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1
Introduction
pain is the most common presenting complaint
seen by physicians (Lawrence and McLemore,
19831. Sometimes the pain is the result of obvious injury or is
associated with readily identifiable disease; at other times, it has no
obvious cause or seems disproportionate to the disease or injury. Some
pain disappears with healing or is self-limited, but some persists. Some
disease processes, of course, cause long-lasting, severe, and even
debilitating pain; but for most people, an episode of acute pain does not
become chronic. Musculoskeletal conditions such as low back pain,
joint pain, arthritis, and rheumatism are the leading causes of disabil-
ity in people during their working years (Kelsey et al., 1979; U.S.
Department of Health and Human Services, 19801. Back complaints
are second only to upper respiratory conditions in accounting for work
absenteeism (Rowe, 19691.
Many different kinds of chronic pain can be identified. Each has its
own characteristics and different effects on patients. For patients the
experience of pain is also highly variable. Some people with moderate
pain are severely impaired, whereas others with severe pain are able
to continue functioning normally. How an individual experiences and
manifests pain depends on a complex interaction among numerous
physiological, psychological, social, and cultural variables, as well as
on past pain experiences and how the pain has been handled by the
practitioners the patient consults.
Because of the considerable differences in types of pain and patients,
it is inappropriate to speak of "the" chronic pain patient as if there
12
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INTRODUCTION 13
were only one type. Similarly, we do not use the term "chronic pain
syndrome," as it implies a homogeneity among conditions that are
actually quite dissimilar.
The experience of pain is more than a simple sensory process. It is a
complex perception involving higher levels of the central nervous
system, emotional states, and higher order mental processes. As is true
for other symptoms, people who experience pain, especially pain of
Tong duration, tend to develop behavioral and psychological responses
to their symptoms. It is not always possible to identify the causes of
pain, how it is expressed, and its behavioral and psychological reac-
tions and consequences. In common parlance, one may hear about
"shirkers" (or malingerers) and other people in "real" pain. In fact,
experienced clinicians believe that true malingerers are relatively
rare. Further, "real" pain is an extraordinarily complicated phenom-
enon. The physical and neurological disorder cannot provide a com-
plete explanation for chronic pain or the patient's experience of pain.
Moreover, neurological mechanisms for pain are not yet fully under-
stood. For example, even in the case of the impingement of a lumbar
disc into a nerve root, a condition that is associated with intense back
pain for many people, neurologists cannot really explain why pain is
experienced.
What, then, accounts for the development of chronic pain? The
concept of illness behavior, a social psychological term used to describe
the responses of persons to being ill or to believing that they are ill,
elucidates and provides a framework for understanding the observed
differences among pain patients. Illness behavior is a process that
includes a perception of one's own symptoms, an attribution of mean-
ing to them (from something trivial to an ominous indicator of
serious illness), and the way in which one seeks help in dealing with
the symptoms. Such behavior is influenced by the person's personality
and coping style and by the surrounding culture and society. The fact
that such factors can be strong influences on the pain or other
symptoms that people experience does not, however, make the pain
any less real.
Not only is pain a symptom that can cause substantial discomfort,
suffering, and alterations in way of life, but as a clinical problem it is
often resistant to diagnosis and treatment. For physicians, who are
trained to diagnose and cure disease, pain reports that are not fully
accounted for by a diagnosable disease can be frustrating. For the
patient in chronic pain who visits a doctor expecting to find relief and
an explanation for the pain, going away with neither can be equally
frustrating. In a search for the pain's cause and for a way of relieving
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14 PAIN AND DISABILITY
it, long rounds of tests, treatments, and referrals to specialists may
ensue, often to no avail and sometimes compounding the problem. A
breakdown in basic trust strains the doctor-patient relationship, mak-
ing medical encounters increasingly difficult for both parties.
In addition to its significance as a personal and clinical problem,
chronic pain has become a sociopolitical and economic problem for
public and private disability insurers. The Social Security Adminis-
tration (SSA) is particularly concerned about how pain should be
considered in the process of determining eligibility for disability
benefits, especially when such pain seems disproportionate to objective
medical findings (e.g., histories, physical examinations, x rays, and
laboratory tests) relating to a past injury or ongoing disease process.
Although recognizing that pain is ultimately a subjective experience,
insurers must have criteria for determining eligibility for benefits that
not only are fair but also can be replicated by multiple assessors. A
serious problem is posed by having to decide how much dysfunction can
be attributed to pain when the severity cannot be measured. Although
medical professionals are relied on for data about disease and dysfunc-
tion, the ultimate judgment about who qualifies for benefits is made by
program administrators, and sometimes judges, who must assess such
data in light of the applicable laws and regulations.
