(1)
Wisconsin Rehabilitation Medicine Professionals, Milwaukee, WI, USA
Any clinician who sees patients with pain will likely see patients with disabilities. Because claims of disability affect the workplace, through federal and private insurance programs and injury litigation, these patients and their cases can be complicated, time consuming, and frustrating. This chapter will provide you an overview of the issues involved in disability-related medicine so you can guide and support your patients. Even though disability medicine often involves monetary payments, case workers, and insurers, the same multidisciplinary pain treatment concepts apply as they do to other chronic pain conditions.
There is no clear correlation between pain and disability, as we have noted in previous chapters nor is there much correlation between relief from pain and greater functionality and return to work (Meier 2013). Moreover, pain linked to work-related and motor vehicle injuries is among the hardest to treat due to the hidden and overt effects of anger, resentment and feelings of being a “victim,” medicolegal factors and family involvement. Complicating the situation are medical, legal, and financial systems that reinforce a disability conviction for patients, insurers, and even clinicians who add inadvertently to the problem by using single modality approaches like opioids, surgery, and injections in isolation and without a supporting multidisciplinary pain approach. As in almost all chronic pain conditions, multidisciplinary pain rehabilitation has an excellent track record when treating disability.
In his eye-opening book, Worried Sick (2008), Nortin Hadler, M.D. observes the philosophical paradox of workers trying to get well in a disability system that forces them to prove they are “ill.” Similarly, many researchers have questioned whether disability programs like the US Workers’ Compensation system discourage or slow patients’ return to work. Burns et al. found, in their research, “support for the popular notion that patients receiving WC [Workers’ Compensation] report more symptoms of pain and greater disability…and may respond less well to treatment than non-WC patients” and cite “pessimistic perception of their ability to return to their former jobs” as a significant factor in nonreturn to work. Other researchers cite the terms “compensation neurosis,” “compensation disease” or “accident/litigation neurosis” to explain patients’ slow recovery and embracing of a disability conviction, often seen in disability systems (Burns et al. 2005).
But Dworkin et al., while they agree that “compensation benefits” predict “poorer short-term outcomes,” suggest the poor outcomes are largely explained by the simple fact that these patients are “less likely to be working” (Dworkin et al. 1985). Moreover, the researchers speculate that “Greater emphasis on patient education, counseling, and vocational intervention,” features of multidisciplinary treatment, are positive factors in worker outcomes that are not always quantified or considered when evaluating return to work rates.
And, there are other paradoxes in contemporary disability medicine. Despite our greater understanding of the biochemical and biopsychosocial processes behind chronic pain and the replacement of many physical jobs with desk jobs in the United States and other industrialized countries, low back pain is still “the most common cause of job-related disability” says the National Institute of Neurological Disorders and Stroke (2014).
The psychological goals of multidisciplinary treatment for chronic pain patients in general—a reduction in illness behaviors, catastrophizing and fear avoidance and an increase in positive self-talk, self-efficacy, and self-care (found in Chaps. 1–4 of this book)—are, not surprisingly, associated with positive outcomes in injured workers (Tait 2013). Tait uses the term “presenteeism” to describe the coping skills needed for patients to maintain ongoing employment in the face of chronic pain. The skillset includes positive self-talk, task persistence, less belief in a “medical cure,” less need for “tangible support” and a high capacity to ignore or control pain, as we see in Table 7.1.
Table 7.1
Predictors of positive disability outcomes in workers
Positive self-talk |
Task persistence |
No expectation of “cure”—focus on control |
Self-care and self-support |
Ability to ignore or control pain |
Minimal catastrophizing |
Minimal fear avoidance and guarding |
Minimal dependency on healthcare system |
Little or no opioid medication |
Yet, since the 1990s, expensive and uncoordinated treatments like surgery and opioids have supplanted multidisciplinary care under the erroneous view of cost-effectiveness, though outcomes suggest otherwise (Meier 2013). For example, Rogers found that multidisciplinary care such as work hardening/work conditioning was more cost-effective in disability cases than surgery. Lower back pain patients who received work hardening/work conditioning but not surgery were half as likely to go on to have surgery and had five times fewer physician visits than those who had surgery but no work hardening/work conditioning, according to insurance information (Rogers et al. 2013). For this reason, even though work hardening/work conditioning can initially increase medical costs from $3000 to $9000, the programs actually save about $1600 per patient when lost wages and reinjury costs are factored in.
