PAIN�

153 (2012) 507–508

w w w . e l s e v i e r . c o m / l o c a t e / p a i n

Commentary

Pain today – Disability tomorrow

Chronic pain is common and tends to be persistent in thepopulation [1,6]. People with chronic pain very often have poorself-rated health [5]. Poor self-rated health is a strong predictorof disability retirement [7]. Not surprisingly, therefore, the largestproportion of costs related to pain is indirect, i.e. costs arising fromabsence through sick leave and disability retirement [3].

It is not a far-fetched idea to assume that pain predisposes aperson to disability retirement. Based on data from more than6000 workers, Saastamoinen et al. [9] in this issue of PAIN providepopulation-level evidence in support of this assumption. Theauthors were able to link their baseline data, which containedpain-specific information, to the Finnish pension register. This par-ticular research setting provides a unique opportunity to analysethe relationship between pain and disability retirement at the pop-ulation level. During an 8-year follow-up they verified 594 disabil-ity retirement events. The data were stratified by self-perceivedlong-standing illness. Chronic pain was significantly associatedwith disability retirement both in subjects who did not perceiveco-occurring long-standing illness and in subjects who did. How-ever, the association was stronger for those with a long-standingillness. The association was strongest for disability retirementdue to musculoskeletal disease, but it was also significant for men-tal and other diseases.

Existing scientific literature about pain-related disability retire-ment has focused mainly on musculoskeletal diseases. Symptomburden, accumulated health problems, comorbidity, low socioeco-nomic status and low educational level have been shown to in-crease the risk of disability retirement in individuals withmusculoskeletal pain-related diagnoses [4,8]. The study by Saasta-moinen et al. suggests that chronic pain increases the risk of retire-ment, regardless of the disability-related outcome diagnosis inquestion. However, even though chronic conditions and diseasesaffected the association between pain and disability retirementmore than education or physical working conditions, the new re-sults did not determine which particular diseases at the baselinepredicted disability retirement. To determine whether the subjecthas or previously had physician-diagnosed diseases at the baseline,the authors included a list of 26 items: chronic conditions and dis-eases of the musculoskeletal, cardiovascular, respiratory, neurolog-ical, endocrine, gastrointestinal and genitourinary systems,malignant neoplasms and mental disorders. The list of reportedchronic conditions included some, but not all significant pain-re-lated diagnoses, e.g. rheumatoid arthritis and osteoarthritis wereincluded, but neither chronic low back and shoulder pain-relateddiagnoses, nor fibromyalgia were included. Furthermore, the asso-ciation between any particular chronic disease or condition at

0304-3959/$36.00 � 2011 International Association for the Study of Pain. Published bydoi:10.1016/j.pain.2011.12.002

q DOI of original article: 10.1016/j.pain.2011.11.005

baseline and retirement was not analysed in the multivariateanalysis. The authors also did not analyse multimorbidity.Although further adjustment was made with occupational classand psychosocial and physical working conditions, these adjust-ments did not markedly affect the association of pain withretirement.

Saastamoinen et al. conclude that prevention and effectivetreatment of chronic pain are important in order to reduce the inci-dence of early retirement due to disability. In general this is evi-dent, but both population- and patient-level research shouldfocus more specifically on potential factors that may reduce dis-ability. Not having chronic pain, of course, is beneficial for one’shealth and unquestionably allows one to retain employment. Butinjury alone does not account for work absences; higher education,self-employment and strong belief in recovery after injury make iteasier to return to work [2]. As the process of disability retirementis long, it is not easy to conduct a controlled longitudinal study thatcould assess the positive effects of different interventions or strat-egies in disability prevention. Therefore, we must use informationthat is based on longitudinal cohorts and clinical studies andimplement this information in policy and practice. It is importantfor health care professionals to understand indicators of poor out-come, to detect them early and to react or rather be proactive withtheir patients. For example, a Finnish twin study has shown thatbody mass index and smoking are related to disability pensiondue to musculoskeletal diseases [8]. A comprehensive proactivepopulation-based strategy in preventing major health-affectingdiseases or conditions such as diabetes, obesity and coronary ar-tery disease may be effective also in preventing chronic pain andchronic pain-related disability. Simply put, this means promotinga healthy lifestyle. In a clinical context with selected patientgroups, multidisciplinary approaches are worth assessing, develop-ing and implementing further [10].

It may seem obvious that pain, and especially chronic pain, con-tributes to early retirement. However, studies such as the one bySaastamoinen et al. are important in demonstrating this empirically,not only for the scientific community, but also for those individualswho are responsible for health care planning and policy-making.While chronic pain is an important determinant in the often lengthydisability retirement process, more attention should be paid to it inprevention, assessment, treatment and management.

Conflict of interest statement

The author has no conflicts of interests in relation to thiscommentary.

Elsevier B.V. All rights reserved.

508 Commentary / PAIN�

153 (2012) 507–508

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Pekka MäntyselkäPrimary Health Care Unit, University of Eastern Finland and Kuopio

University Hospital, P.O. Box 1627, 70211 Kuopio, FinlandE-mail address: pekka.mantyselka@uef.fi