From a sociopolitical and economic perspective, the question is how
to assure benefits for all who need them, while avoiding a policy so
generous that it imposes an unacceptable fiscal burden. Every society
defines some categories of people who are exempt from work because of
their age or infirmity. The distinction between those who are expected
to work and those who need to be supported by public funds varies from
program to program and from country to country. Criteria for eligibil-
ity are often arbitrary, such as the age at which one becomes eligible
for "old age" benefits or the point at which defective vision constitutes
"legal blindness."
Whereas many programs here and abroad recognize disability as
partial and temporary as well as total and permanent, the SSA's
definition is more stringent: "inability to engage in any substantial
gainful activity by reason of a medically determinable physical or
mental impairment which can be expected to result in death or has
lasted or can be expected to last for a continuous period of not less than
12 months" (42 USC, 423 (~) (111. Although disability programs may
set different boundaries to divide those judged disabled from those able
to work, the criteria for those boundaries, even if arbitrary, must
readily distinguish the two groups and be feasible to apply fairly and
equitably. A society may accept conventional definitions of, for exam-
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INTRODUCTION 15
pie, "elderly" as a basis for exemption from work, but may find it
considerably more difficult to judge that a medical disorder is so
incapacitating that it keeps one entirely from working In the case of
a symptom complaint such as pain without identifiable disease pro-
cesses that fully account for it, the task can be extremely complex.
Because the experience of pain is different for each person, how is it
possible to assess pain and determine a severity beyond which one
should not be expected to work? This is the crux of the problem for the
SSA and for others who insure against disability.
OVERVIEW OF THE REPORT
Part I of the report describes the SSA's disability system, exploring
its history, rationale, and sociopolitical context; describing program
characteristics and procedures; and identifying problem areas and
tensions in the way the system works. Many forces and pressures
operate at every level of the system, from an individual's initial
decision to apply for disability benefits, through the eligibility deter-
mination process by which a claimant must show proof of disability to
an agency charged with helping those in need while safeguarding
public money, to the often differing viewpoints of the agency and the
courts as to how disability decisions should be made.
Part II provides a broad view of chronic pain and disability from the
perspectives of economics and epidemiology. Chapter 5 summarizes
what is known about the costs of disability and examines the relation
between disability rates and features of the economy. During times of
economic downturn and high unemployment, more people apply for,
and receive, disability compensation. Estimates of the prevalence of
chronic pain in the general population and its relation to work
disability are examined in Chapter 6.
Part III focuses on the patient who supers from chronic pain.
Chapter 7 reviews the anatomy and neurophysiology of pain drawing
primarily on studies of experimentally induced acute pain. Possible
physiological mechanisms to explain chronic pain and promising
directions in the area of pain measurement are explored. The experi-
ence of pain, how the patient behaves in response to it, and the social
and psychological pressures contributing to its development and main-
tenance are discussed in Chapters 8 and 9.
Issues in the clinical management, assessment, and rehabilitation of
chronic pain and associated dysfunction are examined in Part IV.
Chapter 10 includes a discussion of the many aspects of diagnosing and
treating chronic pain and elements of the doctor-patient relationship
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16 PAIN AND DISABILITY
that may be adversely affected by the often Biscuit search for a
diagnosis and relief. Because pain cannot be measured directly, vari-
ous indirect methods for assessing its effects on patients have been
devised. Chapter 11 reviews a variety of assessment techniques and
suggests ways to use them more appropriately in clinical practice and
in disability determination. Although it is generally believed that
early rehabilitation of pain patients would be an effective means of
managing pain and limiting dysfunction, few data exist to support the
idea. Various approaches to pain rehabilitation are discussed in
Chapter 12. Studies of treatment outcomes, including those that
explore the hypothesized effect of receipt of disability benefits on
outcomes, are analyzed.
Finally, Part V contains the committee's conclusions and recommen-
dations. It should be noted that the committee worked from the
assumption that the existing legal definition of disability for the SSA
(requiring the total inability to work and implying permanent impair-
ment) was so rooted in the philosophical and political issues that led to
the creation of the program and that have accompanied it throughout
its history (discussed in Chapter 2) that it would not be fruitful to
entertain seriously recommendations for changing the definition. Fur-
ther, such an endeavor would be beyond this study's scope and
mandate. Within the constraints of this definition, however, many
programmatic and procedural issues were considered. The committee's
conclusions and recommendations (1) address ways to improve the
assessment of chronic pain patients within the Social Security disabil-
ity programs; (2) suggest demonstration projects to provide further
information for such improvement; (3) offer views on the clinical
management of patients with chronic pain; and (4) identify promising
research and data collection activities that would add significantly to
the existing knowledge about chronic pain, illness behavior, disability,
and their interrelations.