Surgery and Opioids Not Cost-Effective Over Time
Lumbar fusion surgery is popular in the Workers’ Compensation system but outcomes are anything but positive. Two years after lumbar fusion surgery, 26 % of workers had returned to work versus 67 % of workers who did not have fusion surgery (Nguyen et al. 2010). After the surgery, 27 % of the surgery patients needed reoperations and 36 % had complications. Eleven percent of the surgical patients became permanently disabled versus 2 % of the nonsurgical patients. Patients who had surgery missed, on the average, 1140 work days versus nonsurgical patients who missed an average of 316 days (Nguyen et al. 2010). As we noted in Chaps. 1–5, many popular medical procedures for pain lack evidence-base and justifications for their added expense.
While lumbar spine fusion has positive outcomes with spondylolisthesis with instability, traumatic fracture, and tumors, surgery for other diagnoses remain controversial (Nguyen et al. 2010). Nevertheless, 84 % of the studied Workers’ Compensation patients had lumbar spine fusion for disk degeneration, disk herniation, and radiculopathy.
Lumbar surgery also drove opioid use (Nguyen et al. 2010). After lumbar fusion surgery, the use of opioid medications went up by 41 % of patients and 76 % of patients in the Workers’ Compensation system who were studied remained on opioids.
An average Workers’ Compensation claim without opioids was reported in 2012 to be $13,000 but when short-acting opioids like Percocet are added, it leaps to $39,000. Add long–acting opioids like OxyContin and the figure skyrockets to $117,000. An analysis by Accidental Fund Holdings concluded that a workplace injury costs nine times more when treated with opioids. Both private and public employees like firefighters and police officers are excessively treated with long-term opioids with the latter’s costs borne by taxpayers (Meier 2013).
A 2008 study in the journal Spine found people kept on opioids for more than 7 days during the first 6 weeks after an injury were more than twice as likely to be disabled and out of work a year later (Fauber 2012). A study of 300,000 Workers’ Compensation claims by the Workers’ Compensation Research Institute found pain and day-to-day function do not improve in workers when they stay on opioids (Meier 2013). In 2009, the US Centers of Disease Control and Prevention noted that opioids are involved in 14,800 overdose deaths a year (Ranavaya 2012).
Factors Which Complicate Disability
Patients with disability, especially when associated with pain, require you to understand the multidimensional nature of the pain phenomenon, as we discussed in Chaps. 1–5. You also need a basic understanding of the different definitions of disability in their medical and legal contexts to determine residual functional abilities and help the patient return to work.
When you have patients with chronic pain presenting for disability evaluations, the use of opioids complicates your job because many of these patients have an associated dependency on opioids. As we have noted in previous chapters, the harmful effects of opioid abuse include hyperalgesia, endocrine problems, sleep abnormalities, immune deficiency, and cognitive impairment all of which contribute to the rate of disability (Ranavaya 2012). A high percentage of pain patients also have depressive symptoms or other psychopathology symptoms that preceded their chronic pain complaints and may be “self-medicating” with non-prescribed drugs and alcohol use. It is important to exercise an index of suspicion when evaluating disability in patients with use or dependency on opioids and other addictive drugs.
As medical professionals treating pain, our job is not to doubt patients’ pain but to find reasons and treatment for it. However, as we note in Chap. 10 when discussing Complex Regional Pain Syndrome, sometimes patients can exhibit “factitious” conditions—or malingering. While we do not want to be excessively suspicious of patients, including those seeking disability compensation, there are some warning signs that a patient is not totally “above board” such as inconsistencies in his story, “selective” amnesia, alcohol and drug abuse, noncooperation with care and records that show a spotty work history, as seen in Table 7.2 (Jacks 1994).
