© American Academy of Pain Medicine 2015
Timothy R. Deer, Michael S. Leong and Albert L. Ray (eds.)Treatment of Chronic Pain by Integrative Approaches10.1007/978-1-4939-1821-8_2323. Assessing Disability in the Pain Patient
(1)
Feinberg Medical Group, 825 El Camino Real, Palo Alto, CA 94301, USA
(2)
Stanford University School of Medicine, Stanford, CA, USA
(3)
American Pain Solutions, San Diego, CA, USA
(4)
Brigham and Associates, Inc, N. Kalaheo Avenue, Suite C-312, Kailua, HI 96734, USA
(5)
American Medical Association, Chicago, IL, USA
Key Points
Assessing disability in the pain patient is often difficult due to both administrative and clinical issues, yet this assessment is essential.
Clinically, quantifying pain remains problematic as chronic pain is a subjective phenomenon, often associated with confounding behavioral, characterological, personality, and psychological issues.
Typically, the physician does not define “disability”; rather, the physician defines clinical issues, functional deficits, and, when requested, impairment. Disability is most often an administrative determination.
The assessment of disability associated with chronic pain is complex, and the evaluator must approach the clinical evaluation with recognition of the many factors associated with the experience of pain and disability.
The treating physician who has a doctor–patient relationship with the claimant may have a different perspective than the “independent” disability evaluator.
While an independent medical evaluation has some similarities to a comprehensive medical consultation, there are significant differences.
Introduction
Assessing disability in the pain patient is often difficult due to both administrative and clinical issues, yet this assessment is essential. Administratively, it is complicated by numerous states, federal, and private systems and policies with different definitions and benefit systems. Clinically, quantifying pain remains problematic as chronic pain is a subjective phenomenon, often associated with confounding behavioral, characterological, personality, and psychological issues. Additionally, the terms impairment and disability are often misunderstood. Furthermore, underlying personality structure and motivation are often determinates for disability. Chronic-pain complaints may be linked with significant disability [1]. Typically, the physician does not define “disability”; rather, the physician defines clinical issues, functional deficits, and, when requested, impairment. Disability is most often an administrative determination.
Pain is the most common cause of disability, with chronic low back pain alone accounting for more disability than any other condition [2]. Disability related to back pain has increased, although there is no significant change in back injuries or pain [3, 4]. Headache disorders are frequently associated with work loss [5]. Despite advances in physiologic understanding and interventions, challenges associated with chronic pain and disability increase.
The pain associated with specific recognized physical conditions needs to be distinguished from somatoform pain disorder. The essential feature of somatoform pain disorder in DSM-IV [6] is preoccupation with pain in the absence of physical findings that adequately account for the pain and its intensity, as well as the presence of psychological factors that are judged to have a major role. Somatization is defined as a person’s conscious or unconscious use of the body or bodily symptoms for psychological purposes or psychological gain [7, 8]. Somatization is characterized by the propensity to experience and report somatic symptoms that have no pathophysiologic explanation, to misattribute them to disease, and to seek medical attention for them. Somatization can be acute or chronic and may be associated with medical comorbidity, an underlying psychiatric syndrome, a coexistent personality disorder, or a significant psychosocial stressor [9]. Somatoform disorders, factitious disorders, and malingering represent various degrees of illness behavior characterized by the process of somatization.
It is important to recognize that in chronic-pain states, physical and psychological factors typically are both present and overlap and that a quality physical examination is critical before dismissing the problem as being purely psychological.
The biopsychosocial approach is currently viewed as the most appropriate perspective to the understanding, assessment, and treatment of chronic-pain disorders and disability [2–4, 10, 11]. Chronic pain reflects a complex and dynamic interaction among biological, psychological, and social factors.
