Social Security Ruling (SSR) 03-02p contains important information regarding how Social Security adjudicates cases involving Reflex Sympathetic Dystrophy Syndrome, also known as Complex Regional Pain Syndrome Type I (RSD/CRPS).
RSD/CRPS are synonymous terms for a type of chronic pain syndrome that can result from trauma, often occurring to a single extremity. The syndrome is characterized by a constellation of symptoms one of the more common of which is intense localized pain. It can result in autonomic dysfunction. The precipitating trauma may be so slight, that the individual might not even remember it. Often the intensity of pain experience from the syndrome is out of proportion to the severity of the injury sustained. Medical literature suggests the syndrome may also result from surgical procedures, stroke with hemiplegia, drug exposure, and cervical spondylosis. If not treated early, the symptoms may worsen over time, and can last for years.
Although the pathogenesis of RSD/CRPS has not been defined, it has been strongly suggested that the sympathetic nervous system is implicated. This is the system that regulates the body’s “fight or flight” response to external stimuli. This includes reactions such as constricted blood vessels, rapid heart rate and sweating, increased alertness, dilatation of the bronchial tubes and pupils, and constriction of the sphincter muscles. Abnormal functioning of the sympathetic nervous system can produce exaggerated neural signals that are interpreted as pain. Such abnormal functioning can also produce responses such as changes in blood vessels, skin, bone l, and musculature. Early recognition of and treatment of the syndrome within the first three months offers the best chance for effective recovery.
While the pain associated with the syndrome often starts out localized to the area of the trauma or injury, it can spread so as to affect an entire limb, or even spread to other limbs. 50 percent cases present symptoms which last 6 months or longer. Where treatment is not successful, symptoms can persist for years.
Diagnosis of RSD/CRPS requires pain associated with decreased mobility of the affected limb, plus at least one of the following signs or symptoms:
● Autonomic instability such as changes on the color, texture, or temperature of the skin including frequent appearance of abnormal pilomotor erection (goosebumps), excessive or decreased sweating
● Abnormal hair or nail growth
● Osteoporosis, or
● Involuntary movement of the affected area of the initial injury.
Progression of clinical symptoms including pain, muscle atrophy, and spread of the affected areas despite ongoing treatment hallmark a poor prognosis for the condition.
Early diagnosis, patient education, and attempts to increase the mobility of the affected region mark the best chance for effective treatment of the syndrome. In accomplishing this, the use of appropriate medications may be indicated to decrease pain and allow the patient to practice increased mobility of the affected region.
A psychological exam may be requested to determine if there is an underlying psychological impairment that may contribute to decreased pain tolerance. However, it is important to note that this does not mean that the syndrome is not a real physical phenomenon.
In some patients, it is desirable or necessary to inject a long-acting anesthetic to block sympathetic activity, in order to decrease pain and allow increased mobility of the affected area. Patients noted to have a good response to local sympathetic blocks may be considered candidates for a sympathectomy, a procedure which permanently disrupts sympathetic innervation of the affected region. Such a procedure must be performed by a physician who is an expert in the technique and is not without potential complications.
For purposes of social security disability, a diagnosis of a medically determinable impairment must be established by laboratory signs, symptoms, and appropriate laboratory techniques, and not merely by an individual’s statements about his or her symptoms. A longitudinal record of persistent complaints of pain in the affected area (often disproportionate to the severity of the injury) can be important in establishing a diagnosis. The fact that the symptoms may not be present continuously does not negate an otherwise valid diagnosis, as transience of symptoms is characteristic of this syndrome.
Social Security will generally obtain records for the twelve-month period prior to the month of application unless a longer or shorter period is indicated under the circumstances.
If the adjudicator feels the evidence is inadequate to establish disability, he or she will first contact the individual’s treatment providers in an attempt to fill in any evidentiary gaps before scheduling a consultative exam. Conflicts in the evidence in RSD/CRPS cases is not unusual due to the transitory nature of the disease’s symptoms. In resolving such evidentiary conflicts, the adjudicator will first contact the person’s treatment providers. Only if the conflicts cannot be resolved after such contact should a consultative exam be scheduled.
The opinions of medical treatment providers regarding the nature and severity of the individual’s impairments are entitled to deference and, in certain circumstances, may be entitled to controlling wright. If the treatment provider’s opinion is well supported by acceptable clinical and laboratory techniques, and is not inconsistent with other substantial evidence in the record, it is entitled to controlling weight. See also SSR 96-2p (when medical source opinions are entitled to controlling weight), 96-5p (ultimate issues reserved to Commissioner of Social Security).
When evaluating the duration and limiting effects of the impairment, adjudicators should consider all symptoms, including pain, and the effects of medication on the person’s ability to function in daily life.
In cases where disability is determined but medical improvement is expected, the adjudicator should set an appropriate future date for a medical reevaluation.
While a person’s statements alone regarding his or her symptoms are not sufficient to establish a medically determinable impairment, such evidence is used in determining the intensity, duration and limiting effects of the person’s impairments.
Although RSD/CRPS is not one of Social Security’s “listed impairments”, the totality of the evidence may be considered in determining whether the person’s impairment is medically equivalent to one of these listings. The mental/psychological listings may be implicated in these cases as well.
If the person’s impairments are not found to meet or medically equal one of the listings, it still remains to be decided whether the person’s symptoms are sufficiently debilitating to preclude prior work or any gainful work in the national economy. This necessitates a determination of the person’s residual functional capacity (RFC), or their remaining maximum ability to do work like activities. Ser SSR 96-8 (RFC and sustaining full-time work).
Useful sources of evidence, in addition to evidence from acceptable medical providers, may include:
Neighbors, family, friends, clergy, former employers or coworkers, rehabilitation counselors, teachers or other educational personnel;
Naturopath’s, chiropractors, nurses, physician’s assistants, therapists, licensed social workers:
Statements from other sources familiar with the individual’s daily activities; and
The individual’s own statements from sources such as pain diaries or journals.
Individuals ages 18 through 49/with RSF/CRPS are not precluded from a finding of disabled. Although age, education, and prior work history are not considered to be significantly limiting factors for persons under age 50, such younger people may still be found disabled if they are determined to not have the capacity to perform a full range of sedentary work. The extent of the erosion of the sedentary occupational base is often determined with the assistance of a vocational expert. See SSR 96-9p (adjudicating cases where there is a “less than sedentary” RFC).
This material should not be construed as legal advice for any particular fact situation, but is intended for general informational purposes only. For advice specific to any individual situation, an experienced attorney should be contacted.