Disability

Robinson23 and Gatchel1 provided a comprehensive overview of the complexities involved in the assessment of disability of a patient with a painful condition. Such assessment is usually based on subjective self-report measures of restrictions of activities of daily living, such as walking, work, and recreational activities, sleep, sex, and so on. A fundamental goal of such a disability evaluation is usually to ascertain whether a patient can or cannot work. A comprehensive review of such measures has been presented by Gatchel.24 However, again, such a determination is quite difficult in evaluating painful conditions because of the misguided assumption that impairment can be precisely and objectively measured and is closely linked to "mechanical failure'' of an organ or body part. Often, chronic pain patients will report activity restrictions that cannot be fully understood in terms of a specific "mechanical failure.'' As discussed, there is often a low concordance between subjective reports of pain and objective data of impairment. Thus, this will introduce vagaries into the disability evaluation process. One disability evaluator may tend to ignore the patient's subjective reports of pain and disability, and rely more heavily on any objective evidence of mechanical dysfunction that is available. Another evaluator may rely more exclusively on the subjective appraisals and activity restrictions reported by the patient, regardless of whether they can be objectively quantified in terms of any measurable mechanical failure or dysfunction. Another evaluator may attempt to develop a composite of both the subjective and objective measures. Unfortunately, as noted by Robinson23 and Dembe,11 there is currently no totally agreed upon disability evaluation system that can be used. Thus, disability agencies across different states will be quite different in the methods used. It should also be remembered that across the different states, there is no one workers' compensation system; each state's workers' compensation is specific for that state. Therefore, disability evaluations in Texas may be quite different from those in California or Connecticut. Nevertheless, in terms of a disability evaluation, physicians are usually required to address the following areas: assessment and diagnosis, impairment, ability to work, and a need for further treatment. Again, Robinson23 has provided examples of the questions that are usually asked by disability agencies when conducting such evaluations.

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