Pain, impairment, and disability may coexist, or be independent [5]. Pain is a subjective experience defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” [12]. Impairment is defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) [13] as “a significant deviation, loss, or loss of use of any body system or function in an individual with a health condition, disorder, or disease.” Typically, the AMA Guides determines impairment on the basis of specific objective findings, rather than on subjective complaints. The AMA Guides defines disability as “an umbrella term for activity limitations and/or participation restrictions in an individual with a health condition, disorder or disease.” Waddell notes that pain is a symptom, not a clinical sign, or a diagnosis, or a disease, whereas disability is restricted activity [14]. Managing pain does not guarantee that the disability will lessen or resolve. There is not a direct relationship between pain and disability.
Although it is appealing to define disability on the basis of objective as opposed to subjective factors, this is not always the case. The Institute of Medicine Committee on Pain and Disability and Chronic Illness Behavior concluded that “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” [15].
Assessing disability in the pain patient is thus a challenging endeavor. While some individuals present with a clear and direct connection between pathology and loss of function, it is problematic to measure loss of functional ability in the individual whose behavior and perception of disability and functional loss is significant, sometimes far exceeding that which would be expected from the physical pathology. Some people with chronic pain seek the designation of being “disabled” because of perceived incapacity associated with their portrayed pain and physical dysfunction. For some, seeking such designation is a logical extension of suffering a loss of capacity and utilizing an available benefit system. Others may portray being disability as a reflection of anger, dissatisfaction, or a sense of entitlement.
For some, the designation of being disabled is more complex and may involve seeking attention and/or other benefits that for some observers may seem excessive, unreasonable, and unnecessary. The request for assistance or insurance benefits may take various forms such as a disability parking permit, avoiding waiting lines, housing assistance, help with household chores, and benefits such as monetary payments or subsidies. The individual may claim incapacity (including from work) and request disability benefits under various private, state, or federal programs.
The physician performing a clinical evaluation that will be used to determine disability should perform a biopsychosocial assessment, recognizing the array of factors that relate to the experience of pain and disability. From a physical perspective, it is necessary to clarify the physical pathology. Some pathology cannot be directly measured (headache, neuropathic pain, etc.), and other pathology may have been missed (tumor, herniated disk, complex regional pain syndrome). Secondary to problems with chronic pain, there may be other problems, such as physical deconditioning and secondary psychological issues. Two individuals with similar injuries and resulting pathological changes may present with distinctly different experiences and perceptions. The first may have little or no complaints or perceived disability, while the second individual may present with significant pain behavior and dysfunction.
There may be other nonphysical (psychosocial, behavioral, and cultural) ramifications that may help explain the second individual’s pain presentation and assertion of functional loss despite physical findings that do not support the reported disability. Assuming the individual is presenting in an honest and credible manner, the physician then must opine on impairment or functional issues considering physical and these other nonphysical factors. If requested, the physician may also opine on disability. Opining on disability requires an understanding of specific definitions of disability and often specific occupational functional requirements.
Symptom magnification, i.e., illness behavior, is common, particularly in the context of subjective experiences such as chronic pain or litigation. When the individual is not credible or there is purposeful misrepresentation, such as malingering, it may not be possible to accurately define any disability.
The assessment of disability associated with chronic pain is complex, and the evaluator must approach the clinical evaluation with recognition of the many factors associated with the experience of pain and disability.
Symptom Magnification and Malingering
Symptom magnification, inappropriate illness behavior, and embellishment are not uncommon (malingering is less common but occurs and should be considered), particularly in medicolegal circumstances and entitlement programs. Therefore, evaluators need to consider whether the presenting complaints are congruent with recognized conditions and known pathophysiology and have been consistent over time. The evaluator should also determine if there is inappropriate illness behavior.
Pain behaviors (i.e., facial grimacing, holding or supporting affected body part or area, limping or distorted gait, shifting, extremely slow movements, rigidity, moaning, or inappropriate use of a cane) may indicate symptom magnification.
