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Albert M. Drukteinis, M.D., J.D.

In western societies back pain disability is growing at staggering rates. It is the greatest industrial health problem in the United States today. It accounts for 31% of all workers' compensation claims. As many as eight million Americans are disabled partially or permanently each year from back pain, and it is the most frequent cause of limitation of activities in those under 45 years old. Nearly 18% of the population will have back pain in any given year and 10% to 15% will have some work disability connected to it. In one recent decade, the incidents of disabling back pain increased fourteen times that of the general population.

Fortunately, 90% of the people will recover within three months. But, almost 80% of all the costs of back pain treatment are absorbed by the remaining 10% - and those costs are enormous! With an average cost per claim approaching twenty-four thousand dollars, the total cost for lost productivity, workers' compensation benefits, and medical care is estimated by some to be more than fifty billion dollars per year.

In short, we see that back pain disability is a major health problem that is growing in frequency. Intuitively, this suggests that physical disease alone is not responsible. Confounding the problem, or, perhaps indirectly explaining it, are acknowledged observations that in the majority of cases of chronic back pain, a specific cause is not known or cannot be accurately diagnosed! This is in spite of all our extensive and costly diagnostic methods. What often remains are vague labels such as lumbar strain, back sprain, lumbago, or idiopathic back pain. Patients frequently go from one physician to another, expose themselves to various diverse treatment methods, often undergo one or more surgeries and frequently allow practitioners on the fringes of medicine to offer their own brand of snake oil. Traditional treatment methods that are so successful in 90% of acute back pain are often an abysmal failure in chronic back pain.

There is a critical difference between having back pain and being disabled from it. Chronic back pain disability is associated with personal subjective factors which are not easily quantifiable and which may or may not be related to the insult that marked the onset of back pain. These chronic conditions must be addressed as a medical and psychosocial phenomenon. No one psychosocial factor has been established as the prototype for them.

Disability can spring from secondary psychosocial factors which merely complicate an injury or from primary ones unrelated to the injury and which generate and maintain the disability. These can include depression, pain prone personality types, other adverse life events, job dissatisfaction, negative conditioning, and compensation and litigation reinforcers. The motivation of the injured person to recover is the most important component in rehabilitation. That motivation can only be understood in light of all psychosocial variables.

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