Patients with complex regional pain syndrome may be unable to work because of their condition and its related complications. Patients who are unable to work due to complex regional pain syndrome may qualify for long-term disability (LTD) benefits. The insurance company will review your claim to see if you qualify under the terms of your plan.
What Is Complex Regional Pain Syndrome?
Complex regional pain syndrome (CRPS), often referred to as reflex sympathetic dystrophy syndrome (RSDS), describes a constellation of symptoms and signs that can occur after an injury to a bone or soft tissue. The precipitating injury may be so minor that the individual may not even remember having been injured. Other potential precipitants suggested by the medical literature include, but are not limited to, surgical procedures, drug exposure, stroke with hemiplegia, and cervical spondylosis.
CRPS is a chronic pain syndrome that most often commonly results from trauma to a single extremity. It can also result from disease, surgery, or injury to other parts of the body. Even a minor injury can trigger CRPS. The most common acute clinical manifestations include complaints of severe pain and findings suggestive of autonomic dysfunction at the site of the precipitating trauma.
Later, spontaneously occurring pain may be associated with abnormalities in the affected region involving the skin, subcutaneous tissue, and bone. It is characteristic of this syndrome that the reported degree of pain reported is disproportionate to the severity of the injury sustained by the individual. If left untreated, the signs and symptoms of the disorder may worsen over time.
Although the pathogenesis of this disorder (the triggering mechanism(s) of the signs and symptoms characteristic of CRPS) has not been defined, dysfunction of the sympathetic nervous system has been strongly implicated.
The sympathetic nervous system regulates the body’s involuntary physiological responses to stressful stimuli. Sympathetic stimulation results in physiological changes that prepare the body to “fight or flight” in response to a stressful stimulus. The “fight or flight” response is characterized by constriction of the peripheral vasculature (blood vessels that supply the skin), increase in heart rate and sweating, dilation of the bronchial tubes, dilation of the pupils, increased alertness, and constriction of the sphincter muscles.
Abnormal sympathetic nervous system function can produce inappropriate or exaggerated nerve signals that may be misinterpreted as pain. In addition, abnormal sympathetic stimulation may cause changes in blood vessels, skin, muscles, and bones. Early recognition of the syndrome and prompt treatment, ideally within 3 months of the onset of symptoms, provides the greatest chance for effective recovery.
How Does CRPS Typically Present?
Patients with CRPS typically report persistent, burning, aching or searing pain that is initially localized to the site of the injury. The affected area usually has increased tenderness. The degree of pain reported is often disproportionate to the severity of the precipitating injury. Without appropriate treatment, the pain and associated atrophic skin and bone changes may spread to involve an entire limb. Cases have been reported to progress and spread to other limbs or distant parts of the body.
Clinical studies have shown that if treatment is delayed, the signs and symptoms may progress and spread, resulting in long-term and even permanent physical and psychological problems. Some researchers have found that the signs and symptoms of CRPS last more than 6 months in 50 percent of cases and can last for years in cases where treatment is not successful.
What Are the Diagnostic Criteria for CRPS?
A diagnosis of CRPS requires the presence of complaints of persistent, severe pain that results in decreased mobility of the affected region. Progression of the clinical disorder is characterized by worsening of a previously identified finding, or the manifestation of additional abnormal changes in the skin, nails, muscles, joints, ligaments, and bones of the affected region. Clinical progression does not necessarily correlate with specific time frames. Treatment efficacy must be judged based on the effect of treatment on the pain and whether or not progressive changes continue in the tissues of the affected region continue.
Reported pain at the site of the injury may be followed by complaints of muscle aches, joint stiffness, limited range of motion, or abnormal hair, and nail growth in the affected region. In addition, signs of autonomic instability (changes in skin color or temperature and frequent occurrence of goosebumps) may develop in the affected region. Osteoporosis may be detected by appropriate medically acceptable imaging techniques. Pain complaints may become more severe and may be reported to spread to involve other extremities. Muscle atrophy and contractures may also develop. Persistent clinical progression resulting in muscle atrophy and contractures, or progression of pain complaints to other extremities or regions, despite appropriate diagnosis and treatment, is indicative of a poor prognosis.
How Is CRPS Treated?
Patient education and activity programs designed to increase limb mobility and promote use of the affected extremity or region during activities of daily living are considered the most important treatments for CRPS. The medical literature has shown that people with CRPS have a better prognosis if they are diagnosed early and maintaining mobility is prioritized immediately. In some patients, it is necessary to inject a long-acting anesthetic to block sympathetic activity and reduce pain to allow the individual to increase the mobility of the affected region. Various analgesics, including narcotics and neurostimulators, may be used to minimize pain and promote the individual’s ability to tolerate greater mobility.
A psychological evaluation may be requested by treating or other medical sources to determine if there is an undiagnosed psychiatric condition that could potentially contribute to a reduced pain tolerance. It is important to recognize that such evaluations are not based on concerns that CRPS findings are imaginary or etiologically related to mental illness. The behavioral and cognitive effects of the medications used to treat pain must be carefully considered in the evaluation of this syndrome.
Other types of medications may also be used to reduce pain. Anti-inflammatory drugs, psychotropic drugs (e.g., antidepressants), certain antiepileptic drugs, muscle relaxants, and drugs that produce a generalized reduction in sympathetic outflow may be tried in an effort to reduce the signs and symptoms associated with CRPS and improve the mobility of the affected region.
