- Email: [email protected]
Pain today – Disability tomorrow
Ò
PAIN 153 (2012) 507–508
www.elsevier.com/locate/pain
Commentary
Pain today – Disability tomorrow Chronic pain is common and tends to be persistent in the population [1,6]. People with chronic pain very often have poor self-rated health [5]. Poor self-rated health is a strong predictor of disability retirement [7]. Not surprisingly, therefore, the largest proportion of costs related to pain is indirect, i.e. costs arising from absence through sick leave and disability retirement [3]. It is not a far-fetched idea to assume that pain predisposes a person to disability retirement. Based on data from more than 6000 workers, Saastamoinen et al. [9] in this issue of PAIN provide population-level evidence in support of this assumption. The authors were able to link their baseline data, which contained pain-specific information, to the Finnish pension register. This particular research setting provides a unique opportunity to analyse the relationship between pain and disability retirement at the population level. During an 8-year follow-up they verified 594 disability retirement events. The data were stratified by self-perceived long-standing illness. Chronic pain was significantly associated with disability retirement both in subjects who did not perceive co-occurring long-standing illness and in subjects who did. However, the association was stronger for those with a long-standing illness. The association was strongest for disability retirement due to musculoskeletal disease, but it was also significant for mental and other diseases. Existing scientific literature about pain-related disability retirement has focused mainly on musculoskeletal diseases. Symptom burden, accumulated health problems, comorbidity, low socioeconomic status and low educational level have been shown to increase the risk of disability retirement in individuals with musculoskeletal pain-related diagnoses [4,8]. The study by Saastamoinen et al. suggests that chronic pain increases the risk of retirement, regardless of the disability-related outcome diagnosis in question. However, even though chronic conditions and diseases affected the association between pain and disability retirement more than education or physical working conditions, the new results did not determine which particular diseases at the baseline predicted disability retirement. To determine whether the subject has or previously had physician-diagnosed diseases at the baseline, the authors included a list of 26 items: chronic conditions and diseases of the musculoskeletal, cardiovascular, respiratory, neurological, endocrine, gastrointestinal and genitourinary systems, malignant neoplasms and mental disorders. The list of reported chronic conditions included some, but not all significant pain-related diagnoses, e.g. rheumatoid arthritis and osteoarthritis were included, but neither chronic low back and shoulder pain-related diagnoses, nor fibromyalgia were included. Furthermore, the association between any particular chronic disease or condition at
q
baseline and retirement was not analysed in the multivariate analysis. The authors also did not analyse multimorbidity. Although further adjustment was made with occupational class and psychosocial and physical working conditions, these adjustments did not markedly affect the association of pain with retirement. Saastamoinen et al. conclude that prevention and effective treatment of chronic pain are important in order to reduce the incidence of early retirement due to disability. In general this is evident, but both population- and patient-level research should focus more specifically on potential factors that may reduce disability. Not having chronic pain, of course, is beneficial for one’s health and unquestionably allows one to retain employment. But injury alone does not account for work absences; higher education, self-employment and strong belief in recovery after injury make it easier to return to work [2]. As the process of disability retirement is long, it is not easy to conduct a controlled longitudinal study that could assess the positive effects of different interventions or strategies in disability prevention. Therefore, we must use information that is based on longitudinal cohorts and clinical studies and implement this information in policy and practice. It is important for health care professionals to understand indicators of poor outcome, to detect them early and to react or rather be proactive with their patients. For example, a Finnish twin study has shown that body mass index and smoking are related to disability pension due to musculoskeletal diseases [8]. A comprehensive proactive population-based strategy in preventing major health-affecting diseases or conditions such as diabetes, obesity and coronary artery disease may be effective also in preventing chronic pain and chronic pain-related disability. Simply put, this means promoting a healthy lifestyle. In a clinical context with selected patient groups, multidisciplinary approaches are worth assessing, developing and implementing further [10]. It may seem obvious that pain, and especially chronic pain, contributes to early retirement. However, studies such as the one by Saastamoinen et al. are important in demonstrating this empirically, not only for the scientific community, but also for those individuals who are responsible for health care planning and policy-making. While chronic pain is an important determinant in the often lengthy disability retirement process, more attention should be paid to it in prevention, assessment, treatment and management. Conflict of interest statement The author has no conflicts of interests in relation to this commentary.