Nonorganic findings, i.e., findings that are not explained by physical pathology, may also support a conclusion of symptom magnification. Nonorganic findings have been described dating back to the early part of the twentieth century [16]. Since that time, a number of nonorganic signs have been defined [17]. In an effort to maximize information from the evaluation, physicians routinely test for nonorganic physical signs. Gordon Waddell, M.D., described five signs to assist in determining the contribution of psychological factors to patients’ low back pain [18]. He was specifically interested in developing screening tests to determine the likelihood a patient would have a good outcome from surgery. The physician must perform all five Waddell tests—evaluation for excessive tenderness, regional weakness, overreaction, distraction, and simulation. Isolated positive signs have no clinical or predictive value, and only a score of three or more positive signs is considered clinically significant. These tests were not designed to detect malingering.
Malingering is defined in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition-Text Revised (DSM-IV-TR) [19] as the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.” The DSM-IV-TR states:
Malingering should be suspected if any combination of the following is noted:
1.
Medicolegal context of presentation (e.g., the person is referred by an attorney to the clinician for examination)
2.
Marked discrepancy between the person’s claimed stress or disability and the objective findings
3.
Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen
4.
The presence of antisocial personality disorder
Malingering occurs along a spectrum—from embellishment to symptom magnification to blatant misrepresentation. The possibility of obtaining disability benefits or financial rewards or being relieved from other responsibilities, such as work, increases the likelihood of malingering. Patients may unconsciously or consciously exaggerate their symptoms. With malingering, the intent is purposeful. Ill-defined complaints occur in a circumscribed group, perhaps in a setting of poor morale or conflict, also may be viewed with suspicion. If there are suggestions of significant illness behavior or malingering, a careful investigation including a multidisciplinary evaluation and psychological testing may be required [20, 21].
Treating Physician Versus Independent Medical Evaluation
The treating physician who has a doctor–patient relationship with the claimant may have a different perspective than the “independent” disability evaluator. The treating physician often takes a patient-advocate role and may have little desire or experience to comment on disability, nor will that physician be able to define disability in an independent manner [22].
Frequently, conflict and distrust develops between claimants and the independent evaluating physicians who evaluate them and the claims examiners handling their claim. Patients often report that their problem is being discounting, while physician disability evaluators and claims representatives may express doubt and skepticism about claimants’ chronic-pain complaints and reported loss of functional capacity.
The physician has the predicament of viewing the subjective reports in relationship with the objective evidence of tissue damage or organ pathology to come up with some final assessment about the extent to which the patient really is disabled from functional activities. It is not difficult to see how the treating physician advocating for the patient will have a different perspective than the “independent” physician evaluating a claimant for disability.
The “independent” medical evaluator (IME) is also not without his or her biases, and in some jurisdictions, only plaintiff and defense IMEs are the norm. The true IME is used by both sides and in some settings is referred to as the “agreed” medical evaluator (AME).
When the physician provides treatment, the doctor–patient relationship is one of trust. The physician is acting as an agent for the patient. When performing a disability evaluation, the physician is acting as agent for the state or agency requesting the evaluation. In 1992, Sullivan and Loeser recommended that physicians refuse to do disability evaluation on patients they are treating [23].
The problem with this is that adverse consequences may ensue for the patient who may be cut off from benefits absent a signed disability form.
Disability Versus Impairment
The two main terms when discussing disability are impairment and disability. The following definitions are from the AMA Guides, the World Health Organization (WHO), and from various state and federal programs.
The AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition (hereafter referred to as the Guides), defines disability as “an umbrella term for activity limitations and/or participation restrictions in an individual with a health condition, disorder or disease.” The AMA Guides defines impairment as “a significant deviation, loss, or loss of use of any body system or function in an individual with a health condition, disorder, or disease.” The sixth edition, published in December 2007, introduces new approaches to rating impairment. The leadership for this edition was provided by Robert Rondinelli, M.D., an experienced physical medicine and rehabilitation physician; therefore, this edition reflects principles of this specialty. An innovative methodology is used to enhance the relevancy of impairment ratings, improve internal consistency, promote greater precision, and simplify the rating process. The approach is based on a modification of the conceptual framework of the International Classification of Functioning, Disability, and Health (ICF), although the fundamental principles underlying the Guides remain unchanged.