Table 7.2
Signs of possible patient symptom exaggeration/magnification
Medical records | Complaints exceed clinical findings |
Timing of pain | Symptoms worse as return to work approaches |
Inconsistencies | Claims of dysfunction shift |
Spotty work history | Fired, long unemployment periods |
Selective amnesia | Omitting relevant information |
Noncooperation | Missed appointment, imperious attitude |
Litigation history | Patient overly legalistic |
Personality problems | Antisocial, anti-authority, dishonest |
Drug/alcohol abuse | Records show use; patient denies |
When treating patients with disabilities or disability claims, we have to navigate a complicated and frustrating system made even more difficult by the prospect of financial awards, adversarial parties and volatile emotions and the frequent lack of correlation between symptoms of pain and associated disability. No wonder, clinicians have sometimes shied away from patients with disability claims or complaints.
It is not the purpose of this chapter to provide step-by-step guidelines for performing disability evaluations. Instead, this chapter will give you an overview and conceptual framework for the medical determination of disability and an introduction to the many disability systems in the United States. I am including in this chapter, highlights of a presentation I gave at the 15th World Congress of Pain, a meeting of the International Association for the Study of Pain (IASP), in Buenos Aires, Argentina in 2014.
While I have personally conducted thousands of disability evaluations on patients under my care as well as “independent medical evaluations” for other claimants, I understand that you may prefer to refer patients to physicians or specialists who are experts in evaluating disability, especially in complex personal injuries like car accidents, slip and falls, or medical malpractice which result in injury to a person and possible permanent disability.
Still, we are often asked by attorneys, social security agencies, insurance carriers, and other physicians to provide assessments of patient disabilities including residual functional capacity in patients involved in private short or long-term disability policies, FMLA (Family Medical Leave Act), or short-term time “away from work” or “return to work with restrictions” determinations after a mild, self-limiting work injury. In these cases, it is often important for the primary care provider (MD, DO, NP, or PA) to provide timely information by completing forms patients may bring to their appointment, so that your patients are compensated and can receive the appropriate treatment.
It is also important for you to be fair and objective in these disability evaluations and to remember that society entrusts us with helping to compensate the patient adequately for injuries and illnesses that require time off work. At the end of this chapter, there is a reference list of books that would be helpful, if you wish to understand the disability determination process better.
A Framework for Understanding Disability
Like pain, disability is a highly complex and sometimes subjective medical designation with a variety of interpretations and governed by disparate systems. Historically, social justice systems and the concept of disability can be traced back to medieval times, where the “whole person” concept originated—meaning intactness of the body. Injury that resulted in some loss of body parts or function led to efforts to restore that “whole person” as closely as possible to the person inferred to have existed prior to injury. Laws that compensate workers deemed to be disabled can be traced back to Germany in 1911 which provided assistance in restoring an injured worker to competitive employment (Vasudevan and Ajuwon 2014).
Most people searching through the literature addressing pain and disability will encounter gray areas in definitions and evaluations; terms such as “impairment” and “disability” are used in different settings to mean the same thing and, at other times, to mean two different things, as you can see in Table 7.3. Later in this chapter, we will look at individual disability systems in the United States and their basic requirements. But first, let us look at the lexicon of disability shown in Table 7.3.
Table 7.3
Four conceptual components of disability
Pathology | Interruption/interference with bodily process or structure |
Impairment | Loss of psychological, anatomical or physiological structure or function |
Functional limitation | Inability, from impairment, to perform activity within the normal range |
Disability | Inability to perform usual activities from impairment—task specific |
Pathology
Pathology is a disease or trauma that causes changes in the structure or function of the body. When used in the context of disability, pathology refers to an interruption or interference with a normal bodily process or structure. The term includes the initial injury to the body from trauma, infection, metabolic disorder or other etiology, and the body’s response to such injury. Thus, pathology is at the tissue level. Pathology also includes aggravation of a previously existing problem by an injury. Examples of pathology include lumbosacral strain, herniated lumbar disk disease, and diabetic polyneuropathy.