DOI of original article: 10.1016/j.pain.2011.11.005
0304-3959/$36.00 Ó 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2011.12.002
508
Ò
Commentary / PAIN 153 (2012) 507–508
References [1] Elliott AM, Smith BH, Hannaford PC, Smith WC, Chambers WA. The course of chronic pain in the community: results of a 4-year follow-up study. Pain 2002;99:299–307. [2] Clay FJ, Newstead SV, Watson WL, McClure RJ. Determinants of return to work following non life threatening acute orthopaedic trauma: a prospective cohort study. J Rehabil Med 2010;42:162–9. [3] Gustavsson A, Bjorkman J, Ljungcrantz C, Rhodin A, Rivano-Fischer M, Sjolund KF, Mannheimer C. Socio-economic burden of patients with a diagnosis related to chronic pain – register data of 840,000 Swedish patients. Eur J Pain 2011. doi:10.1016/j.ejpain.2011.07.006. [4] Markkula R, Kalso E, Huunan-Seppälä A, Koskenvuo M, Koskenvuo K, LeinoArjas P, Kaprio J. The burden of symptoms predicts early retirement: a twin cohort study on fibromyalgia-associated symptoms. Eur J Pain 2011;15: 741–7. [5] Mäntyselkä PT, Turunen JHO, Ahonen RS, Kumpusalo EA. Chronic pain and poor self-rated health. JAMA 2003;290:2435–42. [6] Papageorgiou AC, Silman AJ, Macfarlane GJ. Chronic widespread pain in the population: a seven year follow up study. Ann Rheum Dis 2002;61: 1071–4.
[7] Pietiläinen O, Laaksonen M, Rahkonen O, Lahelma E. Self-rated health as a predictor of disability retirement – the contribution of ill-health and working conditions. PLoS One 2011;6:e25004. [8] Ropponen A, Silventoinen K, Svedberg P, Alexanderson K, Koskenvuo K, Huunan-Seppälä A, Koskenvuo M, Kaprio J. Health-related risk factors for disability pensions due to musculoskeletal diagnoses: a 30-year Finnish twin cohort study. Scand J Public Health 2011. doi:10.1177/1403494811418283. [9] Saastamoinen P, Laaksonen M, Kääriä S-M, Lallukka T, Leino-Arjas P, Rahkonen O, Lahelma E. Pain and disability retirement: A prospective cohort study. Pain 2012;153:526–31. [10] van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J 2011;20:19–39.
Pekka Mäntyselkä Primary Health Care Unit, University of Eastern Finland and Kuopio University Hospital, P.O. Box 1627, 70211 Kuopio, Finland E-mail address: pekka.mantyselka@uef.fi
PAIN 153 (2012) 507–508
www.elsevier.com/locate/pain
Commentary
Pain today – Disability tomorrow Chronic pain is common and tends to be persistent in the population [1,6]. People with chronic pain very often have poor self-rated health [5]. Poor self-rated health is a strong predictor of disability retirement [7]. Not surprisingly, therefore, the largest proportion of costs related to pain is indirect, i.e. costs arising from absence through sick leave and disability retirement [3]. It is not a far-fetched idea to assume that pain predisposes a person to disability retirement. Based on data from more than 6000 workers, Saastamoinen et al. [9] in this issue of PAIN provide population-level evidence in support of this assumption. The authors were able to link their baseline data, which contained pain-specific information, to the Finnish pension register. This particular research setting provides a unique opportunity to analyse the relationship between pain and disability retirement at the population level. During an 8-year follow-up they verified 594 disability retirement events. The data were stratified by self-perceived long-standing illness. Chronic pain was significantly associated with disability retirement both in subjects who did not perceive co-occurring long-standing illness and in subjects who did. However, the association was stronger for those with a long-standing illness. The association was strongest for disability retirement due to musculoskeletal disease, but it was also significant for mental and other diseases. Existing scientific literature about pain-related disability retirement has focused mainly on musculoskeletal diseases. Symptom burden, accumulated health problems, comorbidity, low socioeconomic status and low educational level have been shown to increase the risk of disability retirement in individuals with musculoskeletal pain-related diagnoses [4,8]. The study by Saastamoinen et al. suggests that chronic pain increases the risk of retirement, regardless of the disability-related outcome diagnosis in question. However, even though chronic conditions and diseases affected the association between pain and disability retirement more than education or physical working conditions, the new results did not determine which particular diseases at the baseline predicted disability retirement. To determine whether the subject has or previously had physician-diagnosed diseases at the baseline, the authors included a list of 26 items: chronic conditions and diseases of the musculoskeletal, cardiovascular, respiratory, neurological, endocrine, gastrointestinal and genitourinary systems, malignant neoplasms and mental disorders. The list of reported chronic conditions included some, but not all significant pain-related diagnoses, e.g. rheumatoid arthritis and osteoarthritis were included, but neither chronic low back and shoulder pain-related diagnoses, nor fibromyalgia were included. Furthermore, the association between any particular chronic disease or condition at