Patients who respond well to local sympathetic blocks may be considered candidates for surgical sympathectomy. This procedure permanently interrupts the sympathetic innervation of the affected region. It involves the destruction of a sympathetic ganglion and must be performed by a physician experienced in this technique. This procedure is not without risk of postoperative complications.
How Is CRPS Evaluated in a Long-Term Disability Claim?
Disability is not usually determined based on an individual’s symptoms alone. CRPS may be the basis for a long-term disability insurance claim if it is documented by appropriate medical signs, symptoms, and laboratory findings, as discussed above.
If longitudinal treatment records document persistent limiting pain in an area where one or more of these abnormal signs have been documented at any time since the date of the precipitating injury, disability claims adjusters can reliably determine that CRPS is present and constitutes a benefit-eligible disability. Treatment records may indicate that these signs are not continuous, or the signs may be present at one examination and not at another. Transient findings are characteristic of CRPS.
How Is Medical Evidence of the Impairment Documented?
In cases involving CRPS, documentation of medical signs or laboratory findings in the medical record at any time since the date of the precipitating injury is critical to establishing the presence of a medical condition that qualifies for long-term disability benefits. In cases where CRPS is alleged, longitudinal clinical records reflecting ongoing medical evaluation and treatment from the individual’s medical sources, particularly treating sources, are extremely helpful in documenting the presence of any medical signs, symptoms and laboratory findings.
It should be noted that conflicting evidence in the medical record is not uncommon in cases of CRPS due to the transient nature of its objective findings and the complicated diagnostic process involved.
Medical opinions from treating sources regarding the nature and severity of an individual’s impairment(s) are important in an LTD claim due to CRPS. If we find that a treating source’s medical opinion on the issue of the nature and severity of an individual’s impairment(s) is well supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record, the insurance adjudicator is more likely to give such opinions great weight.
How Is the Duration and Severity of CRPS Determined?
The signs and symptoms of CRPS may remain stable, improve, or worsen over time. Documentation should include, whenever appropriate, a longitudinal clinical record that includes detailed medical observations, treatment, the individual’s response to treatment, complications of treatment, and a detailed description of how the impairment limits the individual’s ability to function and perform or maintain work activity over time.
Chronic pain and many of the medications prescribed to treat it can affect an individual’s ability to maintain attention and concentration, as well as adversely affect cognition, mood and behavior, and may even reduce motor reaction times. These factors may affect an individual’s ability to sustain work activity over time or preclude sustained work activity altogether. The impact of chronic pain and the use of pain medication should be carefully considered when assessing the duration and severity of the condition and when assessing RFC.
Evidence in a Long-Term Disability Claim Involving CRPS
Because a variety of symptoms may be associated with CRPS, the claims examiner must evaluate the intensity, persistence, and limiting effects of the individual’s symptoms to determine the extent to which the symptoms limit the individual’s ability to perform basic work activities.
For this purpose, whenever the individual’s statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not supported by objective medical evidence, the adjudicator should make a determination about the credibility of the individual’s statements based on a review of the entire case record. This includes the medical signs and laboratory findings, the individual’s own statements about the symptoms, any statements and other information provided by treating or examining physicians or psychologists and others about the symptoms and how they affect the individual, and any other relevant evidence in the case record.
Although symptoms alone cannot be the basis for a disability determination, an individual’s symptoms and the effect(s) of those symptoms on the individual’s ability to function must be considered both in determining the severity of the impairment and in assessing the individual’s residual functional capacity (RFC), as appropriate. In other words, the adjudicator should evaluate whether the pain or other symptoms cause a limitation or restriction that has more than a minimal effect on the individual’s ability to perform basic work activities.
Again, in determining RFC, all of the individual’s symptoms must be considered in deciding how such symptoms may affect functional capacities. Careful consideration must be given to the effect of pain and its treatment on an individual’s ability to perform sustained work-related physical and mental activities in a work setting on a regular and ongoing basis.
Opinions from an individual’s medical sources, particularly treating sources, regarding the effect(s) of CRPS on the individual’s ability to function in a sustained manner in performing work activities or activities of daily living are important in enabling LTD insurance adjudicators to draw conclusions regarding the severity of the impairment(s) and the individual’s RFC.
In this regard, any information that a medical source can provide that contrasts the individual’s medical condition(s) and functional capacities since the alleged onset of CRPS with the individual’s status prior to the onset of CRPS is helpful to the adjudicator in evaluating the individual’s impairment(s) and the resulting functional consequences.
The conclusion as to whether individuals are disabled will depend primarily on the nature and extent of their functional limitations or restrictions.
Long-Term Disability Attorney for Complex Regional Pain Syndrome
Working with an experienced disability attorney will give you the best chance of getting the benefits you deserve for your CRPS. Even if you have been denied benefits, that does not mean your fight is over. Many people are denied benefits the first time they apply. You have the right to file an appeal and try to get more information that may help your case. Getting expert help is often the difference between being denied and being approved for benefits.
While the process can be daunting, your experienced disability attorney will be able to guide you through the process. They do not get paid until you win your case. You can seek help without worrying about upfront costs or unexpected bills. The Ortiz Law Firm has successfully represented people in disability cases throughout the United States. If you would like to speak with an experienced disability lawyer about your CRPS and its impact on your ability to work, call us at (888) 321-8131. We would be happy to evaluate your case and to discuss how we can help you through the appeals process.