Pain, Impairment, and Disability in the AMA Guides

Physicians use the American Medical Association's Guides to the Evaluation of Permanent Impairment, 5th edition to evaluate millions of disability applicants each year. As major contributors to the chapter in the Guides devoted to assessing impairment associated with pain, we confronted the difficulties of incorporating pain into the Guides' overall evaluation system. Analysis of these difficulties is complicated by the paucity of research on the Guides, and by ambiguities and contradictions that pervade it. We propose that the ambiguities can be reduced if impairment is consistently defined in terms of organ or body part derangement, and disability in terms of activity limitations at the level of the whole person. We also propose a distinction between objective factors that may influence a person's ability to perform activities following injury. We suggest that when physicians examine disability applicants, they should evaluate both objective measures of organ or body part dysfunction and subjective reports of applicants -- especially ones regarding pain. We conclude that a comprehensive medical evaluation of disability applicant encompasses more than an impairment assessment.     

Physical Injuries, Pain, and Psychological Trauma: Pathways to Disability

Because physical injuries occur so frequently and are associated with significant mortality and morbidity, these injuries have been acknowledged as a worldwide public health concern. While the greatest cost associated with physical injury is the loss of life, non-fatal injuries are associated with significant personal and societal costs. Traditionally, examinations of the personal costs of physical injuries have emphasized functional losses and limitations, in addition to resulting losses in work productivity and income earning power. Efforts to capture the societal costs associated with physical injury have emphasized medical expenditures related to their treatment as well as costs related to lost work performance and disability compensation. Less emphasized but possibly more relevant to post-injury functional outcomes is the experience of psychological distress that frequently accompanies injury-related changes in function and overall quality of life. Any calculation of the true cost of physical injuries must include a reckoning of their impact on psychological health and the interactive influence of physical and psychological injuries on immediate and long-term recovery of function. In the current article, we briefly summarize data pertaining to the prevalence and cost of physical injuries; we briefly describe the more common consequences of physical injury, including injury-related limitations in physical function, pain and pain-related limitations in physical function, occupational impairment, psychological distress, and impairment in interpersonal relating; we review select theoretical models that are considered to explain the transition from physical injury to disabilities and we identify the pre-, peri-, and post-injury influence of physical and psychological health on injury management, recovery of function, risk of re-injury, and disability.     

A Review of Evidence-Based Biopsychosocial Laws Governing the Treatment of Pain and Injury

The impact of scientific findings on medical, psychological, and legal concepts has led to the adoption of laws and regulations that do not easily fit into the established legal categories of medical law or mental health law. Instead, this convergence of forces has resulted in laws and regulations mandating biopsychosocial treatment guidelines, where both medical and psychological cares are integrated within the framework of a single paradigm. Laws and regulations of this type have been adopted by a number of US states and Canadian provinces, and could be considered to represent a new category, for which we offer the term “biopsychosocial law.” Biopsychosocial laws currently pertain to medical treatment guidelines for workers’ compensation, a medical treatment system noted for high costs, high levels of litigation, and psychological involvement. There are a number of examples of biopsychosocial laws, but the most noteworthy are based on guidelines developed by the Colorado Division of Workers’ Compensation, the American College of Occupational and Environmental Medicine, the Work Loss Data Institute, and The Reed Group. These guidelines differ significantly with regard to features, conditions covered, and strength of evidence basis. However, all of these guideline systems were developed with the intent of providing good care while controlling costs, are evidence based, integrate the practice of medicine and psychology, and are legally mandated in certain jurisdictions. Taken together, these guidelines represent a growing convergence of scientific evidence, professional society positions, payor policies, and legal regulations. These forces are propelling a broad societal shift away from Cartesian assumptions that the body and mind are separate, and toward a biopsychosocial paradigm for the treatment of injury and illness.     