The World Health Organization (WHO) defines impairment as “any loss or abnormality of psychological, physiological or anatomical structure or function.” Problems in body function or structure involve a significant deviation or loss. Impairments of structure can involve an anomaly, defect, loss, or other significant deviation in body structures.
The International Classification of Functioning, Disability, and Health (ICF) [24] changes the emphasis from the word “disability” to activity and activity limitation (WHO 2000). ICF defines activity as “something a person does, ranging from very basic elementary or simple to complex.” Activity limitation is “a difficulty in the performance, accomplishment, or completion of an activity. Difficulties in performing activities occur when there is a qualitative or quantitative alteration in the way in which activities are carried out. Difficulty encompasses all the ways in which the doing of the activity may be affected.”
Federal and state agencies generally use a definition that is specific to a particular program or service. To be found disabled for purposes of Social Security disability benefits, individuals must have a severe disability (or combination of disabilities) that has lasted, or is expected to last, at least 12 months or result in death and which prevents working at a “substantial gainful activity” level (1). Impairment is described as an anatomical, physiological, or psychological abnormality that can be shown by medically acceptable clinical and laboratory diagnostic techniques.
The Americans with Disabilities Act (ADA) has a three-part definition of disability. Under ADA, an individual with a disability is a person who (1) has a physical or mental impairment that substantially limits one or more major life activities, or (2) has a record of such an impairment, or (3) is regarded as having such an impairment. A physical impairment is defined by ADA as “any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological, musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine.”
Regardless of the system, the term impairment defines a measurable change (any loss or abnormality psychological, physiological, or anatomical structure or function) and is consistent and measurable across different systems and programs. On the other hand, disability is a social construct in that each program or system defines it differently and assigns different weights and benefits to those definitions. One can be “disabled” in one system of benefits and not in another despite the same impairment. Disability usually results from an impairment that results in a functional loss of ability to perform an activity.
It is imperative to distinguish the difference between impairment and disability. One individual can be impaired significantly and have no disability, while another individual can be quite disabled with only limited impairment.
For example, a person with a below-knee amputation may be working full time quite successfully as a pianist and, therefore, would not meet the Social Security Administration (SSA’s) definition of being disabled. On the other hand, this same pianist might have a relatively minor injury to a digital nerve that severely limits his/her ability to perform basic work activities such as playing a difficult piano concerto. In some disability systems, a person in this situation might meet the definition of partial disabled, even though he/she can do other work.
Perhaps, another way to distinguish the terms disability and impairment is as follows: Some diseases cause a negative change at the molecular, cellular, or tissue level which leads to a structural or functional change at the organ level, a measurable impairment. At the level of the person, there is a deficit in daily activities and this is the disability.
Because of this difference between impairment and disability, and despite the fact that many disability systems are work-injury-loss related, the widely used AMA Guides has stated that impairment ratings are not intended for use as direct determinants of work disability. The impairment rating is rather based on universal factors present in all individuals, the level of impact of the condition on performance of activities of daily living, rather than on performance of work-related tasks. The sixth edition of the AMA Guides states on p. 6 that “the relationship between impairment and disability remains both complex and difficult, if not impossible, to predict.”
While it is true that the AMA Guides is a widely used source (the vast majority of state workers’ compensation systems require some use of the different editions of the AMA Guides) for assessing and rating an individual’s permanent impairments, there are a number of states and the federal government’s SSA disability program that do not recognize the AMA Guides for rating impairment. In addition, the Veterans Administration has its own unique set of disability rating criteria. There is clearly no consensus on a universal system to measure impairment.
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