Impairment
Impairment is defined as any loss or abnormality of psychological, anatomical, or physiological structure or function. It may be temporary, during active pathology, or may become permanent, continuing even after the pathological process is adequately treated and resolved. Thus, impairments are at the organ level.
Examples of impairments include decreased range of motion from lumbosacral strain or herniated lumbar disk, altered reflexes, decreased strength or loss of sensation from radiculopathy or abnormal electromyography studies seen in a person with a herniated disk or diabetic polyneuropathy. Anatomic impairments include contractures, loss of limb/amputation, deformities, and decreased range of motion. Physiologic impairments include decreased cardiac output, decreased pulmonary function, abnormal electrophysiologic studies, abnormal blood chemistry, and muscle weakness.
Impairment also includes changes in cognition and memory, as seen in persons with closed head injury, and abnormalities of personality detected on the Minnesota Multiphasic Personality Inventory 2 (MMPI 2) which offers objective evidence of psychological impairments. It is important to recognize that impairments are objective and medically determinable through clinical or laboratory assessments.
Functional Limitation(s)
Functional limitation is a restriction in or lack of ability to perform an activity or function in a manner that is within the range considered normal for that person and that results from impairment. Examples of functional limitations include the inability to lift more than 20 lb by an individual with lumbosacral disk and nerve decompression; the inability to follow a two-step direction in a person with head trauma; the inability to do exertional activities, such as climbing stairs in a person with ischemic heart disease; and the inability to function safely in the community in a person with cognitive or affective changes resulting from a closed head injury. Thus, functional limitations are manifestations of impairment, translated in terms of the function of a body part or organ.
Disability
Disability is defined as the inability of a person to perform his or her usual activities and the inability to assume one’s usual obligations. It is any restriction or lack (resulting from impairment) of the ability to perform an activity in the manner or within in the range considered normal for a human being. Disability is task specific. Permanent disability is assumed to be present if a patient’s actual or presumed ability to engage in gainful activity is reduced or absent as a result of an impairment, which in turn may or may not be combined with other factors. Disability is at the person level.
This framework for understanding disability derives from international classifications of impairment, disability and handicap drafted decades ago that include (1) disease, (2) impairment, (3) disability, and (4) handicap (Vasudevan and Ajuwon 2005). Disease is a pathological condition of the body, whereas impairment is the loss of normal anatomic, physiologic, or psychological status. Disability, in this context, is loss of normal function that is task specific and handicap is defined as a loss of normal function that is role specific. Examples of handicap include limited access to public facilities though, increasingly, environmental modifications in work settings and the community can decrease handicap. To summarize, pathology is at the tissue level, impairment is at the organ level, disability at the person level, and handicap at the societal level.
Clearly, the four concepts also interrelate and affect each other. Aggressive treatment of pathology may eliminate or minimize permanent impairments and aggressive treatment of impairments can decrease functional limitations. Limited function can be enhanced by assistive and adaptive devices and acceptance of limitations, through counseling, can decrease a patient’s disability conviction. Multidisciplinary care versus isolated, expensive and uncoordinated care models also encourages greater focus on “abilities” than on “disability.”
Functional Capacity Assessments
In disability medicine, there is also significant confusion between evaluative tests known as “work capacity evaluation,” “physical capacity evaluation,” “functional musculoskeletal evaluation,” “ergonomic job analysis,” “maximum lifting limits,” “functional capacity assessment” (FCA) and “functional capacity evaluation.”
Most of these tests measure a patient’s residual functional capacity to capably sustain dependable performance in response to a broadly defined work demands. The evaluation should be based on a patient’s present medical, physical, and psychological state, not the patient’s physical potential. Because of the lack of accepted definitions and procedures for such evaluations to determine disability, many providers offer “FCAs” which have become a profitable growth industry (Genovese and Galper 2011). Clinicians should exercise some caution when ordering and analyzing such tests.
