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13 Articles in Volume 11, Issue #5
Case Study: Patient With Fibromyalgia And Sleep Apnea
Current Treatments for Phantom Limb Pain
Doctor Shopping
Effective Protocol for the Management of Plantar Fasciitis
Giving Severe and Chronic Pain a Name: Maldynia
Is the New Pain Vocabulary Helping Patient Care?
Medications for Chronic Pain—Other Agents
New Technique Combines Electrical Currents and Local Anesthetic for Pain Management
Pain Management Dilemmas of Sickle Cell Disease
Sleep Apnea in Patients With Fibromyalgia: A Growing Concern
The Essential FDA/PDR Indications and Warnings For Opioid Prescribing
The Role of the Clinician In Determining Disability and Pain
Why Does Acute Postoperative Pain Become Chronic and Can It Be Prevented?

The Role of the Clinician In Determining Disability and Pain

Pain remains one of the most common causes of disability. When appropriate, patients should be encouraged to return to work to prevent the development of long-term sequelae.

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

Defining Disability
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.

Musculoskeletal and Arthritic 
Over the past 50 years, the incidence of musculoskeletal disability has risen dramatically. To qualify for SSD, patients must undergo physical examination, as well as submit a detailed description of orthopedic, neurologic, and other findings specific to the impairment being evaluated. The validity of the disability claim is determined by SSD after an objective assessment and review of the clinical findings. Because abnormal clinical findings may be intermittent, those present over a period time must be confirmed by a record of ongoing physician observation and management.

The examination of the spine should include a detailed description of the gait, quantitative measurements of the range of motion of the spine, measurement of motor and sensory abnormalities, muscle spasm, and deep tendon reflexes. The AMA’s Guides to the Evaluation of Permanent Impairment evaluated spine dysfunction using range of motion limitations.9 This method of testing is pseudo-objective, at best. There are other, more accurate ways to check if the patient is exhibiting a legitimate lumbar flexion.

Today, determination of the severity of spine pain is largely based on subjective complaints. The so-called fifth vital sign (visual analogue scale [VAS]) has been used for many years. The limitations of the VAS are well known—it is considered a symptom marker and not a sign. Patients with chronic pain will often rate their pain at 10. Standardized questionnaires are also used in the evaluation of chronic pain, but these, too, are subjective and cannot be relied on as an accurate indicator of level of pain.

Lumbar spine x-rays are routinely ordered in disability examinations, although this type of imaging study is not generally useful in the evaluation of chronic LBP.

Rockey et al reviewed treatments and outcomes in 440 patients with chronic LBP.12 Of these patients, 
106 (24%) had spine x-rays. It was determined that the radiographs contributed minimally to the diagnoses, had little effect on the therapeutic decisions, and had no appreciable effect on the therapeutic outcomes. Menges found that radiologic abnormalities were not necessarily associated with subjective experience of pain.13 He concluded that x-rays were of little or no diagnostic value.

My own research studied lumbar spine x-ray findings in a series of 91 applicants for disability with chronic, debilitating LBP.14 The x-ray findings were completely normal in 23 patients. Another 17 patients had degenerative disc disease, 11 patients had evidence of old fractures or scoliosis, and 39 had degenerative changes. Only one individual in this study had severe degenerative changes, and in his case, the physical examination was completely normal.
Other imaging studies, such as magnetic resonance imaging (MRI) and computed tomography (CT) scans, have high false-positive rates and are costly procedures. Jensen et al found that the MRIs of 64% of a population of 98 subjects below age 60 without LBP revealed at least one positive finding.15

There are new diagnostic procedures available to assess spinal pain. Sensory nerve conduction testing of A-δ fibers (Neural-Scan) has proven to be a useful technology. Needle electromyography (EMG) studies are thought to be objective markers of nerve injury. Often, when a needle EMG study is negative, the patient’s complaints of numbness, tingling, and pain are labeled as functional. The difficulty with needle EMG is that it measures large-caliber efferent fibers that are physiologically unrelated to pain. Pain is mediated by small pain fibers that are 50 to100 times smaller than motor fibers. The consensus from providers certified in small pain fiber electro-
diagnosis by the American Association of Sensory Electrodiagnostic Medicine (AASEM) is that up to 50% of neck and low back pain patients incorrectly localize the source of pain due to referred symptoms.

We compared small pain sensory nerve conduction in pain patients and controls.16 Testing was performed using the Neural-Scan device, which has a stimulus output of up to 10 mA at 25 volts. The A-δ small pain fibers were assessed using a frequency of 250 Hz in major nerves originating from specific nerve roots. Pathology in the peripheral and/or predorsal root ganglion fibers was detected by comparing the amplitude-initiating A-δ conduction. It was observed that there is chronic hypo-function (fibers require more voltage to cause an action potential) in the affected nerve root in patients with chronic spinal pain. This appears to be useful as an objective marker of severe spine pain.