Primary, Secondary, and Tertiary Losses in Chronic Pain Patients

Treating individuals with chronic illness and disability requires attention to physical, psychological, and social factors. These unique challenges are optimally addressed by utilizing a biopsychosocial approach, while considering the potential array of both gains and losses that chronic pain patients experience. The benefits a patient receives from remaining ill are often referred to as secondary gain. In medicolegal settings, a common example of a secondary gain issue is the effort to obtain financial compensation. While secondary gain can be one factor that contributes to perpetuating illness and disability, there are often more powerful losses that lead to such perpetuation. The losses associated with pain and disability are not frequently discussed. The overall purpose of this paper is to identify primary, secondary, and tertiary loss issues in chronic pain patients, and address issues related to how these factors are important within a medicolegal/forensic context.     

Chronic Pain in the DSM-IV and the DSM-5 Draft: The Pain of It All

The Diagnostic and Statistical Manual, DSM-IV-TR (American Psychiatric Association 2000) includes the diagnosis of pain disorder, and it has been revised in major ways in the DSM-5 draft (American Psychiatric Association 2010). Pain disorder has been relegated as a specifier of the new diagnosis of complex somatic symptom disorder. It cannot be diagnosed prior to 6 months of the pain’s onset. Also, there are still the pejorative connotations with which the disorder is associated. In terms of treatment, it might be more difficult to get treatment plans accepted as a result of the changes, and in terms of the legal arena, it might prove more difficult to have the disorder serve as the basis of action in legal proceedings.     

Perceived Injustice is Associated with Heightened Pain Behavior and Disability in Individuals with Whiplash Injuries

The present study examined the relationship between perceived injustice associated with whiplash injury and displays of pain behavior. Individuals (N?=?85) with whiplash injuries were filmed while performing a simulated occupational lifting task. They were also asked to complete measures of pain, perceived injustice, catastrophic thinking, depression, and functional disability. Consistent with previous research, high levels of perceived injustice were associated with more intense pain, higher levels of catastrophic thinking, depression, and disability. Analyses revealed that individuals with high levels of perceived injustice displayed more protective pain behaviors than individuals with low levels of perceived injustice, regardless of the level of physical demand of the task. The relation between perceived injustice and protective pain behavior remained significant even when controlling for pain severity, catastrophic thinking, and depression. There was no significant association between perceived injustice and displays of communicative pain behavior. The results of this study suggest that the relation between perceived injustice and pain behavior might underlie the high prevalence of occupational disability in individuals who have sustained whiplash injuries. Implications for intervention are addressed.     

Work Impairment and Disability in Posttraumatic Stress Disorder: A Review and Recommendations for Psychological Injury Research and Practice

Work impairment and disability are common consequences of posttraumatic stress disorder (PTSD), as reflected by significant rates of sickness absence, failure to return to work, and reduced work performance. Within the psychological injury field, the issue of work impairment and disability in PTSD often arises in workers’ compensation and disability insurance claims and in personal injury litigation. In this context, clinical and forensic practitioners are faced with challenges in rendering expert opinions on diagnosis, causality, prognosis, and recommendations for treatment and rehabilitation. To promote understanding of this important, yet understudied area, there are three aims of this paper: first, to review the current literature on work impairment and disability associated with PTSD; second, to draw on this literature to present a biopsychosocial framework of work impairment and disability in PTSD; and third, to offer suggestions for improving the assessment and management of PTSD-related work impairment and disability.     