Because of its breadth, this report should interest many different
audiences, including those policymakers, insurers, program adminis-
trators, health care professionals, clinical researchers, and members of
the public who are concerned about the nature of chronic pain and how
it relates (and might better relate) to disability benefits. The detailed
discussions of the nature of pain, the origins and treatment of pain,
and the pathway from acute to chronic pain and then to chronic
disabling pain should provide useful information to clinicians, re-
searchers, and the public. This discussion is also the context for the
analysis of disability policy and procedures, thereby contributing to
the ongoing process of informing public policy.
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INTRODUCTION 1 7
A NOTE ABOUT DEFINITIONS
Terms relating to chronic pain and resulting disability are defined
and used in a number of different ways both in the literature and by
disability program administrators. For example, the SSA uses the
word "impairment" with two quite different meanings: an impairment
is a disease, such as rheumatoid arthritis, and also the inability to do
something that results from a disease. The HHS Commission on the
Evaluation of Pain (U.S. Department of Health and Human Services,
19S7) defined impairment as the psychophysiological manifestation of
an injury or disease. This lack of uniformity arises both from the
varied disciplines concerned with these issues and from the complexity
and incomplete understanding of the concepts themselves.
Recognizing that there is room for disagreement, the committee
chose to adopt a modified version of the World Health Organization
(WHO) definitions of several key terms. These definitions are used
consistently throughout this report in order to avoid misunderstanding.
~ Impairment: Any loss or abnormality of psychological, physiolog-
ical, or anatomical structure or function. (This is the same as the WHO
definition.)
The functions that are lost or become abnormal because of chronic
pain may include walking, sitting, bending over, anticipation, mem-
ory, cognition, and mood.
· Functional limitation: Any restriction or lack of ability to perform
an activity in the manner or within the range considered normal for a
human being that results from an impairment. (This is the WHO
definition of"disability.")
This is a loss of capabilities as a result of the inability to effectively
integrate purposeful functions (physical and/or psychosocial) because
of pain, disease, or impairment. This Toss may include functions such
as visiting family or friends, typing for hours, gardening, houseclean-
ing, shelving merchandise, or operating a chain saw.
· Disability: A disadvantage for a given individual (resulting from
an impairment or a functional limitation) that limits or prevents the
fulfillment of a role that is normal (depending on age, sex, social, and
cultural factors) for that individual. (This corresponds to the WHO
definition of"handicap.")
Disability limits or prevents fulfilling a role in life. Because of pain,
a person may no longer be able to perform satisfactorily at home,
school, and work and in social settings (i.e., as a father, mother,
employee, student, etc.~.
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18 PAIN AND DISABILITY
The committee emphasizes that patients with chronic pain are
heterogeneous. Any time period used to define chronic pain is arbi-
trary. The committee chose to use the terms acute pain and chronic
pain as they were defined by the HHS Commission.
· Acute pain: Pain of recent onset and probable limited duration.
· Chronic pain: Pain lasting for Tong periods of time. More than 6
months is a commonly used duration. Such pain may be associated
with a residual structural defect that persists long after the acute
episode or pain associated with the persistence of the disease process,
as in arthritis. Chronic pain may also be pain persisting past healing
time without objective physical findings of residual structural defect or
pain persisting past the active state of a disease process. Pain that
recurs regularly and frequently over long periods of time is also
considered chronic pain.
As we have noted, all of these terms can and have been used
differently. We try in this report to be as clear as possible. Often, we
use terms such as work disability, social disability, and legal disabil-
ity, as appropriate.
Low back pain is used as an example throughout this report for
several reasons: more clinical, epidemiological, and administrative
information is available for back pain than for other types of pain;
chronic musculoskeletal pain, and particularly chronic low back pain,
is the most common of the "problem" cases for the SSA disability
system; and the issues surrounding the assessment arid management
of back pain and patients with such pain are illustrative of those of
chronic pain conditions in general. This does not mean that back pain
is necessarily representative of all other types of pain.
REFERENCES
Kelsey, J.L., White, A.A., Pastides, H., and Bisbee, G.E. The impact of musculoskeletal
disorders on the population of the United States. Journal of Bone and Joint Surgery
61A:959~964, 1979.
Lawrence, L., and McLemore, T. 1981 Summary: National Ambulatory Medical Care
Survey. NCHS Advance Data, No. 88. U.S. Department of Health and Human
Services Pub. No. (PHS)83-1250, 1983.
Rowe, M.L. Low back pain in industry: a position paper. Journal of Occupational
Medicine 11:161-169, 1969.
United States Department of Health and Human Services. Report of the Commission' on
the Evaluation of Pain. Washington, DC: U.S. Government Printing Office, 1987.
United States Department of Health and Human Services. Social Security Administra-
tion. Disability Survey 72. SSA Pub. No. 13-11812, 1980.
Representative terms from entire chapter:
disability benefits