Researchers at the 2011 AASEM annual conference reported that in 20 neck and back patients who had negative EMGs, the A-δ fiber study correctly identified the pain-generating lesion. All were verified by skin biopsy.17

Complex Regional Pain Syndrome is a difficult and costly disorder to diagnose. Needle EMG studies alone cannot be relied on to rule out this condition, as patients may sometimes mimic signs and symptoms for personal gain. We have shown that A-δ sensory nerve conduction testing can be used to rule in or rule out CRPS.18

Another technology in pain evaluation is surface EMG (SEMG). This is an inexpensive, noninvasive method of evaluating spine pain. SEMG evaluates abnormal electrophysiologic activity of the motor unit. The basic principles of EMG involve measurements of the action potentials generated during muscle contraction. SEMG and electrocardiography (ECG) both measure muscular activity. In cardiac muscle measurements, the gap junctions confirm that the heart behaves as an electrical syncytium, whereas in skeletal muscle, measurement gap junctions are absent and electrical syncytium is not present. This is because skeletal muscles behave as a single unit. Skeletal muscles undergo depolarization and repolarization when electrical impulses travel along individual muscle fibers and create recordable action potentials.

Current SEMG units are designed to filter out the “noise” from underlying muscle groups, and the signals generated by the deeper layers are too weak to produce a recordable signal. In a meta-analysis of SEMG, Geisser et al described this technology as a simple and noninvasive measure of muscle activity that holds promise as an objective marker of LBP.19

Mental Status
Psychological distress contributes to disability. Mental illness affects 1 in 10 adults in the United States at any time. Lifetime prevalence is much higher. It has been estimated that 80% of SSD applicants meet the criteria for major depressive disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The lifetime prevalence is 17%.

A number of studies have demonstrated that chronic disability often is a function of mental issues. Failure to return to work by an introverted personality has been predicted independently in the presence of depressive symptoms during hospitalization.

Under the current regulations, to be disabled on the basis of mental disorders requires documentation of the severity of functional impairment. Consideration of the degree of limitation is based on the individual’s ability to work and consideration of whether these limitations have lasted or are expected to last at least 12 months. For example, a diagnosis of schizophrenia alone would not automatically qualify someone for disability benefits. Along with mental illness, there has to be considerable functional impairment.

Claimants often are sent for psychological evaluations. However, a single examination may not adequately describe an individual’s sustained ability to function. For schizophrenia, the current listings require a medically documented history of a chronic schizophrenic or other psychotic disorder with a 2-year duration and which has caused significant limitation in activities of daily living.

Under the disability law, an IQ of <60 is considered permanently and totally disabling. If someone has an IQ between 60 and 70 and another defined medical problem, he or she also may be considered disabled.

Vocational Issues
If a disability applicant’s problems do not meet certain criteria, (see sidebar), the issue becomes whether the person is able to perform any other kind of work. If an individual cannot do the work he or she did in the past, SSA will determine if he or she is able to adjust to and perform other work. They will consider the medical condition, age, education, past work experience, and any transferable skills that exist. If it is determined that the individual cannot adjust to other work, the claim will be approved.

A 48-year-old man without a high school education or any transferable skills who can only do sedentary work would be considered disabled. Some healthcare providers might feel that such an individual should be able to find work; however, under federal regulations, the person is considered disabled.

Often, SSA will send healthcare providers forms asking their opinion about how much a patient can lift, bend, carry, and so forth. The problem is that one cannot scientifically determine lifting ability from a person’s physical examination. Talmage and Melhorn noted that determination of lifting ability is not scientific.4 Functional capacity evaluations often are a measure of a person’s tolerance, rather than his or her actual ability.

In 2004, SSA redefined its mission to include employment of disability beneficiaries and established the Ticket to Work program.8 Studies have shown that the vast majority of beneficiaries do not intend to return to work. Fewer than one half of 1% of disability recipients return to work and have their benefits terminated. However, 9% of beneficiaries continue to earn income after they are approved. This is both legal and encouraged. Congress has mandated periodic reviews of claims to determine if claimants are still unable to work. This is done once every 7 years, and the same standards used for initial approval of benefits apply.

Researchers agree that disability benefits should be awarded in cases of severe head injury and other catastrophic disorders.2 They appear to take issue with granting benefits in cases of chronic musculoskeletal and psychological problems. Prevention of such illnesses is certainly a laudable goal, but in practice, it is quite difficult.

At present, individuals with chronic pain and/or mental illness are receiving benefits. SSD benefits are not a panacea; they only provide income support at a relatively modest level. Attempts to remove people from disability have not been successful. Only a small number of SSD beneficiaries eventually get off the rolls. The Ticket to Work program has also had limited success: Only 1.1% of beneficiaries were able to maintain long-term employment.

A question commonly asked by the administrative law judge in disability hearings is how many days of work per month the claimant is likely to lose because of his or her health problems. Losing more than 4 days per month because of health problems is generally considered to be inconsistent with the ability to keep a job.

Certainly, return to employment should always be encouraged. However, employment prospects for a 48-year-old coal miner who has an IQ of 70, chronic LBP, and mental illness for which he takes opioids and psychotropics, are extremely limited. What would happen to such an individual were he denied disability benefits? This has been studied, and it has been found that return to work simply does not occur.

In summary, it should be understood that medical problems are only one part of the disability conundrum—mental illness, limited mobility, lack of transferable skills, and motivational factors all play significant roles. Over the past 30 years, there has been a shift in SSA determination of disability. The trend has gone from approving only those with very serious medical problems to deciding that someone cannot work solely because of limited functional ability. It should be noted that the SSA disability program accounts for 5% of the federal budget.

Last updated on: December 9, 2011
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