Disability, disparate impact, and class actions

Following Title VII's enactment, group-based employment discrimination actions flourished due to disparate impact theory and the class action device. Courts recognized that subordination that defined a group's social identity was also sufficient legally to bind members together, even when relief had to be issued individually. Woven through these cases was a notion of panethnicity that united inherently unrelated groups into a common identity, for example, Asian Americans. Stringent judicial interpretation subsequently eroded both legal frameworks and it has become increasingly difficult to assert collective employment actions, even against discriminatory practices affecting an entire group. This deconstruction has immensely disadvantaged persons with disabilities. Under the Americans with Disabilities Act (ADA), individual employee claims to accommodate specific impairments, such as whether to install ramps or replace computer screens, have all but eclipsed a coherent theory of disability-based disparate impact law. Moreover, the class action device has been virtually nonexistent in disability discrimination employment cases. The absence of collective action has been especially harmful because the realm of the workplace is precisely where group-based remedies are needed most. Specifically, a crucial but overlooked issue in disability integration is the harder-to-reach embedded norms that require job and policy modifications. The Article argues that pandisability theory serves as an analogue to earlier notions of panethnicity and provides an equally compelling heuristic for determining class identity. It shows that pandisability undergirds ADA public service and public accommodation class actions in which individualized remedy assessments have been accepted as part of group-based challenges to social exclusion. The Article also demonstrates that this broader vision of collective action is consistent with the history underlying the class action device. Taking advantage of the relatively blank slate of writing on group-based disability discrimination, it offers an intrepid vision of the ADA's potential for transforming workplace environments. In advocating for a return to an earlier paradigm of collective action in the disability context, the Article also provides some thoughts on challenging race- and sex-based discrimination. Future workplace policies should plan for "all jobs to include some physical activity" unrelated to job qualifications in order to "dissuade unhealthy people from coming to work at Wal-Mart."     

Re‐Claiming Disability: Identity,Procedural Justice,and the Disability Determination Process

This research highlights the crucial role of an intimate link between a disabled person's self‐identity and the perceived fairness of legal procedures. In doing so, it brings to the foreground a wholly ignored aspect of procedural justice. Earlier researchers have failed to delve into the role identity politics plays in the relationship between the institutions and the beneficiaries of their services, and the way different members of a group understand and define themselves. This research explores the way people with disabilities in the United States, with different kinds of disability identities, experience and evaluate the procedure of claiming Social Security benefits. The findings suggest that disabled people who identified with the social model of disability (as opposed to the medical‐individual models) hold a critical view of the procedure for retaining benefits. They felt they had no control over it, could not voice their opinions, were mistreated by representatives, and had to present an image that was not necessarily true of their disability. They also saw the procedure as discouraging them from participating fully in the labor market, and consequently integrating better in society, an idea that was not present among disabled people who identify with medical‐individual models. Exposing this relationship between the way people perceive themselves and the way they experience and evaluate legal procedures can contribute to the creation of better policies, while improving communication between the state and members of the disability community, along with other marginalized groups.     

Mental Disorder, Work Disability and the Law

R.J. Bonnie and J. Monahan, eds., Mental Disorder, Work Disability, and the Law (Chicago: University of Chicago Press, 1997): 321 pp.     

The Ethics of Care,Dependence, and Disability*

According to the most important theories of justice, personal dignity is closely related to independence, and the care that people with disabilities receive is seen as a way for them to achieve the greatest possible autonomy. However, human beings are naturally subject to periods of dependency, and people without disabilities are only “temporarily abled.” Instead of seeing assistance as a limitation, we consider it to be a resource at the basis of a vision of society that is able to account for inevitable dependency relationships between “unequals” ensuring a fulfilling life both for the carer and the cared for. **     

Catastrophizing Mediates the Relationship Between the Personal Belief in a Just World and Pain Outcomes Among Chronic Pain Support Group Attendees

Health-related research suggests the belief in a just world can act as a personal resource that protects against the adverse effects of pain and illness. However, currently, little is known about how this belief, particularly in relation to one’s own life, might influence pain. Consistent with the suggestions of previous research, the present study undertook a secondary data analysis to investigate pain catastrophizing as a mediator of the relationship between the personal just world belief and chronic pain outcomes in a sample of chronic pain support group attendees. Partially supporting the hypotheses, catastrophizing was negatively correlated with the personal just world belief and mediated the relationship between this belief and pain and disability, but not distress. Suggestions for future research and intervention development are made.     

Workers' Compensation, Social Security Disability, SSI, and Genetic Testing

This article argues that the use of genetic testing to determine eligibility for worker compensation and/or social security disability benefits would seriously undermine the social purposes of the laws.