The Role of the Clinician In Determining Disability and Pain
History: A 48-year-old man presents to the healthcare provider’s office and requests assistance with filling out the paperwork for Social Security disability (SSD) benefits. He has applied for benefits twice before and has been denied.
A former coal miner, he has been out of work for the past 4 years due to a work-related injury sustained when he fell off a truck. Three years ago, he underwent lumbar fusion surgery.
The patient does not have a high school degree; he left school to take care of relatives. He has had no additional education and has not worked since his injury. In the past year, he was admitted to the psychiatric ward of the local hospital on two occasions. He was diagnosed with borderline intelligence, schizophrenia, and major depression.
His current medications include methadone, oxycodone (OxyContin), alprazolam (Xanax), celecoxib (Celebrex), and lithium.
On physical examination, the patient appears to be in chronic pain. He has decreased range of motion of the lumbar spine. There is tenderness to palpation of the lower back. He has nondermatomal somatosensory deficits in both legs. He cannot walk on his heels or toes or squat and rise. His gait is antalgic and his mental status is blunted.
Disability is a common problem in the United States. About 30% of adults between the ages of 35 and 65 will have at least one long-term disability that lasts 3 months or longer. An additional 15% will be disabled for up to 5 years. According to the US Census Bureau, 12% of the population (>36 million people) has a disability.1 Interestingly, 43% of people with severe disabilities are employed; however, their average annual income is only $12,800. The lowest employment rates are for those with mental disabilities.
Randolph et al noted an increase in the number of people claiming disability, despite a decreased rate of reported injuries.2 The research suggests that healthcare providers play a key role in determining disability, but often lack training in disability assessment. Further, healthcare providers often feel that they are helping their patients by referring them for disability.
Rainville et al found that disability assessments comprise 9% of primary care visits.3 Because a determination of disability has significant health and financial implications, should providers assist patients with the process of obtaining benefits, or should they encourage a return to work, instead?
Return to Employment Key
Talmage and Melhorn found that work is meaningful for an individual’s identity, social role, and status.4 There is a positive association between health and work, as well as a strong positive association between unemployment and many adverse health outcomes. A return to work should be encouraged. Among older workers, involuntary job loss can be a possible risk factor for subsequent cardiovascular and cerebrovascular illnesses. In fact, mortality has been found to be greater in employees who retired at age 55, rather than at 65.5
Healthcare providers can influence a patient’s return-to-work decision. In a study of chronic pain patients receiving workers’ compensation, the incidence of work resumption was found to be 60% when directed by a healthcare provider; 10 months later, 90% were still at work.6 In the absence of direction from a health clinician, only 25% of workers went back to work of their own volition.
The ability of healthcare providers to influence disabled patients to resume work can be quite limited. These individuals often have multiple medical and psychological problems, as well as limited abilities and few transferable skills. Many of these factors cannot be overcome. Research shows that only 25% of those who have been off work for a year, and 10% of those off work for 2 years, will ever return to productive employment.7
The definitions of disability are disparate and confusing. The Social Security Administration (SSA) uses the following definition: “ ... a person shall be considered disabled ... if that individual has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and 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.”8
This definition differs from that of the American Medical Association (AMA). The AMA defines disability as “an alteration of an individual’s capacity to meet personal, social, or occupational demands because of an impairment.”9 In 1980, the World Health Organization defined disability as “any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being.”10
Disability is sometimes confused with impairment, which is a disturbance in body function or structure. It is the manifestation of an underlying pathology and can be temporary or permanent, progressive, regressive or static, intermittent or continuous, or slight to severe. Simply put, impairment describes anatomic and physiologic deficits, whereas disability refers to what a person can and cannot do. Disability is a much broader concept that takes into consideration age, vocational factors, and psychological problems. A person may be severely impaired but not necessarily disabled. For example, a radiologist can perform essential job functions, even if he or she is a quadriplegic. However, a coal miner with chronic low back pain (LBP) and associated mental health issues is usually considered disabled.
The Role of Pain
Chronic pain is one of the most common causes of disability. It often is described as a complex, subjective, and unpleasant sensation that may or may not be related to injury, tissue damage, or nociception. It has been characterized as “timeless, ineluctable, and disconcertingly indefinable.” It is one of the “thorniest problems” a physician can encounter in practice.
Physicians cannot really prove or disprove the existence of pain in a given individual. Unlike cardiopulmonary problems, which have objective markers of dysfunction, pain problems are much more difficult to assess. Sapega observed that, in the 19th century, physicians assessed muscular performance by conducting “crude manual muscle testing and observing posture, gait, and active range of motion.”11 Today, disability determination is still based on these supposedly “objective” techniques. It is, therefore, no wonder that there is disagreement among physicians, medical consultants, insurance representatives, and the general public about what constitutes a legitimate reason for prolonged absence from work.