q
baseline and retirement was not analysed in the multivariate analysis. The authors also did not analyse multimorbidity. Although further adjustment was made with occupational class and psychosocial and physical working conditions, these adjustments did not markedly affect the association of pain with retirement. Saastamoinen et al. conclude that prevention and effective treatment of chronic pain are important in order to reduce the incidence of early retirement due to disability. In general this is evident, but both population- and patient-level research should focus more specifically on potential factors that may reduce disability. Not having chronic pain, of course, is beneficial for one’s health and unquestionably allows one to retain employment. But injury alone does not account for work absences; higher education, self-employment and strong belief in recovery after injury make it easier to return to work [2]. As the process of disability retirement is long, it is not easy to conduct a controlled longitudinal study that could assess the positive effects of different interventions or strategies in disability prevention. Therefore, we must use information that is based on longitudinal cohorts and clinical studies and implement this information in policy and practice. It is important for health care professionals to understand indicators of poor outcome, to detect them early and to react or rather be proactive with their patients. For example, a Finnish twin study has shown that body mass index and smoking are related to disability pension due to musculoskeletal diseases [8]. A comprehensive proactive population-based strategy in preventing major health-affecting diseases or conditions such as diabetes, obesity and coronary artery disease may be effective also in preventing chronic pain and chronic pain-related disability. Simply put, this means promoting a healthy lifestyle. In a clinical context with selected patient groups, multidisciplinary approaches are worth assessing, developing and implementing further [10]. It may seem obvious that pain, and especially chronic pain, contributes to early retirement. However, studies such as the one by Saastamoinen et al. are important in demonstrating this empirically, not only for the scientific community, but also for those individuals who are responsible for health care planning and policy-making. While chronic pain is an important determinant in the often lengthy disability retirement process, more attention should be paid to it in prevention, assessment, treatment and management. Conflict of interest statement The author has no conflicts of interests in relation to this commentary.
DOI of original article: 10.1016/j.pain.2011.11.005
0304-3959/$36.00 Ó 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2011.12.002
508
Ò
Commentary / PAIN 153 (2012) 507–508
References [1] Elliott AM, Smith BH, Hannaford PC, Smith WC, Chambers WA. The course of chronic pain in the community: results of a 4-year follow-up study. Pain 2002;99:299–307. [2] Clay FJ, Newstead SV, Watson WL, McClure RJ. Determinants of return to work following non life threatening acute orthopaedic trauma: a prospective cohort study. J Rehabil Med 2010;42:162–9. [3] Gustavsson A, Bjorkman J, Ljungcrantz C, Rhodin A, Rivano-Fischer M, Sjolund KF, Mannheimer C. Socio-economic burden of patients with a diagnosis related to chronic pain – register data of 840,000 Swedish patients. Eur J Pain 2011. doi:10.1016/j.ejpain.2011.07.006. [4] Markkula R, Kalso E, Huunan-Seppälä A, Koskenvuo M, Koskenvuo K, LeinoArjas P, Kaprio J. The burden of symptoms predicts early retirement: a twin cohort study on fibromyalgia-associated symptoms. Eur J Pain 2011;15: 741–7. [5] Mäntyselkä PT, Turunen JHO, Ahonen RS, Kumpusalo EA. Chronic pain and poor self-rated health. JAMA 2003;290:2435–42. [6] Papageorgiou AC, Silman AJ, Macfarlane GJ. Chronic widespread pain in the population: a seven year follow up study. Ann Rheum Dis 2002;61: 1071–4.
[7] Pietiläinen O, Laaksonen M, Rahkonen O, Lahelma E. Self-rated health as a predictor of disability retirement – the contribution of ill-health and working conditions. PLoS One 2011;6:e25004. [8] Ropponen A, Silventoinen K, Svedberg P, Alexanderson K, Koskenvuo K, Huunan-Seppälä A, Koskenvuo M, Kaprio J. Health-related risk factors for disability pensions due to musculoskeletal diagnoses: a 30-year Finnish twin cohort study. Scand J Public Health 2011. doi:10.1177/1403494811418283. [9] Saastamoinen P, Laaksonen M, Kääriä S-M, Lallukka T, Leino-Arjas P, Rahkonen O, Lahelma E. Pain and disability retirement: A prospective cohort study. Pain 2012;153:526–31. [10] van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J 2011;20:19–39.
Pekka Mäntyselkä Primary Health Care Unit, University of Eastern Finland and Kuopio University Hospital, P.O. Box 1627, 70211 Kuopio, Finland E-mail address: pekka.mantyselka@uef.fi