants, disability is defined as “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”15(p2) “Substantial gainful activity (SGA)” is defined in terms of the amount of money the claimant is making or could make—in 2015, SGA was defined as making more than $1,090 per month.
The SSDI program is construed as a permanent (or at least long-term) disability program, and there is evidence that individuals who have been awarded SSDI rarely return to work.17,18
The SSDI and SSI programs represent the largest disability programs in the United States by a wide margin. More than 2.5 million Americans apply for benefits under one of the programs each year, and as of 2013, 12.71 million were receiving disability benefits.19
Adjudicators for SSA use the following five-step process in determining whether an applicant is to be awarded SSDI/SSI benefits (Fig. 22.1).20,21
Is the claimant currently engaged in SGA as defined earlier? If the claimant is engaged in SGA, he or she is not eligible for SSDI or SSI.
If not, does the claimant have a medically determinable impairment (or a combination of medically determinable impairments) that is severe and either has lasted for more
than 12 months or is expected to last that long? If not, the claimant is not eligible.
FIGURE 22.1 Social Security Disability Insurance steps.
If the criterion in step 2 is met, does the claimant’s impairment meet a “listing,” or is it medically equivalent to a listing? If yes, the claimant is awarded SSDI/SSI. If not, the evaluation proceeds to step 4.
Given the claimant’s impairment, does he or she have sufficient residual functional capacity to perform work that he or she has actually performed in the past or that is similar to that work? If yes, the claimant is not eligible.
Given the claimant’s residual functional capacity and other factors such as age, education, and work experience, does he or she have the ability to do any other kind of work? If yes, the claimant is not eligible.
The SSA provides detailed discussions of each of the steps.20,21 For purposes of this chapter, several points need emphasis.
Adjudicators are instructed to consider both signs and symptoms of claimants. Pain is specifically mentioned as a symptom that should be considered. In theory, symptoms such as pain would make a claimant eligible for disability only if they were associated with signs and were considered secondary to a medically determinable impairment that is severe. The importance of signs is emphasized in “Disability evaluation under Social Security,”6 which states that SSA regulations require “objective medical evidence” of impairment. Although this verbiage appears to require the presence of objective evidence of dysfunction of an organ or body part, a close examination reveals something more subtle. For example, SSA defines signs as “anatomical, physiological, or psychological abnormalities established by medically acceptable clinical diagnostic techniques that can be observed apart from individual’s symptoms.”22 It is plausible to construe signs as akin to the objective medical findings mentioned earlier in this chapter. However, it appears that the SSA definition of “signs” basically acquiesces to the judgments of physicians regarding the findings that qualify as signs of a disease or injury. It does not specify that the findings must be ones that are not under the voluntary control of the claimant.23 Essentially, the same logic applies to “medically determinable impairments.” Again, the SSA defers to the opinions of physicians regarding what represents a medically determinable impairment—it does not require that such impairments be based on findings that cannot be influenced voluntarily by claimants. The evaluation of patients with FM highlights these issues. Because many patients with FM are awarded SSDI benefits,24 it is clear that the SSA accepts either the diagnostic criteria articulated by the American College of Rheumatology in 1990 for diagnosing FM,25 or the 2010, 2011, or 2016 modified criteria.26,27,28 The latter three sets of criteria permit a diagnosis of FM without any clinical signs. The 1990 criteria include the responses of patients during tender point examinations, in which the examining practitioner palpates 18 designated sites on the body of a patient with approximately 4 kg of force and asks whether the palpation is painful. Patients are described as having positive tender point findings if they report pain in 11 or more of the 18 sites. The findings on a tender point examination could be viewed as a sign of FM, but it is obvious that a patient’s responses during the examination are to some extent under voluntary control.Related posts:
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