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COMPENSATION-DRIVEN
DISABILITY
Over the last century, it has been
acknowledged that patients who seek compensation for
their injuries have a prolonged recovery period and
a less satisfactory response to treatment. While the
increase of industrial low back disability in the first
part of the 20th century may be explained on changing
workplace conditions, the epidemic that has followed
is not so easily understood and is often attributed
to availability of compensation. Military medical records
of British forces in the first and second world wars
show a five-fold increase of low back pain complaints
and four-fold increase in the duration of disability
for World War II versus World War I soldiers. In the
United States, the incidence of disabling back pain
between 1971 and 1981 increased 168%, or fourteen times
that of the population growth. Clearly, increased disability
initially created the need for compensation, but now
compensation may be driving the disability.
Terms such as compensation
neurosis or greenback poultice treatment
have been pejoratively used to describe this phenomenon
and have influenced many physicians in the course of
their dealings with workers' compensation patients.
Financial gain has been shown to be a powerful reinforcer
of disability and common sense suggests that someone
who is embroiled in litigation to prove damages may
need to have symptoms continue to make the point. Indeed
studies have shown that patients who have back pain
and are receiving workers' compensation benefits do
poorly in treatment and are disabled longer. One author
described these conditions as:
a state of mind, born out of
fear, kept alive by avarice, stimulated by lawyers,
and cured by a verdict.
However, this connection is not
universally accepted, and in some studies patients receiving
workers' compensation do just as well as those who do
not. More importantly, it might be assumed that once
compensation issues have ceased to exist or a financial
settlement is reached, that symptoms of disability also
improve. Interestingly, this is not the case. Studies
have shown that even up to five years after settlement
of a claim, there is no significant reduction in morbidity
of patients with chronic back pain.
Where no objective organic pathology
exists, psychological and psychosocial factors may be
playing a major role. Here, the reinforcing effect of
compensation is the greatest. In most cases it represents
the phenomenon known as secondary gain, in
which an original injury may have had unexpected environmental
responses that assist in sustaining it. Examples include
financial reimbursement through workers compensation,
attention from the family, or avoidance of less than
satisfactory work conditions. Less common but even more
troublesome is the phenomenon of primary gain
where a psychological conflict or need initiated the
physical symptom in the first place. Here there may
be an avoidance of an unpleasant or threatening personal
situation, or a means to gain an important response
from the environment. The physical symptom serves a
significant psychological purpose and resolves a conflict
with which the individual otherwise cannot deal adequately.
The psychological issue is the main initiating and sustaining
factor.
These are not easy issues to decipher
and simply the presence of symptom magnification should
not lead to the conclusion that the condition is psychological.
Chronic back pain syndrome does not represent a single
entity, and can include heterogeneous conditions which
have different and complex causes. The diagnosis of
malingering may be even more difficult to
make, and it is often used by physicians who are frustrated
with a difficult to treat patient. It is doubtful in
many cases whether the label is valid, since it is usually
given after a limited period of observation or examination.
Frequently, clinicians say that a patient hobbled into
the office but then was seen in the parking lot walking
without any difficulty at all. While that could be some
evidence of malingering, it falls short of being sufficient
for the diagnosis since patients with back pain can
have variable symptoms, and some pain behaviors can
easily present with inconsistencies but may not indicate
intentional falsification. The use of private investigators
by insurance companies can be extremely disconcerting
to suffering patients, but often produces evidence of
major discrepancies in claims of functional impairment.
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