The Disability Evaluation Process
Just as it is difficult to verify pain in a patient, it is difficult to determine disability. This is especially true in patients presenting with only pain as the causative factor in their disability. Yet both conditions respond well to the rehabilitation process and there is ample evidence of the effectiveness of the multidisciplinary pain treatment in decreasing, if not reversing, the disability associated with chronic pain. In treating pain-related disability, the focus should be on improving function with clear goal setting. Notably, assessment of permanent disability should not occur until the patient has completed adequate and appropriate rehabilitation or if the patient declines appropriate psychosocial and multidisciplinary treatment.
The basis of disability evaluation frequently depends on the physician’s ability to assess “medically determinable and objective impairments.” But, assessment of disability is hindered by differing opinions and approaches of physicians. For example, studies have demonstrated that physicians’ evaluations of patients with low back pain, especially based on nonneurological findings, such as muscle spasm and guarding, diverge widely (Waddell et al. 1982).
In addition to physical examinations which are not always an objective and consistent method of determining impairment, radiologic abnormalities are not always useful. As we saw in previous chapters, problems revealed on imaging frequently lack clinical correlation with symptoms. Beware the “X-ray diagnosis.”
There also exists a poor relationship and lack of correlation between objectively demonstrable pathology and an individual patient’s functional level and disability says the Institute of Medicine on the basis of literature reviews (1987).
Assessment of permanent disability should not occur until the patient has completed adequate and appropriate rehabilitation
As early as 1979, Grossman noted that subjective differences in clinical evaluations occur because disability as a concept was viewed differently by various professionals who participated in formulating the concept (Grossman 1979). He compared the disability evaluation process to the fable of three blind men asked to describe an elephant, each having touched only one part of the elephant’s anatomy, and thus viewing things extremely differently. Grossman also pointed out the irony that a patient’s pain symptoms, acknowledged by a treating physician, are at times not admissible in court, whereas testimony from physicians not treating the patient frequently is allowed.
Finally, patients themselves can present challenges when they have disabilities. Many of the biopsychosocial processes seen with chronic pain are more pronounced in patients with disabilities including fear of pain (anticipatory pain), confusing “hurt” with “harm” when they feel pain, high levels of anger, resentment and stress, and intense family dynamics. Like other chronic pain patients, patients with disabilities tend to have
1.
Pain persisting beyond the expected healing period of an injury or illness, excluding cancer
2.
Pain with minimal objective clinical and laboratory findings or residual structural effects that can explain the pain behavior
3.
Pain that lacks specific and clear medical or surgical interventions to treat the underlying problem
4.
Pain associated with sedentary lifestyle changes
But medical professionals can also contribute to the biopsychosocial processes that complicate pain treatment. Bishop et al. (2007) found that when clinicians subscribed to a strong “patho-anatomical” approach, believing in strong links between pain and impairment, biomedical rather than multidisciplinary treatment and that “hurt is harm,” patients were much more likely to have the same beliefs and engage in fear avoidance. Linton et al. also found some clinicians stoking patients’ fear avoidance through their belief that sick leave was an actual treatment for patients, thus reinforcing their disability behaviors (Linton et al. 2002). Instead, clinicians should recognize that “disability” is a behavioral response which, like pain, can be a “learned behavior” (see Chaps. 3 and 4), and therefore should encourage patients to stay active and avoid excessive rest, return to work, and learn and practice self-management with their pain (Bishop et al. 2007).
Employers’ Role in Disability
Employers are clearly “ground zero” when it comes to disabled workers but they could do more to prevent disabling worker events through a shift in perspective from “traditional interventions that treat or rehabilitate the individual, to a more holistic approach to workers’ health,” says Waddell et al. (2008). While accepting that common health problems are an inevitable part of working life, “good occupational management is about preventing persistent and disabling consequences” and encouraging “an environment that “allows workers to maintain and improve their health and well-being,” says Waddell. The philosophical switch is shown in Table 7.4.
